QualChoice Arkansas (Commercial) - Quick Reference, What You Need to Know...
Search Options
- No
changes in search options. This payer supports three search options.
1. Member ID, Patient Last
Name, and Patient First Name.
2. Member ID and Patient Date of Birth.
3. Patient Last Name, Patient First Name, and Patient Date of Birth
- For
successful transaction processing, dependent data may be promoted to the
subscriber loop.
Dates
-
There are no changes in dates.
-
The Plan Date(s)are returned with the
Qualifier of DTP01 = 346 or DTP01= 291.
This depends on the Date of Service of the Plan being inquired upon
having a termination date.
Response Data
Benefits
The following information is based on a
generic “Health Benefit Plan Coverage - 30” inquiry.
-
The primary differences between the 4010 and 5010 271 is the benefit
detail returned is more in depth.
-
The Subscriber Loop 2100C is utilized for all patients as each
member has been assigned a unique Member ID.
-
Tiered Benefits are returned if applicable to the plan the patient
is enrolled in.
-
The Deductible Accumulators for the Individuals and the Family are
now returned.
-
Co-Insurance, Co-Payments, Deductibles, and Out of Pocket for
individual service types and are returned
if applicable to plan.
|
SERVICE TYPE
DESCRIPTION |
Service Type |
|
Emergency Room |
86 |
|
ER
Deductible/Coinsurance |
86 |
|
Network PCP Copay |
98 |
|
Specialist Visits |
98 |
|
SmartCare
Specialist |
98 |
|
Specialist
Deductible/Coin |
98 |
|
PCP Visit |
98 |
|
OB/GYN Visit |
BV |
|
SmartCare PCP
Visit |
98 |
|
SmartCare OB/GYN
Visit |
BV |
|
In Network
Preventive Services |
1 |
|
SmartCare
InNetwork |
30 |
|
In Network |
30 |
|
Out of Network |
30 |
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.