TRICARE (Military) - Quick Reference, What You Need to Know...
Search Options
- No
differences in search options or search criteria. However, Patient Sex
is Required.
However, in the response, the Member ID has moved from a REF segment to
the NM1 segment.
Dates
-
Previously, searches could only be
performed for the current date of service.
Now, dates up to four years in the past are accepted. No future dates
are allowed.
-
Coverage dates have changed from a range
of Service Dates to a single Plan Date.
Response Data
Test cases have shown some variations as a
result of the payer echoing back information on the subscriber and
dependent.
Benefits
The following information is based on a
generic “Health Benefit Plan Coverage - 30” inquiry.
-
No differences in the Deductibles or Out of Pocket (Stop Loss)
information.
-
No differences in Active Coverage information.
Demographics
- The
Dependent is returned as the Subscriber if the request has used the
Subscriber loop.
- The
Middle Initial of the Subscriber and Dependent is returned as it
appeared in the request even if it is wrong.
In other words, the Middle Initial may not be corrected in the response.
- Only
the 1st three characters of the First Name are used in finding the
member. Any characters after the 1st three characters are returned
exactly as they appeared in the request even if they are wrong. In other
words, the First Name may not be corrected in the response.
- Only
the 1st three characters of the Last Name are used in finding the
member. Any characters after the 1st three characters are returned
exactly as they appeared in the request even if they are wrong. In other
words, the Last Name may not be corrected in the response.
- The
Dependent Relationship Code is returned just as it was sent in the
request.
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.