Oxford Health Plan (Commercial) - Quick Reference, What You Need to Know...
Search Options
-
As before, this payer offers three search options. However, some of the
search criteria changed.
The last Name and First name on the first search option are optional.
Now, this payer supports the
following search options.
1. Subscriber ID, Last Name,
First Name, and Date of Birth.
2. Subscriber ID, Last Name, and First Name.
3. Last Name, First Name, and Date of Birth.
- For
successful transaction processing, dependent data may be promoted to the
subscriber loop.
Dates
-
Previously, this payer supported up to one
year in the past. Now, past dates up to 18 months are supported.
-
Previously, this payer supported dates up
to seven days in the future. Now future dates up to the end of the
current month are supported.
-
Previously date spans up to 365 days were
allowed. Now, there are no date range restrictions.
-
Inquiry dates now reference a Plan Date -
291 (DTP01).
-
The response now returns the Plan Begin
Date - 346. (2100C Loop, DTP Segment)
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
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.
-
Now,
this payer uses a W for both In Plan and Out of Plan Network
(EB12=W).
-
Now,
the 5010 response uses the proper qualifiers for Primary Care
Provider (EB01=L)
and Taxonomy Code (PRV02=PXC). Previously, they payer used an
unspecified qualifier (ZZ)
-
The
primary difference is that previous 4010 response contained Message
Segments
that have now been coded in the 5010 response.
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.