Eligibility Response

Sample Eligibility Response

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Patient Address

Payer Address

Aetna Eligibility

NOTICE: This information is classified as individually identifiable healthcare information and is intended strictly for the confidential use of the authorized requestor. Any unauthorized use or disclosure of this information is prohibited.

SEARCH CRITERIA
Provider ID:	1234567
Subscriber Social Security Number:	123456789
Subscriber Date of Birth:	01/19/1936
Eligibility Coverage Type:	General Benefits
Beginning Date of Service:	08/01/2004
Ending Date of Service:	08/01/2004

SUBSCRIBER
Name:	JONES, JANE J
Member ID Number:	123456789
Group Number:	031986123456789
Group Name:	ACME CO
Address:	111 SOMEWHERE LANE
	ANYTOWN, ST 55555
Date of Birth:	01/19/1936
Sex:	FEMALE
Relationship:	SELF
Plan Begin Date:	01/01/2004
Service Date:	08/01/2004 - 08/01/2004

Coverage Level	Service Type	Insurance Type
ACTIVE COVERAGE
Employee Only	General Benefits	Point of Service
Employee Only	Hospital - Outpatient
Employee Only	Diagnostic Medical
Employee Only	Professional (Physician) Visit - Office

PRIMARY CARE PROVIDER
Coverage Level:	Employee Only
Service Type:	General Benefits
Insurance Type:	Point of Service
Period Start:	01/01/2004
Primary Care Provider Name:	DOE, JOHN J M.D.
Telephone:	(555) 555-5555

PRIMARY CARE PROVIDER
Coverage Level:	Employee Only
Service Type:	General Benefits
Insurance Type:	Point of Service

IN-PLAN BENEFITS

Benefit	Coverage Level	Plan Coverage Description	Amount
HOSPITAL - OUTPATIENT
Co-Insurance	Employee Only	HOSPITAL COINSURANCE	85%
Co-Insurance	Employee Only	PLAN INCLUDES ADDL BEN DETAILS
Limitations	Employee Only	CALL FOR AUTHORIZATION

Benefit	Coverage Level	Plan Coverage Description	Amount
PROFESSIONAL (PHYSICIAN) VISIT - OFFICE
Co-Insurance	Employee Only	OFFICE VISIT COINSURANCE	100%
Co-Payment	Employee Only	OFFICE VISIT COPAY	$10.00

Benefit	Coverage Level	Amount
DIAGNOSTIC MEDICAL
Co-Insurance	Employee Only	100%

OUT-OF-PLAN BENEFITS

Benefit	Coverage Level	Amount
HOSPITAL - OUTPATIENT
Co-Insurance	Employee Only	60%

Benefit	Coverage Level	Amount
PROFESSIONAL (PHYSICIAN) VISIT - OFFICE
Co-Insurance	Employee Only	55%

Benefit	Coverage Level	Plan Coverage Description	Amount
DIAGNOSTIC MEDICAL
Co-Insurance	Employee Only	DIAGNOSTIC XRAY LAB EXPENSES	55%

ADDITIONAL INFORMATION

Benefit	Coverage Level
GENERAL BENEFITS
Benefit Description	Employee Only

Benefit	Coverage Level	Time Period	Amount
HOSPITAL - OUTPATIENT
Deductible	Individual		$200.00
Deductible	Individual	Remaining	$200.00
Benefit Description	Employee Only

Benefit	Coverage Level	Plan Coverage Description	Time Period	Amount
PROFESSIONAL (PHYSICIAN) VISIT - OFFICE
Deductible	Individual			$200.00
Deductible	Individual		Remain	$200.00
Limitations	Employee Only	COPAY WITH PCP REFERRAL ONLY
Benefit Description	Employee Only

Benefit	Coverage Level	Time Period	Amount
DIAGNOSTIC MEDICAL
Deductible	Individual		$200.00
Deductible	Individual	Remaining	$200.00
Benefit Description	Employee Only

OTHER SOURCE OF DATA
Facility Name:	Aetna
Facility Identification:	000000001
Address:	SOMEWHERE LANE
	PO Box 999
	ANYTOWN, ST 99999-9999

TransRef Number - 123456789

Passport Reference Number:

200301234567890


Transaction run on 08/01/2004 at 1:28:02 PM CT by John Doe - Passport Health Communications

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