1. Provider, Begin Date, and Recipient ID.
2. Provider, Begin Date, and Card ID Number.
3. Provider, Begin Date, Social Security Number, Last Name, First Name, and Date of Birth.
4. Provider, Begin Date, Recipient ID, Last Name, First Name, and Date of Birth.
Dates
Response Data
Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.
The social security number is not being returned in the 5010 response, even if submitted in the inquiry.
The 5010 response now uses service type codes for Urgent Care – UC and Mental Health – MH.
In some cases, a 3rd Party Administrator may now be identified as a Prior Insurance Carrier.
For example, the previous 4010 response used a “2B” qualifier for a 3rd Party Administrator.
Now, the same entity may be designated with a “P4” qualifier for a Prior Insurance Carrier.
This is specified by the Entity Type in the 2120 LS Loop (NM102) of the new response.
On 5/3/2012, this payer has added a new qualifier to identify Managed Care Organizations (MCOs).
The new qualifier is used in the 2120 LS Loop (NM1=Y2). As before, the 5010 response continues
to use a "2B" qualifier for a 3rd Party Administrator, to also identify an MCO.
As determined on 5/3/2012, this payer is not returning an active coverage qualifier (EB01=1) when
reporting benefit coverage for MCO plan members. In other words, when the response specifies that
an MCO should be contacted for eligibility and benefit information (EB01=U), active coverage is not
indicated. Instead, such a response may indicate "unable to determine coverage."