Health Alliance Medical Plan, Illinois (Commercial) - Quick Reference, What You Need to Know...
Search Options
-
Basically, there are no changes in search options or search criteria.
However, the Family Unit Number should now be contained as part of the
Member ID.
The 5010 inquiry does not support a qualifier for Family Unit Number.
As in the past, this payer supports the following search options.
1. Member ID.
2. Member ID and Patient Date of Birth.
3. Subscriber Social Security Number and Patient Date of Birth.
4. Patient Last Name, Patient First Name, and Patient Date of Birth.
- For
successful transaction processing, dependent data may be promoted to the
subscriber loop.
Dates
-
Basically, there are no changes in date
rules. This payer supports dates up to two years in the past.
No future dates or date spans are allowed.
-
Inquiry dates now reference a Plan Date –
291 (DTP01). Previously, an Eligibility Date – 307 was used.
Response Data
Benefits
The following information is based on a
generic “Health Benefit Plan Coverage - 30” inquiry.
All other response information appears unchanged or is similar to the
previous response, excepted
as noted below.
-
The
eligibility and benefits loop (EB segment) for Active Coverage now
uses a service type
of “30.” (EB03=30) Previously, in the 4010 response, this was not
valued.
-
The
Primary Care Provider ID now uses an “SV” qualifier. (Service
Provider Number)
-
The
IPA/Group Number is now being returned.
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.