1. Provider, Begin Date, End Date, Subscriber ID, Patient Last Name, Patient First Name,
Date of Birth, Group Number, and Relationship to Subscriber.2. Provider, Begin Date, End Date, Subscriber ID, Patient Last Name, Patient First Name,
Group Number, and Relationship to Subscriber.3. Provider, Begin Date, End Date, Subscriber ID, Patient Date of Birth, Group Number, and
Relationship to Subscriber.4. Provider, Begin Date, End Date, Subscriber Social Security Number, Patient Last Name,
Patient First Name, Group Number, and Relationship to Subscriber.5. Provider, Begin Date, End Date, Subscriber Social Security Number, Patient Date of Birth,
Group Number, and Relationship to Subscriber.6. Provider, Begin Date, End Date, Patient Last Name, Patient First Name, Patient Date of Birth,
Group Number, and Relationship to Subscriber.
Dates
Benefits
The following information is based on a generic “Health Benefit Plan Coverage - 30” inquiry.
- Several changes have been observed in this payer’s response. Many service types are not
being returned for a “Health Benefit Plan Coverage - 30” inquiry. In particular, this may affect
the amount of data received for Surgical, X-Ray, and Physical Therapy. Other “category” service
type codes (EQ values) may be used which were not supported by the payer in 4010.
- Co-Payment and Co-Insurance is not being returned on numerous service types.
- Family deductibles are now being returned in 5010, where the 4010 response only had individual
deductibles. When the family deductible is unlimited, the amount of the deductible appears as $99999.99.
This appears strange, but is correct. The remaining family deductible shows $99499.99 if an individual’s
$500 deductible has been met.
- Several service types are not returned in the 5010 response for a generic “Health Benefit Plan Coverage - 30”
inquiry (EQ*30). Specifically, service types for Surgical (2), Diagnostic X-Ray (4), Anesthesia (7),
Other Medical (9), Durable Medical Equipment Purchase (12), Ambulatory Service Center Facility (13),
Dental (35), Hospital Emergency Medical (52), Hospital Ambulatory Surgical (53), Well Baby Care (68),
Pharmacy (88), Brand Name Prescription Drug (91), Generic Prescription Drug (92), Psychotherapy (A6),
Psychiatric Inpatient (A7), Psychiatric Outpatient (A8), and Physical Medicine (AE).
- In some cases, the relationship codes are no longer sent in either the subscriber or dependent loops.
(INS Segment)
- Specific messages (MSG) to distinguish co-payments for specialist or PCP are no longer supplied in the
5010 response.
- Health Care Facility now uses the Provider’s Name and NPI from the 2100B loop (EB*X).
Previously in 4010, Health Care Facility was returned, but this information was not appended.
- A new message (MSG) appears in the 5010 response.
The message text “ADDITIONAL COVERED PER OCCURANCE” is presented and has attached limitations
with no other explanation (EB*F). The meaning of this text is unclear.
- Message texts (MSG) with the service type text have been removed in the 5010 response.
This is less redundant than existed in the 4010 response. Some plans, such as AmeriChoice Rhode Island,
still return this text.
- Group Numbers in the subscriber loop (2100C) now include a leading zero (REF*6P).
- The new 5010 response may use multiple segments for active coverage benefit information (EB*1**30).
For example, UHC ASO CUSTOM PLAN P0032. Some responses have date references (DTPs) attached to
every eligibility benefit (EBs) occurrence.
- Some service type repetitions repeat the same service type code multiple times.
- The PCP now has the taxonomy information in the 5010 response.