BlueCross BlueShield of Massachusetts. Referral Add, Subscriber and Dependent v1.4 Referral Cancel, Subscriber and Dependent v1.4

Transcription

1 BlueCross BlueShield of Massachusetts Referral Add, Subscriber and Dependent v1.4 Referral Cancel, Subscriber and Dependent v

2 This publication is the proprietary property of Emdeon and is furnished solely for use pursuant to a license agreement giving the user the right to use the Emdeon product(s) referenced in this document. All uses of this document are subject to the terms of such license agreement. This document may not be used except as permitted by such license agreement or changed, copied, photocopied, reproduced, translated, or reduced to any electronic medium or machine readable form without the prior consent of Emdeon. Copyright is held by Emdeon Business Services, LLC. Emdeon is not liable for any losses or damages that result from the use of this material, including loss of profit or indirect, special, or consequential damages.

3 Table of Contents Table of Contents Overview About the Transaction Customer Support Requests Transaction Types Subscriber Transactions Dependent Transactions Input Prompts Accident Country Accident Date Accident State Account # Amount Auto Accident Birth Date Cert # Diagnosis 2 through Diagnosis 12 (Svc / Proc Codes) Employ Related First Name Last Name Level of Service Member ID Other Party Resp Principal (Svc / Proc Codes) Req Prov Type Requestor ID Service Date Service Type Svc Prov ID Svc Prov Type Visits Responses About Your Responses Status Input Information Response or (On File) Information Health Care Service Review Review Detail Error Messages Values Service Types Index Emdeon Business Services LLC. All rights reserved. Page i

4 Overview Overview About the Transaction The BlueCross BlueShield of Massachusetts (BCBSMA) Referral Add and Referral Cancel transactions allow you to add, modify, or cancel a referral for a facility or for specialty care and to cancel the referral. Customer Support Emdeon Customer Support customer.service@emdeon.com 2013 Emdeon Business Services LLC. All rights reserved. Page 1

5 Requests Requests Transaction Types Subscriber Transactions Subscriber transactions allow you to add or cancel a referral for a BCBSMA managed care member and for a subscriber of an out-of-state BlueCross BlueShield (BCBS) managed care plan. Dependent Transactions Dependent transactions allow you to submit or cancel a referral when the patient is classified as a dependent. Out-of-state queries are available only for those plans that participate in the Blue Exchange network and that have real-time capability. Input Prompts Prompts are listed in alphabetical order. Accident Country Requirement: Situational; required if Auto Accident is Y. The country in which the accident occurred. Enter the country code or choose one from the drop-down list. Accident Date Requirement: Situational; required if Auto Accident is Y. The date on which the accident occurred, in MMDDCCYY format. Accident State Requirement: Situational; required if Auto Accident is Y. The state in which the accident occurred. Enter the state code or choose one from the drop-down list. Account # Requirement: Optional. The patient s account number. For your internal use only (not sent to the payer). Amount Requirement: Optional. The amount of the claim. For your internal use only (not sent to the payer) Emdeon Business Services LLC. All rights reserved. Page 2

6 Auto Accident Requirement: Situational. BlueCrossBlueShield of Massachusetts Referral Add Cancel Requests Enter Y if the referral is related to an automobile accident. Otherwise, leave blank. Choose a value from the drop-down list. Birth Date Requirement: For subscriber transactions, required for FEP members and nine-digit member IDs (nine digits following the three-character prefix), optional for eleven-digit member IDs. For dependent transactions, required for out-of-state members. The patient s date of birth, in MMDDCCYY format. Cert # Used in: All Referral Cancel transactions. The certification number assigned to the referral. Diagnosis 2 through Diagnosis 12 (Svc / Proc Codes) Requirement: Optional. Up to 11 additional ICD-9-CM or ICD-10-CM diagnosis codes relating to the referral. Employ Related Requirement: Situational. Whether the referral is employment-related. Choose a value from the drop-down list. First Name Requirement: Optional for BCBSMA members; required for out-of-state members. The patient s first name. Last Name Requirement: Optional for BCBSMA members; required for out-of-state members. The patient s last name. Level of Service Requirement: Required for out-of-state patients. The level of service provided Emdeon Business Services LLC. All rights reserved. Page 3

7 Member ID BlueCrossBlueShield of Massachusetts Referral Add Cancel Requests The patient s member ID (three-character prefix plus the nine- or eleven-digit number). For FEP members, do not enter the three-character prefix; enter R plus the eight-digit member number. Other Party Resp Requirement: Situational. Whether or not the referral is employment related. Choose a value from the drop-down list. Principal (Svc / Proc Codes) The patient s ICD-9-CM or ICD-10-CM principal or primary diagnosis code. Req Prov Type The provider type of the requesting provider (1P = Provider or FA = Facility). Choose a value from the drop-down list. Requestor ID The provider ID of the requesting provider. Service Date The proposed or actual date of service, in MMDDYY or MMDDCCYY format. Service Type The type of service rendered. Enter the code or choose one of the following: 1 = Medical Care 40 = Oral Surgery AD = Occupational Therapy AE = Physical Therapy AF = Speech Therapy See Service Types on page 10 for an explanation of abbreviations Emdeon Business Services LLC. All rights reserved. Page 4

8 Svc Prov ID The provider ID of the servicing provider. BlueCrossBlueShield of Massachusetts Referral Add Cancel Requests If the servicing provider has an NPI registered with BlueCross BlueShield of Massachusetts, you must enter the NPI. If you do not enter the NPI, you will receive the error message HT0834 Invalid Service Provider ID. Registration of the provider s NPI with BlueCross BlueShield of Massachusetts may be required prior to its use. Svc Prov Type The provider type of the servicing provider (FA = Facility; 1T = Physician, Clinic or group; or SJ = Provider). Choose a value from the drop-down list. Visits The number of visits required Emdeon Business Services LLC. All rights reserved. Page 5

9 Responses Responses About Your Responses All of the items described in the following response explanation may not appear in every response. The database will return only the information that is applicable to your query. If the database does not return a particular piece or section of information in a specific response, the headings for that information will not print. Items will shift position to fill the vacancy. Your username appears in the upper left corner of the response. See your product User s Guide for information about creating usernames. Additional Reference Documents More information about your response can be found in the following documents: PC-Standard-Health-Care-Service Review-Dictionary.pdf - gives a more detailed description of data fields returned in the standard Emdeon response. Dictionary-of-Transaction-Error-Messages.pdf a complete dictionary of error messages. Common Response Abbreviations.pdf common abbreviations used in the standard Emdeon response, along with their full description. These documents are available on your installation CD, and on the Web at: Note: The above documents are in Portable Document Format (.pdf). You must have the Adobe Acrobat Reader to view this document. If you do not have the Reader, you can download it for free at Status Closed Emdeon received a valid response. Read your response for clarification. Retry Emdeon did not receive a valid response. Read the message in the response for clarification. Error A communications-related error or error of greater severity occurred. Read the message in the response for clarification. Input Information The Input Information section (or the labeled fields in the Input/Response Information section) shows the information you entered in your inquiry. Response or (On File) Information No response data will appear in this section Emdeon Business Services LLC. All rights reserved. Page 6

10 Responses Health Care Service Review This section returns reference information for this particular transaction such as: The transaction reference number. The type of certification: Complete Term Expired Certified in Total Not Certified Pended Modified Cancelled Contact Payer No Action Required The provider ID of the requesting provider. The requesting provider s name. The requesting provider s specialty. If the requesting provider was rejected, this information describes the error condition associated with the rejection. Up to three possible reject reasons can appear. A follow-up message to the preceding reject reason. The subscriber ID of the subscriber. The subscriber s name and date of birth. The dependent s name and date of birth. Up to 12 diagnosis codes associated with the certification number, and their corresponding descriptions. If the patient was rejected, this information describes the error condition associated with the rejection. Up to three possible reject reasons can occur. A follow-up action message for the preceding reject reason. Up to three follow-up action messages can appear, one for each reject reason. Review Detail The Review Detail section contains details about the requested services, such as the servicing provider or facility, procedure codes, certification number and action. Can include the following: The type of service provider. The provider ID of the service provider. The service provider s name. The service provider s specialty. The service provider s phone number. A free-form message about the servicing provider or specialty. The type of facility that will render services to the patient; for example: Performing Ordering 2013 Emdeon Business Services LLC. All rights reserved. Page 7

11 Covering The facility ID. The facility s name. The taxonomy code and description designating the facility s specialty. The facility s telephone number. A free-form message about the facility. BlueCrossBlueShield of Massachusetts Referral Add Cancel Responses The type of group or practice that will render services to the patient; for example: Performing Ordering Covering The group practice ID. The name of the group practice. The group practice s telephone number. A free-form text message about the group or practice. If the service provider was rejected, this field describes the error associated with the rejection. Up to three possible reject reasons can appear. A follow-up action message for the preceding reject reason. Up to three follow-up action messages can appear, one for each reject reason. The review s certification number. The action code (Cert Action) for the requested procedure. If the procedure was rejected, the reason for the rejection. Up to 12 procedure codes associated with the certification number, and their associated descriptions. The authorized quantity of the corresponding procedure (1 through 12). The begin and end dates of the corresponding procedure. Any additional messages relating to the corresponding procedure. The service type code and description identifying the classification of service requested. See Service Types on page 10. The effective and termination date of the requested service. The pattern of delivery of the service. The place of service, i.e., type of facility, where the services will be/were performed. The proposed or actual admission date (Admission Review only). The type of ambulance transport; for example, Initial Trip Return Trip Transfer Trip Round Trip If the service was rejected, an error condition associated with the rejection. Up to three possible reject reasons can appear. A follow-up action message for the preceding reject reason. Up to three follow-up action messages can appear, one for each reject reason Emdeon Business Services LLC. All rights reserved. Page 8

12 Error Messages BlueCrossBlueShield of Massachusetts Referral Add Cancel Responses Transaction-related error messages begin with CL, HT, RH, or another alphabetic prefix, followed by a number and a line or so of text. For a comprehensive description of all error messages, see the document Dictionary of Transaction Error Messages. This document is available on your installation CD, and on the Web at: Emdeon Business Services LLC. All rights reserved. Page 9

13 Values Values Service Types Abbreviation Description Input Code Med Care Medical Care 1 Oral Surg Oral Surgery 40 OT Occupational Therapy AD Physical Medicine Physical Medicine (Therapy) AE Spch Thrpy Speech Therapy AF 2013 Emdeon Business Services LLC. All rights reserved. Page 10

14 Index Index A About the Transaction, 1 About Your Responses, 6 Accident Country, 2 Accident Date, 2 Accident State, 2 Account #, 2 Amount, 2 Auto Accident, 3 B Birth Date, 3 C Cert #, 3 Closed, 6 Customer Support, 1 D Dependent Transactions, 2 Diagnosis 2 through Diagnosis 12 (Svc / Proc Codes), 3 E Emdeon Customer Support, 1 Employ Related, 3 Error, 6 Error Messages, 9 R Req Prov Type, 4 Requestor ID, 4 Response or (On File) Information, 6 Retry, 6 Review Detail, 7 S Service Date, 4 Service Type, 4 Service Types, 10 Status, 6 Subscriber Transactions, 2 Svc Prov ID, 5 Svc Prov Type, 5 T Transaction Types, 2 V Visits, 5 F First Name, 3 H Health Care Service Review, 7 I Input Information, 6 Input Prompts, 2 L Last Name, 3 Level Of Service, 3 M Member ID, 4 O Other Party Resp, 4 P Principal (Svc / Proc Codes), Emdeon Business Services LLC. All rights reserved. Page 11

15 Emdeon is a leading provider of revenue and payment cycle management and clinical information exchange solutions, connecting payers, providers, and patients in the U.S. healthcare system. For more information, visit Emdeon Business Services LLC. All rights reserved Lebanon Pike, Suite 1000 Nashville, TN EMDEON.6 ( )