1. Provider, Date, Subscriber ID, and Date of Birth.
2. Provider, Date, Subscriber ID, Patient Last Name, Patient First Name, Patient Date of Birth,
and Patient Relationship.
3. Provider, Date, Social Security Number, Patient Last Name, Patient First Name, Patient Date of Birth,
and Patient Relationship.
Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.
- This payer response offers several improvements, however there is some reduction in the amount of
detail for specific procedures that was included in the previous response.
- The 5010 response now uses accumulators for deductibles and out of pocket maximums.
- The new response is missing service types for Radiation Therapy (6), Other Medical (9),
Medically Related Transportation (56), and Allergy Testing (79). These service types were
previously provided in the 4010 response. This includes a variety of plan descriptions like
Specialized Scanning and Imaging, O/P Radiation Therapy, etc. The response is missing co-payments
for specialists.
- The 5010 response uses Out of Pocket (Stop Loss) for out of pocket maximum (EB*G).
Previously, the 4010 response designated this as co-payment (EB*B) with text indicating the maximum.
- Additional information is provided for Hospital Outpatient (50), Vision Optometry (AL), Mental Health (MH),
and Urgent Care (UC).
- The 5010 response explicitly states deductible amounts for HMO members (EB*C).
- Dependents in the 5010 response are returned in the dependent loop 2100D.
- The subscriber name is returned in the 5010 response. However, the member’s address is no longer
returned on some members.
- The group number and group name are no longer returned in the 5010 response, and the plan
name is different.
- There is more coding in the text of the active coverage benefit information (EB*1**30).
For example, UAR SV 20-35/100A STNFRDUV.
- Medical Group on HMO Plans now has the actual street address in 5010. Previously, the 4010 response
only provided the name and city.
- PCP also has street address, city, state and zip in the 5010 response.
- The 5010 response also provides Behavioral Health utilization management company.