Introducing enriched BCBS eligibility responses

Stedi now enriches most Blue Cross Blue Shield (BCBS) eligibility responses with the member’s home payer name and primary payer ID. 

BCBS is a collection of 33 entities that operate independently. BlueCard is BCBS’s national program that enables members of one BCBS plan to obtain healthcare service benefits while traveling or living in another BCBS plan’s service area.

Each BCBS plan has access to the BlueCard eligibility network, which means that a provider operating in one state can check eligibility for any nationwide BCBS member using the provider’s local BCBS plan payer ID, as long as the eligibility check includes the member’s first name, last name, birthdate, and full member ID (including the 3-character BCBS alpha prefix).

For example, a provider in Texas might send an eligibility check to “Blue Cross Blue Shield of Texas” for a member whose coverage is actually with “Blue Cross Blue Shield of Alabama.” BCBS of Texas will return a successful response as long as all of the member’s details were correct. 

The problem is that the returned eligibility response doesn’t say which BCBS payer is the patient’s home payer. It just lists the payer to whom the request was sent. In the example above, the eligibility response would have no indication that the member belonged to BCBS of Alabama. 

The reason that BCBS doesn’t include this information is that it’s irrelevant for most traditional care scenarios, since the BlueCard program instructs providers to always submit claims to their local payer – not the member’s home plan. However, for multi-state providers or telehealth scenarios, the rules can differ, and it becomes important for the provider to identify the actual home plan.

To simplify this process, Stedi has developed logic to automatically detect and include the home payer’s name and ID in the eligibility response whenever possible.

When detected, this info now appears in a related benefitsInformation.benefitsRelatedEntities entry in our JSON eligibility responses and in a 2120C or 2120D loop in X12 responses.

No action is needed to take advantage of this new functionality. This enhancement is already live for all related Real-Time Eligibility Check API endpoints.

How the data is included

If you’re using our JSON eligibility API, the home payer’s details appear as a benefitsInformation.benefitsRelatedEntities entry in the response. It’s included in the same benefitsInformation entry that includes the patient’s coverage status.

{
  ...
  "benefitsInformation": [
    {
      "code": "1",
      "serviceTypeCodes": ["30"],
      ...
      "benefitsRelatedEntities": [
        {
          "entityIdentifier": "Party Performing Verification",
          "entityType": "Non-Person Entity",
          "entityName": "Blue Cross Blue Shield of Alabama",
          "entityIdentification": "PI",
          "entityIdentificationValue": "00510BC"
        }
      ]
    },
    ...
  ],
  ...
}

In X12 eligibility responses, the home payer’s information is included in Loop 2120C or 2120D.

LS*2120~
NM1*VER*2*Blue Cross Blue Shield of Alabama*****PI*00510BC~
LE*2120

Try it out

You can see home payer enrichment in action by running a real-time eligibility check for any BCBS member for whom you have the first name, last name, birthdate, and member ID.

If you don’t have production access, request a free trial. Most teams are up and running in less than a day.