IL Mcaid

Illinois (Medicaid) - Quick Reference, What You Need to Know...

Search Options

No changes in search options or search criteria. This payer supports four search options.

1. Recipient ID.
2. Social Security Number and Date of Birth.
3. Last Name, First Name, and Date of Birth.
4. Social Security Number, Last Name, and First Name.

For successful transaction processing, dependent data may be promoted to the subscriber loop.

Dates

There are no changes in dates. This payer uses both begin and end dates for an inquiry.
This payer supports past dates back to 01/01/1950 and date spans up to 90 days.
Dates up to 90-days in future are allowed.
Inquiry dates now includes a Plan Date – 291 (DTP01).
This payer now returns the System Date – 636 (DTP01) in the 2110C loop.

Response Data

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

The 5010 response now returns multiple service type codes in the eligibility benefit loop (EB03).
The response now uses service type codes for Mental Health – MH and Urgent Care – UC.
Specific service type codes are also returned.
Previously, only a single generic “30” was returned (EB03=30).
The Policy Number for Other/Additional Payer is now returned and is designated as a Plan Number.
Previously, it was designated as a Member Identification Number.

For example, the Policy Number for Other/Additional Payer is returned in the 2100C loop,
with EB01=R, and includes a REF segment that designates it as the Plan Number (REF01=18).
Previously, it was designated as a Member Identification Number (REF01=1W).

The Case ID is now returned and designated as a Medical Assistance Category. Previously, it was
designated as a Case Number.

For example, the Case ID is returned in the 2110C loop using a REF segment that designated
it as a Medical Assistance Category (REF01=M7). Previously, it was returned in the 2100C loop
with a REF segment that designated it as a Case Number (REF01=3H).
The Spend Down amount appears as a placeholder value of “999999” instead of the actual amount.

For example, the Spend Down amount (EB01=Y) now uses a placeholder value (EB07=999999)
not the actual Spend Down amount.

Under some scenarios, the Local Education Agency (LEA) information may not be presented in the response.

For example, this could result from the information being NPI dependent.
In other words, it maybe returned for one NPI, but not another.

It is also likely that the LEA information is being returned, but does not include identifying "LEA" text along with the service type code and the text identifying Medicaid Eligibility or Medicaid Expansion Eligibility, as shown below.

Old value (4010) - 53 LEA3 THE STUDENT IS MEDICAID ELIGIBLE
Old value (4010) - 51 LEA1 THE STUDENT IS MEDICAID EXPANSION ELIGIBLE

New value (5010) - 53 THE STUDENT IS MEDICAID ELIGIBLE
New value (5010) - 51 THE STUDENT IS MEDICAID EXPANSION ELIGIBLE

The LEA information is typically returned with specific service type codes in the 50’s
such that service type code 51 is LEA1 and 53 is LEA3.

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.