Anthem West CO, NV (Commercial) - Quick Reference, What You Need to Know...
Search Options
-
No changes in search options or search criteria. However, the optional
field for Patient Sex was removed.
-
For an inquiry, a prefix should be included with the Subscriber ID.
-
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.
Dates
-
Only the current date of service is used
for an inquiry.
Previously, this payer supported up to one year in the past, one year in
the future, and date spans up to 18 months.
-
Dates now reference a Plan Date - 291
(DTP01) and are returned in a range format.
Date references for Eligibility – 307, are not returned.
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 for HMO and Medicare
responses.
(This is a valuable enhancement from the previous 4010 response).
-
In
some cases, changed medical group from primary care provider
(EB01=L) to services restricted to the indicated provider. (EB01=N).
-
Response data is now provided for Chiropractic – 33, Emergency
Services- 86, Mental Health – MH, and Urgent Care – UC.
-
Minimally, benefit information is returned when the benefits are the
same for both an In Plan and Out of Plan Network, or when a Plan
Network benefit does not apply. This may occur regardless of the In
Plan or Out of Plan Network designation. (EB12=W)
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.