Response Data
Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.
- In both the 4010 and 5010 responses, some text describing the plan code may not be returned.
In the previous 4010 response, the text describing the plan code descriptions were added during
transaction processing and will also be included in the 5010 response when such descriptions are known.
- For example, the plan code AAFC still is presented on the 5010 response, but the text
“Work First Family Assistance – Recipient is Eligible for Full Medicaid Coverage” will be added
during transaction processing.
- The Primary Care Provider (PCP) is still presented in the benefit information (EB*L). However, the
5010 response does not include service type “30” Health Benefit Plan Coverage with the PCP as
previously supplied in 4010.
- Response data is now provided for Chiropractic (33), Dental Care (35), Hospital (47),
Emergency Services (86), Pharmacy (88), Professional Physician Visit Office (98),
Vision Optometry (AL), Mental Health (MH) and Urgent Care (UC).
- Service type “30” for Health Benefit Plan Coverage is no longer returned in the 5010 response.
- The plan code that used to be listed with the Health Benefit Plan Coverage “30” (EB03=30) is
now referenced with the list of new service types. Other payers in 5010 are now structured
within the NM1 data segment.
- In 4010, the information was included as message text using the MSG segment. For example,
OTHER INSURANCE GROUP NAME = ____________ and POLICYHOLDER NAME = ____________.
In 5010, this information is included under the benefit related entity name (NM1 Segment).
For example, the other payer’s name in 5010 (NM1*PR), the group name (NM1*GW), and
subscriber’s name on other coverage (NM1*IL).