Dates
Response Data
Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.
This analysis does not take into account the most recent changes this payer has made to their data content in preparation for 5010 processing.
This payer now provides the Member’s Address for HMO, Medi-Cal, and Medicare Advantage responses. This is a valuable enhancement from the previous 4010 response.
Response data is now provided for Urgent Care – UC.
In one test case, the response added an “Other Insurance” with the member’s name and coverage dates, but did not identify the payer.
In one test case, the response combined different place of services for specialist co-pay into a single benefit.
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)
This payer no longer sends Inactive benefits (EB01=6) for service types that are normally included in the 10 mandated service type codes, when they don’t have coverage. In other words, benefits for Dental Care – 35, Pharmacy – 88, and Vision – AL, or other service type codes may not be returned if inactive.
Independent Practice Association or Independent Physicians Association (IPA) is now designated as Services Restricted to the Following Provider (EB01=N). Previously in the 4010 response, this was not designated and was difficult to distinguish an IPA from the primary care provider (PCP).
Additional co-payment information is now provided for the Healthy Families program.
(Ambulatory Surgical, Emergency Room, Office Visit, Mental Health, and Urgent Care.