Group and Pension (TPA) - Quick Reference, What You Need to Know...
Search Options
-
No changes in search options or search criteria. This payer now supports
the following search options.
1. Subscriber ID.
2. Subscriber ID, Dependent Last Name, and Dependent First Name.
3. Subscriber ID and Dependent Date of Birth.
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This payer does not promote dependent data. For this reason, it is
necessary for a transaction to
use either a subscriber or dependent loop. In other words, separate
subscriber and dependent searches
are used (one subscriber search and two dependent searches).
Dates
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This payer requires the begin date for an
inquiry and uses the current date by default.
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This payer supports past dates back to
01/01/1800. Future dates and date spans are not allowed.
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Inquiry dates now reference a Plan Date –
291 (DTP01).
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The response returns the Plan Begin Date –
346.
Previously, the Eligibility Date – 356 was returned. (2100C/D Loop,
DTP01)
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Date references for Eligibility – 307, as
used in 4010 response, are not returned.
Response Data
Benefits
The following information is based on a
generic “Health Benefit Plan Coverage - 30” inquiry.
-
By
default, the inquiry uses a generic “Health Benefit Plan Coverage –
30” service type.
-
To
handle a year-to-date deductible amount issue, minor changes in the
response have been addressed.
In other words, the information contained in the 5010 response is
such that it remains consistent
with the previous information supplied in the 4010 response (No
change).
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.