1. Subscriber ID, Patient Last Name, Patient First Name, Patient Date of Birth, and Relationship to Subscriber.
Response Data
Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.
- Testing of this response identified that members with the plan name “CW PLUS” are no longer available.
- Specifically, a message text indicates “BENEFIT INFORMATION IS CURRENTLY UNAVAILABLE PLEASE
CALL FOR THIS INFORMATION.” Beginning November 9, 2011, this message started occurring in the
4010 response as well. For example, in 4010 found coverage (20120112-*******) and in 5010
did not (20120113-*******).
- The medical group is now designated as “Services restricted to the following provider” (EB*N) instead
of a “primary care provider” (EB*L). However, the name of medical group still uses a “PCP” designation
which appears to be somewhat confusing (NM1*P3). The PCP doctor’s name is still returned in the eligibility
benefit information. (EB*L)
- New active services type codes include Professional Physician Visit - Office (98), Mental Health (MH),
and Urgent Care (UC).
- New information about coordination of benefits is also returned. However, the only example found in
testing returned COB dates, but did not include the payer’s name or an indication of who is primary.