TennCare (Medicaid) - Quick Reference, What You Need to Know...
Search Options
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No changes in search options or search criteria.
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For successful transaction processing, dependent data may be promoted to
the subscriber loop.
- In
some cases, the Name and Date of Birth search does not return any data
in the 2100C Member ID field.
Dates
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Both a Plan Begin and Plan Ending Date are
required for an inquiry.
Previously, the Ending Date of Service was optional.
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Dates now reference a Plan Date – 291
(DTP01). Date references for Eligibility – 307, are not returned.
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This payer supports past dates back to
01/01/1994 and date spans up to 92-days. No future dates allowed.
Response Data
Benefits
The following information is based on a
generic “Health Benefit Plan Coverage - 30” inquiry.
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The
county is no longer returned for the member’s address.
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The
9-digit TennCare ID is not returned in the 2100C NM1 segment of the
response, only the original 11-digit Plan Network or Recipient ID is
returned in the 2100C NM1 and REF segments. In some cases, the
9-digit ID previously returned may not be returned or it may now be
presented in the REF segment.
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The
co-payment information is now structured with an amount that
previously was contained in the plan description text. Plan
description text may be updated in the future.
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Some
plan descriptions may have changed. For example, the plan
description for
“31 - TITLE 19 MEDICAID - AFDC-CN” has been replaced with “31 -
TITLE 19 MEDICAID.”
Plan description text may be updated in the future.
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The
Pharmacy MCO group number is different or has changed.
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In
some cases, the service type General Benefits – 60 was missing on
the nursing facility response. This may include the name of the plan
and the monthly deductible amount.
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.