United Healthcare - UHC (Commercial) - 5010 Service Type Notice

 

As a part of the mandated 5010 conversion, UHC has made several changes to their eligibility transaction.
They now allow providers to request benefits for specific service types when making an eligibility inquiry.
This allows you to request only the benefits that meet your particular business needs. Because you can
now request specific benefits, UHC has significantly reduced the amount of benefits returned when making
a nonspecific generic request.

Web-Based Clients (OneSource and eCare Online)
For the OneSource product, you will have the option to choose a single service type (i.e. surgical,
diagnostic x-ray, hospital inpatient, etc.) or a group of service types when submitting an eligibility
inquiry. The grouped responses will return benefits for all of service types associated with the group.
For example, Mental Health returns benefits such as Psychiatric, Psychotherapy, Psychiatric - In Patient,
and Psychiatric - Out Patient.

See Frequently Asked Questions

If a service type grouping is chosen, you will be billed the number of transactions we run to
compile the response. The available service type groups are listed below.

  

Coverage Type Groups

Type of Benefits Requested

Total Transactions Billed

Standard Benefit Grouping

Health Benefit Plan Coverage
Hospital
Mental Health

 3

Inpatient Hosp Benefit Grouping

Medical Care
Hospital

 2

Outpatient Hosp Benefit Grouping

Health Benefit Plan Coverage
Medical Care
Diagnostic X-Ray
Diagnostic Lab
Hospital
MRI/CAT Scan

 6

Emergency Services Benefit Grouping

Hospital
Emergency Services

 2

Physician Benefit Grouping

Professional Physician
Professional Physician Visit - Office

 2

 

See Service Type Grouping Detail

Integrated Clients (IntelliSource and EDI)

Many of our integrated clients are unable to send specific service types, so Experian Health has implemented a
change in the way we process UHC eligibility transactions. In order to return a response that is comparable
to what you previously received with UHC, we will run multiple transactions using different service types
and combine them into one comprehensive response. We will request generic benefits, hospital benefits,
and mental health benefits and combine the responses into our new standard response.

Below is a comparison of the 4010 response, the new 5010 response without any additions, and the
5010 response compiled using multiple transactions.

UHC 4010 Response

UHC 5010 Response
(No Additional Transactions)

New Standard Response
Generic Response + Hospital Benefits
 + Mental Health Benefits
(3 Transactions)

   

 

Ambulatory Service Center Facility

 

 

Ambulatory Surgery

 

Ambulatory Surgery

Anesthesia

 

 

Brand Name Drugs

 

 

 

Chiropractic

Chiropractic

Dental

Dental

Dental

Diagnostic Lab

 

 

Diagnostic X-Ray

 

 

Durable Medical Equipment Purchase

 

 

Emergency Services

Emergency Services

Emergency Services

General Benefits

 

 

Generic Drugs

 

 

Health Benefit Plan Coverage

Health Benefit Plan Coverage

Health Benefit Plan Coverage

Hospital

Hospital

Hospital

 

 

Hospital - Emergency Accident

Hospital - Emergency Medical

 

Hospital - Emergency Medical

Hospital - Inpatient

Hospital - Inpatient

Hospital - Inpatient

Hospital - Outpatient

Hospital - Outpatient

Hospital - Outpatient

 

 

Hospital - Room and Board

Medical Care

Medical Care

Medical Care

 

Mental Health

Mental Health

Other Medical

 

 

Pharmacy

Pharmacy

Pharmacy

Physical Medicine

 

 

Professional Physician

 

 

Professional Physician Visit - Office

Professional Physician Visit - Office

Professional Physician Visit - Office

Psychiatric

 

Psychiatric

Psychiatric - In Patient

 

Psychiatric - In Patient

Psychiatric - Out Patient

 

Psychiatric - Out Patient

Psychotherapy

 

Psychotherapy

Routine Physical

 

 

Surgical

 

 

 

Urgent Care

Urgent Care

Vision

Vision

Vision

Well Baby

 

 

 

Integrated Clients (eCare NEXT, IntelliSource, EDI, & Nebo)
For clients that are unable to send a specific service type, we will send UHC the Standard Benefit Group which is column three in the table above. This benefit group is compiled by running three eligibility inquiries so you will be charged a total of 3 transactions. If this response doesn’t meet your needs, please contact our Customer Support Team at
customer.support@experianhealth.com regarding other options for response customizations.

For inquiries regarding pricing, please contact your Sales Representative.