Xerox EDI Eligibility Gateway 270/271 Payer Guide Commercial

Transcription

1 Xerox EDI Eligibility Gateway 270/271 Guide Commercial Version 4010 Technical Support: October 16, 2015

2 2015 Xerox Corporation. All rights reserved. Xerox and Xerox and Design are trademarks of Xerox Corporation in the United States and/or other countries. Other company trademarks are also acknowledged. Document Version: October 2015

3 Table of Contents Administrative Services, Inc Aetna Long Term Care AFLAC Dental Aftra Health Fund American National Insurance Company American National Life Insurance Company of Texas American Retirement Life Ins Co Medicare Supp AmeriChoice of New Jersey (Commercial) AMERIGROUP AMGRP... 9 Antares Best Choice Health Plan Best Life and Health Bluegrass Family Health Central Reserve Life Ins Co Medicare Supp Central States Fund CHAMPVA/Spina Bifida/Children of Women Vietnam Vets Community Care of Oklahoma Community Health First Medicare Advantage Community Health Plan of Washington (CHPW) ConnectiCare Continental General Ins Co Medicare Supp CSA Fraternal Live Medicare Supplement DakotaCare Emblem Health Essence Healthcare Fallon Community Health Plan Government Employees Hospital Association (GEHA) Great American Life Insurance Co Medicare Supp Group Practice Affiliates HEALTHe Exchange Health Plan of San Mateo HealthSpring Hometown Health Inland Empire Health

4 Inter Valley Health Plan Integrated Mental Health Services Loyal American Life Insurance Co Medicare Supp Key Benefits Administrators (IN) Managed Health Services Indiana MDWise Hoosier Alliance MedCost Benefit Services MEDST Medigold Health Plans Mercy Care Plan (Arizona) MetLife Dental Family Metropolitan Health Plan (MHP) Molina Healthcare of Washington MVP Health Care (New York) Nationwide Specialty Health NEHEN - Tufts Associated Health Plan NovaSys Health Partners National Health Plans of NC PARTN Partnership Health Plan of California Pittman and Associates Providence Health Plan Provident American Life & Health Ins Co Medicare Supp Public Employees Health Plan (PEHP) Qualchoice QuikTrip Corporation Rocky Mountain Health Plan San Joaquin Health Plan Special Agents Mutual Benefit Association Standard Life and Accident Insurance Company Student Insurance Sunshine State Health Plan TRICARE TRICR Union Pacific Railroad Employees Health Systems United Teacher Assoc Insurance Co Medicare Supp Universal Care of California VNS Choice WEA Trust WEB- TPA Wells Fargo Third Party Administrators, Inc Western Health Advantage

5 Revisions Maintenance Schedule... 92

6 Administrative Services, Inc S1 Member ID S2 SSN Date of Birth S3 Last Name First Name Date of Birth S4 Member ID Last Name First Name Date of Birth No ID R 5 5 AN Federal Tax ID S 9 9 AN NPI S N [NM108=FI] Last Name S3,S AN NM103 First Name S3,S AN NM104 Member ID S1,S AN SSN S2 9 9 N [REF01=SY] REF02 Date of Birth S2,S3,S4 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 1

7 Aetna Long Term Care S1 Member ID Last Name First Name Date of Birth Disclaimer: Receipt of this information does not guaranty payment under state law. Should wish to obtain verification that payment will be made, or if member information returned differs from s patient records, call Aetna Member Services. ID R 5 5 AN Federal Tax ID R 9 9 N NPI S N [NM108=FI] Last Name S AN NM103 First Name S AN NM104 Member ID S AN Date of Birth S1 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 2

8 AFLAC Dental S1 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, medical necessity and other limitations and or exclusions. ID R 5 5 AN Federal Tax ID R 9 9 N [NM108=FI] Last Name S AN NM103 First Name S AN NM104 Member ID S1,D AN Group Number O 1 30 AN [REF01=6P] REF02 Date of Birth S1 8 8 DT CCYYMMDD DMG02 Dependent Dependent Level: 2100D Last Name D AN NM103 First Name D AN NM104 Group Number O 1 30 AN [REF01=6P] REF02 Date of Birth D1 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 3

9 Aftra Health Fund S1 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, medical necessity and other limitations and or exclusions. No ID R 5 5 AN Federal Tax ID R 9 9 N [NM108=FI] Last Name S AN NM103 First Name S AN NM104 Member ID S1,D AN Group Number O 1 30 AN [REF01=6P] REF02 Date of Birth S1 8 8 DT CCYYMMDD DMG02 Dependent Dependent Level: 2100D Last Name D AN NM103 First Name D AN NM104 Group Number O 1 30 AN [REF01=6P] REF02 Date of Birth D1 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 4

10 American National Insurance Company S1 Member ID Date of Birth S2 Member ID Last Name First Name S3 Last Name First Name Date of Birth S4 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Date of Birth Dependent D2 Sub: Member ID Dep: First Name Dep: Last Name Dependent D3 Dep: Last Name Dep: First Name Dep: Date of Birth Dependent D4 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2, S3, S AN NM103 First Name S2, S3, S AN NM104 S1, S2, Member ID S4, D1, 2 80 AN D2, D4 Date of Birth S1, S3, 8 8 DT CCYYMMDD DMG02 S4 Dependent First Name D2, D3, D AN NM104 Last Name D2, D3, D AN NM103 Date of Birth D1, D3, D4 8 8 DT CCYYMMDD DMG02 Dependent Level: 2100D Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 5

11 American National Life Insurance Company of Texas S1 Member ID Date of Birth S2 Member ID Last Name First Name S3 Last Name First Name Date of Birth S4 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Date of Birth Dependent D2 Sub: Member ID Dep: First Name Dep: Last Name Dependent D3 Dep: Last Name Dep: First Name Dep: Date of Birth Dependent D4 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2, S3, S AN NM103 First Name S2, S3, S AN NM104 S1, S2, Member ID S4, D1, 2 80 AN D2, D4 Date of Birth S1, S3, 8 8 DT CCYYMMDD DMG02 S4 Dependent First Name D2, D3, D AN NM104 Last Name D2, D3, D AN NM103 Date of Birth D1, D3, D4 8 8 DT CCYYMMDD DMG02 Dependent Level: 2100D Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 6

12 American Retirement Life Ins Co Medicare Supp S1 Member ID S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth No ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 7

13 AmeriChoice of New Jersey (Commercial) Option Element 1 Element 2 Element 3 S1 Member ID S2 SSN Date of Birth S3 SSN Last Name First Name S4 Last Name First Name Date of Birth 1 Year 1 Year No ID R 5 5 AN Federal Tax ID R 9 9 N NPI S N [NM108=FI] Last Name S3,S AN NM103 First Name S3,S AN NM104 Member ID S1 9 9 AN Card Serial Number S 2 2 N 38 SSN S2,S3 9 9 N [REF01=GH] REF02 [REF01=SY] REF02 Use when card swipe. Date of Birth S2,S4 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 8

14 AMERIGROUP AMGRP S1 Member ID Date of Birth S2 Member ID Last Name First Name S3 Last Name First Name Date of Birth S4 Member ID Last Name First Name Date of Birth 2 years Yes No Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. ID R 5 5 AN AMGRP NPI S N Federal Tax ID S 9 9 N [NM108=FI] Either Tax ID or NPI is required Either Tax ID or NPI is required Last Name S2,S3,S AN NM103 First Name S2,S3,S AN NM104 Member ID S1,S2,S AN Group Number O 1 30 AN [REF01=6P] REF02 Date of Birth S1,S3,S4 8 8 DT CCYYMMDD DMG02 Service Type Code S 1 2 ID 30 EQ01 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 9

15 Antares S1 Member ID Date of Birth S2 Member ID Last Name First Name S3 Last Name First Name Date of Birth S4 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Date of Birth Dependent D2 Sub: Member ID Dep: Last Name Dep: First Name Dependent D3 Dep: Last Name Dep: First Name Dep: Date of Birth Dependent D4 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Xerox EDI Eligibility Gateway 270/ Guide Commercial 10

16 ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S3,S AN NM103 First Name S2,S3,S AN NM104 Member ID S1,S2,S4 D1,D2,D AN AHCCCS Medicaid ID Date of Birth S1,S2,S3,S4 8 8 DT CCYYMMDD DMG02 Service Type Code Dependent O 1 2 ID 30 EQ01 Last Name D2,D3,D AN NM103 First Name D2,D3,D AN NM104 Date of Birth D1,D2,D3,D4 8 8 DT CCYYMMDD DMG02 Gender O 1 1 ID M,F DMG03 Service Type R 1 2 ID 30 EQ01 Code Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Dependent Level: 2100D Xerox EDI Eligibility Gateway 270/ Guide Commercial 11

17 Best Choice Health Plan S1 Member ID Last Name First Name Date of Birth S2 Member ID Date of Birth S3 SSN Date of Birth S4 Last Name First Name Date of Birth Note: Only providers in the North Broward Hospital District can access this coverage. Note: For Dependent Searches, use the Employees Member ID with Dependents Name and Date of Birth, or Employees SSN and Dependents Date of Birth, as a subscriber search. No dependent loops are supported by this payer.. ID R 5 5 AN NPI R N Last Name S AN NM103 First Name S AN NM104 Member ID S1,S AN SSN S3 9 9 N [REF01=SY] REF02 Date of Birth S2 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 12

18 Best Life and Health S1 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth No ID R 5 5 AN Federal Tax ID R 9 9 N [NM108=FI] Last Name S AN NM103 First Name S AN NM104 Member ID S1,D AN Group Number O 1 30 AN [REF01=6P] REF02 Date of Birth S1 8 8 DT CCYYMMDD DMG02 Dependent Dependent Level: 2100D Last Name D AN NM103 First Name D AN NM104 Group Number O 1 30 AN [REF01=6P] REF02 Date of Birth D1 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 13

19 Bluegrass Family Health S1 Member ID Date of Birth S2 Member ID Last Name First Name S3 Last Name First Name Date of Birth S4 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Date of Birth Dependent D2 Sub: Member ID Dep: Last Name Dep: First Name Dependent D3 Dep: Last Name Dep: First Name Dep: Date of Birth Dependent D4 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth ID R 5 5 AN NPI R N Last Name S AN NM103 First Name S2,S3,S AN NM104 Member ID S1,S2,S4, D1,D2,D AN Date of Birth S1,S3,S4 8 8 DT CCYYMMDD DMG02 Service Type Code Dependent R 1 2 ID 30 EQ01 Dependent Level: 2100D Last Name D2,D3,D AN NM103 First Name D2,D3,D AN NM104 Date of Birth D1,D3,D4 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 14

20 Central Reserve Life Ins Co Medicare Supp S1 Member ID S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth No ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 15

21 Central States Fund S1 Member ID Date of Birth S2 Member ID Last Name First Name S3 SSN Date of Birth S4 Last Name First Name Date of Birth S5 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Date of Birth Dependent D2 Sub: Member ID Dep: Last Name Dep: First Name Dependent D3 Dep: SSN Dep: Date of Birth Dependent D4 Dep: Last Name Dep: First Name Dep: Date of Birth Dependent D5 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. Element Name Use Min Max Type Codes and Values Element Notes ID R 5 5 AN Federal Tax ID S 9 9 N ID S 2 20 AN NPI S N [NM108=FI] [NM108=SV] Last Name S2,S4,S AN NM103 First Name S2,S4,S AN NM104 Member ID S1,S2,S5 D1,D2,D AN SSN S3 9 9 N Group Number O 1 17 AN [REF01=SY] REF02 [REF01=6P] REF02 Date of Birth S1,S3,S4,S5 8 8 DT CCYYMMDD DMG02 Xerox EDI Eligibility Gateway 270/ Guide Commercial 16

22 Service Type Code O 1 2 ID 1,2,4,5,7,8,9,24,25,26,27,30,33 35,36,38,40,48,49,50,51,52,53 55,69,78,86,87,88,89,90,96,97 98,99,A0,A1,A2,A3,A4,A5,A6,A7 A8 EQ01 Dependent Dependent Level: 2100D Last Name D2,D4,D AN NM103 First Name D2,D4,D AN NM104 SSN D3 9 9 N [REF01=SY] REF02 Date of Birth D1,D3,D4,D5 8 8 DT CCYYMMDD DMG02 Service Type Code O 1 2 ID 1,2,4,5,7,8,9,24,25,26,27,30,33 35,36,38,40,48,49,50,51,52,53 55,69,78,86,87,88,89,90,96,97 98,99,A0,A1,A2,A3,A4,A5,A6,A7 A8 EQ01 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 17

23 CHAMPVA/Spina Bifida/Children of Women Vietnam Vets S1 Member ID Last Name First Name Date of Birth Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. ID R 5 5 AN Federal Tax ID R 9 9 N NPI S N [NM108=FI] Last Name S AN NM103 First Name S AN NM104 Member ID S AN Group Number O 1 30 AN [REF1=6P] REF02 Date of Birth S1 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 18

24 Community Care of Oklahoma S1 Member ID Date of Birth S2 Member ID Last Name First Name S3 Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Date of Birth Dependent D2 Sub: Member ID Dep: Last Name Dep: First Name Dependent D3 Dep: Last Name Dep: First Name Dep: Date of Birth Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. No ID R 5 5 AN Federal Tax ID R 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S2,D1,D AN Group Number O 1 30 AN [REF1=6P] REF02 Date of Birth S1,S3,D1,D3 8 8 DT CCYYMMDD DMG02 Service Type Code O 1 2 ID 30 EQ01 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 19

25 Community Health First Medicare Advantage S1 Member ID Last Name First Name Date of Birth S2 Member ID Date of Birth S3 SSN Date of Birth S4 SSN Last Name S5 Last Name First Name Date of Birth 1 year 60 days 60 days Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. ID R 5 5 AN NPI S N Federal Tax ID R 9 9 N [NM108=FI] Last Name S1,S4,S AN NM103 First Name S1,S AN NM104 Member ID S1,S AN SSN S3,S4 9 9 ID Group Number O 1 30 AN [REF1=6P] REF02 Date of Birth S1,S2,S4,S5 8 8 DT CCYYMMDD DMG02 Service Type Code O 1 2 ID 30 EQ01 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 20

26 Community Health Plan of Washington (CHPW) 2641 S1 Member ID Last Name First Name Date of Birth S2 Member ID Date of Birth S3 SSN Date of Birth S4 SSN Last Name S5 Last Name First Name Date of Birth 1 Year 60 Days 60 Days Notes: Data updated Monday morning, last day of the month. ID R 5 5 AN 2641 NPI R N Last Name S1,S3,S AN NM103 First Name S1,S AN NM104 Member ID S1,S AN SSN S3,S5 9 9 N [REF01=SY] REF02 Date of Birth S1,S2,S4,S5 8 8 DT CCYYMMDD DMG02 Service Type Code O 1 2 ID 30 EQ01 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 21

27 ConnectiCare S1 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Please Note: **If the patient is subscriber then the Member ID must be 11 digits long and end with 01. If the patient is dependent Member ID must be 11 digits and NOT end with 01 otherwise a AAA*64 response will be returned. **Any 7 digit member ID that begins with the number 1 is for the Medicare division of Connecticare. Our connection does not support eligibility for these Medicare patients ID R 5 5 AN NPI S N ID R 2 80 N [NM108=SV] Last Name S AN NM103 First Name S AN NM104 Member ID S1,D AN See note above Date of Birth S1 8 8 DT CCYYMMDD DMG02 Dependent Dependent Level: 2100D Last Name D AN NM103 First Name D AN NM104 Date of Birth D1 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 22

28 Continental General Ins Co Medicare Supp S1 Member ID S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth No ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 23

29 CSA Fraternal Live Medicare Supplement S1 Member ID S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth No ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 24

30 DakotaCare S1 Member ID S2 Member ID Last Name First Name S3 Member ID First Name Last Name Date of Birth S4 First Name Last Name Date of Birth Dependent D1 Sub: Member ID Dep: First Name Dep: Last Name ID R 5 5 AN NPI R N Last Name S2, S3, S AN NM103 First Name S2, S3, S AN NM104 S1, Member ID S2,S3, 2 20 AN D1 Date of Birth S3, S4 8 8 DT CCYYMMDD DMG02 Service Type Code R 1 2 ID 30 EQ01 Dependent Dependent Level: 2100D First Name D AN NM104 Last Name D AN NM103 Service Type Code R 1 2 ID 30 EQ01 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 25

31 Emblem Health S1 Member ID Last Name First Name Date of Birth 2 years 6 mos Yes ID R 5 5 AN NPI R N Last Name S AN NM103 First Name S AN NM104 Member ID S AN Date of Birth S1 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 26

32 Essence Healthcare S1 Member ID S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Service Type Code O 1 2 ID 4, 5, 7, 11, 12, 13, 14, 15, 16, 18, 19, 30, 34, 41, 42, 45, 48, 50, 53, 56, 58, 60, 62, 70, 71, 73, 75, 76, 77, 78, 79, 80, 81, 86, 88, 90, 94, 98, A7, A8, AD, AE, AF, AI, AJ, AK, AM, AN, AO EQ01 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 27

33 Fallon Community Health Plan S1 ID Card Number Date of Birth S2 Member ID Date of Birth Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. Note: Fallon returns eligibility information for contracted (in-network) providers only. Non-contracted providers should contact the payer directly at ( Relations) or go to the payer s website at No ID R 5 5 AN Federal Tax ID R 9 9 N NPI S N ID Card Number S AN Member ID S AN Group Number O 1 30 AN [NM108=FI] [REF01=6P] REF02 For POS systems mainly Date of Birth S1, S2 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Government Employees Hospital Association (GEHA) Xerox EDI Eligibility Gateway 270/ Guide Commercial 28

34 Element 5 S1 Member ID Last Name First Name Date of Birth Gender Dependent D1 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Dep: Gender Yes ID R 5 5 AN Federal Tax ID R 9 9 N NPI S N [NM108=FI] Last Name S AN NM103 First Name S AN NM104 Member ID S1 8 9 AN Date of Birth S1 8 8 DT CCYYMMDD DMG02 Gender S1 1 1 ID M,F DMG03 Dependent Dependent Level: 2100D Last Name D AN NM103 First Name D AN NM104 Date of Birth D1 8 8 DT CCYYMMDD DMG02 Gender D1 1 1 ID M,F DMG03 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Great American Life Insurance Co Medicare Supp Xerox EDI Eligibility Gateway 270/ Guide Commercial 29

35 S1 Member ID S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth No ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 30

36 Group Practice Affiliates Option Element 1 Element 2 Element 3 S1 Member ID S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 31

37 HEALTHe Exchange Option Element 1 S1 Member ID Date of Birth S2 Member ID Last Name First Name S3 SSN Date of Birth S4 Last Name First Name Date of Birth S5 Member ID Last Name First Name Date of Birth No ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name First Name Date of Birth Member ID S2, S4, S5 S2, S4, S5 S1, S3, S4, S5 S1, S2, S AN NM AN NM DT CCYYMMDD DMG AN SSN S3 9 9 N Service Type Code O 1 2 ID See list below EQ01 [REF01=SY] REF02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 32

38 Health Plan of San Mateo 4758 S1 Member ID Last Name First Name Date of Birth S2 Member ID Date of Birth S3 Last Name First Name Date of Birth 1 Year 60 Days 60 Days Notes: Updates every Monday after 6pm ID R 5 5 AN 4758 NPI S N ID R 2 80 AN [NM108=SV] Last Name S1,S AN NM103 First Name S1,S AN NM104 Member ID S1,S AN Date of Birth S1,S2,S3 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 33

39 HealthSpring S1 Member ID Last Name First Name Date of Birth No ID R 5 5 AN NPI R N Last Name S AN NM103 First Name S AN NM104 Member ID S AN Date of Birth S1 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 34

40 Hometown Health 3597 S1 Member ID Last Name First Name Date of Birth S2 Member ID Date of Birth S3 Last Name First Name Date of Birth 1 Year 60 Days 60 Days Notes: Data updated daily. ID R 5 5 AN 3597 NPI S N ID R 2 80 AN [NM108=SV] Last Name S1,S AN NM103 First Name S1,S AN NM104 Member ID S1,S AN Date of Birth S1,S2,S3 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 35

41 Inland Empire Health 1081 Option Element 1 Element 2 Element 3 S1 Member ID Date of Birth S2 Member ID S3 SSN Date of Birth S4 Last Name First Name Date of Birth 1 Year No No ID R 5 5 AN 1081 ID S 2 80 AN NPI S N [NM108=SV] Last Name S AN NM103 First Name S AN NM104 Member ID S1,S AN SSN S3 9 9 N [REF01=SY] REF02 Date of Birth S1,S3,S4 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 36

42 Inter Valley Health Plan 1052 Option Element 1 Element 2 Element 3 S1 Member ID Date of Birth S2 Member ID S3 SSN Date of Birth S4 Last Name First Name Date of Birth 1 Year No No ID R 5 5 AN 1052 ID S 2 80 AN NPI S N [NM108=SV] Last Name S AN NM103 First Name S AN NM104 Member ID S1,S AN SSN S3 9 9 N [REF01=SY] REF02 Date of Birth S1,S3,S4 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 37

43 Integrated Mental Health Services Option Element 1 Element 2 Element 3 S1 Member ID S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 38

44 Loyal American Life Insurance Co Medicare Supp S1 Member ID S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth No ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 39

45 Key Benefits Administrators (IN) S1 Member ID Date of Birth S2 Member ID Last Name First Name S3 SSN Date of Birth S4 Last Name First Name Date of Birth S5 Member ID Last Name First Name Date of Birth Dependent D1 Member ID Dep. Date of Birth Dependent D2 Member ID Dep. Last Name Dep. First Name Dependent D3 Dep. SSN Dep. First Name Dep. Date of Birth Dependent D4 Dep. Last Name Dep. First Name Dep. Date of Birth Dependent D5 Member ID Dep. Last Name Dep. First Name Dep. Date of Birth Xerox EDI Eligibility Gateway 270/ Guide Commercial 40

46 Element Name Use Min Max Type Codes and Values Element Notes ID R 5 5 AN ID S 2 80 N NPI S N [NM108=SV] Last Name S2,S4,S AN NM103 First Name S2,S4,S AN NM104 Member ID S1,S2,S5,D1,D2,D AN Date of Birth S4 8 8 DT CCYYMMDD DMG02 Service Type Code Dependent O 1 2 ID 30 EQ01 Last Name D2,D4,D AN NM103 First Name D2,D3,D4,D AN NM104 Date of Birth D1,D3,D4,D5 8 8 DT CCYYMMDD DMG02 Service Type Code O 1 2 ID 30 EQ01 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Dependent Level: 2100D Xerox EDI Eligibility Gateway 270/ Guide Commercial 41

47 Managed Health Services Indiana Option Element 1 Element 2 Element 3 S1 Member ID S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 42

48 MDWise Hoosier Alliance S1 Member ID S2 SSN S3 Last Name First Name Date of Birth S4 Member ID Last Name First Name Date of Birth No ID R 5 5 AN ID S 5 12 AN NPI S N [NM108=SV] Last Name S3,S AN NM103 First Name S3,S AN NM104 Member ID S1,S N SSN S2 9 9 N [REF01=SY] REF02 Date of Birth S3,S4 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 43

49 MedCost Benefit Services MEDST S1 Member ID S2 Member ID Date of Birth S3 Member ID Last Name First Name Date of Birth S4 Last Name First Name Date of Birth S5 SSN Date of Birth Dependent D1 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Dependent D2 Sub: Member ID Dep: Date of Birth 1 year No No ID R 5 5 AN MEDST ID S 2 80 N NPI S N [NM108=SV] Last Name S AN NM103 First Name S AN NM104 Member ID S1,D AN Date of Birth S2 8 8 DT CCYYMMDD DMG02 Dependent Dependent Level: 2100D Last Name D AN NM103 First Name D AN NM104 Date of Birth D1 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 44

50 Medigold Health Plans S1 Last Name First Name Member ID Date of Birth No No No ID R 5 5 AN ID R 2 9 N [NM108=SV] Last Name S AN NM103 First Name S AN NM104 Member ID S AN Date of Birth S2 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 45

51 Mercy Care Plan (Arizona) Option Element 1 Element 2 Element 3 S1 Member ID Family Unit Number S2 Last Name First Name Date of Birth 1 Year No No ID R 5 5 AN ID R 2 9 N [NM108=SV] Last Name S AN NM103 First Name S AN NM104 Member ID S AN Family Unit Number S1 2 2 N [REF01=49] REF02 Date of Birth S2 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 46

52 MetLife Dental Family Element 5 S1 S2 Dependent D1 Employee ID SSN Sub: Employee ID Dep: Last Name Dep: First Name Dependent D2 Sub: SSN Dep: Last Name Dep: First Name Dep: Date of Birth Dep: Date of Birth Dep: Relationship Dep: Relationship Disclaimer: Eligibility is not a guarantee of coverage as actual benefit payments are determined only when a claim is adjudicated. Alternate Disclaimer for Alternate Treatment Provision: If MetLife determines that a less costly service than the covered service performed by a dentist, could have been performed to treat a dental condition, MetLife may pay benefits based upon the less costly service if such service 1) would produce a professionally acceptable result under generally accepted dental standards, and 2) would qualify as a covered service. If MetLife pays a benefit it based upon a less costly service, the dentist may charge a patient or a patient's dependent for the difference between the service that was performed and the less costly service. This may be the case, even if the service is performed by an in-network dentist. A pretreatment estimate is recommended before the start of extensive dental treatment such as crowns, veneers, bridgework, implants, orthodontics, and periodontal services. If truncation occurs: More information is available than can be returned in real-time mode. For additional dental benefit information, please contact MetLife at or at No Xerox EDI Eligibility Gateway 270/ Guide Commercial 47

53 ID R 5 5 AN Federal Tax ID R 9 9 N NPI R N PPO Indicator R 1 1 N 1 = Request for In Plan Network 0 = Request for Out of Plan Network [NM108=FI] [REF01=N5] REF02 Both NPI and Tax ID required Both NPI and Tax ID required Last Name R 1 20 AN NM103 First Name R 1 12 AN NM104 Employee ID S1,D1 9 9 AN SSN S2,D2 9 9 N Group Number O 1 30 AN [REF01=A6] REF02 [REF01=SY] REF02 [REF01=6P] REF02 Dependent Dependent Level: 2100D Last Name D1,D AN NM103 First Name D1,D AN NM104 SSN O 9 9 N Group Number O 1 30 AN Relationship D1,D2 2 2 N 01 = Spouse 19 = Child [REF01=SY] REF02 [REF01=6P] REF02 [INS01=N] INS02 Date of Birth D1,D2 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 48

54 Metropolitan Health Plan (MHP) 2548 S1 Member ID Last Name First Name Date of Birth S2 Member ID Date of Birth S3 Member ID Last Name Date of Birth S4 Member ID First Name Date of Birth S5 Last Name First Name Date of Birth Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. No ID R 5 5 AN 2548 NPI R N Last Name S AN NM103 First Name S AN NM104 Member ID S AN Group Number O 9 9 N [REF01=6P] REF02 Date of Birth S1 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 49

55 Molina Healthcare of Washington S1 Member ID Last Name First Name Date of Birth S2 Medicaid Recipient ID Last Name First Name Date of Birth S3 Member ID Date of Birth S4 Medicaid Recipient ID Date of Birth S5 SSN Date of Birth S6 SSN Last Name S7 Last Name First Name Date of Birth Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. 1 Year No No Xerox EDI Eligibility Gateway 270/ Guide Commercial 50

56 ID R 5 5 AN NPI R N Last Name S1,S3,S6,S AN NM103 First Name S1,S2,S AN NM104 Member ID S1,S AN Medicaid Recipient ID S2,S4 SSN S5, S6 Group Number O 1 30 AN [REF01=6P] REF02 Date of Birth S1,S2,S4,S5,S7 8 8 DT CCYYMMDD DMG02 Service Type Code O 1 2 ID 30 EQ01 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 51

57 MVP Health Care (New York) S1 Member ID Last Name First Name Date of Birth S2 Member ID Last Name Date of Birth S3 Member ID Last Name First Name Note: MVP Preferred Care is not included and any member ID s not beginning with 8 are not going to be matched or returned. Yes ID R 5 5 AN Federal Tax ID R 9 N N [NM108=FI] Last Name S AN NM103 First Name S AN NM104 Member ID S AN Group Number O 1 30 AN [REF01=6P] REF02 Date of Birth S1 8 8 DT CCYYMMDD DMG02 Service Type Code O 1 2 ID 1, 30, 35 EQ01 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 52

58 Nationwide Specialty Health Option Element 1 Element 2 Element 3 S1 Member ID Date of Birth S1 First Name Last Name Date of Birth ID R 5 5 AN Federal Tax ID S 9 N N NPI S N [NM108=FI] Last Name S AN NM103 First Name S AN NM104 Member ID S AN Date of Birth S1,S2 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 53

59 NEHEN - Tufts Associated Health Plan Element 5 S1 Member ID Date of Birth S2 Last Name First Name Date of Birth No No Notes: New England Health EDI Network ID R 5 5 AN NPI R N Last Name S AN NM103 First Name S AN NM104 Gender S1 1 1 ID M,F DMG03 Gender Member ID S AN Date of Birth S1 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 54

60 NovaSys Health S1 Member ID Last Name First Name Date of Birth S2 SSN Last Name First Name Date of Birth ID R 5 5 AN NPI R N Last Name S1,S AN NM103 First Name S1,S AN NM104 Member ID S AN SSN S2 Date of Birth S1,S2 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 55

61 Partners National Health Plans of NC PARTN Option Element 1 Element 2 Element 3 S1 Member ID Last Name First Name S2 Last Name First Name Date of Birth 1 Year No No ID R 5 5 AN PARTN ID S 2 80 AN NPI S N [NM108=SV] Last Name S AN NM103 First Name S AN NM104 Member ID S AN Date of Birth S2 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 56

62 Partnership Health Plan of California 1035 Option Element 1 Element 2 Element 3 S1 Member ID Date of Birth S2 Member ID S3 SSN Date of Birth S4 Last Name First Name Date of Birth 1 Year No No ID R 5 5 AN 1035 ID S 2 80 AN NPI S N [NM108=SV] Last Name S AN NM103 First Name S AN NM104 Member ID S1,S AN SSN S3 9 9 N [REF01=SY] REF02 Date of Birth S1,S3,S4 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 57

63 Pittman and Associates S1 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth No ID R 5 5 AN Federal Tax ID R 9 9 N Social Security Number R 9 9 N ID R 2 20 AN NPI R N [NM108=FI] Last Name S AN NM103 First Name S AN NM104 Member ID S1,D AN Date of Birth S1 8 8 DT CCYYMMDD DMG02 [NM108=34] [NM108=SV] Dependent Dependent Level: 2100D Last Name D AN NM103 First Name D AN NM104 Date of Birth D1 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 58

64 Providence Health Plan 2598 S1 Member ID S2 Last Name First Name Date of Birth S3 Last Name First Name Middle Name Date of Birth 18 Months No No ID R 5 5 AN 2598 ID R 2 80 AN NPI S N [NM108=SV] Last Name S2,S AN NM103 First Name S2,S AN NM104 Middle Name S AN NM105 Member ID S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 59

65 Provident American Life & Health Ins Co Medicare Supp S1 Member ID S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth No ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 60

66 Public Employees Health Plan (PEHP) S1 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. Yes ID R 5 5 AN Federal Tax ID R 9 9 N [NM108=FI] Last Name S AN NM103 First Name S AN NM104 Member ID S1,D AN Date of Birth S1 8 8 DT CCYYMMDD DMG02 Service Type Code O 1 2 ID Dependent 2, 4, 5, 7, 12, 18, 33, 35, 42, 48, 50, 52, 54, 56, 59, 69, 80, 82, 86, 88, 98, A4, AD, AE, AI, AL EQ01 Last Name D AN NM103 First Name D AN NM104 Date of Birth D1 8 8 DT CCYYMMDD DMG02 Service Type Code O 1 2 ID 2, 4, 5, 7, 12, 18, 33, 35, 42, 48, 50, 52, 54, 56, 59, 69, 80, 82, 86, EQ01 88, 98, A4, AD, AE, AI, Usage: AL R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Dependent Level: 2100D Xerox EDI Eligibility Gateway 270/ Guide Commercial 61

67 Qualchoice S1 Member ID First Name Date of Birth Dependent D1 Sub: Member ID Dep: First Name Dep: Date of Birth ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] First Name S AN NM104 Member ID S1,D AN Date of Birth S1, 8 8 DT CCYYMMDD DMG02 Dependent Dependent Level: 2100D First Name D AN NM104 Date of Birth D1 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 62

68 QuikTrip Corporation S1 Member ID Date of Birth S2 Member ID S3 Member SSN Date of Birth S4 Last Name First Name Date of Birth S5 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Date of Birth Dependent D2 Sub: Member ID Dep : Last Name Dep : First Name Dependent D3 Dep: SSN Dep: Date of Birth Dependent D4 Dep: Last Name Dep: First name Dep: Date of Birth Dependent D5 Sub: Member ID Dep: Last Name Dep: First name Dep: Date of Birth Xerox EDI Eligibility Gateway 270/ Guide Commercial 63

69 ID R 5 5 AN Federal Tax ID R 9 9 N NPI S N [NM108=FI] Either Tax ID or NPI is required Either Tax ID or NPI is required Last Name S2,S4,S AN NM103 First Name S2,S4,S AN NM104 Member ID S1,S2,S5 D1,D2,D AN Member SSN S3 Date of Birth S1,S3,S4 S5 8 8 DT CCYYMMDD DMG02 Dependent Dependent Level: 2100D Last Name D2,D4,D AN NM103 First Name D2,D4,D AN NM104 Dependent SSN Date of Birth D3 D1,D3,D4 D5 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 64

70 Rocky Mountain Health Plan Option Element 1 Element 2 Element 3 S1 Member ID S2 Medicaid ID S3 Last Name First Name Date of Birth 1 Year No No Note: Our payer intermediary will be transitioning this payer to a new connection with an estimated implementation date of 06/30/2015. As a result, we will not be accepting any new Rocky Mountain Health Plan enrollments at this time. s who are currently enrolled with Rocky Mountain Health Plan will see no interruption in the ability to submit eligibility transactions today. Once the new connection has been established, the acceptance of new enrollment requests will be reinstated. ID R 5 5 AN ID S AN NPI S N [NM108=SV] Last Name S AN NM103 First Name S AN NM104 Member ID S AN Medicaid ID S2 7 7 AN [REF01=NQ] REF02 Date of Birth S3 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 65

71 San Joaquin Health Plan 1046 S1 Member ID Last Name First Name Date of Birth 2 Member ID Date of Birth S3 Last Name First Name Date of Birth 1 Year No No ID R 5 5 AN 1046 NPI S N Last Name S1,S AN NM103 Full name required First Name S1,S AN NM104 Full name required Member ID S1,S AN Date of Birth S1,S2,S3 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 66

72 Special Agents Mutual Benefit Association S1 Member ID Date of Birth S2 Member ID Last Name First Name S3 Last Name First Name Date of Birth S4 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Date of Birth Dependent D2 Sub: Member ID Dep: Last Name Dep: First Name Dependent D3 Dep: Last Name Dep: First Name Dep: Date of Birth Dependent D4 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Disclaimer: This verification is not a guarantee of benefits. All claims are subject to review. We cannot determine if a claim is considered eligible until a claim is received and our investigation is complete. All claims are subject to the contract provisions, exclusions, and limitations. ID R 5 5 AN NPI S N Federal Tax ID S 9 9 N Last Name S2, S3, S AN NM103 First Name S2, S3, S AN NM104 Member ID S1,S2, S4, D1, D2, D AN [NM108=FI] Date of Birth S1, S3, S4 8 8 DT CCYYMMDD DMG02 Service Type O 1 2 ID 30 EQ01 Code Dependent Dependent Level: 2100D Last Name D1, D3, 1 35 AN NM103 D4 First Name D1, D2, 1 25 AN NM104 D4 Date of Birth D1, D3, 8 8 DT CCYYMMDD DMG02 D4 Service Type O 1 2 ID 30 EQ01 Code Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 67

73 Standard Life and Accident Insurance Company S1 Member ID Date of Birth S2 Member ID Last Name First Name S3 Last Name First Name Date of Birth S4 Member ID Last Name First Name Date of Birth ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S3,S AN NM103 First Name S2,S3,S AN NM104 Member ID S1,S2,S AN Date of Birth S1,S3,S4 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 68

74 Student Insurance S1 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. No ID R 5 5 AN Federal Tax ID R 9 9 N [NM108=FI] Last Name S AN NM103 First Name S AN NM104 Member ID S1,D AN Group Number O 1 30 AN [REF01=6P] REF02 Date of Birth S1 8 8 DT CCYYMMDD DMG02 Dependent Last Name D AN NM103 First Name D AN NM104 Group Number O 1 30 AN [REF01=6P] REF02 Date of Birth D1 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Dependent Level: 2100D Xerox EDI Eligibility Gateway 270/ Guide Commercial 69

75 Sunshine State Health Plan S1 Member ID Date of Birth S2 Member ID S3 Last Name First Name Date of Birth 1 Year No No ID R 5 5 AN ID S 2 80 AN NPI S N [NM108=SV] Last Name S AN NM103 First Name S AN NM104 Member ID S1,S AN SSN 9 9 N [REF01=SY] REF02 Date of Birth S1,S3 8 8 DT CCYYMMDD DMG02 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 70

76 TRICARE TRICR S1 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth **Note- Tricare recommends sending SSN in a Ref segment for a better chance of getting a hit.** Yes ID R 5 5 AN TRICR NPI S N Last Name S AN NM103 First Name S AN NM104 Member ID S1,D1 9 9 AN SSN S1 9 9 N [REF01=SY] REF02 Date of Birth S1 8 8 DT CCYYMMDD DMG02 Member ID is the SSN or First 9 digits of DoD ID number and (DBN if applicable) Dependent Dependent Level: 2100D Last Name D AN NM103 First Name D AN NM104 Date of Birth D1 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 71

77 Union Pacific Railroad Employees Health Systems Option Element 1 Element 2 Element 3 S1 Member ID S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 72

78 United Teacher Assoc Insurance Co Medicare Supp S1 Member ID S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth No ID R 5 5 AN Federal Tax ID S 9 9 N NPI S N [NM108=FI] Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 73

79 Universal Care of California 1054 S1 Member ID Last Name First Name Date of Birth S2 Member ID Date of Birth S3 SSN Date of Birth 4 Last Name First Name Date of Birth 1 Year No No ID R 5 5 AN 1054 NPI S N Last Name S AN NM103 Full name required First Name S AN NM104 Full name required Member ID S AN SSN S2 9 9 N [REF01=SY] REF02 Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 74

80 VNS Choice S1 Member ID Date of Birth S2 Last Name First Name Date of Birth S3 Member ID Last Name First Name Date of Birth 2 Years Yes No Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has been received and reviewed in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. ID R 5 5 AN Federal Tax ID S 9 9 N National Identifier (NPI) S N [NM108=FI] Either Tax ID or NPI is required. Either Tax ID or NPI is required. Last Name S2,S AN NM103 First Name S2,S AN NM104 Member ID S1,S AN Date of Birth S1,S2, S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 75

81 WEA Trust S1 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Sub: Last Name Sub: First Name Dep: Last Name Dependent D1 (con t) Dep: First Name Dep: Date of Birth No ID R 5 5 AN NPI R N Last Name S1,D AN NM103 First Name S1,D AN NM104 Member ID S1,D AN Date of Birth S1 8 8 DT CCYYMMDD DMG02 Service Type Code Dependent Dependent Level: 2100D O 1 2 ID 30 EQ01 Last Name D AN NM103 First Name D AN NM104 Date of Birth D1 8 8 DT CCYYMMDD DMG02 Service Type Code Usage: Data Type: O 1 2 ID 30 EQ01 R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 76

82 WEB- TPA S1 Member ID DOB S2 Member ID Last Name First Name S3 SSN DOB S4 Last Name First Name Date of Birth S5 Member ID Last Name First Name Date of Birth Dependent D1 Sub: Member ID Dep: Date of Birth Dependent D2 Sub: Member ID Dep: Last Name Dep: First Name Dependent D3 Dep: SSN Dep: Date of Birth Dependent D4 Dep: Last Name Dep: First Name Dep: Date of Birth Dependent D5 Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth No Xerox EDI Eligibility Gateway 270/ Guide Commercial 77

83 ID R 5 5 AN Federal Taxpayer s ID R 9 9 N NPI R N [NM108=FI] Last Name S2, S4,S AN NM103 First Name S2, S4,S AN NM104 Member ID S1, S2, S4, S5, D1, D2, D AN SSN S3 9 9 N [REF01=SY] REF02 Date of Birth S1,S3, S5 8 8 DT CCYYMMDD DMG02 Service Type Code Dependent Dependent Level: 2100D Last Name First Name O 1 2 ID 30 EQ01 D2, D4, D5 D2, D4, D5 SSN D3 9 9 N Date of Birth Service Type Code Usage: Data Type: D1, D3, D4, D AN NM AN NM104 [REF01=SY] REF DT CCYYMMDD DMG02 O 1 2 ID 30 EQ01 R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 78

84 Wells Fargo Third Party Administrators, Inc Option Element 1 Element 2 S1 Member ID Date of Birth 1 Year No No Notes: (CHIPS/PEIA) Formerly - (Acordia National - CHIPS/PEIA) ID R 5 5 AN ID R 2 80 AN NPI S N Member ID S AN [NM108=SV] Date of Birth S1 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 79

85 Western Health Advantage 1043 Option Element 1 Element 2 Element 3 S1 Member ID S2 SSN Date of Birth S3 Last Name First Name Date of Birth 1 Year No No ID R 5 5 AN 1043 ID S 2 80 AN NPI S N [NM108=SV] Last Name S AN NM103 First Name S AN NM104 Member ID S AN SSN S2 9 9 N [REF01=SY] REF02 Date of Birth S2,S3 8 8 DT CCYYMMDD DMG02 Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 270/ Guide Commercial 80

86 Date Revisions Changes 12/26/07 Change search options for Partners National 2/1/08 Added NPI and ID info to Tricare 2/1/08 Removed 2 recall payers 2/6/08 Added search options to Health Partners of Philadelphia 2/19/08 Removed Coresource AZ/MN. As of 1/2/08 they have been discontinued. 2/25/08 Added dependent search options for MVP Healthcare 2/26/08 Field definitions added for Health Partners 3/6/08 Added provider ID to Better Health and Three Rivers 3/6/08 Added search options for Community Care of OK 3/11/08 Corrected payer name from Start to Star 3/11/08 Added payer AmeriHealth Administrators 3/12/08 Added payer Community Health First Medicare Advantage 3/12/08 Added aka to Great West 3/12/08 Move Carefirst Federal to the Blues guide 3/12/08 Added payer Independence Administrators 3/13/08 Added search options for Molina Healthcare of Washington 4/7/08 Removed ID only search for San Joaquin and now only accepting NPI 4/7/08 Removed ID only search for Universal Care of CA and now only accepting NPI 4/9/08 Added search types to Molina of Washington 4/15/08 Mutual of Omaha has been removed. 4/23/08 Added potential payer list to the end of the guide 4/24/08 Mutual of Omaha has been added back 4/30/08 John Hopkins added NPI 5/19/08 Health Alliance added NPI 5/19/08 Humana corrected service date information 5/19/08 Preferred Health System added NPI 5/20/08 Coresource FMH,OH,NC,IN,MD,PA,IL,Little Rock added NPI 5/23/08 Wells Fargo added NPI 5/23/08 UPMC NPI only now 5/23/08 University Family Care added NPI 5/23/08 Unity Health Plans NPI only now 5/23/08 UHC of River Valley added NPI 5/23/08 Ucare of MN NPI only now 5/23/08 Trustmark added NPI 5/23/08 AvMed added NPI 5/23/08 Ameritas- ALL added NPI 5/23/08 Metlife NPI and Tax ID required 5/23/08 SummaCare NPI only now 5/23/08 Scott and White NPI only now 5/23/08 Providence added NPI 5/23/08 Priority Healthcare Choices NPI only now 5/23/08 Preferred One added NPI 5/23/08 Preferred Health removed NPI 5/23/08 Phoenix added NPI Xerox EDI Eligibility Gateway 270/ Guide Commercial 81

87 5/23/08 Pacificare ALL HMO and POS added NPI 5/23/08 Pacific Source NPI only now 5/27/08 Tufts NPI only now 5/27/08 Harvard Pilgrim NPI only now 5/27/08 Molina of WA NPI only now 5/27/08 Medicare NPI only now 5/27/08 Columbia United NPI only now 5/27/08 Kitsap added NPI 5/27/08 Kaiser Permenente of S CA added NPI 5/27/08 Jackson Memorial added NPI 5/27/08 MS State Employees added NPI 5/28/08 Humana of FL added NPI 5/28/08 Health Partners NPI only now 5/28/08 Health Choice AZ added NPI 5/28/08 Health Alliance NPI only now 5/28/08 Great West added NPI 5/29/08 Fallon Group added NPI 5/29/08 Federated Insurance added NPI 5/29/08 Community HP of WA NPI only now 5/29/08 Community Care of OK added NPI 5/29/08 CareSource added NPI 5/29/08 HealthPlus of MI NPI only now 5/29/08 Best Choice NPI only now 5/30/08 AZ Physicians IPA added NPI 5/30/08 AmeriHealth Mercy NPI only now 5/30/08 Amerihealth Admin NPI only now 5/30/08 AMC Only s added NPI 5/30/08 Aetna LTC added NPI 6/6/08 Tricare added NPI 6/17/08 Removed CHA KY 6/24/08 Independence Admin NPI only now 6/24/08 Tricare- added some info to searches 6/24/08 TLC made notes about payer in stand in 7/11/08 Tricare removed the SSN requirement, added note 7/31/08 Changed payer ID for Accordia 7/31/08 Added 4 th element to NEHEN-Neighborhood 8/13/08 Removed Select Health 8/21/08 Colorado Access NPI only 8/22/08 Removed TLC Family Health Plan 8/27/08 Added Bluegrass Family Health 9/12/08 Tricare NPI only 9/12/08 Added Vista Health Plans 9/12/08 MVP- removed dependent search and added elements to subscriber search 9/12/08 Health Partners of Philadelphia- corrected search types, range and future dates 9/25/08 Modified Inland Empire Health- member ID length 9/25/08 Added AARP (A United Healthcare Insurance Company) 9/25/08 Modified Molina of New Mexico- added Federal Tax ID, NPI and provider ID length 9/25/08 Modified all Kaiser plans- added NPI Xerox EDI Eligibility Gateway 270/ Guide Commercial 82

88 9/25/08 Modified Government Employees Hospital Assoc- added NPI 9/25/08 Modified Health Alliance Medical Plan- added note 9/30/08 NEHEN- Neighborhood Health Plans NPI only now 10/23/08 National Association of Letter Carriers added NPI 10/23/08 Removed Mail Handlers payer sheet and added it to Coventry list of payers 10/23/08 Modified payer MVP Healthcare added additional subscriber search and 2 dependent searches 10/31/08 Added payer Maricopa Care Advantage (AZ) 10/31/08 Added payer Maricopa Health Plan (AZ) 10/31/08 Removed Maricopa Integrated Health System 10/31/08 Added payer University Physicians Care Advantage (AZ) 10/31/08 Added payer University Physicians Health Care Group (AZ) 10/31/08 Added payer HealthFirst NJ 10/31/08 Added payer CHC- CoventryOne 10/31/08 Removed CHC National Network reference sheet because it was merged with Coventry Healthcare reference sheet 10/31/08 Modified payer Santa Clara Valley Health and Hospital NPI now accepted 10/31/08 Modified payer IU NPI now accepted 10/31/08 Modified payer Hometown Health NPI now accepted 10/31/08 Modified payer Health Plan of San Mateo NPI now accepted 10/31/08 Modified payer Erin Group Administrators Federal Tax ID is accepted 10/31/08 Modified payer Denver Health Medical Plan NPI now accepted 10/31/08 Modified payer Connecticare NPI now accepted 10/31/08 Modified payer Community Health First Medicare NPI now accepted 11/3/08 Added payer FamilyCare 11/3/08 Added search requirement to Tufts 11/3/08 Added search options to Best Choice 11/3/08 Corrected ID for Maricopa Health Plan 11/13/08 Corrected Amerihealth Mercy qualifier to 1J 11/13/08 Added SSN to the bottom portion of table for Best Choice 12/17/08 Added NPI and Federal Tax ID requirements to Passport Advantage 12/17/08 Added transaction note to Best Choice Health Plan 12/17/08 Modified payer Preferred One member ID type from AN to N 12/17/08 Removed VA Premier 12/17/08 Added note to Molina CA/IN/OH/UT regarding Federal Tax ID and NPI 1/16/09 Removed Vista Health Plan 1/16/09 Fallon- removed NPI option 1/16/09 Modified Great West Healthcare- changed member ID type to numeric 1/16/09 Modified Maricopa Health Plan Arizona- changed min/max member ID length to 1/24 1/16/09 Modified Maricopa Care Advantage Arizona- changed min/max member ID length to 1/24 1/16/09 Modified University Physicians Healthcare Group Arizona- changed min/max member ID length to 1/24 1/16/09 Modified University Physicians Care Advantage Arizona- changed min/max member ID length to 1/24 1/16/09 Modified Maricopa University Family Care- changed min/max member ID length to 1/24 1/16/09 Modified Keystone Mercy Health- added NPI, removed provider ID 1/29/09 Added Tax ID requirement to Passport Health 1/29/09 Removed Group Benefit Administrators Xerox EDI Eligibility Gateway 270/ Guide Commercial 83

89 2/5/09 Modified search order for Harvard Pilgrim 2/5/09 Modified Cigna- set member ID min/max /5/09 Modified Careplus Health plan set member ID min/max 2-24 and removed related note 2/5/09 Metropolitan Health Plan is NPI only now 2/10/09 Modified Cariten Healthcare- added NPI 2/10/09 Modified Cariten Senior Health- added NPI 2/10/09 Modified TennCare (Coventry)- added NPI 2/10/09 Modified Metropolitan Health Plan- added 4 search options 2/20/09 Removed Member ID only search from UHC of River Valley 3/12/09 Changed payer ID for Lovelace Health Plan 3/12/09 Added Molina Healthcare of Florida 3/12/09 Added CHC- Advantra (TX, NM, AZ only) 3/12/09 Added CHC- Coventry Health and Life- Nevada 3/12/09 Added CHC- Coventry Missouri 3/12/09 Added Central Reserve Insurance Company 3/12/09 Added Sunshine State 3/12/09 Added note to Fallon Community Health Plan regarding out of network providers 3/31/09 Changed NPI requirement for AvMed 4/13/09 Deleted Lumenos, no longer an available payer 4/13/09 Passport Health Plan, changed provider ID requirements 4/13/09 Added Continental General Insurance Company 4/13/09 Added search type codes list for NEHEN- Harvard Pilgrim 4/13/09 Added payer Capital District Physicians Health Plan 4/13/09 Added payer Fidelis Care New York 4/27/09 Modified Medica, added provider ID, NPI as accepted values 4/27/09 Added additional service type codes for Unicare 4/27/09 Modified Fallon Community Health, updated search type 5/6/09 Added Dependent specs for MVP 5/7/09 Added search options, eligibility date options and service type codes to Independence Administrators 5/20/09 Added payer Healthcare Solutions Group 5/20/09 Added payer HealthSpring 5/20/09 Added payer Mercy Health Care Plan 5/20/09 Added payer NovaSys Health 5/20/09 Added payer Virginia Premier Health Plan 5/20/09 Added payer Viva Health 5/20/09 Added payer PHCS Savility s 6/11/09 Modified payer San Joaquin, SSN no longer accepted per payer as of 6/10/09, removed search option 6/23/09 Assurant Health- SSN is optional 7/20/09 Rocky Mountain- removed 2 search options 7/20/09 Added NPI option for Medical Mutual of Ohio 7/20/09 AARP member ID now exactly 11 bytes 8/25/09 Added payer AultCare 8/25/09 Modified payer Medica- added state code requirement to 4 th subscriber search option 8/25/09 Removed payer Memorial Care TPA-payer no longer active 8/25/09 Modified payer Cigna- adjusted past date allowance 8/25/09 Modified payer Trustmark- Federal Tax ID only, removed NPI provider option 8/25/09 Modified payer Unicare- NPI only now Xerox EDI Eligibility Gateway 270/ Guide Commercial 84

90 8/25/09 Modified payer maintenance schedules for Ameritas (all payers), Assurant (all payers), Kaiser (all payers), MetLife Dental 8/25/09 Removed payer IU Health 8/25/09 Modified payer United Healthcare River Valley- added dependent search option 8/25/09 Modified payer Medical Mutual of Ohio- included TPA ID in lieu of Member ID 8/25/09 Added Vista (MCD, FHK, LTC) under Coventry Health Plans 8/25/09 Added payer Coventry Health Care Federal under Coventry Health Plans 8/25/09 Modified payer Lovelace- added optional group number for subscriber search 8/25/09 Modified payer Keystone Mercy Health Plan- member ID now 6-8 bytes 8/25/09 Removed payer Priority Healthcare Choices 8/25/09 Added Central States Fund 8/25/09 Added American Family Insurance Group- Medicare Supplemental 8/25/09 Modified World Insurance- changed search options, added NPI 8/25/09 Modified Continental General- changed search options 8/25/09 Modified Central Reserve- changed search options 8/25/09 Modified American Republic- changed search options 8/25/09 Added Optima/Sentara 9/16/09 Removed Peach State Health Plan 10/22/09 Added Health Partners 11/25/09 Removed Virginia Premier Health Plan 11/25/09 Modified NEHEN Tufts- changed search options, added gender as required 11/25/09 Modified Passport Health- changed search options, removed Federal Tax ID requirement 11/25/09 Modified Lovelace Health Plan- changed search options, removed name/ssn search 11/25/09 Modified Neighborhood Health Partnership added new S1 search, removed 1 year past limit 11/25/09 Modified United Healthcare of River Valley- added search types, changed legacy ID to Federal Tax ID 11/25/09 Modified Medical Mutual of Ohio- changed length of member ID to a min/max of 1/30 11/25/09 Modified Erin Group Administrators- payer changed its name to Significa Benefit Services 11/25/09 Added payer Personal insurance Administrators (PIA) 11/25/09 Removed payer Star HRG 1/06/10 Removed AMC TouchstonePSO- no longer actively updated. 1/6/10 Added MedCost Benefit Services 1/18/2010 Modified Cigna - Added new Service type codes 1/18/2010 Modified Maintenance Schedule for Nippon Life and Principal Life 1/18/2010 Added PrimeWest Health 1/18/2010 Added supported Service Code Types to all Coventry s 1/18/2010 Modified Aetna- updated Service Types codes 1/18/2010 Added additional supported service type codes for all Coventry s 1/18/2010 Removed Fed Tax Id requirement for Keystone Mercy 1/18/2010 Added Priority Health 1/18/2010 Corrected Fed Tax ID Qualifier code for PrimeWest Health 1/18/2010 Modified Appendix B maintenance schedule for Principal Financial Group (Nippon Life) and (Principal Life) 1/18/2010 Modified United Healthcare- updated search types 1/18/2010 Modified payer American Community Mutual added details on dates allowed 1/18/2010 Modified (Mega Life) Chesapeake National Life name change to HealthMarkets, added support of NPI, added search options Xerox EDI Eligibility Gateway 270/ Guide Commercial 85

91 1/18/2010 Modified Mega Life and Health name change to HealthMarkets, added support of NPI, added search options 1/18/2010 Modified (Mega Life) TransAmerica Life name change to HealthMarkets, added support of NPI, added search options 1/18/2010 Modified Cooperative Benefits Administrators removed group option, added svc codes, add NPI req 1/18/2010 Modified Nationwide Health Plans added search types 1/18/2010 Modified AMC Poly America - added support for NPI, created separate payer sheet 1/18/2010 Added note: MVP Healthcare (New York) payer - MVP Preferred Care is not included and any member ID s not beginning with 8 is not going to be matched or returned. 1/18/2010 Modified payer Passport Advantage- Federal Tax Id no longer required, NPI only now 2/4/10 Modified Health Partner- added dependent level searches 2/4/10 Modified Acordia National- removed Mohawk, only Hickory Springs available 2/4/10 Modified ConnectiCare- removed note about 997 s, issue corrected at payer 2/4/10 Added payer UMR 2/4/10 Added payer Freedom Blue 2/4/10 Mercy Health Care Plan- corrected search options 2/8/10 Removed MemorialCare- BCI- merged with TPA and we no longer have access to TPA 2/10/10 Removed Stanislaus County MIA Program 2/23/10 Removed Florida Hospital Healthcare 3/22/10 Health Markets- Corrected 2 nd dependent search option 3/22/10 Removed Jefferson Pilot 3/22/10 Removed Consolidated Associations of Railroad Employees (ECOM PPO) 3/22/10 Added payer Gilsbar 3/22/10 Reinstated payer- AMC Touchstone PSO 3/22/10 Modified United Healthcare- removed service code 30, all service codes now supported. Also added Date of Service restrictions of up to one year in the past. 3/22/10 Modified Medica- removed service code 30, all service codes now supported. Also added Date of Service restrictions of up to one year in the past. 3/22/10 Modified Humana- removed service code 30, all service codes now supported 3/22/10 Modified Avmed- future dates of service now allowed Removed payers Health Net of Arizona 1037, Health Net of California and Oregon 4/19/ and Health Net of the Northeast 1037N. Send these requests to Health Net National /29/10 Added payer QuikTrip Corporation /29/10 Removed Molina Healthcare of Indiana payer discontinued 4/29/10 Modified John Hopkins NPI only now, removed ID 4/29/10 Modified Gilsbar any ID type accepted 4/29/10 Modified Preferred Health added NPI 4/29/10 Modified USAA Life Insurance added NPI 4/29/10 Added payer Wellcare (NY,CT,NJ,LA,TX only) /29/10 Added payer Ohana Health Plan /29/10 Added payer Harmony Health Plan /1/10 Removed Cariten Senior Health payer was merged into Humana database 6/1/10 Added Florida Hospital Health System /1/10 Added GA to Wellcare /1/10 Removed MedCost Benefit Services MEDST- will be reinstated, ETA 8/2/10 6/1/10 Modified HealthFirst NY past dates of service allowed, no future dates 6/1/10 Added OH to Wellcare /1/10 Removed payer PHP Tenncare is no longer available. 6/4/10 Reinstated MedCost Benefit Services MEDST Xerox EDI Eligibility Gateway 270/ Guide Commercial 86

92 6/8/10 Removed payer Acordia (Mohawk Carpet and Hickory Springs) /14/10 Added FL to Wellcare and changed the name to Wellcare Health Plans now that all states are represented. 6/14/10 Added StayWell /14/10 Added StayWell Kids /14/10 Added HealthEase /14/10 Added HealthEase Kids /7/10 Added payer Select Health SC /7/10 Added payer Asuris Northwest Health /12/10 Added payer Molina Healthcare of Missouri /27/10 Added note to AARP digit ID s only accepted at this time 7/27/10 Removed payer CoreSource (NC & IN) /27/10 Added payer WEB- TPA, Inc /27/10 Modified payer American Family Insurance Group 10487, name is now American Family Insurance Group- Medicare Supplemental and PPO policies 8/24/10 Modified payer UPMC Health Plan (Tristate) backdating service dates is no longer supported 8/24/10 Modified payer United Healthcare River Valley removed search, added note 8/24/10 Modified payer CoreSource (MD/PA/IL) changed name to CoreSource (MD/PA/IL/NC/IN/AZ/MN) 8/24/10 Modified payer Oxford Health Plans changed member ID min/max to /23/10 Deactivated payer CarePlus Health Plan HIPAA compliance issues 9/23/10 Modified payer Central State Fund- Updated dependent SSN search 9/23/10 Added payer Coventry Nebraska Medicaid /23/10 Added payer United Teacher Assoc Insurance Co Medicare Supplement /23/10 Added payer SPJST Medicare Supplement /23/10 Added payer Provident American Life & Health Ins Co Medicare Supplement /23/10 Added payer Loyal American Life Insurance Co Medicare Supplement /23/10 Added payer Great American Life Insurance Co Medicare Supplement /23/10 Added payer Great American Life Assurance Co Medicare Supplement /23/10 Added payer CSA Fraternal Live Medicare Supplement /23/10 Added payer Continental General Ins Co Medicare Supplement /23/10 Added payer Central Reserve Life Ins Co Medicare Supplement /23/10 Added payer American Retirement Life Ins Co Medicare Supplement /3/10 Deactivated payer HIP NY a new connection should be up in November (on hold, payer unable to provide updated data) 12/3/10 Added payer CHC- Florida/Vista/Summit /3/10 Modified payer name CHC Personal Care is now CHC- Personal care/coventry Health of Illinois 12/3/10 Modified payer Central Reserve Insurance Company updated list of acceptable service type codes 12/3/10 Modified payer MedCost Benefit Services MEDST-added search options 1/17/11 Modified maintenance schedule for GEHA /17/11 Added payer Qualchoice /17/11 Added payer WEA Trust /17/11 Added payer Sanford Health /31/11 Added payer Carpenter s Health and Welfare Trust of St Louis /31/11 Removed payer Neighborhood Health Partnership payer deactivated and routed to UHC RV /31/11 Modified MMSI added 3 subscriber and 3 dependent searches. Added NPI support for Information Receiver. Removed group number and changed disclaimer 3/31/11 Modified AARP added subscriber gender code row to 2100c loop Xerox EDI Eligibility Gateway 270/ Guide Commercial 87

93 Modified Ameritas Group- added subscriber gender code row to 2100c loop and 3/31/11 dependent gender code row to 2100d loop. Changed to r requirement for service type code 3/31/11 Added payer BMC HealthNet Plan /31/11 Modified Amerigroup AMGRP- added additional subscriber search types and NPI 3/31/11 Modified Continental General corrected list of service type codes, formerly 30. New codes 1,30,33,35,48,50,52,86,88,98,A4,AL 3/31/11 Added payer Antares /31/11 Added payer Absolute Total Care /31/11 Added note to United Healthcare Plan of River Valley migration of Neighborhood Health Partnership 3/31/11 Added payer Advantage by Bridgeway Health Solutions /31/11 Added payer Advantage by Buckeye Community Health Plan /31/11 Added payer Advantage by Managed Health Services /31/11 Added payer Advantage by Superior Health Plan /31/11 Added payers Cenpatico Arizona (10567), Florida (10568), Georgia (10569), Indiana (10570), Kansas (10571), Ohio (10572), South Carolina (10573) 3/31/11 Added payer Buckeye Community Health /31/11 Added payer Bridgeway Arizona /28/11 Corrected search option 2 for Sunshine State (10451) 5/25/11 Modified Fallon Community Health Plan ID Added NPI and updated S2 search type. 5/25/11 Deactivated Recall Systems - SRT Administrators payerid /25/11 Deactivated - CHC Care of South Carolina ID /25/11 Added New - VNS CHOICE /25/11 Added New - Union Pacific Railroad Employees Health Systems /25/11 Added New - MDWise Hoosier Alliance /25/11 Added New - HEALTHe Exchange /25/11 Added New - American National Life Insurance Company of Texas /25/11 Added New payer- American National Insurance Company /25/11 Added New - Affinity Health Plan-ID /25/11 Added New - Standard Life and Accident Insurance Company-ID /25/11 Added New -Superior HealthPlan Texas-ID /25/11 Added New payer- Special Agents Mutual Benefit Association- ID /25/11 Added new payer- Peach State Health Plan - ID /25/11 Added new DakotaCare ID /25/11 Added new payer Celticare- ID /25/11 Added new -Cenpatico Massachusetts-ID /25/11 Added new -Managed Health Services Indiana-ID /25/11 Added new -Managed Health Services Wisconsin-ID /25/11 Added new -Integrated Mental Health Services-ID /25/11 Added new payer-group Practice Affiliates--ID /25/11 Re-Activated - Today s Option /25/11 Added New - Tribute/SelectCare of Oklahoma /25/11 Added New - Today s Health /25/11 Added New - TexanPlus North Texas Area /25/11 Added New - TexanPlus Southeast Texas Area /25/11 Added New - Generations Healthcare /25/11 Added New - Fresenius Medical Care /25/11 Added New - Essence Healthcare Xerox EDI Eligibility Gateway 270/ Guide Commercial 88

94 5/25/11 Added New Deseret Mutual (DMBA), /25/11 Added New Public Employees Health Plan (PEHP) /25/11 Added New Select Health Utah /6/2011 Added New payer Florida Health Care Plans /6/2011 Added note to Connecticare regarding Member ID s 9/6/2011 Added CHC CoventryCares /6/2011 Added Group Health Cooperative /6/2011 Added payer Cook Children s Health Plan /6/2011 Added payer Geisinger Health Plan /6/2011 Added payer Geisinger Health Plan-Gold /6/2011 Updated subscriber search type-community Health Plan of Washington (CHPW) /6/2011 Added payer Windsor Medicare Extra /6/2011 Added note to member ID changes in subscriber loop-tricare TRICR 9/6/2011 Removed Dependent search type and update subscriber search type-mvp HealthCare /18/11 Re-Activated Texas CHIP /18/11 Removed all PacifiCare payers and rerouted them through UHC /18/11 Updated MemberID only search notes for HealthNet National (10385) 10/18/11 Added Freedom Blue (10502) to the Downtime section 10/18/11 Added Emblem Health /18/11 Added list of acceptable service types for Essence Health care /18/11 Changed payer name from Nationwide Health Plan to Nationwide Specialty Health /18/11 Added new payer Administrative Services, Inc-payer ID /16/11 Removed Passport Advantage We are no longer able to guarantee that the data we are accessing is as current or correct as our standards demand. 12/16/11 Updated Texas Chip (10185) to accepting NPI 12/16/11 Updated Medica (00404) D1-dependant search type 12/16/11 Modified NEHEN-Neighborhood Health Plans search types added dependent search type 12/16/11 Modified NEHEN-Tufts Associated Health Plan search types 12/16/11 Modified NEHEN-Harvard Pilgrim Health search types 2/3/2012 Added payer Kentucky Spirit Health Plan /27/12 Added update STC for Health Net National /27/12 Updated HealthFirst NJ (10438) and NY (00240)- new search option criteria 3/30/12 Removed payer Mercy Care Health Plan Transactions now need to be sent to either Coventry Group Health Plan or Coventry Missouri /27/12 Removed the following payers as they are now listed in the 5010 guide- AARP-10431, Aetna-AETNA, American Postal Workers Union-00360, AmeriHealth Mercy-2843, Ameritas Group-00425, 00426, 00428, 00427, 00429, 00430, Assurant Health , 00252, 00253, Asuris , Aultcare , AvMed- AVMED, BMC Health , Capital Physicians District , Cigna , CO Access , Cook Children s Health Plan , CoreSource- FMH and Little Rock 00205, Coventry- all, Denver Health Plan , Family Care , Federated Insurance , Florida Health Care , Florida Hospital Healthcare System , Freedom Blue , Fresenius Medical Care , Geisinger , Geisinger Gold , Generations Healthcare , Gilsbar , Health Alliance Plan , Healthcare Solutions Group , Health Choice AZ , HealthFirst NJ and NY , HealthEase , HealthEase Kids , HealthNet National , HealthPartners MN-10484, HealthPartners PHL , Health Markets , 00248, 00206, 00208, Horizon NJ Health- 2840, Humana , John Hopkins , Kaiser Foundation Plan of CO-00277, HI-00278, Mid Atlantic States-00276, OH and the Northwest-00279, Kaiser Permanente of GA-00281, S CA and N CA-00282, Keystone Mercy- 2232, Xerox EDI Eligibility Gateway 270/ Guide Commercial 89

95 Medica-00404, Medical Mutual of OH-00211, Medicare-CMS, MMSI (Mayo) , Mutual of Omaha , National Assoc of Letter Carriers , NEHEN Harvard Pilgrim , Ohana , Optima/Sentara , Oxford Health Plan , Pacific Source Health Plan- 2597, Passport Health- 2841, Physicians Mutual Insurance , PreferredOne , Principal Financial , 00143, Recall Systems- all, Select Health SC , TexanPlus North Texas Area , TexanPlus Southeast Texas Area , Today s Health , Today s Options , Tribute/Select Care of OK , Trustmark , UMR (Wausau) , Unicare- UCARE, United Healthcare , VA Fee Basis , VIVA Health , Wellcare Health Plans , Windsor Medicare Extra /5/2012 Removed the following payers as they are now listed in the 5010 guide- Continental General Insurance Company 10454, Central Reserve Life Insurance Company 10450, American Family Insurance Group- Medicare Supplement and PPO 10487, American Republic Insurance Company 00224, Cooperative Benefit Administrators 00223, World Insurance (ARIC) 10386, Molina WI 10678, TX 10391, OH 00445, NM 10146, MO 10523, MI 00226, FL 10445, CA 00222, Sanford Health Plan 10533, Unity Health Plans , UCare of Minnesota 2596, SummaCare Health Plan , Santa Clara Valley Health and Hospital , HealthPlus of Michigan 1311, NEHEN Neighborhood Health Plans , Three Rivers Health Plans (Unison Health Plan) 00198, Select Health Utah 10575, Deseret Mutual (DMBA) 10578, Better Health Plans /1/2012 Removed the following payers as they are now listed in the 5010 guide- Affinity Health Plan 10594, Priority Health 10490, Significa Benefit Services 00191, USAA Life Insurance 10195, Independence Administrators 10417, AmeriHealth Administrators 10416, UPMC Tristate , Group Health Cooperative /1/2012 Updated downtimes for GEHA 10394, Medica 00404, Cigna 00001, UHC 00112, Oxford 00016, Qualchoice 10553, MAMSI- MAMSI, AARP 10431, Great West GRWST 8/1/2012 Removed Columbia United s no longer available 8/1/2012 Removed Vytra absorbed into Emblem Health /27/12 Updated Fidelis updated eligibility date options 8/27/12 Deactivated Peach State Health Plan /27/12 Corrected Union Pacific Railroad payer ID to /27/12 Added payer Standard Life and Accident never got added to guide when payer was added to list in /27/2012 Removed the following payers as they are now listed in the 5010 guide- Managed Health Services WI 10587, Kentucky Spirit Health Plan 10620, Cenpatico WI 10634, TX 10633, SC 10573, OH 10572, MA 10588, KY 10632, KS 10571, IN 10570, IL 10631, GA 10569, FL 10568, AZ 10567, CeltiCare 10589, Buckeye Community Health 10566, Bridgeway Arizona 10565, Advantage by Superior Health Plan 10564, Advantage by Managed Health Services 10563, Advantage by Buckeye Community Health Plan 10562, Advantage by Bridgeway Health Solutions 10561, Absolute Total Care /28/12 Removed the following payers as they are now listed in the 5010 guide- CarePlus Health plan 10056, Fidelis Care New York 10459, Great West 10089, University Physicians Healthcare Group (AZ) 10439, University Family Care (AZ) 10194, University Care Advantage (AZ) 10433, Maricopa Health Plan (AZ). 11/2/12 Removed the following payers as they are now listed in the 5010 guide-scott & White Health Plan 10360, Superior Health Plan Texas 10592, MAMSI Health Plan MAMSI, Harmony Health Plan /2/12 Deactivated PHCS Savility s /19/13 Removed the following payers due to deactivation: Director s Guild 00259, Preferred Health 00263, Health Net Medi-Cal 1057, San Francisco Health Plan 1059, CareFirst Federal Employee Program 2744, Texas CHIP 10185, Personal Insurance Administrators (PIA) 10492, PrimeWest Health Systems 10494, Carpenters Health and Welfare 10555, Humana of Florida AV297 1/30/2014 Removed the following payer as they are now listed in the 5010 guide Arizona Physicians IPA (APIPA) 1/30/2014 Removed the following payer as they are now listed in the 5010 guide SPJST Medicare Supplement Xerox EDI Eligibility Gateway 270/ Guide Commercial 90

96 1/30/2014 Removed the following payer as they are now listed in the 5010 guide Kitsap Physician Services /30/2014 Deactivated, the following AMC payers from the guide they are removed from Transunion system effective January 20, 2014: AMC - Alaska Electrical Health & Welfare Fund AMC - American General Life and Accident AMC - Health Future AMC - Poly America AMC - Touchstone AMC - Touchstone PSO They were also removed from the payer list. 2/28/2014 Deactivated payer American Community Mutual /28/2014 Removed the following payer as they are now listed in the 5010 guide Mississippi State Employees and Teachers /28/2014 Added new payer Key Benefits Administrators (IN) /31/2014 Added new payer Medigold Health Plans /30/2014 Removed payer Elder Health (Bravo Health) as they are now listed in the 5010 guide 7/31/2014 Deactivated the following payers: Cariten Healthcare Writer s Guild /31/2014 Removed payer Michigan MIChild 2949 as they are now listed in the 5010 guide as Michigan MIChild /31/2014 Removed the following payer as they are now listed in the 5010 guide United Healthcare Plan of River Valley /31/2014 Deactivated payer Lovelace Health Plan /31/2015 Removed payer CareSource of Ohio 994 they are now listed in the 5010 guide 1/31/2015 Removed payers they are now listed in the 5010 guide: CoreSource (MD/PA/IL/NC/IN/AZ/MN) and CoreSource (OH) 00236: 4/15/2015 Removed Senior Care Action Network (SCAN) HMO as they are now listed in the 5010 guide. 4/23/2015 Removed Phoenix Health Plan ID Real time services no longer offered. 5/5/2015 Removed Jackson Memorial Hospital Health Plan ID /5/2015 Made temporary revision to Rocky Mountain Health Plan Note: Our payer intermediary will be transitioning this payer to a new connection with an estimated implementation date of 06/30/2015. As a result, we will not be accepting any new Rocky Mountain Health Plan enrollments at this time. 10/16/2015 Deactivated Great American Life Assurance Co. Medicare Supp ID Xerox EDI Eligibility Gateway 270/ Guide Commercial 91

97 Maintenance Schedule AARP Advantage by Bridgeway Health Solutions Advantage by Buckeye Community Health Plan Advantage by Managed Health Services Advantage by Superior HealthPlan Aetna Aetna Long Term Care Affinity Health Plan AFLAC Dental Aftra Health Fund Alabama Medicaid American Family Insurance Group-Medicare Supplemental and PPO Policies American National Insurance Company American National Life Insurance Company TX American Postal Workers Union (APWU) American Republic Insurance Company (ARIC) American Retirement Life Ins Co Mcare Supp AmericChoice of New Jersey (Commercial) Amerigroup Corporation AmeriHealth Administrators Ameritas Group Ameritas Life Insurance Co. Ameritas Group First Ameritas of New York Ameritas Group First Reliance Standard Life Ameritas Group Reliance Standard Life Ameritas Group Standard Insurance Ameritas Group Standard Insurance of New York Antares Assurant Health John Alden Insurance Company (JALIC) Assurant Health Time Insurance Company (FIC) Assurant Health Union Security Insurance Company (FBIC) AultCare AvMed Health Plans Best Choice Health Plan Best Life and Health Better Health Plans (Unison Health Plans) Bluegrass Family Health BMC HealthNet Plan Bridgeway Arizona Buckeye Community Health Stated Downtime Thurs 5:30am-8:00am (MT), Sun 9:00am-12:00pm (MT) Sunday 4:00 am 12:00 pm (Eastern) Sunday 4:00 am 12:00 pm (Eastern) sat 11:45pm sun 12pm (Eastern) 1:30 am 6:30am, daily 1:30 am 6:30am, daily 1:30 am 6:30am, daily 1:30 am 6:30am, daily 1:30 am 6:30am, daily 1:30 am 6:30am, daily mon- fri 9pm 5:45am (Central) mon- fri 12am 5:00 am (Central) mon- fri 12am 5:00 am (Central) 12:00 AM Friday to 12:00 AM Saturday of the third weekend every month mon 7pm tue 6am, tue 7pm wed 6am (Central) s Xerox EDI Eligibility Gateway 270/ Guide Commercial 92

98 Capital District Physicians Health Plan (CDPHP) Carefirst Federal Employee Program Carefirst Blue Cross Blue Shield Carpenter s Health and Welfare Trust Fund of St. Louis Celticare Cenpatico - Arizona Cenpatico Georgia Cenpatico Florida Cenpatico Kansas Cenpatico Indiana Cenpatico Ohio Cenpatico - Massachusetts Cenpatico South Carolina Central Reserve Insurance Company Central Reserve Life Ins Co Medicare Supp Central States Funds CHAMPVA/Spina Bifida/Children of Women Vietnam Vets CHC Advantra (TX, NM, AZ Only) CHC Altius Health Plans CHC Advantra Freedom CHC Coventry Health and Life (Nevada) CHC Coventry Health and Life (Oklahoma) CHC Coventry Health Care Carelink (Advantra) CHC Coventry Health Care Carelink Medicaid CHC Coventry Health Care Carenet CHC Coventry Missouri CHC CoventryOne CHC Delaware CHC Diamond Plan (Maryland Medicaid) CHC Florida/Vista/Summit CHC Georgia CHC Group Health Plan (GHP) CHC HealthAmerica & HealthAssurance CHC HealthCare Inc. (Promina) CHC-Coventry Health Care Federal CHC University of Missouri CHC HealthCare USA (HCUSA) CHC Iowa CHC Kansas CHC Louisiana CHC Nebraska CHC OmniCare (Michigan) CHC PersonalCare/Coventry Health of Illinois CHC Southern Health Services (SHS) mon fri 9pm 7am, sat 4pm mon 7am (Pacific) mon fri 9pm 7am, sat 4pm mon 7am (Pacific) Xerox EDI Eligibility Gateway 270/ Guide Commercial 93

99 CHC WellPath Select (Carolinas) CHC Coventry Health and Life (Tenn) CHC Advantra Savings CHC Vista (MCD, FHK, LTC) CHC- CoventryCares CIGNA Colorado Access Columbia United s Community Care of Oklahoma Community HealthFirst Medicare Advantage Community Health Plan of Washington (CHPW) Connecticare Continental General Ins Co Medicare Supp Cooperative Benefit Administrators (CBA) Coventry Healthcare National Network Coventry Nebraska Medicaid CSA Fraternal Live Medicare Supp DakotaCare Denver Health Medical Plan Deseret Mutual (DMBA) Director s Guild Essence Healthcare Fallon Community Health Plan FamilyCare Federated Insurance Company Florida Hospital Healthcare System Fresenius Medical Care Generations Healthcare Gilsbar Government Employees Hospital Association GEHA Great American Life Assurance Co Mcare Supp Great American Life Insurance Co Mcare Supp Group Practice Affiliates Harmony Health Plan Health Alliance Medical Plans (HAP) Health Choice Arizona Health Net Medi-Cal Health Net National Health Partners Health Partners of Philadelphia Health Plan of San Mateo Healthcare Solutions Group HEALTHe Exchange mon fri: 10pm 7am, sat 8pm sun 2pm, sun 8pm mon 7am (Eastern) Thurs 5:30am-8:00am (MT), Sun 9:00am-12:00pm (MT) mon-sun 11:30pm-2:30am (CST) mon - fri 5:20am-6am, 5:25pm-6:55pm, sat 5:20am- 6:35am, sun 12:15pm-2:30pm, 6pm-10:00pm (Central) Thurs 5:30am-8:00am (MT) Sun 9:00am-12:00pm (MT) mon 3am sun 3:15am (Central) 4 th Thursday of every month 5pm 9pm (Pacific) Xerox EDI Eligibility Gateway 270/ Guide Commercial 94

100 HealthEase HealthEase Kids Healthfirst New Jersey Healthfirst New York HealthMarkets (Chesapeake National Life) HealthMarkets (Mid-West National Life) HealthMarkets (TransAmerica Life) HealthMarkets (Mega Life and Health Insurance) HealthNow HealthPlus of Michigan HealthSpring Hometown Health Horizon New Jersey Health Humana Humana of Florida Independence Administrators Independent Health Inland Empire Health Integrated Mental Health Services Inter Valley Health Plan Jackson Memorial Hospital Health Plan John Hopkins Health Plan Kaiser Foundation Health Plan of Colorado Kaiser Foundation Health Plan of Hawaii Kaiser Foundation Health Plan of Ohio 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 Key Benefits Administrators (IN) Keystone Mercy Health Loyal American Life Ins Co Medicare Supp Mail Handlers Benefit Plan Managed Health Services Indiana Managed Health Services Wisconsin Mid Atlantic Medical Services-MAMSI Health Plan Maricopa Care Advantage (Arizona) MDWise Hoosier Alliance Sat evening 6pm until Sunday evening 6pm 2 nd weekend of every month where unavailability will be between 1 hour and 2 days sun 2am sun 3am (Central) No Information Available sat 11:45pm sun 12pm (Eastern) mon sun 3am 3:15am (Central) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) 2 nd weekend of every month where unavailability will be between 1 hour and 2 days mon sun 3am 3:15am (Central) Thurs 5:30am-8:00am (MT), Sun 9:00am-12:00pm (MT) Available 24/7 with regular maintenance scheduled the 2nd Sat of each month; outage may last from late Xerox EDI Eligibility Gateway 270/ Guide Commercial 95

101 Medica Medical Mutual of Ohio Medigold Health Plans Medicare (Part A & B) Mega Life (Oklahoma City) Mercy Care Plan (Arizona) Mercy Health Plan MetLife Dental Family Metropolitan Health Plan (MHP) MMSI (Mayo Health) Molina Healthcare of California Molina Healthcare of Florida Molina Healthcare of Indiana Molina Healthcare of Michigan Molina Healthcare of Missouri Molina Healthcare of New Mexico Molina Healthcare of Ohio Molina Healthcare of Texas Molina Healthcare of Utah Molina Healthcare of Washington Mutual of Omaha MVP Health Care (New York) National Association of Letter Carriers (NALC) Nationwide Health Plans NEHEN Harvard Pilgrim Health Care NEHEN Neighborhood Health Plans NEHEN Tufts Associated Health Plan Nova Healthcare Administrators NovaSys Health Ohana Health Plan Optima/Sentara Oxford Health Plans Pacific Source Health Plan PacifiCare (PPO) PacifiCare of California (HMO) Pacificare of Oklahoma (HMO) Pacificare of Oregon (HMO) Pacificare of Texas (HMO) Pacificare of Washington (HMO) Pacificare of Arizona (HMO) Pacificare of Colorado (HMO) Pacificare of Nevada (HMO) Partners National Health Plans of NC Partnership Health Plan of California Fri - Sun afternoon. Thurs 5:30am-8:00am (MT) Sun 9:00am-12:00pm (MT) sun 10pm mon 3am (Eastern) mon 11pm 12am, tues fri 11am -3a, sat 4pm- 5:30pm, sun 2am 9am, holiday times vary sat 9pm mon 2:15am. (Central) mon thru fri 11pm 6am (Central) wed 9pm thur 2am (Eastern) Sun 4am 6am (Eastern) mon fri 2am 4am sat 11pm 6am (Eastern) Thurs 5:30am-8:00am (MT), Sun 9:00am-12:00pm (MT) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) Xerox EDI Eligibility Gateway 270/ Guide Commercial 96

102 Passport Advantage Passport Health Plan Peach State Health Plan Phoenix Health Plan Physicians Mutual Insurance Company Pittman and Associates Preferred Health Systems PreferredOne PrimeWest Health Principal Financial Group (Nippon Life) Principal Financial Group (Principal Life) Priority Health Providence Health Plan Provident American Life & Health Mcare Supp Public Employees Health Plan Qualchoice QuikTrip Corporation Recall Systems Boon-Chapman Benefit Admin Recall Systems Corporate Benefit Service Recall Systems Group & Pension Administrators Recall Systems JP Farley Corporation Recall Systems Professional Benefits Administrators Recall Systems Underwriters Safety & Claims Rocky Mountain Health Plan Sanford Health Plan San Francisco Health Plan San Joaquin Health Plan Santa Clara Valley Health and Hospital Scott & White Health Plan Select Health SC Select Health Utah Senior Care Action Network (SCAN) HMO Significa Benefit Services Special Agents Mutual Benefit Association Standard Life and Accident Insurance Company Star HRG StayWell StayWell Kids Student Insurance 2 nd weekend of every month where unavailability will be between 1 hour and 2 days 2 nd weekend of every month where unavailability will be between 1 hour and 2 days sun 3am to 3:15am (Central) 11pm- 5:45 am mon-fri 7pm 5:45 am weekends (Central) 11pm- 5:45 am mon-fri 7pm 5:45 am weekends (Central) mon sun 3am to 3:15am (Central) Sun 4:00p-5:00p, occasionally 8:00p-8:30p (EST) Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) mon sun 3am 3:15am (Central) Every second weekend of the month from 1hour to 2 days. sun 11:30pm mon 4am mon 11:30pm tue 4am tue 11:30pm wed 4am wed 11:30pm thu 4am thu 11:30pm fri 4am fri 11:30pm sat 4am sat 11:30pm sun 4am Xerox EDI Eligibility Gateway 270/ Guide Commercial 97

103 SummaCare Health Plan Sunshine State Superior HealthPlan Texas TexanPlus North Texas Area TexanPlus Southeast Texas Area Three Rivers Health Plans (Unison Health Plan) Today s Health Today s Options Tribute/SelectCare of Oklahoma TRICARE Trustmark Insurance Ucare of Minnesota UMR Unicare(Wellpoint) Union Pacific Railroad Employees Health Systems United Healthcare United Teachers Associates Ins Co Mcare Supp Unity Health Plans Univera Universal Care of California UPMC Health Plan (Tristate) USAA Life Insurance Company VA Fee Basis Program Vermont Medicaid VIVA Health VNS CHOICE VYTRA WEA Trust WEB-TPA, Inc. Wellcare Health Plan Wells Fargo Third Party Administrators, Inc. (CHIP and PEIA) Western Health Advantage World Insurance (ARIC) sun 3pm 10pm (Eastern) Tues - Fri: 2:00 a.m. until 5:59 a.m., 6:00pm Saturday until 6:00am Monday (ET) Thurs 5:30am-8:00am (MT), Sun 9:00am-12:00pm (MT) 2nd Friday of the month brief outage at 4am Sun 4:00p-5:00p, occasionally 8:00p-8:30p (EST) Xerox EDI Eligibility Gateway 270/ Guide Commercial 98