1. Subscriber ID, Patient Last Name, Patient First Name, Patient Date of Birth, and
Relationship to Subscriber.
2. Subscriber ID, Patient Last Name, Patient Date of Birth, and Relationship to Subscriber.
3. Subscriber ID, Patient Last Name, Patient First Name, and Relationship to Subscriber.
4. Patient Last Name, Patient First Name, Patient Date of Birth, and Relationship to Subscriber.
Dates
Response Data
Benefits
The following information is based on a generic Health Benefit Plan Coverage - 30 inquiry.
The 5010 response now uses service type codes for Physician Office Visit Sick BY,
Physician Office Visit Well BZ, Mental Health - MH, and Urgent Care UC.The 5010 response now returns multiple service type codes in the eligibility benefit loop (EB03).
This payer has stopped using the U designation for In Plan and Out of Plan Network (EB12=U).
Now, they extensively use a W for both In Plan and Out of Plan Network (EB12=W).
In other words, the use of the In/Out of Network Indicator (EB12) is not consistently utilized.
For example, the EB segment for Out of Pocket (EB01=G) the EB12 value is for the
Remaining Out of Pocket (EB06=29) but is not valued for the Service Year (EB06 =29).
Previously, psychiatric benefits were being returned, but are not returned in the 5010 response.
This analysis was performed with a limited number of test cases. A more comprehensive analysis
is currently being performed and under review.