Delaware (Medicaid) - Quick Reference, What You Need to Know...
Search Options
-
Previously, this payer used four search options. Now, only the following
three search options are supported.
1. Recipient ID.
2. Social Security Number, Last Name, First Name, and Date of Birth.
3. Last Name, First Name, and Date of Birth.
- For
successful transaction processing, dependent data may be promoted to the
subscriber loop.
- This
payer requires the Provider’s designated Taxonomy Code and Provider
Type.
This payer allows extra data to be included in the EDI transaction.
Dates
-
This payer requires only the begin date
for an inquiry. The end date is now optional.
-
Previously, both begin and end dates were
required.
-
This payer supports dates up to one year
in the past. No future dates are allowed.
-
Date spans up to six months are supported.
-
Inquiry dates now reference a Plan Date –
291 (DTP01).
Response Data
Benefits
The following information is based on a
generic “Health Benefit Plan Coverage - 30” inquiry.
-
This payer only responds to a generic “Health Benefit Plan Coverage
– 30” service type.
-
The 5010 response now returns the Identification Card Serial Number
in a reference segment.
(2100C, REF02 with REF01 = GH)
-
The response now uses a more specific qualifier to identify a
Managed Care Organization.
(2120C, NM101 = Y2) Previously, the 4010 response used the same
qualifier as a payer.
(2120C, NM101 = PR)
-
The 5010 response now returns multiple service type codes in the
eligibility benefit loop (EB03).
-
The 5010 response now uses service type codes for Mental Health –
MH, and Urgent Care – UC.
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.