1. Subscriber ID, Patient Last Name, Patient First Name, Patient Date of Birth, and Relationship to Subscriber.
2. Patient Last Name, Patient First Name, Patient Date of Birth, and Relationship to Subscriber.
Dates
Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.
- This test case indicates that dental only shows up as eligible.
Dental only coverage still includes the active coverage benefit information (EB*1**30) as well as
active coverage dental (EB*1**35) however, no other eligibility benefit information is sent.
- On the response, dependents are promoted to subscribers.
Since the subscriber loop only allows an INS02 value of 18 – Self, there is no way to distinguish a
dependent other than the use of a suffix on the Member ID.
- The Group Name has been removed. The Group Number still exists, but the name is no longer returned.
- The Patient’s Gender is now being returned in the 5010 response.
- When the Member ID is entered without the 2-digit suffix, the response will contain a reference segment
with the requested Member ID (REF*Q4).
- The 5010 response now uses the new service types for Mental Health – MH and Urgent Care – UC.
- The response does not use the repeat character in the service type.
- Year-to-date amounts for deductibles and out-of-pocket have been removed. The response still provides
the remaining deductible and out-of-pocket values, so the year-to-date amounts were redundant.
- Non-covered services such as Dental and Vision are not sent anymore with non-covered benefit information (EB*I).
Previously, members with no out-of-network coverage would get non-covered benefit information (EB*I) for
each out-of-network service. Now in 5010, there is only the implied state that no out-of-network benefits exists
when there are no eligibility benefits (EBs) for out-of-network presented in the response.
- PCP and other payers are now designated using the service type for Medical Coverage – 1.
Previously, the 4010 version did not provide a service type.
- Some members now have robust benefits in the response.
Previously, the 4010 response only provided active coverage.
- On some test cases, the response indicates when the provider is an in-network provider.
For example, a message segment (MSG) is attached to the active coverage benefit information
(EB*1**30) that reads “Member is in network based on NPI ID provided in request.”
In this example, both in-network and out-of-network benefits are returned.
- Great-West responses and other administrative responses may have a dependent loop.
In other words, most of the time a dependent is returned in the subscriber loop but not all of the time.
This seems to occur about 5% of the time using a small sample of test cases.