American Postal Workers Union (Commercial) - Quick Reference, What You Need to Know...
Search Options
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Previously, this payer supported four search options. Now, this payer
supports three search options.
1. Subscriber ID, Patient
Date of Birth, and Relationship to Subscriber.
2. Subscriber ID, Patient Last Name, Patient First Name, and
Relationship to Subscriber.
3. Patient Last Name, Patient First Name, Patient Date of Birth, and
Relationship to Subscriber.
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This payer does not promote dependent data. For this reason, it is
necessary for a transaction
to use either a subscriber or dependent loop, depending on the specified
value of the relationship code
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Previously, this payer used the Provider’s Tax ID for an inquiry. Now,
the Provider NPIs are used.
Dates
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Previously, this payer used a current date
by default, Now, both begin and end dates are used for an inquiry.
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This payer supports dates up to two years
in the past and up to a 90-day date span.
No future dates are allowed. Previously, past dates back to 1950 were
allowed.
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Inquiry dates now reference a Plan Date –
291 (DTP01).
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The 5010 response returns a Plan Begin
Date – 346 (DTP01) in Subscriber and Dependent loops (2100C/D).
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The 5010 response returns a Date of Last
Update – 636 (DTP01) in Subscriber and Dependent loops (2100C/D).
For this date qualifier, the DTP03 value appears as the inquiry date.
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The 5010 response returns a Benefit Begin
Date – 348 (DTP01) in Subscriber and Dependent loops (2110C/D).
For this date qualifier, the DTP03 value appears to be the date when the
Member’s plan was created.
For example, the plan “APWU-HO - HI OPTION” appears to uses a specific
DTP03 value equal to 19650101.
For the plan “APWU-CDP – CDHP,” the response appears to set the DTP03
value to 20020101.
Response Data
Benefits
The following information is based on a
generic “Health Benefit Plan Coverage - 30” inquiry.
This payer also supports service types 1, 30, 33, 35, 48, 50, 86, 88,
98, AL, MH, and UC.
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The response now returns the Plan Name in both the Subscriber and
Dependent loops.
The Plan Name is returned in both reference and eligibility benefit
segments.
(2100C/D REF01=18, REF03=“Plan Name”) and (2100C/D EB05=“Plan Name”)
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The response now returns the Group Number in both the Subscriber and
Dependent loops.
The Group Number is returned in a reference segment. (2100C/D
REF01=6P, REF02=“Group Number”)
Previously, this was returned in the 2110C/D loop instead.
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The 5010 response now uses service type codes for Physician Office
Visit Sick – BY,
Physician Office Visit Well – BZ, Mental Health – MH, and Urgent
Care – UC.
Disclaimer
This document is not intended to identify every scenario that may be
presented in the payer response.
It should
also be noted, that the payer response may vary depending on the search
criteria used in the initial inquiry.
Some content
is no longer returned in the X12 5010 271 response. In a similar fashion,
some content has been
modified and
new response information may be returned. Information that appeared
consistent between the
4010 and 5010
responses was not presented in this document.