It has been a couple of years since I was involved with ITS/Blue Card but I will give
you what I remember. If my mind wonders too far someone please correct me. The system
is more than a convince to providers. It was also designed to give one Blue plan the
benefit of other plan's rates when their subscribers traveled.
So if I am from California and see a doctor in Wisconsin. I give the doctor my Blue
membership card which has an ITS prefix appended to my subscriber number. This prefix
is different from the Plan code. The plan code is numeric and one is issued per plan.
The ITS prefix is a three byte alpha ID. There can be more than one ITS ID per plan
(i.e. HMO, PPO, etc...) For example, the plan code for Blue Shield of California is
542 and the ITS prefixes are XEA (PPO) and XEE (HMO) and there may be more.
The doctor submits the claim to BC/BS United of Wisconsin with my subscriber ID of
XEA123456789. Wisconsin takes the claim and sees that I am a Blue Shield of CA
member, based on the XEA prefix. Wisconsin then determines the local negotiated
payment rate and forwards the claim to Blue Shield of CA. Blue Shield then finishes
processing the claim. Then, here is were I am a little fuzzy, I can't remember if
Blue Shield then cuts a check/denial or sends its decision to Wisconsin where the
check/denial is created. Anyway, you get the idea. This is more than a clearinghouse
arrangement. The participating Blue plans are acting as pre-pricers for each other.
I am not sure how this helps us with the rest of the payers but, hopefully, it makes
the Blue's approach clearer.
Robert Barclay
EDS - Wisconsin Medicaid HIPAA Team
[EMAIL PROTECTED]
(608) 221-4746 x3323
>>> "William J. Kammerer" <[EMAIL PROTECTED]> 04/30/02 10:43AM >>>
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
