Eligibility and Benefits Inquiry & Claims Status Inquiry

Transcription

1 BlueExchange Guide Eligibility and Benefits Inquiry & Claims Status Inquiry Independence Blue Cross offers products directly, through Page its 1 subsidiaries of 8 Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield independent licensees of the Blue Cross and Blue Shield Association.

2 Eligibility and Benefits Inquiry The BlueExchange Eligibility and Benefits Inquiry transaction allows users to access up-to-date eligibility and benefits information for BlueCard out-of-area members. Note: If you are searching for benefits information for Independence Blue Cross (IBC) members, please use the Eligibility and Benefits Inquiry option from the Plan Transactions menu. To access the transaction, select BlueExchange (Out-of-Area) from the Plan Transactions menu, and then select Eligibility and Benefits Inquiry. The search screen appears: Steps to inquire about BlueExchange Eligibility and Benefits information for out-of-area members: 1. Enter your search criteria (see search criteria rules on page 4 for details). 2. Select Search. You will see one of the following: If one search result is returned: You will see the BlueExchange Eligibility and Benefits Details screen. If more than one search result is returned: You will see the BlueExchange Search Results screen. If eligibility details are unavailable: A message explaining why no details are available will appear. If applicable, retry your search using different search criteria (see search criteria rules on page 4 for details). Page 2 of 8

3 On the BlueExchange Eligibility and Benefits Search Results screen: If multiple members are displayed, click anywhere in the appropriate row in the results table to view the BlueExchange Eligibility and Benefits Details screen for that member. If you do not see the result you were searching for, select the Show Search Criteria link, edit your search criteria, and select Search (see search criteria rules on page 4 for details). On the BlueExchange Benefit Details screen, read the top portion of the screen for important information regarding this member's benefits, such as: member information subscriber information primary care provider other coverage service type Page 3 of 8

4 Search criteria rules NaviNet offers different search options for conducting a BlueExchange Eligibility and Benefits Inquiry. The following table shows the required fields based on search type: Search type Subscriber ID/ Date of Birth Subscriber ID/Name Required fields Subscriber ID Subscriber Date of Birth Selected Service Types Date of Service Subscriber ID Subscriber Last Name Subscriber First Name Selected Service Types Date of Service Tips: The three-character alpha prefix on the member ID card determines which Blues plan will receive the request. To search for Federal Employee Program (FEP) member information, enter the member ID number, including the preceding "R" in the Member ID field. For example, R If the alpha prefix identifies an IBC member, NaviNet will send an alert that directs you to use the Eligibility and Benefits Inquiry option from the Plan Transactions menu. The date of service defaults as today s date. The date of service can be up to two years in the past or up to six months in the future. This field must contain a date formatted as mm/dd/yyyy. You can still call the toll-free BlueCard Eligibility number BLUE (2583) with questions about out-of-area BlueCard members eligibility and benefits. Page 4 of 8

5 Claims Status Inquiry The BlueExchange Claim Status Inquiry transaction allows users to retrieve claims status information for BlueCard out-of-area members. To access the transaction, select BlueExchange (Out-of-Area) from the Plan Transactions menu, and then select Claim Status Inquiry. The search screen appears: Steps to inquire about claims status for out-of-area members: 1. Enter your search criteria (see search criteria rules on page 7 for details). 2. Select Search. You will see one of the following: If one search result is returned: You will see the BlueExchange Claim Status Details screen. If more than one search result is returned: You will see the BlueExchange Search Results screen. If claim details are unavailable: A message explaining why no details are available will appear. If applicable, retry your search using different search criteria (see search criteria rules on page 7 for details). Page 5 of 8

6 On the BlueExchange Claim Status Search Results screen: If you see the claim you are searching for, click the row in the results table to view the claim details screen. If you do not see the claim you were searching for, select the Show Search Criteria link, edit your search criteria, and select Search. On the BlueExchange Claim Status Details screen, view the screen for important information regarding this claim such as: patient information subscriber information provider information claim information definitions Page 6 of 8

7 Search Criteria Rules The required fields on the BlueExchange Claim Status Inquiry screen change depending on the "Patient Is" option that is selected: Patient Is Subscriber Dependent Required fields Billing Provider Subscriber ID Subscriber Last Name Subscriber Date of Birth Service Start Date Service End Date Billing Provider Subscriber ID Subscriber Last Name Dependent Last Name Dependent Date of Birth Service Start Date Service End Date Tips: On the BlueExchange Claim Status Inquiry Search screen: Subscriber IDs require the alpha prefix. If the alpha prefix identifies a local member, NaviNet will send an alert that directs you to use the Claim Status Inquiry option from the Plan Transactions menu. The Service Start Date defaults as three months prior to today's date. The Service End Date defaults to the current date. If inquiring on a facility claim, enter the Institutional Bill Type for a more successful search. If claim status details are not available, a message will appear indicating the reason. If the search criteria provide one result, you are taken directly to the BlueExchange Claim Status Details screen. If the search criteria provide more than one result, you are taken to the BlueExchange Search Results screen. On the BlueExchange Claim Status Inquiry Search Results screen: This screen displays up to 50 results. If more results are available, a message appears indicating that the maximum number of claims has been returned for the inquiry and that there may be additional claims that meet the criteria. Click on a patient in the search results table to select that claim and view the claim details. Page 7 of 8

8 If you do not see the claim you are searching for, use the Show Search Criteria link to narrow your search criteria and try again. 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 8 of 8