BlueCross BlueShield of New York (Empire) Specialty Care Review, Subscriber and Dependent v1.1 12.16.2013
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Table of Contents Table of Contents Overview --------------------------------------------------------------------------------------------------------------- 1 About the Transaction -------------------------------------------------------------------------------------------- 1 Customer Support ------------------------------------------------------------------------------------------------- 1 Requests --------------------------------------------------------------------------------------------------------------- 2 Request Data ------------------------------------------------------------------------------------------------------ 2 Input Prompts ----------------------------------------------------------------------------------------------------- 2 Account # ----------------------------------------------------------------------------------------------------- 2 Amount -------------------------------------------------------------------------------------------------------- 2 Date of Birth -------------------------------------------------------------------------------------------------- 2 Days ----------------------------------------------------------------------------------------------------------- 3 First Name ---------------------------------------------------------------------------------------------------- 3 Last Name ----------------------------------------------------------------------------------------------------- 3 Principal Diag ------------------------------------------------------------------------------------------------- 3 Rel of Info ----------------------------------------------------------------------------------------------------- 3 Requestor ID -------------------------------------------------------------------------------------------------- 3 Subscriber ID ------------------------------------------------------------------------------------------------- 3 Svc Date Begin ------------------------------------------------------------------------------------------------ 3 Svc Prov ID --------------------------------------------------------------------------------------------------- 3 Svc Prov Type ------------------------------------------------------------------------------------------------- 3 Visits ----------------------------------------------------------------------------------------------------------- 4 Responses -------------------------------------------------------------------------------------------------------------- 5 About Your Responses -------------------------------------------------------------------------------------------- 5 Status --------------------------------------------------------------------------------------------------------- 5 Input Information --------------------------------------------------------------------------------------------- 5 Health Care Service Review ---------------------------------------------------------------------------------- 5 Review Detail ------------------------------------------------------------------------------------------------- 6 Error Messages ---------------------------------------------------------------------------------------------------- 7 Index ------------------------------------------------------------------------------------------------------------------- 8 2013 Emdeon Business Services LLC. All rights reserved. Page i
Overview Overview About the Transaction The BlueCross BlueShield of New York (Empire) subscriber and dependent Specialty Care Review transaction allows you add a Specialty Care review. Specialty Care Review transactions allow you to request approval to refer a patient to another provider, generally a specialist. Note: If you are using Emdeon MAX shell versions prior to 2.3 or Server versions prior to 4.11, you must run this transaction using dialup. Customer Support Emdeon Customer Support 800.333.0263 customer.service@emdeon.com 2013 Emdeon Business Services LLC. All rights reserved. Page 1
Requests Requests Request Data The following list shows the information for which you are prompted in a typical subscriber or dependent Specialty Care Review transaction. See Input Prompts on page 2 for specific requirements. Requesting Provider Information Provider ID Service Provider Information Provider type Provider ID Patient Information Subscriber ID Last name First name Date of birth Service-Related Information Service begin date Number of days Number of visits Administrative Information Principal diagnosis Release of information Input Prompts Prompts are listed in alphabetical order. 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). Date of Birth Requirement: Required for dependent transactions; optional for subscriber transactions. The patient s date of birth, in MMDDCCYY format. 2013 Emdeon Business Services LLC. All rights reserved. Page 2
Requests Days The number of days for the service request. First Name Requirement: Required for dependent transactions; optional for subscriber transactions. The patient s first name. Last Name Requirement: Required for dependent transactions; optional for subscriber transactions. The patient s last name. Principal Diag The ICD-9-CM or ICD-10-CM principal diagnosis code or the reason that the patient was admitted. Rel of Info Indicates whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. Choose a value from the drop-down list. Requestor ID The provider ID of the requesting provider. Subscriber ID The BlueCross BlueShield of New York (Empire) subscriber ID of the plan subscriber. Svc Date Begin The proposed or actual beginning date of service, in MMDDYY or MMDDCCYY format. Svc Prov ID The service provider s ID. Enter the type of ID identified in the Srv Prov Type field. Consult the payer to determine whether you should submit the service provider s NPI at this time. Svc Prov Type The type of service provider ID used in this transaction. Choose a value from the drop-down list. 2013 Emdeon Business Services LLC. All rights reserved. Page 3
Requests Visits The number visits for the service request. 2013 Emdeon Business Services LLC. All rights reserved. Page 4
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: www.emdeon.com/resourcelibrary/#84 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 www.adobe.com. 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 shows the information you entered in your inquiry. Health Care Service Review This section returns reference information for this particular transaction; such as: The transaction reference number. The type (status) of certification: Complete 2013 Emdeon Business Services LLC. All rights reserved. Page 5
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. BlueCross BlueShield of New York (Empire) Specialty Care Review Responses 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 Covering The facility ID. The facility s name. The taxonomy code and description designating the facility s specialty. The facility s phone number. A free-form message about the facility. 2013 Emdeon Business Services LLC. All rights reserved. Page 6
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. 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 date of the corresponding procedure. Any additional messages relating to the corresponding procedure. The service type code and description identifying the classification of service requested. 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. Error Messages Transaction-related error messages begin with CL, HT, RH, or another alphabetic prefix, followed by a number and a line or so of text. Messages are self-explanatory. 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: www.emdeon.com/resourcelibrary/#84 2013 Emdeon Business Services LLC. All rights reserved. Page 7
Index Index A About the Transaction, 1 About Your Responses, 5 Account #, 2 Amount, 2 C Closed, 5 Customer Support, 1 D Date of Birth, 2 Days, 3 E Emdeon Customer Support, 1 Error, 5 Error Messages, 7 F First Name, 3 H Health Care Service Review, 5 I Input Information, 5 Input Prompts, 2 L Last Name, 3 P Principal Diag, 3 R Rel of Info, 3 Request Data, 2 Requestor ID, 3 Retry, 5 Review Detail, 6 S Status, 5 Subscriber ID, 3 Svc Date Begin, 3 Svc Prov ID, 3 Svc Prov Type, 3 V Visits, 4 2013 Emdeon Business Services LLC. All rights reserved. Page 8
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 www.emdeon.com. 2013 Emdeon Business Services LLC. All rights reserved. 3055 Lebanon Pike, Suite 1000 Nashville, TN 37214-2230 877.EMDEON.6 (877.363.3666) www.emdeon.com