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.
The members address is now provided in most 5010 responses.
Response Data
Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.
This payer now provides the Member’s Address on most responses.
(This is a valuable enhancement from the previous 4010 response).For Inactive Benefits, the service type for Dental Care – 35, is no longer used.
This payer follows the convention that if a generic “Health Benefit Plan Coverage - 30” inquiry is made,
(the omission of one of the ten generic coverage types) it means that a benefit is not part of the member’s coverage.This payer has changed the coding for HMO Medical Group. Previously, it was specified as a Primary Care Provider. Now, coding for HMO Medical Group specifies that the Services Restricted to Following Providers.
In other words, only a Primary Care Physician (PCP) is specified as a PCP, not an HMO Medical Group.In one test case, the Individual Deductible Remaining – 29 for Indemnity Coverage was not returned.
The Insurance Type for Other – OT, may not be returned for Medicare Advantage.
The new response only provides the Relationship Code. Previously, Student and Handicap indicators were also used.
“Urgent Care” is now converted from text and designated by a proper "UC" code.