West Virginia (Medicaid) - Quick Reference, What You Need to Know...
Search Options
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No changes in search options or criteria. As before, this payer supports
two search options.
1. Subscriber ID.
2. Social Security Number and Date of Birth.
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For successful transaction processing, dependent data may be promoted to
the subscriber loop.
Dates
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As before, this payer requires both begin
and end dates for an inquiry.
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This payer supports past dates back to
01/01/1999.
There are no restrictions on date spans. No future dates are allowed.
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Inquiry dates now reference a Plan Date –
291 (DTP01).
Previously, date references for Eligibility – 307 were used.
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The response now returns the additional
Plan Begin Date – 346 (DTP01) in the 2100C Loop.
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The response also returns the Plan Begin
Date – 346 (DTP01) in the 2120 C Loop.
Response Data
Benefits
The following information is based on a
generic “Health Benefit Plan Coverage - 30” inquiry.
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The response now returns the text “MOLINA” instead of “UNISYS” in
all data elements.
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The response now indicates a Managed Care Coordinator (EB01=MC)
instead of
Other or Additional Payer (EB01=R). This occurs when general Health
Benefit Plan
Coverage (EB03=30) is specified with either a Health Maintenance
Organization - HMO or
Preferred Provider Organization - PPO. (When EB04 specifies either
an HM or PR).
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The corresponding 2120C Loop for a Managed Care Coordinator now
specifies the
Plan Sponsor Name (NM104). Previously, this was valued as “HMO” or
“PAAS” in the
4010 response. The entity contact name (PER02) is no longer valued
in the 5010 response.
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For entities other than the Managed Care Coordinator, both the Name
(NM104) and
Contact Name (PER02) in the 2120C Loop are valued in the same manner as in the
previous 4010
response.
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.