That "mumbo-jumbo" is a fairly accurate, albeit abbreviated description of the process. :-)
The Local Plan, where the provider is located, accepts a transaction and contacts the Plan where the member is from to determine if the person is eligible for coverage, whether the coverage includes the service provided, and what copays or coinsurance should be applied. Upon receiving this response, the Local Plan processes the claim and responds to the provider. The choice for the provider is whether they want to connect to one local Plan or 50 some odd Plans all around the country. As for using the Blue Plan identifier, not all Plans want to use that identifier on the standard transactions. The ones I am familiar with are using the NAIC code. Furthermore, with HHS slated to issue a Payer ID regulation, I think you will find it difficult to influence Plans to change their processes prior to the HHS regulation being issued. Ken Fody Independence Blue Cross -----Original Message----- From: William J. Kammerer [mailto:[EMAIL PROTECTED]] Sent: Tuesday, April 30, 2002 11:44 AM To: 'WEDi/SNIP ID & Routing' Subject: Searching on Blue Cross Blue Shield Association Plan Code 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 CONFIDENTIALITY NOTICE: This E-Mail is intended only for the use of the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If you have received this communication in error, please do not distribute and delete the original message. Please notify the sender by E-Mail at the address shown. Thank you for your compliance.
