A correspondent has confirmed that the most powerful ID for identifying
BC/BS entities is the Plan Code. He said it was used in several
inter-plan claims exchange systems and is universally used by all Blue
plans on membership cards. Which is true enough, considering my own
Anthem card shows plan codes of 332/834 (Institutional vs. Professional)
on the front.
Now it seems reasonable that my doctor ("shorthand" for saying his
staff, software, billing agent or Clearinghouse - let's not get pedantic
here) could take the "834" and look up Anthem's electronic Partner
Profile (CPP) in the Healthcare Registry to see where to send claims or
eligibility inquiries.
Obviously, "834" by itself doesn't mean much - it has to be qualified by
some code to say that it is a Blue Cross Blue Shield Association Plan
Code (in both the CPP and the Registry search key). The first place to
look for such qualifiers would be the X12 ISA Interchange ID Qualifier -
even though the BC/BS Plan Code is obviously not a HIPAA compliant ISA
receiver ID. Such an animal doesn't appear there, but D.E. 66 -
Identification Code Qualifier - used in the NM1 does have code value AD
meaning "Blue Cross Blue Shield Association Plan Code."
So the Registry search key could be shown (stylized) as something like
66:AD:834 (meaning D.E. 66 code value AD qualifies value 834) which
could be used to locate Anthem's CPP (assuming Anthem placed a list of
all their associated plan codes in their CPP: 160 and 660 for Kentucky,
130 and 630 for Indiana, and 332 and 834 for Ohio). There's no reason
the Healthcare CPP parts which specify Delivery Channels could not
account for all plans using the same or different EDI portals, depending
on Anthem's preferences. I'll leave the details for defining this stuff
in the CPP to the volunteers who are authoring the "Elements of the
Healthcare CPP" working paper (Marcelee Jackson, Dave Minch, Dick Brooks
and Chris Feahr).
Other persons familiar with BC/BS have mentioned in the past some
mumbo-jumbo about how claims are submitted to the BC/BS home office
where the provider is located, which in turn forwards the claims to the
BC/BS of the patient. Was that done merely as a convenience to
providers? And would it still be advantageous now that EDI portals of
the particular patient's BC/BS could easily be located for direct
submission?
William J. Kammerer
Novannet, LLC.
+1 (614) 487-0320
