Dates
Response Data
Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.
The 4010 response had Professional Physician Office Visit (98), Psychiatric-Inpatient (A7), and
Psychiatric-Outpatient (A8) co-payment and co-insurance for Medicare Advantage members and POS members.
However, this information is not showing up in the 5010 response. The Professional Physician Office Visit (98) may
be replaced by the use of a Physician Visit Office Sick (BY) and Physician Visit Office Well (BZ).
Medicare Advantage limitations for days and visits on Professional Physician Office Visit (98) and
Psychiatric-Inpatient (A7) are not presented in 5010 response.
The PCP name may not be separated into the first and last name fields. In other words, the first name may be
combined in the last name field.
IPA names are now sent as a contracted service provider (NM101=13).
This is an improvement, as it was previously designated as an Other Provider (73) in the 4010 response.
Sparingly, Blue Shield of California uses a “W” designation for In Plan and Out of Plan Networks (EB12=W).
In other words, benefit information may be 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.
The group name has been added for some lines of business like POS and PPO.
Response data is now provided for Chiropractic (33), Physician Visit Office Sick (BY),
Physician Visit Office Well (BZ), and Urgent Care (UC).
Utilization management contact has been added for specific service types. For example, Hospital (48) may now include
a contact name for utilization management (NM101=X3) including the telephone and fax number (in a PER Segment).
The plan name is now showing up for active coverage under health benefit plan coverage (EB*1**30 segment).
Previously, the plan name was not returned.
In one test case, the search criteria used resulted in a time out. This issue is currently being reviewed, but likely
that the payer was not responding.