Coventry-Plans

Coventry Health Care Plans (Commercial and Medicaid) - Quick Reference, What You Need to Know...
The old payer resource names for Coventry Health Care Plans will remain in 5010, until which time the 4010
version is retired. Once the 4010 version is retired, the official payer names will be changed accordingly.

Search Options

Previously, these payers used several search options.
Now, as listed below, this payer supports three search options for Commercial inquiries, and four
search options for Medicaid inquiries. The Recipient ID search is used for Medicaid inquiries only.
For successful transaction processing, dependent data may be promoted to the subscriber loop.

For Commercial Inquiries:
1. Provider, Beginning and Ending Dates, and Subscriber ID.
2. Not Used for Commercial Inquires.
3. Provider, Beginning and Ending Dates, Social Security Number, and Date of Birth.
4. Provider, Beginning and Ending Dates, Last Name, First Name, and Group Number.

For Medicaid Inquiries:
1. Provider, Beginning and Ending Dates, and Subscriber ID.
2. Provider, Beginning and Ending Dates, and Recipient ID.
3. Provider, Beginning and Ending Dates, Social Security Number, and Date of Birth.
4. Provider, Beginning and Ending Dates, Last Name, First Name, and Group Number.

Dates

Basically, no changes in date rules. The inquiry uses a begin date and an optional end date.
Dates now reference a Plan Date – 291 (DTP01) in a range format.
Date references for Eligibility – 307 are not returned.

Response Data

Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.

As expected, the 5010 responses for Coventry Health Care Plans are essentially identical
to the 4010 responses.
The 5010 response contains service type codes for Mental Health (MH) and Urgent Care (UC)
that were not in the 4010 version. However, the 4010 response had the mental health and
urgent care data presented in text.
The 5010 response has a benefit description qualifier (EB01=D) for Mental Health and Urgent Care
coverage codes and message text (MSG) indicating “These are non covered service type codes.”
The list of coverage added now includes the following service types.

The Social Security Number may be missing from the 5010 version.

Coventry Health Care Plans
Eligibility information for Coventry Health Care Plans is determined by the health plan for which a valid
Member or Subscriber belongs. When a different health plan is submitted in an eligibility inquiry, a response
is still provided for a valid Member or Subscriber and the correct Coventry Health Care Plan, for which the
Member belongs, will be indicated. For example, if the incorrect Coventry Plan is used for an inquiry
for a valid Member, a response is provided with the correct plan name and member’s eligibility information.

The following table provides a list of Coventry Health Care Plans for which a valid Member or Subscriber
may belong. The eligibility inquiry should attempt to use the correct health plan for a Member or Subscriber
even though a response is provided when an incorrect plan is used.

Altius Health Plans
CHC Florida/Vista/Summit
Coventry Advantra (Texas, New Mexico, Arizona only)
Coventry Advantra Freedom
Coventry Advantra Savings
Coventry Cares – (Medicaid)
Coventry Health and Life - Nevada
Coventry Health Care - Federal
Coventry Health Care Carelink
Coventry Health Care Carelink Medicaid
Coventry Health Care Carenet – (Medicaid)
Coventry Health Care Group Health Plan (GHP)
Coventry Health Care Health America/ Health Assurance of PA (HAPA)
Coventry Health Care National Network
Coventry Health Care of Delaware
Coventry Health Care of Georgia
Coventry Health Care of Iowa
Coventry Health Care of Kansas
Coventry Health Care of Kansas
Coventry Health Care of Louisiana
Coventry Health Care of Nebraska
Coventry Health Care Southern Health Services (SHS)
Coventry Health Care USA (HCUSA) – (Medicaid)
Coventry Health Life – Oklahoma only
Coventry Health Life – Tennessee only
Coventry Missouri
Coventry Nebraska Medicaid – (Medicaid)
CoventryOne
Diamond Plan (Maryland Medicaid)
Mail Handlers Benefit Plan
MHNET Behavioral Health
Omnicare Health Plan – (Medicaid)
PersonalCare/Coventry Health of Illinois
University of Missouri
Vista (MCD, FHK, LTC) – (Medicaid)
Wellpath / Coventry Health Care of the Carolinas

Disclaimer
This document is not intended to identify every scenario that may be presented in the payer response.

It should also be noted, that the payer response may vary depending on the search criteria used in the
initial inquiry. Some content is no longer returned in the X12 5010 271 response. In a similar fashion,
some content has been modified and new response information may be returned. Information that
appeared consistent between the 4010 and 5010 responses was not presented in this document.