Physicians Mutual Insurance Company (Commercial) - Quick Reference, What You Need to Know...
Search Options
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This payer supports only a single search. Now, the Patient Sex is a
required field.
As before, the Patient Group Number remains as an optional field.
1. Subscriber ID, Patient
Last Name, Patient First Name, Patient Date of Birth, Patient Sex,
Patient Group Number, and Relationship to
Subscriber..
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This payer does not promote dependent data. For this reason, it is
necessary for a transaction to use
either a subscriber or dependent loop, depending on the specified value
of the relationship code.
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Previously, this payer may have required the Provider’s Tax ID to be
supplied in an inquiry.
Dates
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This payer requires both begin and end
dates for an inquiry.
Previously, this payer used only a begin date of service.
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This payer supports dates up to one year
in the past and up to a 30-day date span.
No future dates are allowed.
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Inquiry dates now reference a Plan Date –
291 (DTP01).
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When the member has coverage under a
single plan, the response returns
Benefit Begin – 348 (DTP01) and Benefit End – 349 (DTP01) in the 2110C
loop.
When a member has multiple coverage, the 2110C loop contains two DTP
segments.
Response Data
Benefits
The following information is based on a
generic “Health Benefit Plan Coverage – 30” inquiry.
This is also used as the default service type for the transaction.
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The 5010 response now identifies when a member has coverage on two
or more plans.
For example, additional coverage for Medical, Dental, Vision, or
Long Term Care.
When this occurs, the 2110C loop of the response will contain a
reference with the
Member’s ID associated to the corresponding plan. (REF01=IL and
REF02=Member’s ID)
Thus, the Member ID values that are returned in the 2110C/REF02 may
be submitted
in another inquiry if needed.
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.