1. Provider, Date, Subscriber ID, Patient Last Name, Patient First Name, Patient Date of Birth, and Relationship to Subscriber.
2. Provider, Date, Subscriber ID, Patient Last Name, Patient First Name, and Relationship to Subscriber.
3. Provider, Date, Subscriber ID, Patient Date of Birth, and Relationship to Subscriber.
4. Provider, Date, Patient Last Name, Patient First Name, Patient Date of Birth, and Relationship to Subscriber.
Blue Exchange transactions still return the dependents from other home plans as expected.
The patients address for subscribers and dependents is provided in the 5010 response.
Response Data
Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.
Group numbers have been trimmed and the last 4 characters are not being returned. Cursory examination shows that the trimmed data was 0000 or 0001.
The plan name has been moved from a REF segment and placed in an EB segment as a plan description.
For some plans, such as Medicare Supplement, Co-payment and Co-insurance is now provided.
Response data for Psychiatric - A4, Psychiatric Inpatient - A7, and Psychiatric Outpatient - A8 is not returned.
Additional information is provided for Chiropractic - 33, Emergency Services - 86, Physicians Visit Office Sick - BY, Physicians Visit Office Well - BZ, Mental Health – MH, and Urgent Care – UC.
More response messages (MSG Segments) are provided with “Facility Benefit” and “Professional Benefit.”
The 5010 response uses structured naming for the Pharmacy, Vision, and Mental Health payers, which includes contact information. Previously, this was provided in the message segments (MSG) of the 4010 response.
This payer response uses an EB segment to convey information about utilization management contacts. Specifically, in regards to Managed Care Coordinators (MC). However, this use of Managed Care Coordinators is not consistent with other payers.
This payer has removed a confusing deductible remaining for hospital admissions. Now, the response provides one deductible amount per admission.
Some inconsistencies exists between the 4010 and the 5010 response for individual co-payments and co-insurance.
The Primary Care Provider (PCP) may be attached to multiple service types and to each of the co-payment and co-insurance for those service types. This may complicate text rendering.