1. Medicare ID (HIC Number), Last Name, First Name, Suffix, and Date of Birth.
2. Medicare ID (HIC Number), Last Name, First Name, and Suffix.
3. Medicare ID (HIC Number), Last Name, Suffix, and Date of Birth.
Response Data
Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.
Added active service types for Medical Care – 1, Chiropractic – 33, Dental Care – 35,
Emergency Services – 86, Pharmacy – 88, Vision (Optometry) – AL, Mental Health – MH,
Urgent Care – UC, and Professional Physician Office Visit – 98.For these service types, a list is created in the OneSource interface that precedes the A & B text.
For EDI and IntelliSource users that are using a step down conversion to 4010,
Eligibility or Benefit information is provided in an EB loop for each of these active service types.The service type for Pharmacy is not returned when no Medicare Part D payer is listed.
Slight differences exist in the way Part A and Part B coverage is formatted.
The Eligibility or Benefit information no longer specifies an individual coverage level code. (EB02=IND)
Since Medicare is based on individual coverage, this was not needed.
Now, it is specified using the generic Health Benefit Plan Coverage (EB03=30).The service type for Blood Charge – 10, or the Blood Unit deductible has been restructured.
Previously, it was specified as individual deductible.
Now, it is returned as a benefit description without the individual coverage level code. (EB02=IND).
New coverage in 5010 for Pulmonary Rehabilitation – BF, and Cardiac Rehabilitation – BG, that also includes
message text for “Intensive Cardiac Rehabilitation.”
New benefit dates for Health Care Facility – X, specifically physician re-certification for Medicare-covered
home health services. This includes HCPCS codes and start dates.
The service type for Home Health Care – 42, has been restructured.
Message text for Home Health Episode History (HHEH) that specifies Start Date, End Date,
Date of Earliest Billing Action (DOEBA) and Date of Latest Billing Action (DOLBA) is not returned.HHEH dates now reflect the Service Date – 472. This allows HHEH dates to be distinguished from
the billing dates. For example, Period Start Date – 193 and Period End Date – 194.The NPIs for a Home Health Care organization is now returned in a different segment.
Previously, under 4010, this NPI was returned within a PRV segment. Now, it is provided using an NM1 segment.
In other words, the NPI is still provided, but now the NPI is specified as a “Benefit Related Entity Name” instead
of “Benefit Related Provider Information.”The response for Home Health Care now provides two related entities or NM1 segments within the same 2120 loop.
For example, the response for Home Health Care may contain both a Payer’s Name and a Provider’s NPI.The OneSource interface will not display the Provider’s NPI.
Message text for “Revocation Code” has been added where applicable.
The date format for Renal Supplies in the Home – 14, has been changed.
Previously, the 4010 response referenced a Completion Date – 198. Now, the date specifies a Discharge Date – 096.
The message text “ESRD Transplant Discharge Date” is no longer provided.
Other cosmetic changes include:
A reference to the CMS website, as provided in the Information Source Contact Information (2100A, PER Segment).
The removal of the Subscriber Relationship code (2100C, INS Segment).
Since Medicare is based on individual coverage, it is always set to “Self” and was not useful.Now, for other payers such as Part D, TPL, and Advantage, a website URL is provided as additional contact information.
This is in addition to the payer’s telephone number that existed in previous response. (PER Segment).