1. Subscriber ID, Patient Last Name, Patient First Name, Patient Date of Birth, and Relationship to Subscriber.
Dates
Response Data
Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.
By default, a generic “Health Benefit Plan Coverage - 30” is used for the inquiry.
This payer supports all service type codes.
The most noticeable change in the 5010 response is the use of message (MSG) segments to return
Information Related to Pay Maximum, Amount Remaining, Visits, and Limitations.
The patient’s address is being returned in the 5010 response.
The patient’s group number is being returned in the 5010 response.
The 5010 response now uses service type codes for Physician Office Visit Sick – BY,
Physician Office Visit Well – BZ, Urgent Care – UC, and Mental Health – MH.
The 5010 response now returns multiple service type codes in the eligibility benefit loop (EB03).
This payer has stopped using the “U” designation for In Plan and Out of Plan Network (EB12=U).
Now, they extensively use a “W” for both In Plan and Out of Plan Network (EB12=W). In other words,
use of In/Out of Network indicator value of “W” is used to combine In and Out of Network EB segments,
thus replacing the pervious value when a “U” or “Null” was used in 4010.
Co-Payment Maximum, Amount Remaining, Visits, and Limitations for specific service types are being
returned in the message (MSG) segments.