X12 270 5010 CG

Aetna (Commercial) - Quick Reference, What You Need to Know...

Search Options

No differences in search options or search criteria.
However, patients with unique identification numbers should be entered as a subscriber. For example, a child or spouse having a unique identification number should be entered as a subscriber. In other words, a family member is considered a subscriber when each family member has been issued a unique identification.

Dates

Eligibility Dates are not returned. Instead, a Plan Begin Date and/or an Eligibility Begin Date are used.
Service dates are not returned in a date range. Instead only a single date is provided.
Previously, a search could be performed up to 27 months in the past with no future dates.
Now, dates may be up to one year in the past and may use up to a 90-day date span. Future dates are not allowed.

Response Data

Benefits
The following service types are not returned for a “Health Benefit Plan Coverage - 30” inquiry.

Hospital In-Patient – 48

Hospital Out-Patient – 50

Diagnostic Medical – 73

Any additional service type codes in the original transaction may not be considered for processing.

Some response changes include the removal of many text messages that were previously sent in the response.

An error message may be returned when the search results in multiple members being identified.

Information on the response is now grouped by financial detail rather than a specific type of service.

The response now includes information for both active and inactive plan coverage for which a member is enrolled. This may include plans related to a specific service type inquiry, unless that information is not found.

Enhanced service type grouping allows an inquiry for groups of services related to:

Health Benefit Plan Coverage - 30

Dental Care – 35

Hospital – 47

Additional response information may be provided for Medical, Chiropractic, Dental Care, Hospital, Emergency Services, Pharmacy, Professional Physician Office Visit, Vision Optometry, Mental Health, and Urgent Care.

Demographics

The Plan Number, Group Number, and Plan Network ID for an HMO Subscriber may not be returned.
The Relationship Code and Insured Indicator may not be returned.

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.