1. Subscriber ID, Patient Last Name, Patient First Name, Patient Date of Birth, Patient Sex,
Group Number, and Relationship to Subscriber.
2. Provider, Date, Patient Social Security Number, Patient Last Name, Patient First Name,
Patient Date of Birth, Patient Sex, Group Number, and Relationship to Subscriber.
Response Data
Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.
This payer has stopped using service type codes for Emergency Services (86),
Psychiatric Inpatient (A7), and Psychiatric Outpatient (A8).
New services type codes used include Physician Visit - Office Sick (BY),
Physician Visit - Office Well (BY), and Urgent Care (UC).
A new feature is provided by sending the Group Name in the 5010 response.
The response added PCP co-payment and co-insurance amounts.
Hospital employee special rates are now included in the 5010 response.
The employer is listed as the payer on each service.
The utilization management company is now included in the response.
However, all test responses show that BCBS of Tennessee is the utilization company,
so this is not particularly helpful.
This payer use to send the minimum age on some co-payments and co-insurance.
These have been removed on the 5010 response. The payer is sending only the
co-payments and co-insurance that apply to the patient instead of the provider
having to determine which age range a patient is categorized.
Extensively, this payer uses a “W” code for both In Plan and Out of Plan Network.
In other words, benefit information is returned when benefits are the same for both
an In Plan and Out of Plan Network, or when a plan network does not apply,
regardless of the designation. (EB12=W)