Xerox EDI Eligibility Gateway 270/271 Payer Guide Commercial

Transcription

1 Xerox EDI Eligibility Gateway 270/271 Payer Guide Commercial Version 5010 Technical Capital Support: Updated November 12, 2014

2 2014 Xerox Corporation. All rights reserved. XEROX and XEROX and Design are trademarks of the Xerox Corporation in the United States and/or other countries. Other company trademarks are also acknowledged. Document Version: November 2014

3 Table of Contents Revision Table and 5010 Compatibility... 9 Enrollment and Data Collection... 9 AARP Absolute Total Care Advantage by BridgewayHealthSolutions Advantage by Buckeye Community Health Plan Advantage by Managed Health s Advantage by Superior Health Plan Advantage Health Solutions Aetna Administrator Medicare Supplement Aetna AETNA Aetna Better Health (NE) Aetna Better Health (IL) Aetna Better Health (PA) Aetna Better Health (TX) Aetna Better Health (TX) CHIP Aetna Senior Supplemental Affinity Health Plan Medicare Affinity Health Plan AFLAC AFLAC Medicare Supplemental Alan Sturm and Associates Dental Allegiance Benefit Plan Management Allied Benefit Systems Altus Dental American FamilyInsurance Group- Medicare Supplement and PPO American Medical Security (AMS) American Network Ins. Medicare Supplement American Postal Workers Union American Republic Insurance Company (ARIC) AmeriHealth (DE, NJ, PA) AmeriHealth Administrators AmeriHealth Caritas Louisiana (LaCare) AmeriHealth Caritas Pennsylvania Ameritas Group Arbor Health Plan Arise Health Plan Medicare Select Policy Arizona Physicians IPA (APIPA) Associacion De Maestros Puerto Rico Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial i

4 Assurant Health Asuris Northwest Health Aultcare Automated Benefit s Auxiant Avera Health Plans AvMed Health Plans AVMED Bankers Life and Casualty Banner Health Plans Benefit Management Inc Best Choice Health Plans Better Health Plans (Unison Health Plan) Blue Benefit Administrators of Mass BlueChoice Health Plan South Carolina Medicaid BMC HealthNet Boon Group Bravo Health Bridgespan Bridgeway Arizona Brokers National Dental Buckeye Community Health Butler Benefit s, Inc Capitol Administrators Capital District Physicians Health Plan CAPROCK CareSource Health (OH) Care Improvement Plus CarePlus Health Plan CarePoint Medicare Advantage Carolina Care Plan, Inc. (CCP) CDS Group Health Celticare Celtic Insurance Cenpatico Centene Health Plans CenterLight Healthcare Central California Alliance for Health Central Reserve Life Insurance Company Central Senior Care Central States Indemnity CHAMPVA/Spina Bifida/Children of Women Vietnam Vets Children s Mercy PCN CHP Direct Christian Brothers s Cigna-GWH Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial ii

5 CMFG Life Insurance Colonial Penn Life Colorado Access Commerce Benefits Group Community Health Plan of Washington (CHPW) ConnectiCare Consolidated Associates Railroad Consumers Life Continental General Insurance Company Cooperative Benefits Administrators Cook Children s Health Plan CoreSource Country Cupboard Country Life Insurance Company Covenant Administrators (TPA) Coventry Healthcare Cox Health Plan CTI Administrators DeCare Dental Health Insurance Definity Health Dental Benefit Providers Delaware Physicians Care Delta Dental Denver Health Medical Plan Deseret Mutual (DMBA) Director s Guild EBMS Employee Benefit s Dental EPIC Life Insurance EssenceHealthcare Evangelical Community Hospital Evercare Everence Financial Evergreen Health Co-Op Family Care Federated Insurance Company Fidelis Care New York Fidelis SecureCare of Michigan FirstCare First Medical Network Flex Compensation Dental Florida Combined Life Dental Florida Health Care Plans Florida Hospital Healthcare System Florida True Health Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial iii

6 Food Employers & Bakery Confectionary Workers Benefit Freedom Blue Fresenius Medical Care Gateway Health Plan Geisinger Health Plan Geisinger Health Plan Gold Generations Healthcare Gerber Life Insurance* GHI Group Health Incorporated Gilsbar Great American Life Insurance Co Medicare Supplement Group Health Cooperative Group Health Cooperative of South Central Wisconsin Dental Guardian Life Insurance Co. of America Dental Harmony Health Plan Hawaii Medical Assurance Association Dental Health Alliance Medical Plan (IL) Health Alliance Medical Plans (HAP) Health Choice Arizona Health First Health Plan Health First New Jersey Health First New York Health Net National Health New England Health Partners (Minnesota) Health Partners Philadelphia Health Plan of San Mateo Health Share of Oregon Health s for Children with Special Needs Healthcare Solutions Group HealthEase HealthEase Kids Healthgram HealthMarkets HealthPlan of Nevada HealthPlans Inc HealthPlus of Michigan HealthScope (Morris Assoc, Central Benefits, Employer s Health, Plan Handlers) Healthsource Provident Dental HealthSpring Healthy Texas Heritage Physician Network (Houston) Hershey Healthsmile Dental HIPNY Horizon NJ Health Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial iv

7 Humana Humana CareSource (KY) IBM Insurance Outsourcing s IBEW Local 508 Health Plan Ideal Life Insurance Independence Administrators Island Home Insurance John Hopkins Health Plan Kaiser Foundation Health Plan of Colorado Kaiser Foundation Health Plan of Hawaii Kaiser Foundation Health Plan of Hawaii (DHMO Choice) Kaiser Foundation Health Plan of the Mid Atlantic Kaiser Foundation Health Plan of the Northwest Kaiser Permanente of Georgia Kaiser Permanente of Northern CA Kaiser Permanente of Southern CA Kentucky Health Exchange Keystone Mercy Health Kitsap Physician s KSKJ Life Leggett & Platt Leon Medical Centers Health Plan Lifewise Arizona Lincoln Financial Lincoln Heritage Loomis Company Louisiana Health Exchange Magellan Behavioral Health Magnacare MAMSI Health Plan MAMSI Managed Care of America Managed Health s Wisconsin MAPFRE Medicare Excel MAPFRE Life Puerto Rico Maricopa Health Plan Arizona MDWise Hoosier Alliance MedBen Newark OH MedCost Benefit s Medica Medical Associates Health Plan/Health Choices Medical Card System Medical Mutual of Ohio Medicare CMS Medicare y Mucho Mas (INMEDIATA HEALTH GROUP) Med-Pay, Inc Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial v

8 MedStar Family Choice MedStar Health Plan Mercy Health Care Plan Meritain Health Michigan MI Child Mississippi State Employees and Teachers Missouri Care MMSI (Mayo Health) Molina Healthcare Municipal Health Benefit Fund Mutual Assurance Administrators Mutual Health s Mutual of Omaha National Association of Letter Carriers (NALC) National Telecommunications Cooperative Association (NTCA) NEHEN Harvard Pilgrim Health Care NEHEN Harvard Pilgrim Health Care NEHEN- Neighborhood Health Plans Neighborhood Health Plan (RI) Network Health Network Health Plan of WI NGS American North Carolina Medicaid Nova Healthcare Administrators Ohana Operating Engineers Local.428 Health and Welfare Optima/Sentara Orange County Fire Authority Oscar (NY) Oxford Health Plans Pacific Source Health Plan Panamerican Life Puerto Rico Paramount Health Parkland Community Health Plan Partners National Health Plans of NC Passport Health Plan Patriot Dental Peoples Health Physicians Health Plan Northern IN (PHPNI) Physicians Mutual Insurance Company Piedmont (GA) Piedmont Wellstar HealthPlans Plan de Salud Hospital Menonita Planned Administrators Inc Preferred Care Partners Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial vi

9 Preferred Health System of Kansas Preferred Medicare Choice (PMC) (INMEDIATA HEALTH GROUP) Preferred One Premier Health Presbyterian Health Plan Prestige Health Choice Primary PhysicianCare Inc Principal Financial Group (Nippon Life) Priority Health Providence Health Plan Provident Preferred Network Dental Puritan Life Insurance Qualcare Recall Systems Royal Neighbors of America S and S Healthcare Strategies Sanford Health Plan Santa Clara Family Health Plan Schaller Anderson Schaller Anderson Schaller Anderson Aetna Better Health of OH Schaller Anderson Texas CHRISTUS Scott & White Health Plan Secure Health Plans of Georgia Securian Dental Securian/Patriot Dental Security Health Plan Senior Health s Center Universal American Family of Companies Senior Whole Health Select Health SC Select Health Utah Shenandoah Life Insurance Sierra Health s Significa SPJST Medicare Supplement Star HRG State Mutual Med Supp Staywell Staywell Kids Sterling Investors Life Insurance Student Insurance SummaCare Superior Health Plan Texas TennDent TexanPlus North Texas Area Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial vii

10 TexanPlusSoutheast Texas Area The Kempton Company Three Rivers Health Plans TMG Network Health Insurance Today s Health Today s Option Total Healthcare TRICARE for Life Triple-S Salud (BCBS Puerto Rico) Trustmark Tribute/Select Care of Oklahoma Tricare TRICR Ucare of Minnesota Ultimate Health Plans UMR (Wausau) UNICARE Dental Unicare UCARE United Concordia (Dental) United Healthcare United Healthcare Plan River Valley UnitedHealthcare Community Plan Kansas UnitedHealthcare Facets Detroit Community and State UnitedHealthcare Facets Pittsburgh Community and State United Healthcare SecureHorizons UnitedHealthcare Nevada Market Unity Health Plan University Care Advantage Arizona University Family Care University of Arizona Health Plan-UHM University of Utah Health Plans University Physicians Care Advantage (AZ) University Physicians Healthcare Group (Arizona) UPMC Health Plan (Tristate) USAA Life Insurance Company VA Fee Basis Program VA Healthcare VA Health Administration Center Vantage Health Plan, Inc VIVA Health VYTRA Washington National Well Sense Wellcare Health Plans Western Health Advantage Wilson McShane Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial viii

11 World Insurance (ARIC) WPS Health Insurance Zenith Administrators (MN) Dental Payer Maintenance Schedule Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial ix

12 Revision Table Change Origination of 5010 Payer Guide 11/25/2011 Aetna AETNA Added 11/25/2011 BMC HealthNet Added 11/25/2011 Coventry Healthcare Added 11/25/2011 Optima/Sentara Added 11/25/2011 AARP added 4/30/2012 American Postal Workers Union added 4/30/2012 AmeriHealth Mercy Health Plan added 4/30/2012 Assurant Health- added 4/30/2012 Asuris Northwest Health added 4/30/2012 AultCare added 4/30/2012 AcMed Health Plans- AVMED added 4/30/2012 Capital District Health Plan added 4/30/2012 Cigna added 4/30/2012 Cook Children s Health Plan added 4/30/2012 Family Care added 4/30/2012 Federated Insurance Company added 4/30/2012 Florida Health Care Plans added 4/30/2012 Florida Hospital Healthcare System added 4/30/2012 Freedom Blue added 4/30/2012 Fresenius Medical Care added 4/30/2012 Geisinger Health Plan added 4/30/2012 Geisinger Health Plan Gold added 4/30/2012 Generations Healthcare added 4/30/2012 Gilsbar added 4/30/2012 Health Alliance Medical Plans (HAP) added 4/30/2012 Healthcare Solutions Group added 4/30/2012 Health Choice Arizona added 4/30/2012 Health First New Jersey added 4/30/2012 Health First New York added 4/30/2012 HealthMarkets- added 4/30/2012 HealthNet National added 4/30/2012 Health Partners MN added 4/30/2012 HealthEase added 4/30/2012 HealthEase Kids added 4/30/2012 Horizon NJ Health added 4/30/2012 Humana added 4/30/2012 John Hopkins Health Plan added 4/30/2012 Kaiser Foundation Health Plan of Colorado added 4/30/2012 Kaiser Foundation Health Plan of Hawaii added 4/30/2012 Kaiser Foundation Health Plan of Mid-Atlantic States added 4/30/2012 Kaiser Foundation Health Plan of the Northwest added 4/30/2012 Kaiser Foundation Health Plan of Ohio added 4/30/2012 Kaiser Permanente of Georgia added 4/30/2012 Kaiser Permanente of Northern CA added 4/30/2012 Kaiser Permanente of Southern CA added 4/30/2012 Keystone Mercy Health added 4/30/2012 Medica added 4/30/2012 Medical Mutual of Ohio added 4/30/2012 Medicare (Part A & B)- CMS added 4/30/2012 Mercy Health Care Plan added 4/30/2012 MMSI (Mayo Health) added 4/30/2012 Mutual of Omaha added 4/30/2012 National Association of Letter Carriers (NALC) added 4/30/2012 NEHEN- Harvard Pilgrim Health Care added 4/30/2012 Ohana added 4/30/2012 Date Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 1

13 Oxford Health Plan added 4/30/2012 Pacific Source Health Plan added 4/30/2012 Passport Health Plan added 4/30/2012 Physicians Mutual Insurance Company added 4/30/2012 PreferredOne added 4/30/2012 Recall Systems-added 4/30/2012 Select Health SC added 4/30/2012 Staywell added 4/30/2012 Staywell Kids added 4/30/2012 TexanPlus North Texas Area added 4/30/2012 TexanPlus Southeast Texas Area added 4/30/2012 Today s Health added 4/30/2012 Today s Option added 4/30/2012 Trustmark added 4/30/2012 Tribute/Select Care of Oklahoma added 4/30/2012 UMR (Wausau) added 4/30/2012 Unicare- UCARE added 4/30/2012 United Healthcare added 4/30/2012 VA Fee Basis Program added 4/30/2012 VIVA Health added 4/30/2012 Wellcare Health Plans added 4/30/2012 Windsor Medicare Extra added 4/30/2012 Added new payer HealthScope /29/2012 Added new payer Universal Healthcare /29/2012 Added new payer- Network Health /8/2012 Added Standard Insurance of New York added 6/8/2012 Added Standard Insurance added 6/8/2012 Added Reliance Standard Life 6/8/2012 Added First Reliance Standard Life added 6/8/2012 Added First Ameritas of New York added 6/8/2012 AARP updated search options 6/8/2012 Added new payer- Health New England /8/2012 Added Health Partners of Philadelphia added 6/8/2012 Added Colorado Access added 6/8/2012 Added Denver Health Plan added 6/8/2012 Medicare- CMS updated search options 6/8/2012 Added Principal Financial Group (Nippon Life) added 6/8/2012 Added CoreSource Little Rock added 6/8/2012 Added CoreSource FMH added 6/8/2012 Denver Health added note to 6/27/2012 Added Continental General Insurance Company /5/2012 Added Central Reserve Life Insurance Company /5/2012 Added American Family Insurance Group- Medicare Supplement and PPO /5/2012 Added American Republic Insurance Company /5/2012 Added Cooperative Benefit Administrators /5/2012 Added World Insurance (ARIC) /5/2012 Added Molina WI 10678, TX 10391, OH 00445, NM 10146, MO 10523, MI 00226, FL 10445, CA /5/2012 Cigna corrected/updated search options 7/5/2012 Added Sanford Health Plan /5/2012 Mutual of Omaha updated search options 7/5/2012 Added Unity Health Plans /5/2012 Added Ucare of Minnesota /5/2012 Added SummaCare Health Plan /5/2012 Added Santa Clara Valley Health and Hospital /5/2012 Added HealthPlus of Michigan /5/2012 Added NEHEN Neighborhood Health Plans /5/2012 Added Three Rivers Health Plans (Unison Health Plan) /5/2012 Added Select Health Utah /5/2012 Added Deseret Mutual (DMBA) /5/2012 Added Better Health Plans /5/2012 Added Group Health Cooperative /1/2012 Added UPMC Health Plan , notes, updated date restrictions and updated maintenance times 8/1/2012 Added AmeriHealth Administrators /1/2012 Added Independence Administrators /1/2012 Added USAA Life Insurance Company /1/2012 Added Significa Benefit s /1/2012 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 2

14 Updated downtimes for GEHA, Medica, Cigna, UHC, Oxford Health Plan, QualChoice, MAMSI, AARP and 8/1/2012 Great West Added Priority Health /1/2012 Added Affinity Health Plan /1/2012 Removed Tax ID requirement for UMR- only 8/1/2012 Removed Tax ID requirement for Aetna- only 8/1/2012 Added new payer Neighborhood Health Plan (RI) /27/2012 Added Managed Health s WI /27/2012 Added Kentucky Spirit Health Plan /27/2012 Added Cenpatico WI 10634, TX 10633, SC 10573, OH 10572, MA10588, KY 10632, KS 10571, IN 8/27/ , IL 10631, GA 10569, FL 10568, AZ Added CeltiCare /27/2012 Added Buckeye Community Health /27/2012 Added Bridgeway Arizona /27/2012 Added Advantage by Superior Health Plan /27/2012 Added Advantage by Managed Health s /27/2012 Added Advantage by Buckeye Community Health Plan /27/2012 Added Advantage by Bridgeway Health Solutions /27/2012 Added Absolute Total Care /27/2012 Added new payer Meritain Health /27/2012 Added CarePlus Health Plan /28/2012 Added Fidelis Care New York /28/2012 Added Great-West /28/2012 Added University Physicians Healthcare Group Arizona /28/2012 Added University Family Care Arizona /1/2012 Added Maricopa Health Plan Arizona /1/2012 Principal Financial Group (Nippon Life) is now a parent plan under Nippon Life Benefits 10/1/2012 Added Scott & White Health Plan /2/2012 Added new payer Qualcare /2/2012 Removed payer Cenpatico Georgia database no longer available 11/2/2012 Added Superior Health Plan of Texas /2/2012 Added Harmony Health Plan /2/2012 Added MAMSI Health Plan 11/2/2012 Updated date option Ucare Minnesota /2/2012 Added new payer Alameda Alliance Health Plan /2/2012 Added note to subscriber ID section Sanford Health Plan /2/2012 Added New Payer LACare /2/2012 Added new payer Arbor Health Plan /2/2012 Removed payer Alameda Alliance Health Plan /16/2013 Updated search options for Geisinger Health Plan and Geisinger Health Plan Gold /20/2013 Added Tricare TRICR 2/20/2013 Added Coresource (MD/PA/IL/NC/IN/AZ/MN) 2/20/2013 Added Coresource (OH) 2/20/2013 Added Essence Healthcare /20/2013 Added MDWise Hoosier Alliance /20/2013 Removed Alameda Alliance Health Plan /20/2013 Reformatted/consolidated payer specific element and specific data requirements for each payer. Per ASC 2/27/2013 X12 standards, data elements designated in ASC X12 Implementation guides cannot be reprinted in payer specific guides. Added HealthSpring /03/2013 Removed SSN search option for Kaiser Foundation Health Plan for Mid-Atlantic States /03/2013 Updated Search options for Kaiser Permanente of Georgia /03/2013 Great West Healthcare deactivated due to Cigna merger 4/03/2013 Updated Cigna-GWH since merger with Great West Healthcare 4/03/2013 Removed payer Universal Healthcare /15/2013 Added Community Health Plan of Washington /17/2013 Added Best Choice Health Plans /17/2013 Added ConnectiCare /17/2013 Added Student Insurance /17/2013 Added CHAMPVA/Spina Bifida/Children of Women Vietnam Vets /6/2013 Added Providence Health Plan modified search options for /6/2013 Best Choice Health Plan removed SSN, DOB search option 12/6/2013 Community Health Plan of Washington 2641 modified search options, removed dependent search option 12/6/2013 Added United Healthcare of River Valley /6/2013 Reactivated Nova Healthcare Administrators /6/2013 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 3

15 Added CoventryCares of Kentucky /6/2013 Deactivated Mercy Health Care Plan 10465(split into payerid and 10449) 12/6/2013 Deactivated Kentucky Spirit Health Plan /6//2013 Corrected service type code for Select Health UTAH /6/2013 Modified search options for Independence Administrators /6/2013 Added additional search options USAA Life Insurance Co /6/2013 Updated Healthspring to reflect supported states TN, AL, MS, TX, AR, OK, WV & GA 12/6/2013 Modified search options for UMR Wausau /6/2013 Modified search options for HealthNet National /6/2013 Community Health Plan of Washington 2641 modified search options 12/17/2013 Correction: Deactivated Mercy Health Care Plan 10465(split into CHC payerid00184 and 10449) 12/17/2013 Added a note for USAA Life Insurance Company /17/2013 Updated 4010 / 5010 compatibility note 12/17/2013 Added Great American Life Insurance Co Medicare Supp /17/2013 Added Gateway Health Plan /17/2013 Added Schaller Anderson Parkland Community Health Plan /17/2013 Modified search options for Providence Health Plan /17/2013 Deactivated Santa Clara Valley Health and Hospital System /30/2014 Modified search options for Advantage by Superior Health Plan /30/2014 Added search option for CHAMPVA/Spina Bifida/Children of Women Vietnam Vets /30/2014 Added note to VIVA Health /30/2014 Added note to NEHEN Harvard Pilgrim Health Care /30/2014 Added Arizona Physicians IPA (APIPA) /30/2014 Updated AARP search option # 6- payer ID /30/2014 Added SPJST Medicare Supplement /30/2014 Added new payer Physicians Health Plan Northern IN (PHPNI) /30/2014 Added new payer MHNet Behavioral Health Payer ID /30/2014 Added new payer CAPROCK /30/2014 Modified search option for NEHEN Harvard Pilgrim Health Care under Coventry Healthcare 01/30/2014 Added Kitsap Physician s and Modified search options for Kitsap Physician s /30/2014 Modified Absolute Total Care (payer ID: 10560) 5010 search options effective immediately. 01/30/2014 Added new payer Centene-Magnolia Health Plan payer ID: /30/2014 Added new payer Easy Choice payer ID /30/2014 Added new payer Missouri Care payer ID /30/2014 Added new payer Med-Pay, Inc /30/2014 Added new payer Affinity Health Plan Medicare -: /28/2014 Added new payer AFLAC Medicare Supplemental /28/2014 Added new payer Benefit Management Inc /28/2014 Added new payer CDS Group Health /28/2014 Added new payer Health First Health Plan /28/2014 Added new payer Leon Medical Centers Health Plan /28/2014 Added new payer Lincoln Financial /28/2014 Added new payer Senior Health s Center Universal American Family of Companies /28/2014 Added new payer The Kempton Company /28/2014 Added new payer University Care Advantage Arizona /28/2014 Added new payer Mutual Health s /28/2014 Added new payer Panamerican Life Puerto Rico /28/2014 Added new payer Schaller Anderson Maryland Physicians Care /28/2014 Added new payer Schaller Anderson Mercy Care /28/2014 Added new payer Schaller Anderson Missouri Care /28/2014 Added new payer Schaller Anderson Texas CHRISTUS /28/2014 Modified search options for payer Cigna /28/2014 Added new payer Banner Health Plans /28/2014 Added new payer MedBen Newark OH /28/2014 Added Mississippi State Employees and Teachers /28/2014 Added new payer Celtic Insurance /28/2014 Added new payer CenterLight Healthcare /28/2014 Added new payer Consolidated Associates Railroad /28/2014 Added new payer Country Life Insurance Company /28/2014 Added new payer CTI Administrators /28/2014 Added new payer FCE Benefit Administrators Inc /28/2014 Added new payer Island Home Insurance /28/2014 Added new payer Kaiser Foundation Health Plan of Hawaii (DHMO Choice) /28/2014 Added new payer MAPFRE Medicare Excel /28/2014 Added new payer MAPFRE Life Puerto Rico /28/2014 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 4

16 Added new payer Medical Associates Health Plan/Health Choices /28/2014 Added new payer Molina Healthcare of Illinois /28/2014 Added new payer Municipal Health Benefit Fund /28/2014 Added new payer Network Health Plan of WI /28/2014 Added new payer Primary PhysicianCare Inc /28/2014 Added new payer Preferred Care Partners /28/2014 Added the following new payer for Delta Dental: 03/31/2014 Delta Dental Ins. Co. Alabama (10709) Delta Dental of Minnesota (10725) Delta Dental Ins. Co. Florida (10710) Delta Dental of Nebraska (10726) Delta Dental Ins. Co. Georgia (10711) Delta Dental of New Jersey (10727) Delta Dental Ins. Co. Louisiana (10712) Delta Dental of New Mexico (10728) Delta Dental Ins. Co. Mississippi (10713) Delta Dental of New York (10729) Delta Dental Ins. Co. Montana (10714) Delta Dental of North Carolina (10730) Delta Dental Ins. Co. Nevada (10715) Delta Dental of North Dakota (10731) Delta Dental Ins. Co. Texas (10716) Delta Dental of Ohio (10732) Delta Dental Ins. Co. Utah (10717) Delta Dental of Pennsylvania (10733) Delta Dental of California (10705) Delta Dental of Rhode Island (10734) Delta Dental of Colorado (10718) Delta Dental of Tennessee (10735) Delta Dental of Connecticut (10719) Delta Dental of Virginia (10736) Delta Dental of Delaware (10720) Delta Dental of Washington DC (10737) Delta Dental of Hawaii (10721) Delta Dental of Washington State (10738) Delta Dental of Indiana (10722) Delta Dental of West Virginia (10739) Delta Dental of Maryland (10723) DeltaCare USA Claims (10740) Delta Dental of Michigan (10724) DeltaCare USA Encounters (10741) Added the new payer Loomis Company /31/2014 Added the new payer Magellan Behavioral Health /31/2014 Added the new payer TMG Network Health Insurance /31/2014 Added the following new payers for Cenpatico: 03/31/2014 Cenpatico Behavioral Health Cenpatico Mississippi Cenpatico Behavioral Health Texas Cenpatico Missouri Cenpatico Georgia Cenpatico New Hampshire Added the following new payers for Centene: 03/31/2014 Centene Advantage by Peach State Centene- IlliniCare Health Plan Centene Advantage by Sunshine State Centene-Kentucky Spirit Health Plan Centene Advantage Plans Centene-Louisiana Healthcare Connections Centene-Coordinated Care Centene-Magnolia Health Plan Centene-California Health & Wellness Centene-Peach State Health Plan Centene Granite State Health Plan Centene-Sunflower State Health (Kansas) Centene-Home State Health Plan Added the new payer Carolina Care Plan, Inc. (CCP) /31/2014 Added the new payer Everence Financial /31/2014 Added the new payer Health Choice Insurance Company /31/2014 Added the new payer Windsor Health Plan /31/2014 Added the new payer BlueChoice Health Plan South Carolina Medicaid /31/2014 Added the new payer Centene Sunshine State Health Plan /31/2014 Added the new payer North Carolina Medicaid /31/2014 Added the following new payer for United Concordia (Dental): 03/31/2014 United Concordia Federal Employees Program Dental United Concordia Companies, Inc. Dental Added the new payer Florida Combined Life Dental /31/2014 Deactivated payer Windsor Health Plan /31/2014 Modified search options for payer Windsor Medicare Extra /31/2014 Modified search options for payer BlueChoice Health Plan South Carolina Medicaid /31/2014 Added the new payer Blue Benefit Administrators of Mass /31/2014 Added the new payer Care Improvement Plus /31/2014 Added the new payer Evercare /31/2014 Added the new payer GHI Group Health Incorporated /31/2014 Added the new payer HealthPlans Inc /31/2014 Added the new payer HealthPlan of Nevada /31/2014 Added the new payer Total Healthcare /31/2014 Added the new payer Cariten Senior Health /31/2014 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 5

17 Added the new payer Director s Guild /31/2014 Added information multiple STCs in the Specific data requirements and/or for payer Humana- 03/31/ Added the new payer HIPNY /31/2014 Added the new payer National Telecommunications Cooperative Association (NTCA) /31/2014 Added the new payer Sierra Health s /31/2014 Added the new payer VYTRA /31/2014 Added the following new payers for Dental: 03/31/2014 DeCare Dental Health Insurance Group Health Cooperative of South Central Wisconsin Dental Patriot Dental Brokers National Dental Employee Benefit s Dental Hawaii Medical Assurance Association Dental Altus Dental Dental Benefit Providers Guardian Life Insurance Co. of America Dental Healthsource Provident Dental Provident Preferred Network Dental UNICARE Dental Securian Dental Securian/Patriot Dental TennDent Hershey Healthsmile Dental Zenith Administrators (MN) Dental Wilson McShane Dental Alan Sturm and Associates Dental Flex Compensation Dental Added the new payer American Medical Security (AMS) /30/2014 Added the new payer AmeriHealth Caritas Pennsylvania /30/2014 Added the new payer Boon Group /30/2014 Added the new payer CarePoint Medicare Advantage /30/2014 Added the new payer Cox Health Plan /30/2014 Added the new payer Definity Health /30/2014 Added the new payer Florida True Health /30/2014 Added the new payer Health Share of Oregon /30/2014 Added the new payer Healthy Texas /30/2014 Added the new payer Integral Quality Care Florida /30/2014 Added the new payer Lifewise Arizona /30/2014 Added the new payer Louisiana Health Exchange /30/2014 Added the new payer MedStar Family Choice /30/2014 Added the new payer Molina Healthcare of South Carolina /30/2014 Added the new payer Piedmont Wellstar HealthPlans /30/2014 Added the new payer Preferred Health System of Kansas /30/2014 Added the new payer Premier Health /30/2014 Added the following new payers for Schaller Anderson: 04/30/2014 Schaller Anderson Aetna Better Health of New York Schaller Anderson Delaware Physicians, Inc Schaller Anderson MajestaCare VA Added the new payer Star HRG /30/2014 Added the new payer UnitedHealthcare Community Plan Kansas /30/2014 Added the new payer UnitedHealthcare Facets Detroit Community and State /30/2014 Added the new payer UnitedHealthcare Facets Pittsburgh Community and State /30/2014 Added the new payer UnitedHealthcare Nevada Market /30/2014 Added the new payer VA Healthcare /30/2014 Added the new payer Well Sense /30/2014 Added the new payer Bridgespan /30/2014 Deactivated payer Easy Choice /30/2014 Deactivated payer Health Choice Insurance Company /30/2014 Added the new payer Kentucky Health Exchange /30/2014 Added the new payer Fidelis SecureCare of Michigan /30/2014 Added the new payer Vantage Health Plan, Inc /30/2014 Reactivated payer Presbyterian Health Plan /30/2014 Added the new payer Central States Indemnity /30/2014 Added the new payer Gerber Life Insurance* /30/2014 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 6

18 Added the new payer Heartland National Life /30/2014 Added the new payer Ideal Life Insurance /30/2014 Added the new payer KSKJ Life /30/2014 Added the new payer Lincoln Heritage /30/2014 Added the new payer Puritan Life Insurance /30/2014 Added the new payer Royal Neighbors of America /30/2014 Added the new payer Shenandoah Life Insurance /30/2014 Added the new payer State Mutual Med Supp /30/2014 Added the new payer Sterling Investors Life Insurance /30/2014 Added the new payer Evergreen Health Co-Op /30/2014 Added the new payer IBM Insurance Outsourcing s /30/2014 Deactivated payer Heartland National Life /30/2014 Added the new payer Centene Total Care Carolina /30/2014 Added the new payer Bravo Health /30/2014 Added the new payer Bankers Life and Casualty /30/2014 Added the new payer Colonial Penn Life /30/2014 Added the new payer Washington National /30/2014 Added the new payer Evergreen Health Co-Op /30/2014 Added the new payer WPS Health Insurance /30/2014 Added the new payer TRICARE for Life /30/2014 Added the new payer FirstCare /30/2014 Added the new payer S and S Healthcare Strategies /30/2014 Added the new payer Covenant Administrators (TPA) /30/2014 Added the new payer Secure Health Plans of Georgia /30/2014 Added the new payer Oscar (NY) /30/2014 Added the new payer Piedmont (GA) /30/2014 Added the new payer NGS American /30/2014 Added the new payer Health Alliance Medical Plan (IL) /30/2014 Added the new payer Santa Clara Family Health Plan /30/2014 Added the new payer Arise Health Plan Medicare Select Policy /30/2014 Added the new payer Avera Health Plans /30/2014 Changed payer AmeriHealth Mercy Health Plan to AmeriHealth Caritas Pennsylvania /30/2014 Added the new payer Central California Alliance for Health /30/2014 Added the new payer Magnacare /30/2014 Updated payer Gilsbar 10-digit receiver ID 06/30/2014 Updated the (NM108=SV and the NM109 should be nine digits) for the following payers: 06/30/2014 Recall Systems Professional Benefits Administrators Recall Systems Underwriters Safety & Claims Added the new payer Schaller Anderson Aetna Better Health of OH /30/2014 Added the new payer Managed Health s Wisconsin /30/2014 Added the new payer Planned Administrators Inc /30/2014 Added the new payer University of Arizona Health Plan-UHM /30/2014 Added the new payer Ultimate Health Plans /30/2014 Deactivated payer Cariten Senior Health /31/2014 Added the new payer Automated Benefit s /31/2014 Added the payer Michigan MI Child /31/2014 Added the new payer CareSource Health /31/2014 Added the new payer MedCost Benefit s /31/2014 Added the new payer Aetna Administrator Medicare Supplement /31/2014 Added the new payer Aetna Better Health (IL) /31/2014 Added the new payer Aetna Better Health (PA) /31/2014 Added the new payer Aetna Better Health (TX) /31/2014 Added the new payer Aetna Better Health (TX) CHIP /31/2014 Added the new payer Aetna Senior Supplemental /31/2014 Added the new payer Allied Benefit Systems /31/2014 Added the new payer American Network Ins. Medicare Supplement /31/2014 Added the new payer Auxiant /31/2014 Added the new payer Bridgeway Arizona /31/2014 Added the new payer Butler Benefit s, Inc /31/2014 Added the new payer Capitol Administrators /31/2014 Added the new payer Central Senior Care /31/2014 Added the new payer Children s Mercy PCN /31/2014 Added the new payer CHP Direct /31/2014 Added the new payer Christian Brothers s /31/2014 Added the new payer CMFG Life Insurance /31/2014 Added the new payer Commerce Benefits Group /31/2014 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 7

19 Added the new payer Consumers Life /31/2014 Added the new payer Country Cupboard /31/2014 Added the new payer Delaware Physicians Care /31/2014 Added the new payer EPIC Life Insurance /31/2014 Added the new payer Evangelical Community Hospital /31/2014 Added the new payer First Medical Network /31/2014 Added the new payer Healthgram /31/2014 Added the new payer Heritage Physician Network (Houston) /31/2014 Added the new payer Humana CareSource (KY) /31/2014 Added the new payer Health Net National /31/2014 Added the new payer Health Plan of San Mateo /31/2014 Added the new payer IBEW Local 508 Health Plan /31/2014 Added the new payer Operating Engineers Local.428 Health and Welfare /31/2014 Added the new payer Food Employers & Bakery Confectionary Workers Benefit /31/2014 Added the new payer Triple-S Salud (BCBS Puerto Rico) /31/2014 Added the new payer Preferred Medicare Choice (PMC) (INMEDIATA HEALTH GROUP) /31/2014 Added the new payer Medicare y Mucho Mas (INMEDIATA HEALTH GROUP) /31/2014 Added the new payer Associacion De Maestros Puerto Rico /31/2014 Added the new payer VA Health Administration Center /31/2014 Added the new payer Advantage Health Solutions /31/2014 Added the new payer Health s for Children with Special Needs /31/2014 Added the new payer AFLAC /31/2014 Added the new payer Plan de Salud Hospital Menonita /31/2014 Added the new payer Orange County Fire Authority /31/2014 Added the new payer Medical Card System /31/2014 Added the new payer Peoples Health /31/2014 Added the new payer Prestige Health Choice /31/2014 Updated LACare to AmeriHealth Caritas Louisiana (LaCare) /31/2014 Changed payer name from United Healthcare Plan of River Valley to United Healthcare Plan 07/31/2014 River Valley Added the new payer Western Health Advantage /29/2014 Added the new payer AmeriHealth (DE, NJ, PA) /29/2014 Added the new payer Partners National Health Plans of NC /29/2014 Added the new payer Security Health Plan /29/2014 Added the new payer Leggett & Platt /29/2014 Deactivated payer Integral Quality Care Florida /9/2014 Changed search options payer Meritain Health /9/2014 Added the new payer Allegiance Benefit Plan Management /30/2014 Added the new payer Aetna Better Health (NE) /30/2014 Added the new payer United Healthcare SecureHorizons /30/2014 Added the new payer EBMS /30/2014 Added the new payer Senior Whole Health /30/2014 Added the new payer University of Utah Health Plans /31/2014 Added the new payer Paramount Health /31/2014 Deactivated payers Kaiser Foundation Health Plan of Ohio /31/2014 Updated search option 6 CareSource Health and change to CareSource Health (OH) /31/2014 Deactivated payers Windsor Medicare Extra /31/2014 Deactivated payers FCE Benefit Administrators Inc /31/2014 Corrected Delta Dental data requirements. 11/12/2014 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 8

20 4010 and 5010 Compatibility This Companion Guide documents only those connections which are currently available in end to end 5010 format. Submitters can send 5010 transactions to any of our payers from our existing 4010 Companion Guide, and our system will automatically convert to the necessary version. We will then return a 271 response matching the version you sent. Some payers have still not migrated to end to end Even if your software moves to a 5010 only platform, you can continue sending to those 4010 payers using the existing search types and 270 requirements until they complete their conversions. Enrollment and Data Collection While Xerox EDI Direct does not require enrollment of your providers with us, some payers do require special enrollment. For those payers you can work with our customer support team and they will step you through the process of getting your providers enrolled. You can contact them at egateway@xerox.com. We can provide a full list of those payers. Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 9

21 AARP Option Subscriber Last First Subscriber S2 Last Subscriber S3 First Subscriber S4 Subscriber S5 Last First Subscriber S6 Last First No No No and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID,S2,S5,S6,S3,S5,S6,S2,S3,S4,S5 Min = 10 Max= 12 Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Date of Birth,S2,S3,S4,S6 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 10

22 Absolute Total Care Option Subscriber Last First No No No and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 11

23 Advantage by BridgewayHealthSolutions Option Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth S2,S3 S2,S3,S3 Min/Max = 11 S2,S3 Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 12

24 Advantage by Buckeye Community Health Plan Option Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth S2,S3 S2,S3,S3 Min/Max = 11 S2,S3 Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 13

25 Advantage by Managed Health s Option Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth S2,S3 S2,S3,S3 Min/Max = 11 S2,S3 Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 14

26 Advantage by Superior Health Plan Option Subscriber Last First No No No and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth Min/Max = 11 Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 15

27 Advantage Health Solutions Option Subscriber Subscriber S2 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Subscriber Last Subscriber First Subscriber Subscriber S2 S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 16

28 Aetna Administrator Medicare Supplement Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM1 09 Last or Required. No Type and/or 1, 2, 3, 30, 33, 35, 47, 48, 50, 51, 52, 53, 73,76, 86, 88, 98, AL, BV, BY, DM, MH, and UC Federal Tax ID and/or Situational. No Situational. No Last First S2, S3 S2, S3,S2,D1,D2, S3 Dependent Dep. Last Dep. First Dep. Date of Birth D2,D3 D2,D3 D1, D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 17

29 Aetna AETNA Option Subscriber Subscriber S2 (CUMB ID) (HMO) Subscriber S3 (SSN) Subscriber S4 SSN Subscriber S5 Last First Subscriber S6 Employee ID Dependent D1 Sub: (CUMB ID) Dep: Dependent D2 Sub: (SSN) Dep: Dependent D3 Sub: SSN Dep: Dependent D4 Sub: Last Sub: First Dep: Last Dep: First Dependent D5 Sub: Employee ID Dep: 2 Years No Yes Disclaimer: Receipt of this information does not guaranty payment under state law. Should Provider wish to obtain verification that payment will be made, or if member information returned differs from Provider s patient records, call Aetna Member s. and/or AETNA = [NM108=PI]NM109 Last or Subscriber Last First (CUMB ID) Min/Max = 9 indicated. S5,D4 S5,D4,D1 Min=10 Max=12 Type Group Number and/or 2,3,4,5,6,8,9,10,12,13, 17,18,20,23,24,25,26,3 0,33,34,35,36,37,38,39,40,41,42,44,45,47,48, 50,51,52,53,57,59,60,6 1,62,65,66,68,69,73,74,75,76,78,79,80,81,82, 83,84,86,88,89,90,91,9 2,94,97,98,99,A0,A1,A 2,A4,A6,A7,A8,AB,AC, AD,AE,AF,G,AH,AI,AL, AM,AN,AO,BG,BH Optional. No notes indicated. and/or Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 18

30 (HMO) (SSN) Employee ID SSN Dependent Last First CUMB ID is for Non- HMO line of business. It will be identified on the ID card by a leading W; i.e. W Omit any dashes. S2 Min=8 Max=13 HMO Subscriber ID is captured via swipe, or if the ID is 8 digits with at least one alpha character, or if the card specifies HMO or POS. S3,D2 Min/Max=9 S6,D5 Min=1 Max=10 S4,D3,S3,S4,S5,S6 D4 D4 D1,D2,D3,D4,D5 Group Number Relations hip Optional. No notes indicated. 01,19,34 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 19

31 Aetna Better Health (NE) Option Subscriber Last First Subscriber S2 Last First Subscriber S3 Last First No End of current month No and/or = [NM108=PI]NM109 Last or Type and/or 30 and/or Situational. National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Last First,S2,S3,S2,S3,S2 Min=7 Max=10,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 20

32 Aetna Better Health (IL) Option Subscriber Subscriber S2 Last First 1 year No 90 Day Date Ranges Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 1, 30, 33, 35, 47, 48, 50, 52, 86, 88, 98, A4, AL, MH, and UC. Last First Required. No,S2.S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 21