BlueExchange Referral and Authorization Submission Guide

Transcription

1 BlueExchange Referral and Authorization Submission Guide Effective November 8, 2013 Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield independent Page licensees 1 of 5 of the Blue Cross and Blue Shield Association.

2 The BlueExchange Referral/Auth Submission transaction lets you submit real-time referral and authorization requests for out-of-area members. Submitting a referral or authorization From the Plan Transactions menu, select BlueExchange (Out of Area), then select Referral/Auth Submission. The BlueExchange Ref/Auth Submission screen will appear. Follow these steps on the BlueExchange Ref/Auth Submission screen: Enter your search criteria (see next section of this guide for details). Click Search. Search Criteria Rules Fields that are required on the BlueExchange Ref/Auth Submission screen will vary depending on how you answer the following two questions: Is the patient the subscriber? Is the referred from/requesting provider the same as the referred to/servicing provider? Page 2 of 5

3 Is the patient the subscriber? Yes. If you answer yes, the following fields are required: patient ID patient date of birth patient last name patient first name No. If you answer no, the following fields are required: patient ID patient date of birth patient last name patient first name relationship to insured subscriber date of birth subscriber last name subscriber first name Is the referred from/requesting provider the same as the referred to/servicing provider? Yes. If you answer yes, the following fields are required: referred from/requesting billing provider referred from/requesting service provider service provider address No. If you answer no, the following fields are required: referred from/requesting group or facility referred from/requesting service provider service provider address referred to/billing provider number or referred to/service facility number The following table outlines the remaining required fields on the BlueExchange Ref/Auth Submission screen: Diagnosis Procedure Request Other Required fields Primary diagnosis code Procedure code 1 Request type Service type Place of service Office contact name Office contact phone number Service date Response screen The BlueExchange Ref/Auth Submission Response screen will appear. You will find important data on this screen, which may include the following: referral/authorization Page 3 of 5

4 patient subscriber referred from and requesting provider referred to and servicing provider service Note: Information provided in the BlueExchange Ref/Auth Submission Response screen is returned from the Home Plan. Fields shown in the example below may not all populate. Tips On the BlueExchange Ref/Auth Submission Detail Entry screen: If Ref/Auth Submission is not available, a message will appear indicating the reason. The providers you select on the Request screen are available throughout the Home Plan and are not restricted by product. In the Referred To/Servicing Provider Information section, use the Search links to search for a specialist or facility. To search for a diagnosis code, use the Search link next to any diagnosis code field. You can add up to 12 diagnosis codes by selecting the Add More link. Page 4 of 5

5 To search for a procedure code, use the Search link next to any procedure code field. You can add up to 12 procedure codes by selecting the Add More link. The Quantity field is required when a Quantity Type is selected. You can narrow down your search results by entering into any fields in addition to the required fields. The BlueExchange Ref/Auth Submission Response screen is populated with the data entered on the Request screen, as well as any status returned to NaviNet from the Home Plan in the real-time response. NaviNet is a registered trademark of NaviNet, Inc., an independent company. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. Page 5 of 5