Xerox EDI Eligibility Gateway 270/271 Payer Guide Commercial

Transcription

1 Xerox EDI Eligibility Gateway 270/271 Payer Guide Commercial Version 5010 Technical Capital Support: Updated May 22, 2015

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

3 Table of Contents Revision Table and 5010 Compatibility Enrollment and Data Collection AARP Absolute Total Care ACS Benefit s Advantage by BridgewayHealthSolutions Advantage by Buckeye Community Health Plan Advantage by Managed Health s Advantage by Superior Health Plan Advantage Health Solutions Aetna Administrator Medicare Supplement Aetna AETNA Aetna Better Health (IL) Aetna Better Health (LA) Aetna Better Health (MI) Aetna Better Health (NE) Aetna Better Health (NJ) Aetna Better Health (PA) Aetna Better Health (TX) Aetna Better Health (TX) CHIP Aetna Senior Supplemental Aetna Signature Administrators Affinity Health Plan Medicare Affinity Health Plan AFLAC AFLAC - Medicare Supplemental Alan Sturm and Associates - Dental All Savers Life Insurance Allegiance Benefit Plan Management Allied Benefit Systems AlohaCare Alternative Insurance Resources, Inc Altus Dental American FamilyInsurance Group- Medicare Supplement and PPO American Income Life Insurance Company American Medical Security (AMS) American Network Ins. Medicare Supplement American Postal Workers Union (APWU) American Republic Insurance Company (ARIC) AmeriBen Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial i

4 AmeriHealth (DE, NJ, PA) AmeriHealth Administrators AmeriHealth Caritas Louisiana (LaCare) AmeriHealth Caritas Pennsylvania Ameritas Group Anthem Vivity Arbor Health Plan Arise Health Plan Medicare Select Policy Arizona Physicians IPA (APIPA) ASR Health Benefits Associacion De Maestros Puerto Rico Assurant Health Asuris Northwest Health Aultcare Automated Benefit s Auxiant Avera Health Plans AvMed Health Plans AVMED Bankers Life and Casualty Banner Health Plans Benefit Management Inc Best Choice Health Plans Better Health Plans of Florida Better Health Plans (Unison Health Plan) Blue Benefit Administrators of Mass BlueChoice Health Plan South Carolina Medicaid BMC HealthNet Boon Chapman Benefit Admin Boon Group Bravo Health Bridgespan Bridgeway Arizona Brokers National - Dental Buckeye Community Health Butler Benefit s, Inc Capitol Administrators Capital District Physicians Health Plan CAPROCK Care1st Health Plan Arizona CarePlus Health Plan CarePoint Medicare Advantage CareSource Health (OH) Carolina Care Plan, Inc. (CCP) CDS Group Health Celticare Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial ii

5 Celtic Insurance Cenpatico Centene Health Plans CenterLight Healthcare Central California Alliance for Health Central Reserve Life Insurance Company Central Senior Care Central States Indemnity Cerner Health Plan CHAMPVA/Spina Bifida/Children of Women Vietnam Vets Children's Mercy PCN CHP Direct Christian Brothers s CHRISTUS Health Plan New Mexico CHRISTUS Health Plan NM Medicare Advantage Cigna-GWH Claims Management Inc CMFG Life Insurance Colonial Penn Life Colorado Access Commerce Benefits Group Community Health Plan of Washington (CHPW) ConnectiCare Consolidated Associates Railroad Consumers Life Continental General Insurance Company Cooperative Benefits Administrators Cook Children s Health Plan CoreSource Corporate Benefit Country Cupboard Country Life Insurance Company Covenant Administrators (TPA) Coventry Healthcare Cox Health Plan CTI Administrators Culinary Health Fund UNITE HERE Health Dean Health Plan DeCare Dental Health Insurance Definity Health Dental Benefit Providers Delaware Physicians Care Delta Dental Denver Health Medical Plan Deseret Mutual (DMBA) Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial iii

6 Director's Guild EBMS Elderplan Employee Benefit s - Dental EPIC Life Insurance EPSI, Inc EssenceHealthcare Evangelical Community Hospital Evercare Everence Financial Evergreen Health Co-Op Expert Benefit Solutions Family Care FCE Benefit Administrators Federated Insurance Company Fidelis Care New York Fidelis SecureCare of Michigan FirstCare First Medical Network First United American Insurance Company Flex Compensation - Dental Florida Combined Life Dental Florida Health Care Plans Florida Hospital Healthcare System Florida True Health Food Employers & Bakery Confectionary Workers Benefit Freedom Blue Fresenius Medical Care Gateway Health Plan Geisinger Health Plan Geisinger Health Plan Gold GHI - Group Health Incorporated Gilsbar Globe Life & Accident Insurance Company Group & Pension Administrators Group Health Cooperative Group Health Cooperative of South Central Wisconsin - Dental Guardian Life Insurance Co. of America Dental Harmony Health Plan Hawaii Medical Assurance Association Dental Health Alliance Medical Plan (IL) Health Alliance Medical Plans (HAP) Health Choice Arizona Health Cost Solutions Health First Health Plan Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial iv

7 Health First New Jersey Health First New York Health Net National Health New England Health Partners (Minnesota) Health Partners Philadelphia Health Plan of San Mateo Health Share of Oregon Health s for Children with Special Needs Healthcare Solutions Group HealthComp Administrators HealthEase HealthEase Kids Healthgram HealthMarkets HealthPlan of Nevada HealthPlans Inc HealthPlus of Michigan HealthScope (Morris Assoc, Central Benefits, Employer s Health, Plan Handlers) Healthsource Provident - Dental HealthSpring Healthy Texas Heritage Physician Network (Houston) Hershey Healthsmile - Dental HIPNY Horizon NJ Health Humana Humana CareSource (KY) IBM Insurance Outsourcing s IBEW Local 508 Health Plan Ideal Life Insurance Independence Administrators Insurers Administrative Corporation (IAC) International Medical Card Inc Island Home Insurance John Hopkins Health Plan Kaiser Foundation Health Plan of Colorado Kaiser Foundation Health Plan of Hawaii Kaiser Foundation Health Plan of Hawaii (DHMO Choice) Kaiser Foundation Health Plan of the Mid Atlantic Kaiser Foundation Health Plan of the Northwest Kaiser Permanente of Georgia Kaiser Permanente of Northern CA Kaiser Permanente of Southern CA Kentucky Health Exchange Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial v

8 Keystone Mercy Health Kitsap Physician s KSKJ Life Leggett & Platt Leon Medical Centers Health Plan Liberty National Life Insurance Company Lifetime Benefit Solutions (RMSCO) Lifewise Arizona Lifewise Health Plan of Oregon Lifewise Health Plan of Washington Lincoln Financial Lincoln Heritage Local LoneStar TPA Loomis Company Louisiana Health Exchange Magellan Behavioral Health Magnacare Mid Atlantic Medical s, LLC MAMSI Managed Care of America Managed Health s Wisconsin MAPFRE Medicare Excel MAPFRE Life Puerto Rico Maricopa Health Plan Arizona MDWise Hoosier Alliance MedBen - Newark OH MedCost Benefit s Medica Medica Health Plans Medical Associates Health Plan/Health Choices Medical Card System Medical Mutual of Ohio Medicare CMS Medicare Advantage - Pennsylvania Medicare y Mucho Mas (INMEDIATA HEALTH GROUP) Med-Pay, Inc MedStar Family Choice MedStar Health Plan Meritain Health Meritus Health Partners Michigan MI Child Mississippi State Employees and Teachers Missouri Care MMSI (Mayo Health) Moda Health Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial vi

9 Molina Healthcare Municipal Health Benefit Fund Mutual Health s Mutual of Omaha MVP Health Care (New York) National Association of Letter Carriers (NALC) National Telecommunications Cooperative Association (NTCA) NEHEN Harvard Pilgrim Health Care NEHEN Harvard Pilgrim Health Care NEHEN- Neighborhood Health Plans Neighborhood Health Plan (RI) Network Health Network Health Plan of WI New Era Life Insurance Company NGS American North Carolina Medicaid Nova Healthcare Administrators Ohana Oklahoma Employees Group Insurance Division Operating Engineers Local.428 Health and Welfare Optima/Sentara Orange County Fire Authority Oscar (NY) Oxford Health Plans Pacific Source Health Plan Panamerican Life Puerto Rico Paramount Health Parkland Community Health Plan Partners National Health Plans of NC Passport Health Plan Patriot Dental People First Peoples Health Personal Insurance Administrators (PIA) Physicians Health Plan Northern IN (PHPNI) Physicians Health Plan of Mid-Michigan Physicians Mutual Insurance Company Physicians Plus Insurance Corp Piedmont (GA) Piedmont Wellstar HealthPlans Plan de Salud Hospital Menonita Planned Administrators Inc Plumbers and Pipefitters Local Union 525 Health & Welfare Trust Preferred Care Partners Preferred Health System of Kansas Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial vii

10 Preferred Medicare Choice (PMC) (INMEDIATA HEALTH GROUP) Preferred One Premier Health Presbyterian Health Plan Prestige Health Choice Principal Financial Group (Nippon Life) Priority Health Pro-Claim Plus Professional Benefits Administrators Providence Health Plan Provident Preferred Network - Dental Puritan Life Insurance Qualcare Royal Neighbors of America S and S Healthcare Strategies Santa Clara Family Health Plan Schaller Anderson Aetna Better Health of New York Schaller Anderson Aetna Better Health of OH Schaller Anderson Delaware Physicians Care, Inc Schaller Anderson MajestaCare VA Schaller Anderson Maryland Physicians Care Schaller Anderson Mercy Care Schaller Anderson Mercy Maricopa Schaller Anderson Missouri Care Schaller Anderson Parkland Community Health Plan Schaller Anderson Texas CHRISTUS Scott & White Health Plan Secure Health Plans of Georgia Securian - Dental Security Health Plan Select Health SC Select Health Utah Senior Care Action Network (SCAN) HMO Senior Dimensions Senior Health s Center Universal American Family of Companies Senior Whole Health Shenandoah Life Insurance Sierra Health s Significa Simply Healthcare Plans Soundpath Health Spectrum Health SPJST Medicare Supplement Star HRG State Mutual (Lincoln Novation) Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial viii

11 State Mutual Med Supp Staywell Staywell Kids Sterling Investors Life Insurance Student Insurance SummaCare Superior Health Plan Texas TennDent TexanPlus North Texas Area TexanPlusSoutheast Texas Area The Kempton Company Three Rivers Health Plans TMG Network Health Insurance Today s Health Today s Option Triple-S Salud (BCBS Puerto Rico) Trustmark Tribute/Select Care of Oklahoma Tricare TRICR UCare of Minnesota Ultimate Health Plans UMR (Wausau) Underwriters Safety & Claims UNICARE - Dental Unicare UCARE United American Insurance Company United Concordia (Dental) United Healthcare United Healthcare Community Plan Kansas United Healthcare Community Plan River Valley United Healthcare Community Plan Tennessee United Healthcare Facets Detroit Community and State United Healthcare Facets Pittsburgh Community and State United Healthcare Nevada Market United Healthcare SecureHorizons Unity Health Plan University Care Advantage Arizona University Family Care University of Arizona Health Plan-UHM University of Utah Health Plans University Physicians Care Advantage (AZ) University Physicians Healthcare Group (Arizona) UPMC Health Plan (Tristate) USAA Life Insurance Company VA Fee Basis Program Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial ix

12 VA Healthcare VA Health Administration Center Vantage Health Plan, Inc VIVA Health VYTRA Washington National Well Sense Wellcare Health Plans Western Health Advantage Wilson McShane Windsor Medicare Extra World Insurance (ARIC) WPS Health Insurance Payer Maintenance Schedule Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial x

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

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

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

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

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

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

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

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

21 Change Date Added the new payer Lifetime Benefit Solutions (RMSCO) /30/2014 Deactivated payer Gerber Life Insurance* /30/2014 Deactivated payer Colorado Access /30/2014 Deactivated payer Mutual Assurance Administrators /30/2014 Added the new payer Local /30/2014 Added the new payer Care1st Health Plan Arizona /30/2014 Added the new payer Meritus Health Partners /30/2014 Updated search option for the following payers: 11/30/2014 Kaiser Foundation Health Plan of Colorado Kaiser Foundation Health Plan of Hawaii Kaiser Foundation Health Plan of Hawaii (DHMO Choice) Kaiser Foundation Health Plan of the Mid Atlantic Kaiser Foundation Health Plan of the Northwest Kaiser Permanente of Georgia Kaiser Permanente of Northern CA Kaiser Permanente of Southern CA Added the new payer State Mutual (Lincoln Novation) /31/2014 Added the new payer Aetna Signature Administrators /31/2014 Added the new payer ASR Health Benefits /31/2014 Added the new payer Lifewise Health Plan of Washington /31/2014 Added the new payer Lifewise Health Plan of Oregon /31/2014 Added the new payer Dean Health Plan /31/2014 Deactivated payer Zenith Administrators (MN) - Dental /31/2014 Added the new payer AmeriBen /31/2014 Added the new payer United American Insurance Company /31/2014 Added the new payer First United American Insurance Company /31/2014 Added the new payer Globe Life & Accident Insurance Company /31/2014 Added the new payer United American Insurance Company /31/2014 Added the new payer Liberty National Life Insurance Company /31/2014 Added the new payer New Era Life Insurance Company /31/2014 Added the new payer American Income Life Insurance Company /31/2014 Added the new payer Simply Healthcare Plans /31/2015 Deactivated payer Generations Healthcare /31/2015 Added the new payer MVP Health Care (New York) /31/2015 Added Senior Care Action Network (SCAN) HMO Formerly 4010 payer. 4/15/2015 Added Oklahoma Employees Group Insurance Division /15/2015 Added Plumbers and Pipefitters Local Union 525 Health & Welfare Trust /20/2015 Added Culinary Health Fund UNITE HERE Health /20/2015 Added Aetna Better Health (NJ) (payer ID: 10994) 4/20/2015 Reactivated Personal Insurance Administrators (payer ID: 10492) 4/21/2015 Deactivated Total Healthcare Payer ID /21/2015 Edited for Geisinger Health Plan (Payer ID: 10611) and Geisinger Health Plan Gold 4/23/2015 (Payer ID: 10612). Remove search option of Subscriber ID only this is not permitted. Deactivated Care Improvement Plus Payer ID /23/2015 Removed Recall Systems name from the following payers. They are are now listed independently. 4/24/2015 Boon-Chapman Benefit Admin Group & Pension Administrators Underwriters Safety & Claims Corporate Benefit Professional Benefits Administrators Added Anthem Vivity /29/2015 Deactivated TRICARE for Life (payer ID: 10879) 5/5/2015 Added Better Health Plans of Florida (Payer ID: 10999) 5/5/2015 Added Medicare Advantage - Pennsylvania (Payer ID: 11000) 5/5/2015 Added Claims Management Inc. (Payer ID: 11001) 5/5/2015 Deactivated Sanford Health Plan (payer ID: 10533). Payer was returning innacurate data. 5/5/2015 Deactivated Molina Healthcare of Missouri, payer ID /5/2015 Added Alternative Insurance Resources, Inc. (Payer ID: 11002) 5/5/3015 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 9

22 Change Date Added ACS Benefit s /11/2015 Added AlohaCare /11/2015 Added Cerner Health Plan /11/2015 Added Elderplan /11/2015 Added EPSI, Inc /11/2015 Added Expert Benefit Solutions /11/2015 Added Health Cost Solutions /11/2015 Added HealthComp Administrators /11/2015 Added Insurers Administrative Corporation (IAC) /11/2015 Added LoneStar TPA /11/2015 Added Physicians Health Plan of Mid-Michigan /13/2015 Added Pro-Claim Plus /13/2015 Added Senior Dimensions /13/2015 Added Moda Health (Payer ID: 11005) 5/14/2015 Added UnitedHealthcare Community Plan TN (Payer ID: 11025) 5/14/2015 Added Aetna Better Health (MI) (Payer ID: 11026) 5/14/2015 Added All Savers Life Insurance /14/2015 Added International Medical Card Inc. (Payer ID: 11028) 5/14/2015 Added CHRISTUS Health Plan New Mexico /14/2015 Added CHRISTUS Health Plan NM Medicare Advantage /15/2015 Modified search options for Santa Clara Family Health Plan /15/2015 Added Medica Health Plans /15/2015 Reactivated Colorado Access (payer ID: ) 5/15/2015 Updated search options for Mid Atlantic Medical s, LLC - MAMSI (Payer ID: MAMSI) 5/18/2015 Updated search options for Oklahoma Employees Group Insurance Division /18/2015 Added Centene - Michigan Fidelis Secure Care (payer ID: 11034) 5/18/2015 Corrected Search options for Health First Health Plan /18/2015 Added Spectrum Health (Payer ID 10936) 5/18/2015 Added Soundpath Health /18/2015 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 10

23 4010 and 5010 Compatibility This Companion Guide documents only those connections which are currently available in end to end 5010 format. Submitters can send 5010 transactions to any of our payers from our existing 4010 Companion Guide, and our system will automatically convert to the necessary version. We will then return a 271 response matching the version you sent. Some payers have still not migrated to end to end Even if your software moves to a 5010 only platform, you can continue sending to those 4010 payers using the existing search types and 270 requirements until they complete their conversions. Enrollment and Data Collection While Xerox EDI Direct does not require enrollment of your providers with us, some payers do require special enrollment. For those payers you can work with our customer support team and they will step you through the process of getting your providers enrolled. You can contact them at [email protected]. We can provide a full list of those payers. Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 11

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

25 Absolute Total Care Option Subscriber Last First No No No and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 13

26 ACS Benefit s Option Subscriber Last First Dependent D1 Sub: Dep: Last name Dep: First name Dep: No No No and/or = [NM108=PI]NM109 Last or Organizatio n Last First Dependent Dep. Last Dep. First Dep. Date of Birth,D1 Min/Max = 16 D1 D1 D1 Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 14

27 Advantage by BridgewayHealthSolutions Option Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth S2,S3 S2,S3,S3 Min/Max = 11 S2,S3 Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 15

28 Advantage by Buckeye Community Health Plan Option Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth S2,S3 S2,S3,S3 Min/Max = 11 S2,S3 Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 16

29 Advantage by Managed Health s Option Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth S2,S3 S2,S3,S3 Min/Max = 11 S2,S3 Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 17

30 Advantage by Superior Health Plan Option Subscriber Last First No No No and/or = [NM108=PI]NM109 Last or Last First Min/Max = 11 Type and/or and/or 30 Federal Tax ID Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 18

31 Advantage Health Solutions Option Subscriber Subscriber S2 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Subscriber Last Subscriber First Subscriber Subscriber S2 S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 19

32 Aetna Administrator Medicare Supplement Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM1 09 Last or Required. No Type and/or 1, 2, 3, 30, 33, 35, 47, 48, 50, 51, 52, 53, 73,76, 86, 88, 98, AL, BV, BY, DM, MH, and UC Federal Tax ID and/or Situational. No Situational. No Last First S2, S3 S2, S3,S2,D1,D2, S3 Dependent Dep. Last Dep. First Dep. Date of Birth D2,D3 D2,D3 D1, D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 20

33 Aetna AETNA Option Subscriber Subscriber S2 (CUMB ID) (HMO) Subscriber S3 (SSN) Subscriber S4 SSN Subscriber S5 Last First Subscriber S6 Employee ID Dependent D1 Sub: (CUMB ID) Dep: Dependent D2 Sub: (SSN) Dep: Dependent D3 Sub: SSN Dep: Dependent D4 Sub: Last Sub: First Dep: Last Dep: First Dependent D5 Sub: Employee ID Dep: 2 Years No Yes Disclaimer: Receipt of this information does not guaranty payment under state law. Should Provider wish to obtain verification that payment will be made, or if member information returned differs from Provider s patient records, call Aetna Member s. and/or AETNA = [NM108=PI]NM109 Last or Subscriber Last First (CUMB ID) Min/Max = 9 indicated. S5,D4 S5,D4,D1 Min=10 Max=12 Type Group Number and/or 2,3,4,5,6,8,9,10,12,13, 17,18,20,23,24,25,26,3 0,33,34,35,36,37,38,39,40,41,42,44,45,47,48, 50,51,52,53,57,59,60,6 1,62,65,66,68,69,73,74,75,76,78,79,80,81,82, 83,84,86,88,89,90,91,9 2,94,97,98,99,A0,A1,A 2,A4,A6,A7,A8,AB,AC, AD,AE,AF,G,AH,AI,AL, AM,AN,AO,BG,BH Optional. No notes indicated. and/or Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 21

34 (HMO) (SSN) Employee ID SSN Dependent Last First CUMB ID is for Non- HMO line of business. It will be identified on the ID card by a leading W; i.e. W Omit any dashes. S2 Min=8 Max=13 HMO Subscriber ID is captured via swipe, or if the ID is 8 digits with at least one alpha character, or if the card specifies HMO or POS. S3,D2 Min/Max=9 S6,D5 Min=1 Max=10 S4,D3,S3,S4,S5,S6 D4 D4 D1,D2,D3,D4,D5 Group Number Relations hip Optional. No notes indicated. 01,19,34 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 22

35 Aetna Better Health (IL) Option Subscriber Subscriber S2 Last First 1 year No 90 Day Date Ranges Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 1, 30, 33, 35, 47, 48, 50, 52, 86, 88, 98, A4, AL, MH, and UC. Last First Required. No,S2.S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 23

36 Aetna Better Health (LA) Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Last First Required. No S2,S3 S2,S3,S2 Min\Max=24,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 24

37 Aetna Better Health (MI) Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or = [NM108=PI]NM109 Last or Required. No Situational Type and/or Operating set Last First Required. No S2,S3 S2,S3,S2 Min\Max=24,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 25

38 Aetna Better Health (NE) Option Subscriber Last First Subscriber S2 Last First Subscriber S3 Last First No End of current month No and/or = [NM108=PI]NM109 Last or Type and/or 30 and/or Situational. National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Last First,S2,S3,S2,S3,S2 Min=7 Max=10,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 26

39 Aetna Better Health (NJ) Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or 1, 30,33,35, 47,86, 88, 98,AL,MH,UC,A4 and/or Situational. National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Last First S2,S3 S2,S3,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 27

40 Aetna Better Health (PA) Option Subscriber Subscriber S2 Last First 1 year No 90 Day Date Ranges Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 1, 30, 33, 35, 47, 48, 50, 52, 86, 88, 98, A4, AL, MH, and UC. Last First Required. No,S2.S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 28

41 Aetna Better Health (TX) Option Subscriber Subscriber S2 Last First 1 year No 90 Day Date Ranges Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 1, 30, 33, 35, 47, 48, 50, 52, 86, 88, 98, A4, AL, MH, and UC. Last First Required. No,S2.S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 29

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

43 Aetna Senior Supplemental Option Subscriber Last First Subscriber S2 SSN Subscriber S3 Last First No No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 1, 2, 3, 30, 33, 35, 47, 48, 50, 51, 52, 53, 73, 76, 86, 88, 98, AL, BV, BY, DM, MH, and UC Last First SSN Required. No,S2.S2 S2,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 31

44 Aetna Signature Administrators Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: No No No and/or = [NM108=FI]NM109 = XX Last or Last First, D1 Type and/or 1,2,4,5,6,7,8,12,13,18,20,3 0,33,35,40,42,47,49,50,51, 52,53,62,65,68,73,76,78,8 0,81,82,86,88,93,98,99,A0,A3,A6,A7,A8,AD,AE,AF,A G,AI,AL,BG,BH,MH,UC Federal Tax ID, and/or Situational. Federal Tax ID if NM108 = FI if NM108 = XX. Last Dependent Last First, D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 32

45 Affinity Health Plan Medicare Option Subscriber Last First Gender and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First Subscriber Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 33

46 Affinity Health Plan Option Subscriber Subscriber S2 SSN Subscriber S3 Last First Subscriber S4 Last First No and/or = [NM108=PI]NM109 Last or Last First SSN S3,S4 S3,S4,S4 Min= 10 Max = 12 S2,S3,S4 S2 Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 34

47 AFLAC Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: First Dep: No No No and/or = [NM108=PI]NM109 Last or Subscriber Last Subscriber First Subscriber Subscriber Dependent Subscriber Dep. Last Dep. First Dep. Date of Birth S4 S2,S4, S2,S3,D1 S2,S4, D1 D1 D1 D1 Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 35

48 AFLAC - Medicare Supplemental Option Subscriber Dependent D1 Subscriber Subscriber Last Subscriber Last First Gender Dep. Last Dep. First Dep. Date of Birth Dep. Gender and/or s and Values = = [NM108=PI]NM109 Last or Subscriber Last Subscriber First Subscriber Member ID Subscriber Date of Birth, D1, D1 Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Gender Dependent Subscriber Member ID Subscriber Last Dependent Last Dependent First Dependent Date of Birth DependentGender, D1, D1 D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 36

49 Alan Sturm and Associates - Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 37

50 All Savers Life Insurance Option Subscriber Last Subscriber S2 First Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First Dependent D1 Sub: Dep: Last Dep: Dependent D2 Sub: Dep: First Dep: Dependent D3 Sub: Dep: Dependent D4 Sub: Dep: Last Dep: First Dependent D5 Dep: Last Dep: First Dep: No No Date Ranges are allowed Required Situational and/or and/or [NM108=PI]NM109 Last or Required. No Type Operating Set Last First Dependent Last First Required. No,S4,S5 S2,S4,S5,S2,S3,S4,D1,D2,D3,D4,S2,S3,S5 D1,D4,D5 D2,D4,D5 D1,D2,D3,D5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 38

51 Allegiance Benefit Plan Management Option Subscriber Last First Subscriber S2 Last Subscriber S3 Last First No End of current month No and/or = [NM108=PI]NM109 Last or Type and/or 30 and/or Situational. National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Last First,S3 S2,S3,S2 Min=7 Max=10,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 39

52 Allied Benefit Systems Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Subscriber S4 SSN Subscriber S5 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. Dependent D4 Sub. SSN Dep. Dependent D5 Sub. Dep. Last name Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2 S3,S5 First S2 S3,S5,S2,S5.D1.D2, D5,S3,S4,S5 Dependent Dep. Last Dep. First Dep. D1,D2,D3,D5 D1,D3.D5 D1, D3,D4,D5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 40

53 AlohaCare Option Subscriber Last Subscriber S2 Subscriber S3 Last Subscriber S4 Last First No No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Last,S3 First S4,S2,S4 Min/Max=24 S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 41

54 Alternative Insurance Resources, Inc Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Dependent D4 Sub: SSN Dep: No No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Last S2 S3 First S2 S3,S2,D1,D2,S3,D3,D4 Dependent Dep. Last Dep. First Dep. Dep. SSN D2,D3 D2,D3 D1,D4 D4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 42

55 Altus Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 43

56 American FamilyInsurance Group- Medicare Supplement and PPO Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Dependent D4 Sub: Dep: Last Dep: First Dep: and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date Birth of Dependent Last First Date of Birth S2,S3,S4 S2,S3,S4,S2,S4,D1,D2,D4,S3,S4 D2,D3,D4 D2,D3,D4 D1,D3,D4 Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 44

57 American Income Life Insurance Company Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2 S2, S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 45

58 American Medical Security (AMS) Option Subscriber Last First Subscriber S2 Last Subscriber S3 Frist Subscriber S4 Subscriber S5 Last First Dependent D1 Sub. Dep. Last name Dep. First Dep. Dependent D2 Sub. Dep. Last name Dep. Dependent D3 Sub. Dep. First name Dep. Dependent D4 Sub. Dep. Dependent D5 Sub. Dep. Last name Dep. First No No No and/or = [NM108=PI]NM109 Last or Type and/or 1, 30, 33, 35, 47, 86, 88, 98, AL, MH, UC Federal Tax ID and/or Situational. No Situational. No Last S2 S3,S5,S6 First S2 S3,S5,S6,S2,S3,S4,S5.D1. D2,D3,D4,D5,S2,S3,S4,S5 Dependent Dep. Last Dep. First Dep. Date of Birth D1,D2,D5 D1,D3.D5 D1,D2,D3,D4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 46

59 American Network Ins. Medicare Supplement Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM109 Last or Type and/or 1, 2, 3,30, 33, 35, 47, 48, 50, 51, 52, 53, 73, 76, 86, 88, 98, AL, BV,BY, DM, MH, and UC Federal Tax ID and/or Situational. No Situational. No Last First S2, S3 S2, S3,S2,D1,D2, S3 Dependent Dep. Last Dep. First Dep. Date of Birth D2,D3 D2,D3 D1, D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 47

60 American Postal Workers Union (APWU) Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Dependent D4 Sub: Dep: Last Dep: First Dep: 1 year 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. and/or s and Values = = [NM108=PI]NM109 Last or Last First Dependent Last First S2, S3, S4 S2, S3, S4, S2, S4, D1, D2, D4, S3, S4 D2, D3, D4 D2, D3, D4 D1, D3, D4 Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 48

61 American Republic Insurance Company (ARIC) Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Dependent D4 Sub: Dep: Last Dep: First Dep: and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth Dependent Last First Date of Birth S2,S3,S4 S2,S3,S4,S2,S4,D1,D2,D4,S3,S4 D2,D3,D4 D2,D3,D4 D1,D3,D4 Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 49

62 AmeriBen Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM109 Last or Type and/or 1, 2, 3,30, 33, 35, 47, 48, 50, 51, 52, 53, 73, 76, 86, 88, 98, AL, BV,BY, DM, MH, and UC Federal Tax ID and/or Situational. No Situational. No Last First S2, S3 S2, S3,S2,D1,D2, S3 Dependent Dep. Last Dep. First Dep. Date of Birth D2,D3 D2,D3 D1, D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 50

63 AmeriHealth (DE, NJ, PA) Option Subscriber Last First Subscriber S2 Last Subscriber S3 Last First Dependent D1 Subscriber Dep. Last Dep. First Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. and/or s and Values = = [NM108=PI]NM 109 Last or Subscriber Last Subscriber First Subscriber Subscriber Date of Birth Dependent Subscriber Subscriber Last Dep. Last Required. No,S2,S3,S3,S2,S3,D1,D2,S3,S2,D1,D2, D1 D1,D2,D3 Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Dep. First Dep. D1,D3 D1,D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 51

64 AmeriHealth Administrators Option Subscriber Dependent D1 Sub: Dep: and/or = [NM108=PI]NM109 Last or Organiza tion Member ID Date of Birth Dependent Date of Birth,D1 D1 Type and/or and/or 30 Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 52

65 AmeriHealth Caritas Louisiana (LaCare) Option Subscriber Subscriber S2 SSN Subscriber S3 Last First Area of coverage: Louisiana Yes No No Required and/or = [NM108=PI]NM109 Last or Required. No Required. No Optional Type and/or 30 Last First SSN S3 S3 Min/Max=8 S2 S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 53

66 AmeriHealth Caritas Pennsylvania Option Subscriber Subscriber S2 SSN Subscriber S3 Last First No No No and/or = [NM108=PI]NM109 Last or Organizati on Last First Member ID SSN Date Birth of S3 S3 S2 S3 Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 54

67 Ameritas Group Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Payers Payer Payer ID Payer Payer ID Ameritas Life Insurance Co First Ameritas of New York First Reliance Standard Life Reliance Standard Life Standard Insurance Standard Insurance of New York and/or See table above = [NM108=PI]NM109 Last or Organizati on Last First Member ID Date of Birth Dependent Last First Date of Birth,D1 D1 D1 D1 Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 55

68 Anthem Vivity Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: No No No and/or = [NM108=PI]NM109 Last or Last First, D1, D1, D1, D1 Type and/or 1,2,4,5,6,7,8,9,10 11,12,13,14,15,16 17,18,19,20,21,22 23,24,25,26,27,28 30,32,33,34,35,36 37,38,39,40,41,42 43,44,45,46,47,48 49,50,51,52,53,54 55,56,57,60,61,62 65,68,69,73,76,78 80,81,82,83,84,86 88,93,98,99,A0,A3 A6,A7,A8,AD,AE AF,AG,AI,AL,BG BH,MH,UC / Federal Tax ID and/or Situational. National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 56

69 Arbor Health Plan Option Subscriber Subscriber S2 Last First Subscriber S3 SSN Area of coverage: Nebraska Yes No No and/or = [NM108=PI]NM109 Last or Last First SSN S2 S2 S3 S2 Type and/or and/or 30 Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 57

70 Arise Health Plan Medicare Select Policy Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2 S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 58

71 Arizona Physicians IPA (APIPA) Option Subscriber Last First 1 Year 30 Days Yes and/or See table above = [NM108=PI]NM109 Last or Organizatio n Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 59

72 ASR Health Benefits Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: No No No and/or s and Values = = [NM108= FI, XX NM109 Last or Last First Required. No, D1 Type and/or 1,2,4,5,6,7,8,12,13,18,2 0,30,33,35,40,42,47,49, 50,51,52,53,62,65,68,7 3,76,78,80,81,82,86, 88,93,98,99,A0,A3,A6, A7,A8,AD,AE,AF,AG,AI,AL,BG,BH,MH,UC Federal Tax ID, and/or Federal Tax ID if NM108 = FI if NM108 = XX. Last Dependent Last First, D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 60

73 Associacion De Maestros Puerto Rico Option Subscriber No No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 61

74 Assurant Health Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: No Payers Payer Payer ID Payer Payer ID John Alden Insurance Company (JALIC) Time Insurance Company (FIC) Union Security Insurance Company (FBIC) and/or See table above = [NM108=PI]NM109 Last or Organizatio n Last First Dependent Last First,D1 D1 D1 D1 Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 62

75 Asuris Northwest Health Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: 24 mos 6 weeks Yes and/or = [NM108=PI]NM109 Last or Organizatio n Last First, D1 Type and/or 30 Federal Tax ID and/or Situational. No Last Dependent Last First, D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 63

76 Aultcare Option Subscriber Subscriber S2 Last Subscriber S3 Last Dependent D1 Sub: Dep: Last Dep: First Note: The new Aultcare system requires that all data supplied be exact. Yes No No and/or = [NM108=PI]NM109 Last or Organizatio n and/or and/or Last S2,S3,S2,D1 Type Dependent Last First,S3 30 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 64

77 Automated Benefit s Option Subscriber Dependent D1 Subscriber Member ID Dep. Last Dep. First Dep. No No No and/or = [NM108=PI]NM109 Last or Dependent.D1 Min/Max=10 Type and/or 30 Federal Tax ID Provider ID and/or Situational. Federal Tax ID if NM108=FI. Situational. National Provider ID if NM108=XX. Situational. Provider ID if NM108=SV Dep. Last Dep. First Dep. Date Of Birth D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 65

78 Auxiant Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Subscriber S4 SSN Subscriber S5 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. Dependent D4 Sub. SSN Dep. Dependent D5 Sub. Dep. Last name Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2 S3,S5 First S2 S3,S5,S2,S5.D1.D2, D5,S3,S4,S5 Dependent Dep. Last Dep. First Dep. D1,D2,D3,D5 D1,D3.D5 D1, D3,D4,D5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 66

79 Avera Health Plans Option Subscriber Subscriber S2 SSN Last Subscriber S3 Last First Group Number 1 year No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S2, S3 First S2, S3 Group Number S3 S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 67

80 AvMed Health Plans AVMED Option Subscriber 1 year No Yes and/or AVMED = [NM108=PI]NM109 Type and/or and/or 30 Situational. No Provider ID Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 68

81 Bankers Life and Casualty Option Subscriber Last First Subscriber S2 Subscriber S3 Last First 1 year End of current month Yes **Note: This a Medicare Supplemental Plan and/or = [NM108=PI]NM109 Last or Type and/or 30 and/or Situational. National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Last First,S3 S2,S3,S2 Min=7 Max=10,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 69

82 Banner Health Plans Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. and/or s and Values = = [NM108=PI]NM 109 Last or Subscriber Last Subscriber First Subscriber Subscriber Date of Birth Dependent Subscriber Subscriber Last Dep. Last Required. No S2,S3,S2,D3,D4,S3, D1, D1 D2,D3 Type and/or 1, 2, 4, 5, 6, 7, 8, 12, 13, 18, 20, 30, 33, 35, 40, 42, 45, 50, 52, 53, 62, 65, 68, 73, 76, 78, 86, 87, 88, 93, 98, 99, A0, A3, A6, A7, A8, AD, AE, AF, AG, AI, AL, BG, BH, MH, UC Federal Tax ID and/or Situational. No Situational. No Dep. First Dep. D2,D3 D1,D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 70

83 Benefit Management Inc Option Subscriber Dependent D1 Subscriber Subscriber Last Subscriber Last First Gender Dep. Last Dep. First Dep. Date of Birth Dep. Gender and/or = [NM108=PI]NM109 Last or Subscriber Last Subscriber First Subscriber Subscriber, D1, D1 Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Gender Dependent Subscriber Subscriber Last Dep. Last Dep. First Dep. Date of Birth Dep.Gender, D1, D1 D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 71

84 Best Choice Health Plans Option Subscriber Last First Subscriber S2 Subscriber S4 Last First Note: Only providers in the North Broward Hospital District can access this coverage. Note: For Dependent Searches, use the Employees with Dependents and Date of Birth, or Employees SSN and Dependents, as a subscriber search. No dependent loops are supported by this payer. 1 year No Yes and/or = [NM108=PI]NM109 Last or required. Type and/or 30 required. and/or Last First,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 72

85 Better Health Plans of Florida Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First No No No Required and/or = [NM108=PI]NM109 Last or required. Optional Type and/or 30 required. Last S3, S4 First S3, S4, S2, S3 Min/Max=20 S2, S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 73

86 Better Health Plans (Unison Health Plan) Option Subscriber Last First 1 year No Yes and/or = [NM108=PI]NM109 Last or Last First required. Min/Max=12 Type and/or 30 Federal Tax ID Provider ID Plan Network ID Facility Network ID and/or Either Federal Tax ID or Provider ID is required. Min=2 Max=13 Either Federal Tax ID or Provider ID is required. Min/Max=12 Either Plan Network ID or Facility Network ID is required. Min/Max=12 Either Plan Network ID or Facility Network ID is required. Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 74

87 Blue Benefit Administrators of Mass Option Subscriber Last First Dependent D1 Sub: Dep. Last Dep. First Dep. No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First Subscriber, D1 Dependent Last Subscriber Dependent D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 75

88 BlueChoice Health Plan South Carolina Medicaid Option Subscriber Last First No No No and/or = [NM108=PI]NM109 Type and/or 30 Federal Tax ID and/or Situational. No Last Situational. No First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 76

89 BMC HealthNet Option Subscriber Subscriber S2 Last First Gender No and/or = [NM108=PI]NM109 Type and/or 30 and/or Last S2 First S2 S2 Gender S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 77

90 Boon Chapman Benefit Admin Option Subscriber Last First Dependent D1 Sub: Dep: First Dep: Yes and/or See table above = [NM108=SV]NM109 Type and/or and/or 30 Situational. No notes indicated. Last Provider ID Situational. No notes indicated. First,D1 Max=9 Dependents First D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 78

91 Boon Group Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2, S3 First S2, S3,.D1.D2, S3 Dependent Dep. Last Dep. First Dep. Date of Birth D2,D3 D2,D3 D1, D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 79

92 Bravo Health Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or 30 and/or Situational. No Last First S2,S3 S2,S3,S2 Min=7 Max=10,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 80

93 Bridgespan Option Subscriber Last First Subscriber S2 Last Subscriber S3 Last First Subscriber S4 Last First Subscriber S5 1 year No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last, S2, S3,S4 First S3,S4,S2,S3, S5,S2,S4,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 81

94 Bridgeway Arizona Option Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or = [NM108=PI]NM109 Last or Organizatio n Last S2,S3 Type and/or 1, 30, 33, 47, 48, 50, 86, 98, MH, and UC Federal Tax ID and/or Situational. No Situational. No First S2,S3,S3 Min=2 Max=20 S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 82

95 Brokers National - Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 83

96 Buckeye Community Health Option Subscriber Subscriber Last First Subscriber Last First No and/or = [NM108=PI]NM109 Last or Organizatio n Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Last S2,S3 First S2,S3,S3 Min=2 Max=20 S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 84

97 Butler Benefit s, Inc Option Subscriber Last First Subscriber S2 SSN Subscriber S3 Last First 1 year No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Last First SSN Required. No,S2.S2 S2,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 85

98 Capitol Administrators Option Subscriber Subscriber S2 Last First 1 year No 90 Day Date Ranges and/or = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Last First S2 S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 86

99 Capital District Physicians Health Plan Option Subscriber Subscriber S2 Last First 1 year Yes Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Last S2 First S2,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 87

100 CAPROCK Option Subscriber Last First Dependent D1 Sub: Dep. Last Dep. First Dep. and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2, S3, S4 First Subscriber, D1, D1 Dependent Last Subscriber Dependent D1, D3, D4, D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 88

101 Care1st Health Plan Arizona Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or 30 Federal Tax ID and/or No No No Last First S2,S3 S2,S3,S2 Min/Max=12,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 89

102 CarePlus Health Plan Option Subscriber Subscriber S2 Last First 1 year No No : CPHP is limited to only the Providers who are in the following counties in Florida: Palm Beach, Broward and Miami Dade. and/or = [NM108=PI]NM109 Last or Organizatio n Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2 First S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 90

103 CarePoint Medicare Advantage Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First No No No and/or = [NM108=PI]NM109 Last or Organizati on Last First Member ID SSN Date Birth of S3 S3 S2 S3 Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 91

104 CareSource Health (OH) 994 Option Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First Subscriber S6 SSN Last 12 months 60 days 60 days and/or 994 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last,S2, S4,S5, S6 First S4,S5,S2,S3,S4 SSN S6,S2,S3,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 92

105 Carolina Care Plan, Inc. (CCP) Option Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep. Last Dep. First Dep. No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2 First Sub: Member ID S2, D1, S2 Dependent Last Dep. First Dep. Date of Birth D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 93

106 CDS Group Health Option Subscriber Dependent D1 Subscriber Subscriber Last Subscriber Last Option (cont.) 5 6 Subscriber Gender Dependent D1 Dep. Dep. Gender First Dep. Last Dep. First and/or s and Values = = [NM108=PI]NM10 9 Last or Subscriber Last Subscriber First Subscriber Subscriber Date of Birth Gender Dependent Subscriber Subscriber Last Required. No, D1, D1, D1, D1 Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Dep. Last Dep. First Dep. Date of Birth Dep. Gender D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 94

107 Celticare Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Dependent D4 Sub: Dep: Last Dep: First Dep: No No No 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. and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2, S3, S4 First S2, S3, S4,S2, S4, D1, D2, D4 Min=2 Max=20, S3, S4 Dependent Last D1, D3, D4 First D1, D2, D4 D1, D3, D4 Last D1, D3, D4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 95

108 Celtic Insurance Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. No No No and/or = [NM108=PI]NM109 Last or Subscriber Last Subscriber First Subscriber Subscriber Date of Birth Dependent Subscriber Subscriber Last Dep. Last S2,S3,S2,D3,D4,S3, D1, D1 D2,D3 Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Dep. First Dep. D2,D3 D1,D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 96

109 Cenpatico Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Payers Payer Payer ID Payer Payer ID Cenpatico- Arizona Cenpatico- Massachusetts Cenpatico Behavioral Health Cenpatico - Mississippi Cenpatico Behavioral Health Texas Cenpatico - Missouri Cenpatico- Florida Cenpatico - New Hampshire Cenpatico - Georgia Cenpatico- Ohio Cenpatico- Illinois Cenpatico- South Carolina Cenpatico- Indiana Cenpatico- Kansas Cenpatico- Kentucky Cenpatico- Texas Cenpatico- Wisconsin 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. and/or See above table = [NM108=PI]NM109 Type and/or 30 Federal Tax ID and/or Situational. No Last S2,S3 Situational. No First S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 97

110 ,S3 S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 98

111 Centene Health Plans Option Subscriber Last First No No No Payers Payer Payer ID Payer Payer ID Centene - Advantage by Peach State Centene-Kentucky Spirit Health Plan Centene - Advantage by Sunshine State Centene-Louisiana Healthcare Connections Centene Advantage Plans Centene-Magnolia Health Plan Centene-Coordinated Care Centene - Michigan Fidelis Secure Care Centene-California Health & Wellness Centene-Peach State Health Plan Centene - Granite State Health Plan Centene-Sunflower State Health (Kansas) Centene-Home State Health Plan Centene-Sunshine State Health Plan Centene- IlliniCare Health Plan Centene-Total Care Carolina and/or See above table = [NM108=PI]NM109 Type and/or All code types accepted Federal Tax ID and/or Situational. National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Last Situational. National Provider ID if NM108=XX. First Federal Tax ID if NM108=FI. Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 99

112 Min/Max=20 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 100

113 CenterLight Healthcare Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First Required and/or = [NM108=PI]NM109 Last or Situational Federal Tax ID and/or Situational. No Required. No Situational. No Last First Type S3,S4 S3,S4, S2,S3 S4 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 101

114 Central California Alliance for Health Option Subscriber Last First No No No and/or = [NM108=PI]NM109 Type and/or 30 Federal Tax ID and/or Situational. No Last Situational. No First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 102

115 Central Reserve Life Insurance Company Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Required and/or = [NM108=PI]NM109 Last or Situational Federal Tax ID and/or Situational. No Required. No Situational. No Last First Type S2,S3 S2,S3 S2,S3 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 103

116 Central Senior Care Option Subscriber Last First Up to 3 Years in Past No Yes and/or = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Last First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 104

117 Central States Indemnity Option Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan and/or = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 105

118 Cerner Health Plan Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Last Dep: First Dependent D2 Sub: Dep: Dependent D3 Dep: Last Dep: First Dep: No No No Required and/or = [NM108=PI]NM109 Last or Required. No Situational Type and/or 30 Last First No, S2, D1,D2 Min/Max=24 S2,S3 S2,S3,S3 Dependent Last First D1 D1 D2,D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 106

119 CHAMPVA/Spina Bifida/Children of Women Vietnam Vets Option Subscriber Last First Subscriber S2 Last First Required 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. and/or = [NM108=PI]NM109 Last or Organizatio n Last Situational Federal Tax ID and/or Required. Required. No Situational. No, S2 Group Number Optional. First, S2, S2 Type 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 107

120 Children's Mercy PCN Option Subscriber Subscriber S2 SSN Subscriber S3 Last First No No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type 30 and/or Last First SSN Required. No S3 S3 S2 S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 108

121 CHP Direct Option Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Dependent D2 Dep: Last Dep: First Dep: 3 years No 90 day Date Ranges and/or = [NM108=PI]NM109 Last or Type and/or and/or 1) 30 Situational. No Federal Tax ID Situational. No Subscriber Last Subscriber First Subscriber Subscriber S2 S2, D1 S2 Dependent Subscriber Dep. Last Dep. First Dep. Date of Birth, D1 D2 D2 D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 109

122 Christian Brothers s Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. No No No and/or = [NM108=PI]NM109 Last or Subscriber Last Subscriber First Subscriber Subscriber Dependent Subscriber Dep. Last Dep. First Dep. Date of Birth S2,S3 S2,S3, S2,D1, D2 S2, S2,D1, D2 D2,D3 D2,D3 D1,D3 Type and/or and/or 2) 30 Situational. No Federal Tax ID Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 110

123 CHRISTUS Health Plan New Mexico Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: No No No Required and/or = [NM108=PI]NM109 Last or Required. No Situational Type and/or The operating rule code set. Last First Required. No Min/Max=9,S2,D1,D2 S2,S3 S2,S3,S3 Dependent Last First D2,D3 D2,D3 D1,D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 111

124 CHRISTUS Health Plan NM Medicare Advantage Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or = [NM108=PI]NM109 Last or Last Required. No Max=80,S2 S2,S3 Situational Federal Tax ID, Type and/or Federal Tax ID if NM108 = FI if NM108 = XX The operating rule codeset. First S2,S3,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 112

125 Cigna-GWH Option Subscriber Last First Subscriber S2 Last Subscriber S3 Last First Subscriber S4 Subscriber S5 Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Dependent D2 Sub: Dep: Last Dep: Dependent D3 Sub: Dep: Last Dep: First Dependent D4 Sub: Dep: Dependent D5 Dep: Last Dep: First Dep: Disclaimer: This is not a guarantee of benefits. Benefits are contingent upon the plan being in force and that the patient is covered at the time the services are rendered. Note: Great West Healthcare has been merged with Cigna No limit- all historical data stored 30 days No Required and/or = [NM108=PI]NM109 Last or Required,S2,S3,S4,D1,D2,D3,D4 Situational Federal Tax ID and/or Situational. No Situational. No Last First Dependent Last First Type,S2,S3,S5,D1,D2,D3,D4,S3,S5 S2,S4,S5 D1,D2,D3,D5 D1,D3,D5 D1,D2,D4,D5 1,2,4,5,6,7,8,9,10,12,13,17,19,20,22,30,33,35,42,45,46,47,48,49,50,51,52,53,56,59,6 1,62,64,67,68,69,7071,72,73,74,75,76,78, 79,80,81,82,83,84,86,88,90,91,92,93,96,9 7,98,99,A3,A6,A7,A8,AA,AC,AD,AF,AG,AI, AJ,AK,AL,AM,AN,AO,AR,BB,BC,BD,BF,B G,BH,BK Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 113

126 Claims Management Inc Option Subscriber Last First Dependent D1 Sub: Dep: First Dep: 3 Years in the Past. No 90 Day Required and/or = [NM108=PI]NM109 Last or Required. No Situational Type and/or 30 Last First Required. No Min/Max=24, D1 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 114

127 CMFG Life Insurance Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. No No No and/or = [NM108=PI]NM109 Last or Subscriber Last Subscriber First Subscriber Subscriber Dependent Subscriber Dep. Last Dep. First Dep. Date of Birth S2,S3 S2,S3, S2,D1, D2 S2, S2,D1, D2 D2,D3 D2,D3 D1,D3 Type and/or 1, 2, 3, 30, 33, 35, 47, 48, 50, 51, 52, 53, 73, 76, 86, 88, 98, AL, BV, BY, DM, MH, and UC Federal Tax ID and/or Situational. No Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 115

128 Colonial Penn Life Option Subscriber Last First Subscriber S2 Last Subscriber S3 Last First 1 year End of current month No **Note: This a Medicare Supplemental Plan and/or = [NM108=PI]NM109 Last or Type and/or 30 Federal ID and/or Situational National Provider ID if NM108=XX. Situational Federal Tax ID if NM108=FI. Last First,S3 S2,S3,S2 Min=7 Max=10,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 116

129 Colorado Access Option Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First Last 1 year End of current month No Required Optional and/or and/or = [NM108=PI]NM109 Last or Required. No Type 30 Last First Required. No,S2,S4,S5,S4,S5,S2,S3,S4 Min=2 Max=80 S3,S3,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 117

130 Commerce Benefits Group Option Subscriber Subscriber S2 Last First No No No and/or = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Last First S2 S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 118

131 Community Health Plan of Washington (CHPW) 2641 Option Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First 1 year 60 days 60 days Required : Data updated Monday morning, last day of the month. and/or 2641 = [NM108=PI]NM109,S2 Situational Type,S2,S3,S5 SSN S3,S5 Last,S2,S4,S5 First,S4,S5 and/or Situational. No 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 119

132 ConnectiCare Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Please Note: **If the patient is subscriber then the must be 11 digits long and end with 01. If the patient is dependent 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 Required and/or = [NM108=PI]NM109 Last or Required. No Situational. No Optional Type Provider ID and/or 30 Required. No Last S2 First S2,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 120

133 Consolidated Associates Railroad Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. Required and/or = [NM108=PI]NM109 Last or Required,S2,,D1,D2 Situational Federal Tax ID and/or Situational. No Situational. No Last First Dependent Last First Type S2,S3 S2,S3 S3 D2,D3 D2,D3 D1,D3 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 121

134 Consumers Life Option Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Dependent D2 Dep: Last Dep: First Dep: 3 years No 90 day Date Ranges and/or = [NM108=PI]NM109 Last or Type and/or and/or 3) 30 Situational. No Federal Tax ID Situational. No Subscriber Last Subscriber First Subscriber Subscriber S2 S2, D1 S2 Dependent Subscriber Dep. Last Dep. First Dep. Date of Birth, D1 D2 D2 D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 122

135 Continental General Insurance Company Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Dependent D4 Sub: Dep: Last Dep: First Dep: No and/or = [NM108=PI]NM109 Last or Type and/or 1, 30, 33, 35, 48, 50, 86,88, 92, AL Federal Tax ID and/or Situational. No Situational. No Last First S2,S3,S4 S2,S3,S4,S2, S4 D1,D2,D4 Min=10 Max=11,S3,S4 Dependent Last First D2,D3,D4 D2,D3,D4 D1,D3,D4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 123

136 Cooperative Benefits Administrators Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Dependent D4 Sub: Dep: Last Dep: First Dep: and/or = [NM108=PI]NM109 Last or Federal Tax ID No No No Type and/or 30 and/or Last First S2,S3,S4 S2,S3,S4,S2,S4,D1,D2,D4,S3,S4 Dependent Last First D2,D3,D4 D2,D3,D4 D1,D3,D4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 124

137 Cook Children s Health Plan Option Subscriber Subscriber S2 Last First Subscriber S3 SSN Disclaimer: This is not a guarantee of benefits. Benefits are contingent upon the plan being in force and that the patient is covered at the time the services are rendered. No Current DOS only No Required and/or = [NM108=PI]NM109 Last or Required. No Last First SSN Required. No S2,S3 S2 S2 S3 Type 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 125

138 CoreSource Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Payers Payer Payer ID Payer Payer ID FMH Little Rock MD/PA/IL/NC/IN/AZ/MN Ohio and/or See table above = [NM108=PI]NM109 Last or Last specified,d1 Min=10 Max=11 Type and/or 30 Federal Tax ID and/or Situational. No Situational. No First Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 126

139 Corporate Benefit Option Subscriber Last First Dependent D1 Sub: Dep: First Dep: Yes and/or See table above = [NM108=SV]NM109 Type and/or and/or 30 Situational. No notes indicated. Last Provider ID Situational. No notes indicated. First,D1 Max=9 Dependents First D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 127

140 Country Cupboard Option Subscriber Subscriber S2 Last First No No No and/or = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Last First S2 S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 128

141 Country Life Insurance Company Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. No No No Required and/or = [NM108=PI]NM109 Last or Required,S2,S3,D1,D2 Situational Federal Tax ID and/or Situational. No Situational. No Last First Dependent Last First Type S3,S4 S3,S4 S4 D2,D3 D2,D3 D1,D3 Accept all STC Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 129

142 Covenant Administrators (TPA) Option Subscriber Last First Subscriber S2 Subscriber S3 Last First Subscriber S4 Last Subscriber S5 Last First 1 year No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S3,S4,S5 First,S3,S5,S2,S3,S4,S2,S4,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 130

143 Coventry Healthcare Option Subscriber Subscriber S2 Medicaid ID Subscriber S3 SSN Subscriber S4 Group Number Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First 18 Months 3 Months Yes Precertification decisions certify medical necessity only and do not guarantee payment of the related claim. Precertification does not certify that the member s benefit plan covers the requested service or that the member is eligible for coverage on the date of the service. Benefit plan limits and eligibility are subject to change and will be determined at the time that the applicable claim is processed for payment. Payers Payer Payer ID Payer Payer ID Advantra (TX, NM, AZ Only) Healthcare USA(HCUSA) Altius Health Plans Iowa Advantra Freedom Kansas Coventry Health &Life Nevada Louisiana Coventry Health and Life (Oklahoma) Missouri Coventry HealthCare Carelink (Advantra) Nebraska Coventry Health Care Carelink Medicaid OmniCare (Michigan) Coventry Health Care Carenet PersonalCare/Coventry Health of Illinois Delaware Southern Health s (SHS) Diamond Plan (Maryland Medicaid) WellPath Select (Carolinas) Georgia Coventry Health and Life (Tenn) Group Health Plan (GHP) Advantra Savings HealthAmerica&HealthAssurance Mail Handlers Benefit Plan HealthCare Inc. (Promina) Coventry Healthcare National Network University of Missouri Coventry Health Care Federal CoventryOne Coventry Nebraska Medicaid Vista (MCD, FHK, LTC) CoventryCares Florida/Vista/Summit CoventryCares of Kentucky MHNet Behavioral Health Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 131

144 and/or See table above = [NM108=PI]NM109 Type and/or 1,2,4,5,6,7,9,10,12,20,22, 23,26,30,33,35, 36,37,38,40,41,42,45,47,4 8,49,50,52,65, 68,69,70,71,72,73,74,75,7 6,78,79,80,81, 82,83,84,86,88,98,A0,A3, A4,A7,A8,A9,AD, AF,AG,AI,AL,AM,AN,AQ,B G,BQ and/or Situational. No Last or Federal Tax ID Situational. No Last S4 First S4,D1,D2 Min=10 Max=11 Medicaid ID S2 Min=8 Max=12 SSN S3 Group Number S4 S3 Last D2 First D2 D1 Relationship 01,19,34 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 132

145 Cox Health Plan Option Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Frist 12 months 60 days No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2 S3,S4 First S2 S4,S5,S2,S3,S4,S5,S2,S3,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 133

146 CTI Administrators Option Subscriber Subscriber S2 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. No No No Required and/or = [NM108=PI]NM109 Last or Required,D1,D2 Situational Federal Tax ID and/or Situational. No Situational. No Last First Dependent Last First Type S2 S2 S3 D2,D3 D2,D3 D1,D3 1,30,33,35,47,86, 88,98,AL,MH,UC Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 134

147 Culinary Health Fund UNITE HERE Health Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: No No No and/or = [NM108=PI]NM109 Last or Type and/or 1, 30,33,35, 47,86, 88,98,AL,MH,UC,A4 and/or Either Tax ID or is required Last S2,S3 First S2,S3,S2, D1, D2 Dependent Dep. Last Dep. First Dep. Date of Birth,S3 D2, D3 D2, D3 D1, D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 135

148 Dean Health Plan Option Subscriber Last First Subscriber S2 Last First Subscriber S3 Last Yes Future dates allowed up to 7 days Yes and/or = [NM108=PI]NM109 Last or Type and/or 1,2,4,5,6,7,8,12,18,20, 33,35,40,42,45,47,48, 50,51,52,53,62,65,68, 73,76,78,80,81,82,86, 88,93,98,99,A0,A3,A6, A7,A8,AD,AE,AF,AG, AI,AL,BG,BH,MH,UC and/or Situational. No Last S2,S3 First S2,S3 S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 136

149 DeCare Dental Health Insurance Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Federal Tax ID Last First Provider Tax ID Required Type and/or 30 and/or if NM108 = XX Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 137

150 Definity Health Option Subscriber Last First Subscriber S2 Last First Subscriber S3 Dependent D1 Subscriber Dep. First Dep. Dependent D2 Dep. Last Dep. First Dep. 6 months 30 days No Required and/or = [NM108=PI]NM109 Last or Required,D1,D2 Situational Federal Tax ID and/or Situational. No Situational. No Last First Dependent Last First Type S2 S2 S3 D2,D3 D2,D3 D1,D3 All s accepted. Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 138

151 Dental Benefit Providers Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 139

152 Delaware Physicians Care Option Subscriber Subscriber S2 Last First No No No and/or = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 1, 30, 33, 35, 47, 48, 50, 52, 86, 88, 98, A4, AL, MH, and UC Federal Tax ID and/or Either Tax ID or is required Last First S2 S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 140

153 Delta Dental Option Subscriber Last First No No No Payers Payer Payer ID Payer Payer ID Delta Dental Ins. Co. - Alabama Delta Dental of Minnesota Delta Dental Ins. Co. - Florida Delta Dental of Nebraska Delta Dental Ins. Co. - Georgia Delta Dental of New Jersey Delta Dental Ins. Co. - Louisiana Delta Dental of New Mexico Delta Dental Ins. Co. - Mississippi Delta Dental of New York Delta Dental Ins. Co. - Montana Delta Dental of North Carolina Delta Dental Ins. Co. - Nevada Delta Dental of North Dakota Delta Dental Ins. Co. - Texas Delta Dental of Ohio Delta Dental Ins. Co. - Utah Delta Dental of Pennsylvania Delta Dental of California Delta Dental of Rhode Island Delta Dental of Colorado Delta Dental of Tennessee Delta Dental of Colorado Delta Dental of Virginia Delta Dental of Delaware Delta Dental of Washington DC Delta Dental of Hawaii Delta Dental of Washington State Delta Dental of Indiana Delta Dental of West Virginia Delta Dental of Maryland DeltaCare USA - Claims Delta Dental of Michigan DeltaCare USA - Encounters Required and/or See table above [NM108=PI]NM109 Last or Required. No Optional Type and/or 30, 35 Tax ID Last First if NM108 = XX Required. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 141

154 Denver Health Medical Plan Option Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First 1 year 60 days 60 days Required and/or = [NM108=PI]NM109 Last or Required. No,S2,S3,S4 Note: must include the dash - in the inquiry or a Not Found will be returned.,s2,s3,s5 Situational Federal Tax ID and/or Situational. No Situational. No Last First Type,S2,S4,S5,S4,S5 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 142

155 Deseret Mutual (DMBA) Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Yes Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be after the claim has been received in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. Required and/or = [NM108=PI]NM109 Last or Federal Tax ID Required. No Required. No Last First Type Last First,D1 Min=10 Max=12 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 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 143

156 Director's Guild Option Subscriber Last First Subscriber S2 Last First Dependent D1 Sub: Dep. Last Dep. Dependent D2 Sub: Dep. No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last,S2 First Sub: Member ID,S2, D1,D2, S2 Dependent Dep. Last Dep. First Dep. Date of Birth D1 D1 D1,D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 144

157 EBMS Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM1 09 Last or Required. No Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First S2, S3 S2, S3,S2,D1,D2, S3 Dependent Dep. Last Dep. First Dep. Date of Birth D2,D3 D2,D3 D1, D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 145

158 Elderplan Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First No No No Required and/or = [NM108=PI]NM109 Last or Required. No Situational Type and/or 30 Last First Required. No, S2, S3 Min =2 Max=80 S3,S4 S3,S4 S2,S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 146

159 Employee Benefit s - Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 147

160 EPIC Life Insurance Option Subscriber Last First No No No and/or = [NM108=XX]NM109 Last or Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Last First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 148

161 EPSI, Inc Option Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: Required and/or = [NM108=PI]NM109 Last or No Optional Type and/or 30 Last First No Min/Max=16,D2 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 149

162 EssenceHealthcare Option Subscriber Last First Subscriber S2 Subscriber S3 Last First Required and/or = [NM108=PI]NM109 Last or Required. No Situational and/or Situational. No Provider ID Last First Type Required. No,S2,S2,S3,S3,S3 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 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 150

163 Evangelical Community Hospital Option Subscriber Subscriber S2 Last First No No No and/or = [NM108=XX]NM109 Last or Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Last First S2 S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 151

164 Evercare Option Subscriber Subscriber S2 Last First Subscriber S3 SSN Subscriber S4 SSN Last First Subscriber S5 Last First Subscriber S6 Last First Dependent D1 Sub. Dep. Last name Dep. First Dep. Dependent D2 Dep. Last name Dep. First Dep. and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2 S3,S5,S6 First S2 S3,S5,S6,S2,S3,D1,S3,S5,S6 SSN S3,S4 Dependent Dep. Last Dep. First Dep. Date of Birth D1,D2 D1,D2 D1,D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 152

165 Everence Financial Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. Required and/or = [NM108=PI]NM109 Last or Required,S2,D1,D2 Situational Federal Tax ID and/or Situational. No Situational. No Last First Dependent Last First Type S2,S3 S2,S3 S3 D2,D3 D2,D3 D1,D3 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 153

166 Evergreen Health Co-Op Option Subscriber Last First Subscriber Member Subscriber Last Subscriber First Dependent D1 Dep. ID No No No and/or = [NM108=PI]NM109 Last or Last First Date Of Birth,D1.D1 Min/Max=10 Type and/or 30 Federal Tax ID Provider ID and/or Situational. Federal Tax ID if NM108=FI. Situational. National Provider ID if NM108=XX. Situational. Provider ID if NM108=SV Dependent Dep. Last Dep. First Dep. Date Of Birth D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 154

167 Expert Benefit Solutions Option Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: Required and/or = [NM108=PI]NM109 Last or No Optional Type and/or 30 Last First No Min/Max=16,D2 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 155

168 Family Care Option Subscriber Last First Subscriber S2 Subscriber S3 Last First 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 60 days Yes Required and/or = [NM108=PI]NM109 Last or Required. No Situational and/or Situational. No Provider ID Last First Type Required. No,S2,S2,S3,S3,S3 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 156

169 FCE Benefit Administrators Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Last First Required. No Min/Max=24,S2,S3 S2,S3 S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 157

170 Federated Insurance Company Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Dependent D4 Sub: Dep: Last Dep: First Dep: 1 year Yes No Disclaimer: The provided information is not a guarantee of coverage. Actual benefits are determined only when the claim is received. Note: certain procedures may require pre-approval. and/or = [NM108=PI]NM109 Last or Type and/or 1, 30, 33, 48, 50, 52, 86,88, 98, A4, AL Federal Tax ID and/or Situational. No Situational. No Last First S2,S3,S4 S2,S3,S4,S2, S4 D1,D2,D4 Min=10 Max=11 S3,S4 Dependent Last First D2,D3,D4 D2,D3,D4 D1,D3,D4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 158

171 Fidelis Care New York Option Subscriber Last First Subscriber S2 Subscriber S3 SSN Subscriber S4 SSN Last First Subscriber S5 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or 30 and/or Situational. No Last First SSN,S4,S5,S4,S5,S2 Min=7 Max=10 S3,S4 S2,S3,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 159

172 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 160

173 Fidelis SecureCare of Michigan Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or 30 and/or Situational. No Last First S2,S3 S2,S3,S2 Min=7 Max=10,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 161

174 FirstCare Option Subscriber Last First Subscriber S2 Subscriber S3 Last First Subscriber S4 Last Subscriber S5 Last First 1 year No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S3,S4,S5 First,S3,S5,S2,S3,S4,S2,S4,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 162

175 First Medical Network Option Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Dependent D2 Dep: Last Dep: First Dep: 3 years No Yes and/or = [NM108=XX]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Subscriber Last Subscriber First Subscriber Subscriber S2 S2, D1 S2 Dependent Subscriber Dep. Last Dep. First Dep. Date of Birth, D1 D2 D2 D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 163

176 First United American Insurance Company Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2 S2, S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 164

177 Flex Compensation - Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 165

178 Florida Combined Life Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 30, 35 Federal Tax ID and/or Either Tax ID or is required S! Last First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 166

179 Florida Health Care Plans Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: 24 mos 12 mos No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First,D1 Min=10 Max=11 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 167

180 Florida Hospital Healthcare System Option Subscriber Subscriber S2 Subscriber S3 Last First 1 year No 90 days and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First S3 S3,S2,S3 Min=10 Max=11 S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 168

181 Florida True Health Option Subscriber Subscriber S2 Last First Subscriber S3 SSN Past Date allowed: unrestricted 60 days No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First SSN S2 S2 Min=10 Max=11 S3 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 169

182 Food Employers & Bakery Confectionary Workers Benefit Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2,D4,D5, S3 Dependent Dep. Last Dep. First Dep. D2,D3 D2,D3 D1, D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 170

183 Freedom Blue Option Subscriber Last First Subscriber S2 Subscriber S3 Last First Subscriber S4 Last Subscriber S5 First Dependent D1 Sub: Dep: Last Dep: First Dep: Dependent D2 Sub: Dep: Dependent D3 Sub: Dep: Last Dep: First Dependent D4 Sub: Dep: Last Dep: Dependent D5 Sub: Dep: First Dep: Note: Freedom Blue is a Highmark Blue Shield Medicare Advantage PPO. 2 years 6 mos No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Last First Last First Last R,S3,S4,S3,S5,S2, S3,S4.S5 D1,D2,D3,D4,D5 Min=10 Max=11,S2,S4,S5 D1,D3,D4 D1,D3,D5 D1,D2,D4,D5 D1,D3,D4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 171

184 Fresenius Medical Care Option Subscriber Last First and/or = [NM108=PI]NM109 Last or Last Type and/or 23, 24, 25, 26, 27, 28, 35, 36, 37, 38, 39, 40, 41, 88, 89, 90, 91, 92 First and/or Min=1 Max=24 Note: Required if entity is a person. First Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 172

185 Gateway Health Plan Option Subscriber Last First Subscriber S2 Subscriber S3 SSN Subscriber S4 SSN Last First Subscriber S5 Last First Note: Data updated daily. Area of coverage Pennsylvania and Ohio. 1 year 60 days 60 day Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type Required. No Provider ID Optional and/or 30, S2 Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 173

186 Geisinger Health Plan Option Subscriber Last First Note: Lines of business: Pennsylvania/Commercial. 1 year No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Last First Required. No Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 174

187 Geisinger Health Plan Gold Option Subscriber Last First Note: Lines of business: Pennsylvania/Medicare. 1 year No Required and/or = [NM108=PI]NM109 Last or Required. No Required. No Optional Type and/or 30 Last First Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 175

188 GHI - Group Health Incorporated Option Subscriber Last First and/or = [NM108=PI]NM109 Last or R Type and/or 30 First and/or Required is entity is a person Last First R Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 176

189 Gilsbar Option Subscriber Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: First Required and/or = [NM108=PI]NM109 Dependent Required. Either Tax ID or is required. 10-digit max.,d1,d2 Min=10 Max=11 Optional Type Federal Tax ID and/or 30 Either Tax ID or is required First D2 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 177

190 Globe Life & Accident Insurance Company Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2 S2, S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 178

191 Group & Pension Administrators Option Subscriber Last First Dependent D1 Sub: Dep: First Dep: Yes and/or See table above = [NM108=SV]NM109 Type and/or and/or 30 Situational. No notes indicated. Last Provider ID Situational. No notes indicated. First,D1 Max=9 Dependents First D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 179

192 Group Health Cooperative Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required and/or = [NM108=PI]NM109 Last or Required. No Required. No Last First Type, D1 30 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 180

193 Group Health Cooperative of South Central Wisconsin - Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 181

194 Guardian Life Insurance Co. of America Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 182

195 Harmony Health Plan Option Subscriber Last First Subscriber S2 Last First Subscriber S3 1 Year No No Required and/or = [NM108=PI]NM109 Required. No Optional Type and/or 30 Last First, S2, S2, S3 Min=4 Max=12, S2, S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 183

196 Hawaii Medical Assurance Association Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 184

197 Health Alliance Medical Plan (IL) Option Subscriber Subscriber S2 Subscriber S3 SSN Subscriber S4 Last First 2 years No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S5 First S5,S2 S2,S3,S4 SSN S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 185

198 Health Alliance Medical Plans (HAP) Option Subscriber Subscriber S2 SSN Subscriber S3 Last First Subscriber S4 Last First Note: This connection does not support eligibility requests for Illinois plan members. 1/1/1996 No No Required and/or = [NM108=PI]NM109 Last or Required. No Required. No Optional Type and/or 30 Last First SSN S3,S4 S3,S4,S4 Min/Max=12 S2,S2,S3,S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 186

199 Health Choice Arizona Option Subscriber Subscriber S2 Last First 1 year No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Provider ID Situational. No notes required. Situational. No notes required. Last First S2 S2 Min/Max=12 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 187

200 Health Cost Solutions Option Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: Required Optional and/or and/or = [NM108=PI]NM109 Last or No Last First Type Dependent Last First No Min/Max=16,D2 The operating rule codeset D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 188

201 Health First Health Plan Option Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Date of Birth Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Date of Birth No No No Required and/or = [NM108=PI]NM109 Last or Identification Subscriber Subscriber Last Subscriber First Subscriber Dependent Required. No or Tax ID required Min/Max=9,D1,D2 S2 S2 S2 Situational Type and/or 1, 2, 4, 5, 6, 7, 8, 12, 13, 18, 20, 30, 33, 35, 40, 42, 45, 47, 48, 50, 51, 52, 53, 62, 65, 68, 69, 73, 76, 78, 80, 81, 82, 86, 88, 93, 96, 98, 99, A0, A3, A6, A7, A8, AD, AE, AF, AG, AI, AL, BG, BH, MH, UC Dep. Last Dep. First Dep. Date of Birth D2,D3 D2,D3 D1,D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 189

202 Health First New Jersey Option Subscriber Last First and/or = [NM108=PI]NM109 Last or Last Type and/or and/or 30 Provider ID Min/Max=7 First Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 190

203 Health First New York Option Subscriber Last First and/or = [NM108=PI]NM109 Last or Last Type and/or and/or 30 Provider ID Min/Max=7 First Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 191

204 Health Net National Option Subscriber Last First Subscriber S2 SSN Subscriber S3 Subscriber S4 SSN Last First Note: *( only searches) ID s without the suffix are 9 digits and if you send a member ID only search you must submit the 9 digit plus the person number/suffix for commercial members. When the proper ID and person number/suffix is sent it should return a valid response example: RXXXXXXXXMM1 or RXXXXXXXX00. Note: For CA Medicaid members, the 9 digit Medicaid CIN (8 numbers and 1 suffix) is sufficient. Note: For ID-only search (S3), must be characters for commercial patient or can be 9 digits for CA Medicaid patients Note: HealthNet Medi-Cal members should be submitted through Health Net National effective 7/1/ year End of current month Yes Required and/or = [NM108=FI, XX]NM109 Last or Federal Tax ID if NM108 = FI if NM108 = XX Required. No Required. No Optional Type and/or 1, 2, 4, 5, 6, 7, 8, 12, 13, 18, 20, 30,33, 35, 40, 42, 45,48, 50, 51, 52, 53, 62, 65,68,73, 76, 78, 80, 81, 82, 86, 88, 93, A0, A3, A6, A7, A8, AD, AE, AF, AG, AI, AL, BG, BH STC 30 will return benefit information for STC 1, 30, 33, 35, 48, 50, 86, 88, 98, AL Last First SSN S3,S4,S2,S3,S4 Min/Max=12 S2,S4,S2,S3,S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 192

205 Health New England Option Subscriber Subscriber S2 Last First and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Last First S2 S2 Min/Max=12 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 193

206 Health Partners (Minnesota) Option Subscriber Last First Subscriber S2 Last Subscriber S3 First Subscriber S4 Subscriber S5 Last First Subscriber S6 Last First 1 year 60 days 60 days and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Last First,S2,S5,S6,S3,S5,S6,S2,S3,S4,S5 Min/Max=12,S2,S4,S6 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 194

207 Health Partners Philadelphia Option Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First Note: PA Children s Health Insurance Program, KidzPartners 1 year 60 days 60 days and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First,S2,S5,S6,S4,S5,S2,S3,S4 Min/Max=12,S2,S5,S6 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 195

208 Health Plan of San Mateo Option Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year 60 days 60 days Required Optional and/or and/or = [NM108=SV or XX]NM109 Provider ID if NM108 = SV if NM108 = XX Type 30 Last First Required. No,S2,S2,S3 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 196

209 Health Share of Oregon Option Subscriber Subscriber S2 Last Subscriber S3 Last First Subscriber S4 Last No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First S2,S3,S4 S3,S2,S3,S4 Min/Max=12,S2,S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 197

210 Health s for Children with Special Needs Option Subscriber Subscriber S2 Last First Subscriber S3 SSN No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last First S2 S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 198

211 Healthcare Solutions Group Option Subscriber Last First Subscriber S2 Last First Note: This connection currently only includes one Healthcare Solutions Group- M8063: City Utilities. More groups may be added in the future. Required and/or = [NM108=PI]NM109 Last or Required. No Required. No Optional Type and/or 30 Last First,S2,S2 Min/Max=12,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 199

212 HealthComp Administrators Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Last Dep: First Dependent D2 Sub: Dep: Dependent D3 Dep: Last Dep: First Dep: No No No Required and/or = [NM108=PI]NM109 Last or No No Optional Type and/or 30 Last First Dependent Last First,S2,S2,S2,D1,D2 Min/Max=24,S3 D1,D3 D1,D3 D2,D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 200

213 HealthEase Option Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year No No Required and/or = [NM108=PI]NM109 Optional Type and/or 30 Last First Required. No,S2,S2,S3 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 201

214 HealthEase Kids Option Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year No No Required and/or = [NM108=PI]NM109 Optional Type and/or 30 Last First Required. No,S2,S2,S3 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 202

215 Healthgram Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM 109 Last or Subscriber Last Subscriber First Subscriber Subscriber Date of Birth Dependent Subscriber Subscriber Last Dep. Last Required. No S2,S3,S2,D3,D4,S3, D1, D1 D2,D3 Type and/or 1,4,30,33,35,47,48,50, 86, 88,98,AL,MH,UC Federal Tax ID and/or Situational. No Situational. No Dep. First Dep. D2,D3 D1,D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 203

216 HealthMarkets Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Dependent D4 Sub: Dep: Last Dep: First Dep: 1 year 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. Payers Payer Payer ID Payer Payer ID Chesapeake National Life Mid-West National Life TransAmerica Life Mega Life and Health Insurance and/or See table above = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First S2,S3,S4 S2,S3,S4,S2, S4 D1,D2, D4 Min=10 Max=11,S2,S3,S4 Dependents Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 204

217 Last First D2,D3,D4 D2,D3,D4 D1,D3,D4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 205

218 HealthPlan of Nevada Option Subscriber Subscriber S2 Last First Subscriber S3 SSN Subscriber S4 SSN Last First Subscriber S5 Last First Subscriber S6 Last First Dependent D1 Sub. Dep. Last name Dep. Dependent D2 Dep. State Dep. First Dep. Last name Dep. No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2 S3,S5,S6 First Sub. Member ID S2 S3,S5,S6,S2,S3,D1,S3,S5,S6 SSN S3,S4 Dependent Dep. Last Dep. First Dep. Date of Birth D1,D2 D1,D2 D1,D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 206

219 HealthPlans Inc Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or = [NM108=PI]NM109 Optional Type and/or 30 Last First Required. No,S2,S2,S2 Min/Max=12 S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 207

220 HealthPlus of Michigan 1311 Option Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First No No No and/or 1311 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First,S2,S4,S5,S4,S5,S2,S3,S4 Min/Max=12,S2,S3,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 208

221 HealthScope (Morris Assoc, Central Benefits, Employer s Health, Plan Handlers) Option Subscriber Last First Subscriber S2 SSN Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Not supported Not supported Not supported Note: HealthScope includes the following entities: Morris Associates, Central Benefits, Employer s Health Coalition, Plan Handlers and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Last First SSN,S2,S2, D1 Min=10 Max=11 S2,S2 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 209

222 Healthsource Provident - Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 210

223 HealthSpring Option Subscriber Last First Not supported Not supported Not supported Note: Only the following states are supported; AL, AR,GA, FL, IL, MS, OK, TN, TX, and WV and/or = [NM108=XX]NM109 Last or Type and/or and/or 30 Situational. No Last First,S2,S2, D1 Min=2 Max=20,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 211

224 Healthy Texas Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2, S3 First S2, S3, S2, D1, D2, S3 Dependent Dep. Last Dep. First Dep. Date of Birth D2, D3 D2, D3 D1, D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 212

225 Heritage Physician Network (Houston) Option Subscriber Last First 3 years No 4) 90 day Date Ranges and/or = [NM108=XX]NM109 Last or Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Last First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 213

226 Hershey Healthsmile - Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 214

227 HIPNY Option Subscriber Last First No No No and/or = [NM108=PI]NM109 Type and/or 30 Federal Tax ID and/or Situational. No Last Situational. No First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 215

228 Horizon NJ Health 2840 Option Subscriber Subscriber S2 SSN Subscriber S3 Last First 3 years No No Required and/or 2840 = [NM108=PI]NM109 Last or No Optional Type and/or 30 Facility ID Last First SSN No Min/Max=9 Federal Tax ID S3 S3 Min/Max=12 S2 S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 216

229 Humana Option Subscriber Subscriber S2 Medicare ID Subscriber S3 Medicaid ID State 1 year 1 year No Disclaimer: This is an estimate of the benefits provided under this contract. Any payment is subject to coordination of benefits with any other insurance that may cover the services rendered and the coverage being in effect on the date of service. If your plan requires a Primary Care Physician (PCP), your PCP would be responsible for providing or authorizing all care. The above information is usually updated within 24 hours of being processed by Humana. The information may contain inaccuracies or errors. Required and/or = [NM108=PI]NM109 Optional Type and/or All service type codes accepted. Note: Only one service code type allowed per member transaction. Required. No Min/ Max=12 Medicare ID Medicaid ID State If is a ChoiceCare Subscriber, pleaseprovide the number including the two-digit suffix. S2 Min/ Max=12 S3 Min/ Max=12,S2,S3 S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 217

230 Humana CareSource (KY) Option Subscriber Subscriber S2 Last First 1 year Up to end of current month Yes and/or = [NM108=XX]NM109 Last or Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Last First S2 S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 218

231 IBM Insurance Outsourcing s Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2, S3 First S2, S3, S2, D1, D2, S3 Dependent Dep. Last Dep. First Dep. Date of Birth D2, D3 D2, D3 D1, D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 219

232 IBEW Local 508 Health Plan Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2,D4,D5, S3 Dependent Dep. Last Dep. First Dep. D2,D3 D2,D3 D1, D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 220

233 Ideal Life Insurance Option Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan and/or = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 221

234 Independence Administrators Option Subscriber Subscriber S2 Last First Subscriber S3 Last Subscriber S4 First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Sub: Dep: Last Dep: Dependent D4 Sub: Dep: First Dep: and/or = [NM108=PI]NM109 Type and/or 1,2,4,5,6,7,8,12,13,18,20, 30,33,40,42,48, 50,51,52,53,61,62,65,68,6 9,73,76,78,80, 81,82,84,86,93,98,99A0,A 3,A6,A7,A8,AD, AE,AF,AG,AI,BG,BH and/or Situational. No Last or,s2, S3, S4, D1, D2, D3, D4, S3, S4, D1, D3, D4 Dependent D1, D3, D4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 222

235 Insurers Administrative Corporation (IAC) Option Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: No No No Required and/or = [NM108=PI]NM109 Last or No No Optional Type and/or 30 Last First Dependent Last First,D1 Min/Max=16 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 223

236 International Medical Card Inc Option Subscriber Last First No No No Required and/or = [NM108=PI]NM109 Last or Identification Last No Tax ID or required. Optional Type and/or The operating rule codeset First Min/Max=24 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 224

237 Island Home Insurance Option Subscriber Subscriber S2 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or Complete code set. Situational. No Provider ID Situational. No Last First S2 S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 225

238 John Hopkins Health Plan Option Subscriber 1 year 1 year No Note: Employee Health Plan This connection does not support members whose ID start with U. and/or = [NM108=PI]NM109 Last or Min/Max=12 Type and/or and/or 30 Situational. No Provider ID Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 226

239 Kaiser Foundation Health Plan of Colorado Option Subscriber Subscriber S2 Last First Gender No No No Required and/or = [NM108=PI]NM109 Last or Federal Tax ID Last First Gender Type Required. No Required. No Required. No,S2,S2 Min/Max=12 S2,S2 The operating rule codeset Optional Type and/or 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 227

240 Kaiser Foundation Health Plan of Hawaii Option Subscriber Last First Subscriber S2 SSN Last First Subscriber S3 Last First Gender No No No Required and/or = [NM108=PI]NM109 Federal Tax ID Last First Gender SSN Type Required. No Required. No,S2, S3,S2, S3 Min/Max=12 S2 S2,S2, S3 The operating rule codeset Optional Type and/or 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 228

241 Kaiser Foundation Health Plan of Hawaii (DHMO Choice) Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. No No No Required and/or = [NM108=PI]NM109 Last or Required,S2,D1,D2 Situational Federal Tax ID and/or Situational. No Situational. No Last First Type Dependent Last First Type S2,S3 S2,S3 S3 The operating rule codeset D2,D3 D2,D3 D1,D3 The operating rule codeset Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 229

242 Kaiser Foundation Health Plan of the Mid Atlantic Option Subscriber Subscriber S2 Last First Gender No No No Required and/or = [NM108=PI]NM109 Optional Type and/or 30 Federal Tax ID Last First Gender Type Required. No Required. No S2 S2 Min/Max=12 S2 S2 The operating rule codeset Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 230

243 Kaiser Foundation Health Plan of the Northwest Option Subscriber Subscriber S2 Last First Gender No No No Required and/or = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Last First Gender Type Required. No S2 S2 Min/Max=12 S2 S2 The operating rule codeset Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 231

244 Kaiser Permanente of Georgia Option Subscriber Subscriber S2 Last First Subscriber S3 Last No No No Required and/or = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Last First Type Required. No S2,S3 S2, S2,S3 Min/Max=12,S2 The operating rule codeset Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 232

245 Kaiser Permanente of Northern CA Option Subscriber Subscriber S2 Last First Gender No No No Required and/or = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Last First Gender Type Required. No S2 S2 Min/Max=12 California s are a total of 12 digits. The ID numbers are left zero filled to 10 digits and then a prefix is added for the region (11 for Northern California and 00 for Southern California members). An ID that is would be for Northern California and for Southern California S2 S2 The operating rule codeset Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 233

246 Kaiser Permanente of Southern CA Option Subscriber Subscriber S2 Last First No No No Required and/or = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Last First Type Required. No S2 S2 Min/Max=12 California s are a total of 12 digits. The ID numbers are left zero filled to 10 digits and then a prefix is added for the region (11 for Northern California and 00 for Southern California members). An ID that is would be for Northern California and for Southern California S2 The operating rule codeset Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 234

247 Kentucky Health Exchange Option Subscriber Last First Dependent D1 Subscriber Member ID Dep Last Dep. First Dep. No No No and/or = [NM108=PI]NM109 Subscriber Last or Last Type and/or 30 Federal Tax ID and/or Situational. No Situational. No First Date Of Birth,D1.D1 Min/Max=10 Dependent Dep. Last Dep. First Dep. Date Of Birth D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 235

248 Keystone Mercy Health 2232 Option Subscriber Subscriber S2 SSN Subscriber S3 Last First 1 year No No Required and/or 2232 = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Last First SSN Required. No Last First Min/Max=12 SSN Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 236

249 Kitsap Physician s 2644 Option Subscriber Last First Subscriber S2 Subscriber S3 First Subscriber S4 Last Subscriber S5 Last First 1 Year 60 Days 60 Days : Data updated twice weekly. Required and/or 2644 = [NM108=PI]NM109 Last or Last First Required. No Required. National Provider ID if NM108=XX Provider ID if NM108=SV,S4,S5,S3,S5,S2, S3, S4, S5,S2, S3, S4 Optional Type and/or 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 237

250 KSKJ Life Option Subscriber Last First Np No No *Note: This is a Medicare Supplemental Plan and/or = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 238

251 Leggett & Platt Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 SSN Subscriber S5 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S3,S5 First SSN S2 S3,S5,S2,S3.D1.D2 S4 S2,S4,S5 Dependent Dep. Last Dep. First Dep. D2,D3 D2,D3 D1, D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 239

252 Leon Medical Centers Health Plan Option Subscriber Last First Gender Required and/or = [NM108=PI]NM109 Last or Required. No Required. No Optional Type and/or 30 Last First Gender Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 240

253 Liberty National Life Insurance Company Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2 S2, S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 241

254 Lifetime Benefit Solutions (RMSCO) Option Subscriber Last First No No No and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 242

255 Lifewise Arizona Option Subscriber Last First and/or = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 243

256 Lifewise Health Plan of Oregon Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: 1 Year No No and/or = [NM108=PI]NM109 Last or Last First, D1 Type and/or All valid service types are supported Only (1) EQ01 segment per transaction and/or National Provider ID. Last Dependent Last First, D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 244

257 Lifewise Health Plan of Washington Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: 1 Year No No and/or = [NM108=PI]NM109 Last or Last First, D1 Type and/or All valid service types are supported Only (1) EQ01 segment per transaction and/or National Provider ID. Last Dependent Last First, D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 245

258 Lincoln Financial Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. and/or s and Values = = [NM108=PI]NM109 Last or Subscriber Last Subscriber First Subscriber Subscriber Date of Birth Dependent Subscriber Last S2, S3 S2,S3, S2,D1,D2 S3, D1 Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Dep. Last Dep. First Dep. Date of Birth D2,D3 D2,D3 D1,D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 246

259 Lincoln Heritage Option Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan Optional Situational Required and/or and/or and/or = [NM108=PI]NM109 Type 30 Federal Tax ID Situational. No Last or Last First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 247

260 Local Option Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep. Last Dep. First Dep. No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last,S2 First Sub: Member ID,S2, D1,D2, S2 Dependent Dep. Last Dep. First Dep. Date of Birth D1 D1 D1,D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 248

261 LoneStar TPA Option Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: Required and/or = [NM108=PI]NM109 Last or Required. No No Optional Type and/or 30 Last First,D1 Min/Max=16 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 249

262 Loomis Company Option Subscriber Last First Dependent D1 Subscriber Subscriber Last Dep. First Dep. No No No and/or = [NM108=PI]NM109 Last or Last,D1 Type and/or 30 Federal Tax ID and/or Situational. No Situational. No First Date Of Birth Dependent Dep. Last Dep. First Dep. Date Of Birth,D1.D1 Min/Max=10 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 250

263 Louisiana Health Exchange Option Subscriber Last First Subscriber Member Subscriber Last Subscriber First Dependent D1 Dep. ID No No No and/or = [NM108=PI]NM109 Last or Last Type and/or 30 Federal Tax ID and/or Situational. No Situational. No First Date Of Birth,D1.D1 Min/Max=10 Dependent Dep. Last Dep. First Dep. Date Of Birth D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 251

264 Magellan Behavioral Health Option Subscriber Dependent D1 Last First Subscriber Subscriber Last Subscriber First Dep. Last Dep. First Dep. Date of Birth No No No and/or = [NM108=PI]NM109 Last or Last Type and/or 30 Federal Tax ID and/or Situational. No Situational. No First Date Of Birth Dependent Dep. Last Dep. First Dep. Date Of Birth,D1.D1 Min/Max=10 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 252

265 Magnacare Option Subscriber Last First Subscriber S2 SSN Last First No No No Required and/or = [NM108=PI]NM109 Last or Last Situational Federal Tax ID and/or Situational. No Required. No Situational. No.S2 First SSN Type.S2 Min=10 Max=12 S2.S2 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 253

266 Mid Atlantic Medical s, LLC MAMSI Option Subscriber Subscriber S2 Last First Subscriber S3 SSN Subscriber S4 SSN Last First Subscriber S5 Last First State Subscriber S6 Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Date of Birth Dependent D2 Sub: Dep: Last Dep: First Dep: Date of Birth Dep: State Up to 18 months in the Past Up to the end of the current month in the Future End date of date range must be no greater than the end of the current month and/or MAMSI = [NM108=PI]NM109 Group Number and/or Min/Max=7 Optional, but recommended. / Federal Tax ID/Provider ID and/or National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Last or Org Member ID No,S2,S6,D1,D2 Min/Max=9 Type Provider ID if NM108=SV. 1,2,3,4,5,6,7,8,10, 12,13,18,20,23,24, 25,26,27,28,33,35, 36,37,38,39,40,41,42,45,4 7,48,49,50,51,52,53,62,65,68,73,76,78,80,81,82,83, 86,88,,89,90,91,92,93,98, 99,A0,A3,A4,A5,A6,A7,A8, AD,AE,AF,AG,AI,,AJ,AK,A L,BG,BH,BT,BU,BV,BW,B X,BY,BZ,DM,GF,GN,MH, UC Last S2,S4,S5,S6 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 254

267 First S2,S4,S5,S6 SSN State Date of Birth S3,S4 S5,S3,S5,S6 Dependent Last First Date Of Birth State D1,D2 D1,D2 D1,D2 D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 255

268 Managed Care of America Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First 1 year No No and/or = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Last First S3,S4 S3,S4,S2,S3 S2, S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 256

269 Managed Health s Wisconsin Option Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or = [NM108=PI]NM109 Last or Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Last First S2,S3 S2,S3,S3 S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 257

270 MAPFRE Medicare Excel Option Subscriber Required and/or = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Type Required. No Min/Max=12 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 258

271 MAPFRE Life Puerto Rico Option Subscriber No No No Required and/or = [NM108=PI]NM109 Required. No Optional Type and/or Complete code set Federal Tax ID Type Required. No Min/Max=12 Complete code set Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 259

272 Maricopa Health Plan Arizona Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Dependent D2 Sub: Dep: and/or = [NM108=PI]NM109 Last or Type and/or 1,30,35,38,47,48,50,86,88, 98,AL Federal Tax ID and/or Situational. No Situational. No Last First Date Of Birth S3,S4 S3,S4,S2,S3,D1,D2 Min/Max=10 S2,S3,S4 Dependent Last First Date Of Birth D1 D1 D1,D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 260

273 MDWise Hoosier Alliance Option Subscriber Subscriber S2 SSN Subscriber S3 Last First Subscriber S4 Last First No Use Min Max Type s and Values Payer Payer ID R 5 5 AN Provider Information Source Level: 2100A [NM108=PI] NM109 Information Receiver Level: 2100B Provider ID S 5 12 S Subscriber Subscriber Level: 2100C Last First S3,S4 S3,S4,S SSN S2 S3,S4 Type O 30 Usage: R=Required, O=Optional, S=Situational Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 261

274 MedBen - Newark OH Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM 109 Last or Subscriber Last Subscriber First Subscriber Subscriber Date of Birth Dependent Subscriber Subscriber Last Dep. Last Required. No S2,S3,S2,D3,D4,S3, D1, D1 D2,D3 Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Dep. First Dep. D2,D3 D1,D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 262

275 MedCost Benefit s Option Subscriber Last First Subscriber Dependent Last Dependent Date of Dependent D1 Dependent First Birth and/or = [NM108=PI]NM109 Last or Subscriber, D1 Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First Dependent Dependent Last Dependent First Dependent Dependent Gender D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 263

276 Medica Option Subscriber Subscriber S2 SSN Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: First Dep: Last Dep: Dependent D2 Dep: Last Dep: First Dep: 1 year No No Required and/or = [NM108=PI]NM109 Situational /Federal Tax ID and/or National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Provider ID (legacy) if NM108=SV. Last or Required. No Type All services type codes accepted. Last S3,S4 First S3,S4,S3,D1 Min/Max=9 SSN S2 Group Number D1 Min=1 Max=17,S2,S4 CCYYMMDD Dependent Last D1,D2 First D1,D2 D1,D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 264

277 Medica Health Plans Option Subscriber Subscriber S2 Last First No No No and/or = [NM108=PI]NM109 Last or and/or Gender M,F Type and/or The operating rule codeset. Last First Min/Max=12,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 265

278 Medical Associates Health Plan/Health Choices Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dep. Dependent D3 Dep. Last Dep. First Dep. No No No Required and/or = [NM108=PI]NM109 Last or Required,S2,D1,D2 Situational Federal Tax ID and/or Situational. No Situational. No Last First Type Dependent Dep. Last Dep. First Type S2,S3 S2,S3 S3 Full code set D1,D3 D1,D3 Full code set Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 266

279 Medical Card System Option Subscriber No No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 267

280 Medical Mutual of Ohio Option Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Disclaimer: This information is provided "as is" without warranty of any kind, either express or implied. Provider/Submitter understands that eligibility and benefit information does not guarantee payment of a related claim. Eligibility and benefit plan limitations are subject to change and will be determined at the time that the applicable claim is processed. and/or = [NM108=PI]NM109 Last or Last S2 Type and/or 1, 30, 35, AL, 98, 68, 52, 81, 49, A8 Provider ID and/or Situational. No Situational. No First S2,S2,D1 Min=10 Max=12 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 268

281 Medicare CMS Option Subscriber Last First Subscriber S2 Last Subscriber S3 Last First 28 months 4 months from current date Yes Note: Medicare Payer Id CMS is a direct connection to the real-time CMS database. This payer includes all possible Medicare patients. There is no separate PayerID for Railroad Medicare, or any other Regional Medicare eligibility; CMS is the sole PayerId for all Medicare eligibility at a national level. Required and/or CMS = [NM108=PI]NM109 Last or Required. No Required. No Optional Type and/or 30, 14, 15, 42, 45, 47, AG Last First,S2,S3,S3,S2,S3 Min=10 Max=12,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 269

282 Medicare Advantage - Pennsylvania Option Subscriber Last First Dependent D1 Sub: Dep: First Dep: 2 Years in the Past. 18 Months in the Future. No Date Ranges allowed. Required Optional and/or and/or = [NM108=PI]NM109 Last or Required. No Required. No Type 30 Last First Dependent Dep. Last Dep. First Min\Max = 24 D1 D2 D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 270

283 Medicare y Mucho Mas (INMEDIATA HEALTH GROUP) Option Subscriber No No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 271

284 Med-Pay, Inc Option Subscriber Last First No No No Required and/or = [NM108=PI]NM109 Last or Required. No Required. No Optional Type and/or 1, 33, 35, 47, 48, 50, 86, 88, 98, AL, MH, UC Last First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 272

285 MedStar Family Choice Option Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First Subscriber S6 SSN Last and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last,S2,S3,S4,S5, S6 First S4,S5,S2,S3,S4 SSN S6,S2,S3,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 273

286 MedStar Health Plan Option Subscriber Last First Subscriber S2 Last and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last,S2 First,S2,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 274

287 Meritain Health Option Subscriber Last Subscriber S2 Last First Dependent D1 Subscriber Dep. Last Dep. Dependent D2 Subscriber Dep. Last Dep. First Required and/or = [NM108=PI]NM109 Last or Required,S2,D1,D2 Situational Federal Tax ID and/or Situational. No Situational. No Last First,S2 S2 Type 30 Dependent Dep. Last Dep. First D1,D2 D2 D1 Type 30 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 275

288 Meritus Health Partners Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: No Yes No and/or s and Values = = [NM108=PI]NM109 Last or Last First Dependent Last First S2, S3 S2, S3, S2, S4, D1, D2, S3 D2, D3 D2, D3 D1, D3 Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 276

289 Michigan MI Child Option Subscriber Subscriber S2 SSN Subscriber S3 SSN Last First Subscriber S4 Last First 1 year End of the current month Yes and/or = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth SSN S3,S4 S3,S4 Min= 10 Max = 12 S2,S4 S2,S3 Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 277

290 Mississippi State Employees and Teachers Option Subscriber Dependent D1 Subscriber Subscriber Last Subscriber Last First Dep. Last Dep. First Dep. Date of Birth and/or = [NM108=PI]NM109 Last or Subscriber Last Subscriber First Subscriber Subscriber, D1, D1 Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Gender Dependent Subscriber Subscriber Last Dep. Last Dep. First Dep. Date of Birth, D1, D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 278

291 Missouri Care Option Subscriber Last First Subscriber Subscriber S2 Last First Subscriber S3 Subscriber and/or = [NM108=PI]NM109 Last or Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Last First Subscriber,S2,S2,S3,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 279

292 MMSI (Mayo Health) Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Dependent D4 Sub: Dep: Last Dep: First Dep: Required Disclaimer: The provided information is not a guarantee of coverage. Actual benefits are determined only when the claim is received. Note,certain procedures may require pre-approval. and/or = [NM108=PI]NM109 Last or Situational Federal Tax ID and/or Situational. No Required. No Situational. No Last First Type S2,S3,S4 S2,S3,S4,S2,S4 D1,D2,D4 Min=10 Max=12,S3,S4 30 Dependent Last First D2,D3.D4 D2,D3,D4 D1,D3,D4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 280

293 Moda Health Option Subscriber Last First Subscriber S2 Last Subscriber S3 Last First Subscriber S4 Last First Up to 1 year in the Past Future Dates allowed up to end of current month Date Ranges allowed Required and/or = [NM108=PI]NM109 Required. No Situational Type and/or Operating Set Last First,S2,S3,S4,S3,S4,S2,S3 Min=12 Max=80,S2,S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 281

294 Molina Healthcare Option Subscriber Subscriber S2 Last First 1 year No No Payers Payer Payer ID Payer Payer ID Molina Healthcare of California Molina Healthcare of South Carolina Molina Healthcare of Florida Molina Healthcare of Texas Molina Healthcare of Illinois Molina Healthcare of Utah Molina Healthcare of Michigan Molina HealthCare of Washington Molina Healthcare of New Mexico Molina Healthcare of Wisconsin Molina Healthcare of Ohio and/or See table above = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Last First,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 282

295 Municipal Health Benefit Fund Option Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Dependent D2 Dep: Last Dep: First Dep: No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or Full set Situational. No Federal Tax ID Situational. No Subscriber Last Subscriber First Subscriber Subscriber S2 S2, D1 S2 Dependent Subscriber Dep. Last Dep. First Dep. Date of Birth, D1 D2 D2 D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 283

296 Mutual Health s Option Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Dependent D2 Dep: Last Dep: First Dep: 18 months Current Month No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Subscriber Last Subscriber First Subscriber Subscriber S2, D2 S2, D1 S2 Dependent Subscriber Subscriber Last Dep. Last Dep. First Dep. Date of Birth, D1 S2, D2 D2 D2 D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 284

297 Mutual of Omaha Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Disclaimer: Mutual of Omaha will deliver a disclaimer message in the MSG segment. Trading Partners must display the disclaimers as returned. Required and/or = [NM108=PI]NM109 Last S2 Situational Provider ID and/or Situational. No Situational. No First Type S2,D1 Min=10 Max=12,S2 30 Dependent Last First D1,D2 D1,D2 D1,D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 285

298 MVP Health Care (New York) Option Subscriber First First Subscriber S2 Last Subscriber S3 Last First No No No and/or = [NM108=PI]NM109 Last or Required. Must match the name associated with the in the NPPES database. Type and/or 1,30,35 Federal Tax ID and/or Either Tax ID or is required Last First Required. S3,S4 S3,S4,S2,S3 MVP Preferred Care is not included and any member ID s not beginning with 8 is not going to be matched or returned. S2, S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 286

299 National Association of Letter Carriers (NALC) Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required Situational and/or and/or = [NM108=PI]NM109 Last or Last Federal Tax ID Situational. No Required. No Situational. No First Type Dependent Last First,D1 Min=10 Max=12 30 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 287

300 National Telecommunications Cooperative Association (NTCA) Option Subscriber Last First Subscriber S2 SSN Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required Situational and/or and/or = [NM108=PI]NM109 Last or Last Federal Tax ID Situational. No Required. No Situational. No First Sub: Member ID SSN Type Dependent Last First,D1 Min=10 Max=12 S2.S2 30 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 288

301 NEHEN Harvard Pilgrim Health Care Option Subscriber Subscriber S2 Last First Subscriber S3 Last First 3 years No No Note: New England Health EDI Network. Harvard Pilgrim issues a unique member ID to each member (whether they are subscriber or dependent). As such, all members shall be sent and returned as the subscriber. ID-only searches may fail if more than one patient belongs to that ID in the Harvard system. Please send as much information as possible for best results. Note: NEHEN Harvard Pilgrim supports Health Plan and Well Sense membership. Use Min Max Type s and Values Payer Payer ID R 5 5 ID Provider Information Source Level: 2100A [NM108= PI] NM109 Transunion Payer ID Information Receiver Level: 2100B Last or R 60 AN R 2 10 ID Subscriber Search options:,s AN NM103 [NM108= XX] NM109 [NM108= MI] NM109 Last S2,S AN NM103 First S2,S AN NM104 S2,S3 8 8 DT CCYYMMDD DMG02 National Provider ID if NM108 = XX Subscriber Level: 2100C Type O 1 2 ID 1,2,4,5,6,7,8,11,12,13,18,20,22,30, 33,40,42,45,48,50,51,52,53,62,65,68, 73,76,78,80,81,82,86,93,98,99, A0,A3,AB,AD,AE,AF,AG,AL,BG,BH EQ01 Usage: R=Required, O=Optional, S=Situational Data N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Type: Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 289

302 NEHEN Harvard Pilgrim Health Care Option Subscriber Subscriber S2 Last First Subscriber S3 Last First 3 years No No Required Disclaimer: New England Health EDI Network. Harvard Pilgrim issues a unique member ID for each member (whether they are subscriber or dependent). As such, all members shall be sent and returned as the subscriber. ID-only searches may fail if more than one patient belongs to that ID in the Harvard system. Please send as much information as possible for best results. Note: NEHEN Harvard Pilgrim supports Health Plan and Well Sense membership. and/or = [NM108=PI]NM109 Last or Required. No Required. No Last First Type S2 S2 Min=10 Max=12 S2 1,2,4,5,6,7,8,11,12,13,18,20,22,30,33,40,42,45,48,50,51,52,53,62,65,68,73,76,78,80,81, 82,86,93,98,99,A0,A3,AB,AD,AE,AF,AG,AL,BG,BH Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 290

303 NEHEN- Neighborhood Health Plans Option Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Last Dep: First Required and/or = [NM108=PI]NM109 Last or Required. No Situational and/or Situational. No Last First Type Dependent Last First S2 S2,D1 Min=10 Max=12 S2 30 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 291

304 Neighborhood Health Plan (RI) Option Subscriber Subscriber S2 Last First 1 year No 60 days Required and/or = [NM108=PI]NM109 Last or Required. No indicated. Optional Type and/or 30 Last First S2 S2 Min=10 Max=12 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 292

305 Network Health Option Subscriber Subscriber S2 Last First 1 year 1 year No Required and/or = [NM108=PI]NM109 Last or Required. No indicated. Optional Type and/or 30 Last First S2 S2 Min/Max=12 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 293

306 Network Health Plan of WI Option Subscriber Subscriber S2 Last First Yes No No Required and/or = [NM108=PI]NM109 Last or Required. No indicated. Optional Type and/or 1,2,4,5,6,7,8,12,13,18,20,30,3 3,35, 40, 42, 45, 47, 48, 50,51, 52,53,62,65,68,73,76,78,80,81,82,86,88,93,98,99,A0,A3,A6, A7,A8,AD,AE,AF,AG, AI, AL, BG, BH, MH,UC Last First S2 S2,S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 294

307 New Era Life Insurance Company Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 SSN Subscriber S5 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Sub. SSN Dep. Dependent D4 Dep. Last name Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2,S5 First SSN S2,S5,S2,S3.D1.D2 S4,D3 S2,S4,S5 Dependent Dep. Last Dep. First Dep. D2,D4 D2,D4 D1, D3,D4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 295

308 NGS American Option Subscriber Last First Gender 2 years No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX.. Federal Tax ID Situational. No Last First Subscriber Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 296

309 North Carolina Medicaid Option Subscriber Last First Subscriber S2 SSN Subscriber S3 SSN Subscriber S4 Last Subscriber S5 Last First Subscriber S6 Last First No No No Required and/or = [NM108=PI]NM109 Optional Type indicated. SSN S2, S3 and/or 30 Last First, S4, S5, S6 S5,S6,S3, S4.S5 S2,S3,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 297

310 Nova Healthcare Administrators Option Subscriber Last First Subscriber S2 Last First Subscriber S3 Subscriber S4 Last First SSN Subscriber S5 SSN Subscriber S6 SSN Dependent 1 Sub: Dep: Last name Dep: First Dep: Yes No No Required Optional and/or and/or = [NM108=PI]NM109 Type indicated. SSN S4, S5, S6 Last,S2, S4 Dependent First,S2, S4 Last D1,S3, S6, D1 Min/Max=80 First S2,S3,S5 D1 30 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 298

311 Ohana Option Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year No No Required and/or = [NM108=PI]NM109 indicated. Optional Type and/or 30 Last First,S2,S2,S3 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 299

312 Oklahoma Employees Group Insurance Division Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First Dependent D5 Sub: Dep: Dependent D6 Sub: Dep: Last Dep: First Dependent D7 Dep: Last Dep: First Dep: No No No and/or = [NM108=PI]NM109 Last or Type and/or 1, 2, 4, 5, 6, 7, 8, 12, 13, 18, 20, 30, 33, 35, 40, 42, 45, 47, 48, 50, 51, 52, 53, 62, , 76, 78, 80, 81, 82 86, 88, 93, 98, 99, A0 A3, A6, A7, A8, AD, AE, AF, AG, AI, AL BG, BH, MH, UC Federal Tax ID and/or Situational. No notes Situational. No notes Last First Dependent Dep. Last Dep. First Dep. Date of Birth S3, S4 S3, S4,S2, S3,D5,D6 S2, S4 D6,D7 D6,D7 D1, D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 300

313 Operating Engineers Local.428 Health and Welfare Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. No No No and/or s and Values = = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2,D4,D5, S3 Dependent Dep. Last Dep. First Dep. D2,D3 D2,D3 D1, D3 Optima/Sentara Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 301

314 Option Subscriber Last First Subscriber S2 Subscriber S3 SSN Note: Members in the Optima Health system can uniquely be identified using their unique member number. Dependent loops and their respective Hierarchy Levels will not be used. Each member is consider a subscriber for our EDI transactions Yes No No Required and/or = [NM108=PI]NM109 indicated. Optional Type and/or 30 Last First SSN Min/Max=12 S3 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 302

315 Orange County Fire Authority Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S2,S3 First S2,S3,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 303

316 Oscar (NY) Option Subscriber Last First Subscriber S2 Subscriber S3 Last First Subscriber S4 Last Subscriber S5 Last First 1 year No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S3,S4,S5 First,S3,S5,S2,S3,S4,S2,S4,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 304

317 Oxford Health Plans Option Subscriber Last First Subscriber S2 Last Subscriber S3 First Subscriber S4 Subscriber S5 Last First Subscriber S6 Last First Note: Oxford Health Plans has unique member ID s, therefore submit all patients as subscribers. 18 months No greater than end of current month No Required and/or = [NM108=PI]NM109 Last or indicated. indicated. Optional Type and/or 1,2,3,4,5,6,7,8,12,13,18,20,23,24,25,26, 27,28,30,33,35,36,37,38,39,40,41,42,45, 47,48,49,50,51,52,5362,65,68,73,76,78, 80,81,82,83,86,88,89,90,91,92,93,98,99, A0,A3,A4,A5,A6,A7,A8,AD,AE,AF.AG AI,AJ,AK,AL,BG,BH,BT,BU,BV,BW, BX,BY,BZ,DM,GF,GN,MH,UC Last First,S2,S5,S6,S3,S5,S6,S2,S3,S4,S5 Min/Max=12 Note: OHP has unique member ID s,s2,s3,s4,s6 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 305

318 Pacific Source Health Plan 2597 Option Subscriber Last First Subscriber S2 Subscriber S3 Last First 1 year 60 days 60 days Required and/or 2597 = [NM108=PI]NM109 Last or indicated. indicated. Optional Type and/or 30 Last First,S3,S3,S2 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 306

319 Panamerican Life Puerto Rico Option Subscriber No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or Full code set Provider ID Min/Max=7 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 307

320 Paramount Health Option Subscriber Last First 1 year No No and/or = [NM108=PI] NM109 Type and/or and/or 30 Situational. No notes Middle Optional. No notes Last First Min/Max=13 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 308

321 Parkland Community Health Plan Option Subscriber Last First Subscriber S2 Last First No No yes Required and/or = [NM108=PI]NM109 Last or indicated. Optional Type indicated. Federal Tax ID Last S2 and/or 1,30,33,35,47,48, 50,52,86,88,98,A4, AL,MH,UC Optional First S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 309

322 Partners National Health Plans of NC Option Subscriber Last Subscriber S2 Last First Dependent D1 Sub: Dep. Last Dep. First Dep. No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last, S2 First Sub: Member ID S2, S2, D1, S2 Dependent Last Dep. First Dep. Date of Birth D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 310

323 Passport Health Plan 2841 Option Subscriber Subscriber S2 SSN Subscriber S3 Last First 1 year No No Required and/or 2841 = [NM108=PI]NM109 Last or indicated. indicated. Optional Type and/or 30 Last First SSN S3 S3 Min/Max=12 S2 S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 311

324 Patriot Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 312

325 People First Option Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: Required and/or = [NM108=PI]NM109 Last or Required. No No Optional Type and/or 30 Last First Dependent Last First,D1 Min/Max=16 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 313

326 Peoples Health Option Subscriber Last First and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 314

327 Personal Insurance Administrators (PIA) Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: No No No and/or = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 1, 30,33,35, 47,86, 88,98,AL,MH,UC,A4 Federal Tax ID and/or Either Tax ID or is required Last First Dependent Dep. Last Dep. First Dep. Date of Birth S2,S3 S2,S3,S2,D1, D2, S3 D2, D3 D2, D3 D1, D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 315

328 Physicians Health Plan Northern IN (PHPNI) Option Subscriber Last First Note: If no response is received after the second attempt, the provider s system should submit no more than 5 duplicate transactions within the next 15 minutes. Since PHP has unique Member Identification Numbers then the patient is considered to be the subscriber and is to be identified in the Subscriber Level. Past Dates 30 Days Yes Yes Required and/or = [NM108=PI]NM109 Last or indicated. indicated. Optional Type and/or 30 Last First Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 316

329 Physicians Health Plan of Mid-Michigan Option Subscriber Subscriber S2 SSN Subscriber S3 Last First Dependent D1 Dep: Date of Birth Dependent D2 Sub: SSN Dep: Date of Birth Dependent D3 Dep: Last Dep: First Dep: No No No Required and/or = [NM108=PI]NM109 Last or No notes indicated. No notes indicated. Optional Type and/or 30 Last First SSN Min/Max=9,D1 S3,S2 S2 Dependent Last First SSN D3 D3 D1,D2,D3 D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 317

330 Physicians Mutual Insurance Company Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required and/or = [NM108=PI]NM109 Last or indicated. Situational and/or Situational. No notes indicated. Last First Type,D1 Min=10 Max=12 30 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 318

331 Physicians Plus Insurance Corp Option Subscriber SSN Last First Subscriber S2 SSN Subscriber S3 Last First No No No Required and/or = [NM108=PI]NM109 Last or /Federal Tax ID indicated. National Provider ID Optional Type and/or 30 Last First SSN,S3,S3,S2,S3 Min\Max=14,S2, S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 319

332 Piedmont (GA) Option Subscriber Last First Subscriber S2 Subscriber S3 Last First Subscriber S4 Last Subscriber S5 Last First 1 year No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S3,S4,S5 First,S3,S5,S2,S3,S4,S2,S4,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 320

333 Piedmont Wellstar HealthPlans Option Subscriber Last First Subscriber S2 and/or = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Last First S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 321

334 Plan de Salud Hospital Menonita Option Subscriber Group Number No No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Group Number Required. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 322

335 Planned Administrators Inc Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First 1 year No No and/or = [NM108=PI]NM109 Last or Last Either Tax ID or is required S3,S4 Type and/or 30 Federal Tax ID and/or Either Tax ID or is required First S3,S4,S2,S3 S2, S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 323

336 Plumbers and Pipefitters Local Union 525 Health & Welfare Trust Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: No No No and/or = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 1, 30,33,35, 47,86, 88,98,AL,MH,UC,A4 Federal Tax ID and/or Either Tax ID or is required Last First Dependent Dep. Last Dep. First Dep. Date of Birth S2,S3 S2,S3,S2,D1, D2, S3 D2, D3 D2, D3 D1, D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 324

337 Preferred Care Partners Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or s and Values = = [NM108=PI]NM 109 Last or Required. No Type and/or and/or Full set Situational. No Federal Tax ID Situational. No Last S2,S3 First,S2,S2 S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 325

338 Preferred Health System of Kansas Option Subscriber Subscriber S2 Last First Subscriber S3 SSN No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First SSN S2 S2 Min=10 Max=11 S3 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 326

339 Preferred Medicare Choice (PMC) (INMEDIATA HEALTH GROUP) Option Subscriber Subscriber S2 No No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No.S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 327

340 Preferred One Option Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required Note: Preferred One will return a positive response using member ID only if a unique match on the member is found. This is for products where a unique member ID is assigned to each member of the family. For products that do not require unique ID s for each member, this search option will not work. We do NOT recommend searches using member ID only, as a submitted member ID could be entered wrong, but still be a valid ID for another member. and/or = [NM108=PI]NM109 Last or Situational Provider ID and/or Min/Max=9 indicated. Situational. No notes indicated. Last First Type S2 S2,D1 Min=10 Max=12 S2 30 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 328

341 Premier Health Option Subscriber Last First Subscriber S2 No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First S2 S2 Min=10 Max=11, S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 329

342 Presbyterian Health Plan Option Subscriber Last First No No No and/or = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 330

343 Prestige Health Choice Option Subscriber Last First Yes No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 331

344 Principal Financial Group (Nippon Life) Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required and/or = [NM108=PI]NM109 Last or indicated. Situational Federal Tax ID and/or Situational. No notes indicated. Situational. No notes indicated. Last First Type,D1 Min=2 Max=9 30 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 332

345 Priority Health Option Subscriber Last First Up to 1 year Yes No Note: Priority Health purchased Care Choices so plan is now encompassed as part of Priority Health Required and/or = [NM108=PI]NM109 Last or Min=1 Max=24 Optional Type and/or 30 Last First indicated. Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 333

346 Pro-Claim Plus Option Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: Required and/or = [NM108=PI]NM109 Last or No notes indicated. Optional Type and/or 30 Last First No notes indicated. Min/Max=16, D2 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 334

347 Professional Benefits Administrators Option Subscriber Last First Dependent D1 Sub: Dep: First Dep: Yes and/or See table above = [NM108=SV]NM109 Type and/or and/or 30 Situational. No notes indicated. Last Provider ID Situational. No notes indicated. First,D1 Max=9 Dependents First D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 335

348 Providence Health Plan Option Subscriber Last First Subscriber S2 First Subscriber S3 1 year 60 days 60 days Note: Plans are Choice Options, Health Connections, Joint Marketing, Open Options, Open Self-Funded, Oregon Opt Medicaid, Personal Option, Personal Self-Funded, Providence Group Option, Providence Medicare Extra, Providence Medicare Choice PPO, Providence Option, Self-Funded Option, Traditional Option and PEBB and/or 2598 = [NM108=PI]NM109 Last or Min=1 Max=60 Type and/or Min=1 Max=2 30 Federal Tax ID and/or Min/Max=9 Last First Min/Max=10 Min=1 Max=14 S2 Min=1 Max=14, S2, S3 Min=12 Max=12, S2, S3 Min/Max=8 CCYYMMDD Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 336

349 Provident Preferred Network - Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 337

350 Puritan Life Insurance Option Subscriber Last First *Note: This is a Medicare Supplemental Plan and/or = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 338

351 Qualcare Option Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Last Dep: First Dependent D2 Sub: Dep: Dependent D3 Dep: Last Dep: First Dep: Supported back to policy begin date Yes No and/or = [NM108=PI]NM109 Last or Min=1 Max=60 Type and/or Min=1 Max=2 30 Federal Tax ID and/or Min/Max=9 Last First Min/Max=10 S2 Min=1 Max=35 S2 Min=1 Max=25, D1, D2 Min=2 Max=80 S2 Min/Max=8 CCYYMMDD Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 339

352 Royal Neighbors of America Option Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan and/or = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 340

353 S and S Healthcare Strategies Option Subscriber Last First Subscriber S2 Subscriber S3 Last First Subscriber S4 Last Subscriber S5 Last First 1 year No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational National Provider ID if NM108=XX.. Federal Tax ID Situational. No Last S3,S4,S5 First,S3,S5,S2,S3,S4,S2,S4,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 341

354 Santa Clara Family Health Plan Option 1 2 e Subscriber Last First 1 year Up to 60 days 60 day NOTE: Eligibility is available only for: Medi Cal Managed Care, Healthy Families, Healthy Kids, and Healthy Workers as delegated to Valley Health Plan Network. and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX.. Max=20 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 342

355 Schaller Anderson Aetna Better Health of New York Option Subscriber Subscriber S2 Last First Required and/or = [NM108=PI]NM109 Last or indicated. indicated. Situational Type and/or The operating rule codeset Last First S2 S2 Min/Max=20 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 343

356 Schaller Anderson Aetna Better Health of OH Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Last First Required. No S3,S4 S3,S4,S2,S3 S2, S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 344

357 Schaller Anderson Delaware Physicians Care, Inc Option Subscriber Subscriber S2 Last First Required and/or = [NM108=PI]NM109 Last or Required. No Situational Type and/or The operating rule codeset Last First Required. No S2 S2 Min/Max=20 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 345

358 Schaller Anderson MajestaCare VA Option Subscriber Subscriber S2 Last First Required and/or = [NM108=PI]NM109 Last or Required. No Situational Type and/or The operating rule codeset Last First Required. No S2 S2 Min/Max=20 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 346

359 Schaller Anderson Maryland Physicians Care Option Subscriber Subscriber S2 Last First No No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Last First Required. No S2 S2 Min/Max=9 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 347

360 Schaller Anderson Mercy Care Option Subscriber Subscriber S2 Last First No No No Required and/or = [NM108=PI]NM109 Last or Required. No Situational Type and/or The operating rule codeset Last First Required. No S2 S2 Min/Max=9 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 348

361 Schaller Anderson Mercy Maricopa Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or = [NM108=PI]NM109 Last or Identification Required. No Tax ID or required. Situational Type and/or 1,30,33,35, 47,86, 88, 98,AL,MH,UC,A4,A5 Last First S2,S3 S2,S3 Min=2 Max=80,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 349

362 Schaller Anderson Missouri Care Option Subscriber Subscriber S2 Last First No No No Required and/or = [NM108=PI]NM109 Last or Required. No Required. No Situational Type and/or 1,30,33,35, 47,86, 88, 98,AL,MH,UC,A4,A5 Last First S2 S2 Min/Max=9 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 350

363 Schaller Anderson Parkland Community Health Plan Option Subscriber Subscriber S2 Last First No No Date Ranges are allowed. Required and/or = [NM108=PI]NM109 Last or Required. No Situational / Federal Tax ID Type and/or National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. The operating rule codeset. Last First Either Tax ID or is required S2 S2 Min/Max=20 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 351

364 Schaller Anderson Texas CHRISTUS Option Subscriber Subscriber S2 Last First No No No Required and/or = [NM108=PI]NM109 Last or indicated. indicated. Situational Type and/or The operating rule codeset Last First S2 S2 Min\Max=9 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 352

365 Scott & White Health Plan Option Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First 1 Year 60 days 60 days and/or = [NM108=PI] NM109 Last or Last Min=1 Max=60,S2,S4,S5 Type and/or and/or 30 Min/Max=10 Federal Tax ID Min/Max=9 First,S4,S5,S2,S3,S4 Min/Max=12,S2,S3,S5 s and Values =CCYYMMDD Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 353

366 Secure Health Plans of Georgia Option Subscriber Last First Subscriber S2 Subscriber S3 Last First Subscriber S4 Last Subscriber S5 Last First 1 year No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX Federal Tax ID Situational. No Last S3,S4,S5 First,S3,S5,S2,S3,S4,S2,S4,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 354

367 Securian - Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 355

368 Securian/Patriot - Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 356

369 Security Health Plan Option Subscriber Last First Gender No No No and/or s and Values = = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 357

370 Select Health SC Option Subscriber Subscriber S2 SSN Subscriber S3 Last First 4 years No No Required and/or = [NM108=PI]NM109 Last or indicated. indicated. Optional Type and/or 30 Last First SSN S3 S3 Min/Max=12 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 358

371 Select Health Utah Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: No No Yes and/or = [NM108=PI]NM109 Last or Last First,D1 Type and/or 1,2,4,5,7,11,12,13,18,23 24,25,26,27,28,30,33,34 35,36,37,38,39,40,41,42, 44,47,48,49,,50,52,53,54 56,59,62,66,68,69, 73 75,77,80,81,82,86,88,94 97,98,A4,A6,A8,AD,AF AI,AL,AM,AN,AO,B1,BT BU,BV,CC,CD,CF,CH, CJ,CP,DG,DM,IC,MH,NI PT,RT,UC /Federal Tax ID and/or National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Dependent Dep. Last Dep. First Dep. Date Of Birth D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 359

372 Senior Care Action Network (SCAN) HMO Option Subscriber Last First Subscriber S2 Last Subscriber S3 Last First Up to 2 years No Yes Required and/or = [NM108=PI]NM109 Last or indicated. Required. Not notes indicated Situational Type and/or 30, 47, 86, 88, 98, AL, MH, UC Last First, S2, S3, S3,S2, S3,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 360

373 Senior Dimensions Option Subscriber Last First 1 year No No Required and/or = [NM108=PI]NM109 Last or No notes indicated. Optional Type and/or 30 Last First No notes indicated. Min/Max=16 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 361

374 Senior Health s Center Universal American Family of Companies Option Subscriber Subscriber S2 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. First Dep. Last Dependent D3 Dep. Date of Dep. Last Dep. First Birth and/or s and Values = = [NM108=PI]NM 109 Last or Subscriber Last Subscriber First Subscriber Subscriber Date of Birth Gender Dependent Subscriber Subscriber Last Dep. Last Required. No S2,D3,D4 S2, D1, D1 D2 Type and/or 1, 2, 3, 30, 33, 35, 47, 48, 50, 51, 52, 53, 73, 76, 86, 88, 98, AL, BV, BY, DM, MH, UC Federal Tax ID and/or Situational. No Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 362

375 Dep. First Dep. D3 D1 Senior Whole Health Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First 1 year No No and/or = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Last First S3,S4 S3,S4,S2,S3 S2, S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 363

376 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 364

377 Shenandoah Life Insurance Option Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan and/or = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 365

378 Sierra Health s Option Subscriber Subscriber S2 Last First Subscriber S3 SSN Subscriber S4 SSN Last First Subscriber S5 Last First Subscriber S6 Last First Dependent D1 Sub. Dep. Last name Dep. First Dep. Dependent D2 Dep. State Dep. Last name Dep. First Dep. No No Yes and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2 S3,S5,S6 First S2 S3,S5,S6,S2,S3,D1,S3,S5,S6 SSN S3,S4 Dependent Dep. Last Dep. First Dep. State Dep. Date of Birth D1,D2 D1,D2 D2 D1,D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 366

379 Significa Option Subscriber Dependent D1 Sub: Dep: Yes and/or = [NM108=PI]NM109 Last or indicated. Type and/or 30 Federal Tax ID and/or Situational. No notes indicated.,d1 Dependent D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 367

380 Simply Healthcare Plans Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First 1 year No No Required and/or = [NM108=PI]NM109 Last or Required. No Situational Type and/or The operating rule codeset Last First Required. No S3,S4 S3,S4,S2,S3 S2, S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 368

381 Soundpath Health Option Subscriber No No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 369

382 Spectrum Health Option Subscriber Subscriber S2 Last First Up to 1 year in Past No No Required and/or = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Last First Required. No S2 S2 S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 370

383 SPJST Medicare Supplement Option Subscriber Last First 1 Year 60 Days 60 Days : Data updated twice weekly. Required and/or = [NM108=PI]NM109 Last or Required. No Situational Type and/or if NM108 = XX The operating rule codset Last First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 371

384 Star HRG Option Subscriber Last First Subscriber Member Subscriber Last Subscriber First Dependent D1 Dep. ID No No No and/or = [NM108=PI]NM109 Last or Last Type and/or 30 Federal Tax ID and/or Situational. No Situational. No First Date Of Birth,D1.D1 Min/Max=10 Dependent Dep. Last Dep. First Dep. Date Of Birth D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 372

385 State Mutual (Lincoln Novation) Option Subscriber Last First No No No and/or = [NM108=PI]NM109 Last or Last First Type and/or 30 /Federal Tax ID and/or National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 373

386 State Mutual Med Supp Option Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan and/or = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 374

387 Staywell Option Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year No No Required and/or = [NM108=PI]NM109 Last or indicated. Optional Type and/or 30 Last First indicated.,s2,s2,s3 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 375

388 Staywell Kids Option Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year No No Required and/or = [NM108=PI]NM109 Optional Type and/or 30 Last First indicated.,s2,s2,s3 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 376

389 Sterling Investors Life Insurance Option Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan and/or = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 377

390 Student Insurance Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: 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 Required and/or = [NM108=PI]NM109 Last or Federal Tax ID Last indicated. indicated.,s2 Optional Type Group Number and/or 30,D1 First,S2,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 378

391 SummaCare Option Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First No No No Required and/or = [NM108=PI]NM109 Last or indicated. Optional Type and/or 30 Last First indicated.,s2,s4,s5,s4,s5,s2,s3,s4 Min/Max=12,S2,S3,S5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 379

392 Superior Health Plan Texas Option Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or = [NM108=PI]NM109 Last or Last First Min=1 Max=60 S2,S3 Min=1 Max=35 S2,S3 Min=1 Max=25,S3 Min=2 Max=80 S2,S3 Min/Max=8 s and Values= CCYYMMDD Type and/or 30 Min=1 Max=2 Federal Tax ID and/or Min/Max=10 Min/Max=9 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 380

393 TennDent Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 381

394 TexanPlus North Texas Area Option Subscriber Last First and/or = [NM108=PI]NM109 Last or Min=1 Max=24 Type and/or 23, 24, 25, 26, 27, 28, 30, 35, 36, 37, 38, 39, 40, 41, 88, 89, 90, 91, 92 First and/or Min=1 Max=24 Last First Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 382

395 TexanPlusSoutheast Texas Area Option Subscriber Last First and/or = [NM108=PI]NM109 Last or Min=1 Max=24 Type and/or 23, 24, 25, 26, 27, 28, 30, 35, 36, 37, 38, 39, 40, 41, 88, 89, 90, 91, 92 First and/or Min=1 Max=24 Last First Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 383

396 The Kempton Company Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. First Dep. Last Dependent D3 Dep. Date of Dep. Last Dep. First Birth No No No and/or s and Values = = [NM108=PI]NM 109 Last or Subscriber Last Subscriber First Subscriber Subscriber Date of Birth Dependent Subscriber Subscriber Last Dep. Last Required. No S2,S3,S2,D3,D4,S3, D1, D1 D2,D3 Type and/or 1, 2, 4, 5, 6, 7, 8, 12, 13, 18, 20, 30, 33, 35, 40, 42, 45, 50, 52, 53, 62, 65, 68, 73, 76, 78, 86, 87, 88, 93, 98, 99, A0, A3, A6, A7, A8, AD, AE, AF, AG, AI, AL, BG, BH, MH, UC Federal Tax ID and/or Situational. No Situational. No Dep. First Dep. D2,D3 D1,D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 384

397 Three Rivers Health Plans Option Subscriber Last First Yes and/or = [NM108=PI]NM109 Last or Type and/or 30 Federal Tax ID Provider ID Last Plan Network ID First Facility Network ID Min/Max=12 and/or Either Federal Tax ID or Provider ID is required. Min=2 Max=13 Either Federal Tax ID or Provider ID is required. Min/Max =12 Either Plan Network ID or Facility Network ID is required. Min/Max=12 Either Plan Network ID or Facility Network ID is required. Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 385

398 TMG Network Health Insurance Option Subscriber Subscriber S2 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or Complete code set Federal Tax ID and/or Situational. No Situational. No Last First Date Of Birth Min/Max=10 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 386

399 Today s Health Option Subscriber Last First and/or = [NM108=PI]NM109 Last or Last Type and/or 23, 24, 25, 26, 27, 28, 30, 35, 36, 37, 38, 39, 40, 41, 88, 89, 90, 91, 92 First and/or Required if entity is a person. First Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 387

400 Today s Option Option Subscriber Last First and/or = [NM108=PI]NM109 Last or Type and/or 23, 24, 25, 26, 27, 28, 30, 35, 36, 37, 38, 39, 40, 41, 88, 89, 90, 91, 92 First and/or Required if entity is a person. Last First Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 388

401 Triple-S Salud (BCBS Puerto Rico) Option Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Last Dep: First Dep: No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Subscriber Last Subscriber First Subscriber Subscriber S2 S2, D1 S2 Dependent Subscriber Subscriber Last Dep. Last Dep. First Dep. Date of Birth, D1 S2 D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 389

402 Trustmark Option Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required and/or = [NM108=PI]NM109 Last or Required. No Required. No Optional Type and/or 30 Last First,D1 Min=10 Max=11 Dependents Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 390

403 Tribute/Select Care of Oklahoma Option Subscriber Last First and/or = [NM108=PI]NM109 Last or Type and/or 23, 24, 25, 26, 27, 28, 30, 35, 36, 37, 38, 39, 40, 41, 88, 89, 90, 91, 92 First and/or Required if entity is a person. Last First Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 391

404 Tricare TRICR Option Subscriber Last First Opt. Gender Dep: Date of Opt. Dep. Dependent D1 Sub: Dep: Last Dep: First Birth Gender Yes and/or TRICR Type=AN = [NM108=PI]NM109 Last or Last First Gender Dependent Last NM103 NM103 NM104,D1 [NM108=MI] NM109 Note: is the SSN or First 9 digits of DoD ID number and DMG02 S4 DMG03 D1 Type and/or 30 EQ01 and/or [NM108=XX] NM109 First Gender D1 D1 DMG02 S4 DMG03 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 392

405 UCare of Minnesota 2596 Option Subscriber Last First Subscriber S2 Last Subscriber S3 Note: UCare Complete, prepaid medical assist program, Minnesota Care, Minnesota Senior Health Options, UCare for Seniors, South County Health Alliance, UCare Senior Select, SCHA Minnesota Care 12 months 60 days No Required and/or 2596 = [NM108=PI]NM109 Optional Type and/or 30 Last First Required. No,S2,S2,S3 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 393

406 Ultimate Health Plans Option Subscriber Subscriber S2 Last First No No No and/or = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Last First S2 S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 394

407 UMR (Wausau) Option Subscriber Subscriber S2 Last First Subscriber S3 SSN Subscriber S4 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Sub: SSN Dep: Dependent D4 Dep: Last Dep: First Dep: Required and/or = [NM108=PI]NM109 Last or Required. No Last First SSN Type Required. No S2,S4,S5 S2,S4,S5,S2,S5 D1,D2,54 Min=10 Max=12 S3,D3,S3,S4,S5 1, 11, 12, 18, 23, 30, 33, 34, 35, 38, 41, 42, 48, 50, 52, 86, 88, 98, 99, A0, A4, A7, A8, AG, AL, AM, AN, AO, BB Dependent Last First D2,D4,D5 D2,D4,D5 D1,D3,D4,D5 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 395

408 Underwriters Safety & Claims Option Subscriber Last First Dependent D1 Sub: Dep: First Dep: Yes and/or See table above = [NM108=SV]NM109 Type and/or and/or 30 Situational. No notes indicated. Last Provider ID Situational. No notes indicated. First,D1 Max=9 Dependents First D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 396

409 UNICARE - Dental Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 397

410 Unicare UCARE Option Subscriber Dependent D1 Sub: Dep: Last Dep: First Dep: No No No Required and/or UCARE = [NM108=PI]NM109 Last First Type Required. No, D1 Min=10 Max=12 1,2,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,30,32,33,34,35,3637,38,39,40,41,42,43 44,45,46,47,48,49,50,51,52,53,54,55,56,57,60,61,62,65,68,69,7376,78,80,81,82,83,84,86,88,93,98,99,A0,A3,A6, A7,A8,AD,AE,AF,AG,AI,AL,BG,BH,MH,UC Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 398

411 United American Insurance Company Option Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2 S2, S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 399

412 United Concordia (Dental) Option Subscriber Last First No No No Payers Payer Payer ID Payer Payer ID United Concordia Federal Employees Program United Concordia Companies, Inc and/or See table above [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 400

413 United Healthcare Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Subscriber S4 SSN Last First Subscriber S5 Last First State Dependent D1 Sub: Dep: Last Dep: First Dep: Dependent D2 Sub: Dep: Last Dep: First Dep: Option 5 Dependent D2 con t Dep: State 1 year No No Required and/or = [NM108=PI]NM109 Last or Required. No Situational Federal Tax ID Provider ID and/or Situational. No Min=2 Max=9 Last First SSN State Type Required. No S2,S3,S4,S5 S2,S3,S4,S5,S2,S3 D1,D2 Min=10 Max=12 S4 S5,S2,S5 All service type codes accepted Dependent Last D1,D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 401

414 First State D1,D2 D2 D1,D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 402

415 United Healthcare Community Plan Kansas Option Subscriber Last First Subscriber S2 Last Subscriber S3 First Subscriber S4 Subscriber S5 Last First Subscriber S6 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last,S2, S4,S5 First S3,S5, S6,S2,S3,S4,S5,S2,S3,S4,S6 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 403

416 United Healthcare Community Plan River Valley Option Subscriber Last First Dependent D1 Subscriber Member ID Dep. Last Dep. First Dep. 1 year No No Required Note 1: If the subscriber has a dependent, the Subscriber ID search will result in duplicate records. Therefore you must use the Subscriber /DOB search to locate the subscriber s information and the Dependent search to locate dependent information. Note 2: Neighborhood Health Partnership (00422) has migrated their membership to UH River Valley. All NHP transactions can be sent through this payer. and/or = [NM108=PI]NM109 Last or Required. Min=1 Max=24 Optional Type Dependent Required. No Last D1 Last S2,S3 First D1 First S2,S3 D1 and/or 30,S3,D1 Min/Max=9 S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 404

417 United Healthcare Community Plan Tennessee Option Subscriber Last First Subscriber S2 Last Subscriber S3 First Subscriber S4 Subscriber S5 Last First Subscriber S6 Last First Up to 6 months in the Past Up to the end of the current month in the Future Date Ranges allowed - End date of date range must be no greater than the end of the current month Required and/or = [NM108=PI]NM109 Last or /Federal Tax ID/Provider ID No National Provider ID Situational Type and/or 1,2,3,4,5,6,7,8,10, 12,13,18,20,23,24, 25,26,27,28,33,35,36,37,38,39,40,41,4 2,45,47, 48,49,50,51,52,53, 62,65,68,73,76,78,80,81,82,83,86,88,, 89,90,91,92,93,98,99,A0,A3,A4,A5,A6, A7,A8,AD,AE,AF,AG,AI,,AJ,AK,AL,BG,BH,BT, BU,BV,BW,BX,BY,BZ, DM,GF,GN,MH,UC Last First,S2,S5,S6,S3,S5,S6,S2,S3,S4,S5 Min=2 Max=80,S2,S3,S4,S6 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 405

418 United Healthcare Facets Detroit Community and State Option Subscriber Last First Subscriber S2 Last Dependent D1 Sub. Dep. Last name Dep. First name Dependent D2 Sub. Dep. First Dep. and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last, S2 First,S2,D1.D2, S2 Dependent Dep. Last Dep. First Dep. Date of Birth D1 D1,D2 D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 406

419 United Healthcare Facets Pittsburgh Community and State Option Subscriber Last First Subscriber S2 Last Dependent D1 Sub. Dep. Last name Dep. First name Dependent D2 Sub. Dep. First Dep. and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last, S2 First,S2,D1.D2, S2 Dependent Dep. Last Dep. First Dep. Date of Birth D1 D1,D2 D2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 407

420 United Healthcare Nevada Market Option Subscriber Last First and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 408

421 United Healthcare SecureHorizons Option Subscriber Subscriber S2 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. and/or s and Values = = [NM108=PI]NM 109 Last or Subscriber Last Subscriber First Subscriber Subscriber Date of Birth Dependent Dep. Last Required. No S2 S2, D1,D2,S2 D2,D3 Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Dep. First Dep. D2,D3 D1,D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 409

422 Unity Health Plan Option Subscriber Last First Subscriber S2 Last 12 months 60 days 60 days Required and/or = [NM108=PI]NM109 Last or Required. Min=1 Max=24 Required. No Optional Type and/or 30 Last First,S2,S2 Min/Max=12,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 410

423 University Care Advantage Arizona Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. First Dep. Last Dependent D3 Dep. Date of Dep. Last Dep. First Birth and/or s and Values = = [NM108=PI]NM 109 Last or Subscriber Last Subscriber First Subscriber Subscriber Date of Birth Dependent Subscriber Subscriber Last Dep. Last Required. No S2,S3,S2,D3,D4,S3, D1, D1 D2,D3 Type and/or 1, 30, 35, 38, 47, 48, 50, 86, 88, 98, AL Federal Tax ID and/or Situational. No Situational. No Dep. First Dep. D2,D3 D1,D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 411

424 University Family Care Option Subscriber Subscriber S2 SSN Subscriber S3 SSN Last First Subscriber S4 Last First 1 Year No No and/or = [NM108=PI]NM109 Last or Provider ID Min=2 Max=16 Type and/or and/or 30 Situational. No notes Last First SSN S3,S4 S3,S4 Min=1 Max=24 S2,S3 S2,S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 412

425 University of Arizona Health Plan-UHM Option Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First 1 year No No and/or = [NM108=PI]NM109 Last or Last Either Tax ID or is required S3,S4 Type and/or 30 Federal Tax ID and/or Either Tax ID or is required First S3,S4,S2,S3 S2, S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 413

426 University of Utah Health Plans Option Subscriber Last First 1 year No No and/or = [NM108=PI] NM109 Type and/or and/or 30 Situational. No notes Middle Optional. No notes Last First Min/Max=13 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 414

427 University Physicians Care Advantage (AZ) Option Subscriber Subscriber S2 SSN Subscriber S3 SSN Last First Subscriber S4 Last First 1 Year No No and/or = [NM108=PI]NM109 Provider ID Min=2 Max=16 Type and/or and/or 30 No Last First SSN S3,S4 S3,S4 Min=1 Max=24 S2,S3 S2,S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 415

428 University Physicians Healthcare Group (Arizona) Option Subscriber Subscriber S2 SSN Subscriber S3 SSN Last First Subscriber S4 Last First 1 Year No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 No No Provider ID Min=2 Max=16 Last First SSN Date Of Birth S3,S4 S3,S4 Min=1 Max=24 S2,S3 S2,S4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 416

429 UPMC Health Plan (Tristate) Option Subscriber Last First Subscriber S2 Last First Note: For the /DOB only search, UPMC requires the member name to be submitted exactly as it is on file with the payer. Current active span Current active span Current active span Required and/or = [NM108=PI]NM109 Last or No Optional Type and/or 30 Last First No,S2,S2 Min/Max=12,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 417

430 USAA Life Insurance Company Option Subscriber First Last Subscriber S2 Subscriber S3 First Last Subscriber S4 Medicare HIC # Dependent D1 Dep: First Dep: Last Dependent D2 Dep: Dependent D3 Dep: First Dep: Last Dep: Note: Always assume current date regardless of DTP date. Additionally, the payer USAA Life Insurance Company has advised they have loaded all active members with a middle initial as part of the member s first name. If the member s first name is used in search option (1 and 3) without the middle initial AAA*67 (Patient Not found) results are returned. (*Please note there is no separator between the first name and middle initial) Example: NM1*IL*1*DOE*JANE M and/or = [NM108=PI]NM109 Last or Medicare HIC Number No Min/Max=12 S2 Min=1 Max=12 Type and/or and/or 30 No Federal Tax ID No,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 418

431 VA Fee Basis Program Option Subscriber Last First Disclaimer: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be after the claim has been received and review in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. : The Department of Veterans Affairs Fee Basis Program is not a health insurance plan. The Fee Basis Program is designed to assist veterans who cannot easily receive care at a VA Medical Center. Each individual veteran s eligibility status and medical care needs are legally and medically reviewed for each episode of care. Each local Fee site determines whether non-va treatment can be approved. For these reasons, all Fee Basis Program eligibility responses will return an Inactive status along with contact information for the local Fee office. Required and/or = [NM108=PI]NM109 Last or No No Optional Type and/or 30 Provider City Provider State Provider Zip Last First No No No Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 419

432 VA Healthcare Option Subscriber Last First and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 420

433 VA Health Administration Center Option Subscriber Subscriber S2 Last First No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Subscriber Last Subscriber First Subscriber Subscriber S2 S2 S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 421

434 Vantage Health Plan, Inc Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. No No No and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2, S3 First S2, S3, S2, D1, D2, S3 Dependent Dep. Last Dep. First Dep. Date of Birth D2, D3 D2, D3 D1, D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 422

435 VIVA Health Option Subscriber Last First Subscriber S2 Last First Note: Drummond Plan format is Alpha prefix + 9 digits Required and/or = [NM108=PI]NM109 Last or No Optional Type and/or 30 Last First No,S2,S2 Min/Max=12,S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 423

436 VYTRA Option Subscriber Last First Required and/or = [NM108=PI]NM109 Last or No Optional Type and/or 30 Last First No Min/Max=12 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 424

437 Washington National Option Subscriber Last First Subscriber S2 Last Subscriber S3 Last First 1 year End of current month No and/or = [NM108=PI]NM109 Last or Type and/or 30 Federal ID and/or Situational. National Provider ID if NM108=XX. Federal Tax ID if NM108=FI.. Situational. Federal Tax ID if NM108=FI. Last First,S2, S3 S2,S3,S2 Min=7 Max=10,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 425

438 Well Sense Option Subscriber Last First Subscriber and/or = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First S2 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 426

439 Wellcare Health Plans Option Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year No No Required and/or = [NM108=PI]NM109 Optional Type and/or 30 Last First No,S2,S2,S3 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 427

440 Western Health Advantage 1043 Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Subscriber Dep. Dependent D2 Subscriber Dep. Last Dep. First Dependent D3 Dep. Last Dep. First Dep. and/or s and Values = = [NM108=XX,FI] NM109 Last or Subscriber Last Subscriber First Subscriber Subscriber Date of Birth Dependent Subscriber Subscriber Last Dep. Last Required. No S2,S3,S2,D1,D2,S3,S2,D1,D2, D1 D2,D3 Type and/or 30,56,57,59,61,64,67,69 70,71,75,79,83,AB,AM, AN,AO,BB,CF,CG,CI,CJ DM,DS,RT Federal Tax ID and/or Situational. No Situational. No Dep. First Dep. D2,D3 D1,D3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 428

441 Wilson McShane Option Subscriber Last First No No No and/or [NM108=PI]NM109 Last or Last First Either Tax ID or is required Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 429

442 Windsor Medicare Extra Option Subscriber Subscriber S2 Last First Subscriber S3 Last First 1 year No No Note: Medicare Part A and Medicare Part B. Termination Date of is a valid day of member eligibility. and/or = [NM108=PI]NM109 Last or Type and/or 30 Federal Tax ID and/or No No No Last First S2,S3 S2,S3,S2 Min/Max=12,S3 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 430

443 World Insurance (ARIC) Option Subscriber Subscriber S2 Last First Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Dependent D4 Sub: Dep: Last Dep: First Dep: and/or = [NM108=PI]NM109 Last or Type and/or 30 Federal Tax ID and/or No No No Last First S2,S3,S4 S2,S3,S4,S2,S4,D1,D2,D4,S3,S4 Dependent Last First D2,D3,D4 D2,D3,D4 D1,D3,D4 Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 431

444 WPS Health Insurance Option Subscriber Last First Gender and/or = [NM108=PI]NM109 Last or Type and/or and/or All Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last First Subscriber Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 432

445 Payer Maintenance Schedule Payer AARP Absolute Total Care ACS Benefit s Advantage by Bridgeway Health Solutions Advantage by Buckeye Community Health Plan Advantage by Managed Health s Advantage by Superior Care Improvement Advantage Health Solutions Aetna Aetna Administrator Medicare Supplement Aetna Better Health (IL) Aetna Better Health (LA) Aetna Better Health (MI) Aetna Better Health (NE) Aetna Better Health (PA) Aetna Better Health (TX) Aetna Better Health (TX) CHIP Aetna Senior Supplemental Aetna Signature Administrators Aetna Long Term Care Affinity Health Plan Affinity Health Plan Medicare AFLAC AFLAC Dental AFLAC - Medicare Supplemental Aftra Health Fund Alan Sturm and Associates - Dental Allegiance Benefit Plan Management Allied Benefit Systems AlohaCare Alternative Insurance Resources, Inc Altus Dental AMC Alaska Electrical Health & Welfare Fund AMC American General Life and Accident AMC Health Future AMC Poly America AMC Touchstone AMC Touchstone PSO American Community Mutual American Family Insurance Group-Medicare Supplemental and PPO Policies American Income Life Insurance Company American Medical Security (AMS) American National Insurance Company American National Life Insurance Company TX Stated Downtime Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) Sunday 4:00 am 12:00 pm (Eastern) Mon- Fri 12am 5:00 am (Central) Sunday 4:00 am 12:00 pm (Eastern) Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 433

446 Payer American Network Ins. Medicare Supplement American Postal Workers Union (APWU) American Republic Insurance Company (ARIC) American Retirement Life Ins Co McareSupp AmeriBen AmericChoice of New Jersey (Commercial) AMERIGROUP Amerigroup Corporation AmeriHealth Administrators AmeriHealth Caritas Pennsylvania AmeriHealth (DE, NJ, PA) 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 Anthem Vivity Arise Health Plan Medicare Select Policy Arizona Physicians IPA (APIPA) ASR Health Benefits Associacion De Maestros Puerto Rico Assurant Health John Alden Insurance Company (JALIC) Assurant Health Time Insurance Company (FIC) Assurant Health Union Security Insurance Company (FBIC) AultCare Automated Benefit s Auxiant Avera Health Plans AvMed Health Plans Bankers Life and Casualty Banner Health Plans Benefit Management Inc. Best Choice Health Plan Best Life and Health Better Health Plans of Florida Better Health Plans (Unison Health Plans) BlueChoice Health Plan South Carolina Medicaid Bluegrass Family Health Blue Benefit Administrators of Mass BMC HealthNet Plan Stated Downtime 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 sun 3am 3:15am (Central) Mon- Fri 12am 5:00 am (Central) 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 s Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 434

447 Payer Boon Group Bridgespan Bravo Health Bridgeway Arizona Brokers National - Dental Buckeye Community Health Butler Benefit s, Inc. Capitol Administrators Capital District Physicians Health Plan (CDPHP) CAPROCK Care Improvement Plus Care1st Health Plan Arizona Carefirst Federal Employee Program Carefirst Blue Cross Blue Shield CarePoint Medicare Advantage CareSource Health (OH) Carolina Care Plan, Inc. (CCP) Carpenter s Health and Welfare Trust Fund of St. Louis CDS Group Health Celticare Celtic Insurance Cenpatico - Arizona Cenpatico Behavioral Health Cenpatico Behavioral Health Texas Cenpatico Florida Cenpatico Georgia Cenpatico Indiana Cenpatico Kansas Cenpatico - Massachusetts Cenpatico - Mississippi Cenpatico - New Hampshire Cenpatico Ohio Cenpatico South Carolina Centene - Advantage by Peach State Centene - Advantage by Sunshine State Centene Advantage Plans Centene-Coordinated Care Centene-California Health & Wellness Centene - Granite State Health Plan Centene-Home State Health Plan Centene- IlliniCare Health Plan Centene-Kentucky Spirit Health Plan Centene-Louisiana Healthcare Connections Centene-Magnolia Health Plan Centene-Peach State Health Plan Stated Downtime mon fri 9pm 7am, sat 4pm mon 7am (Pacific) mon fri 9pm 7am, sat 4pm mon 7am (Pacific) mon sun 3am 3:15am (Central) Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 435

448 Payer Centene-Sunflower State Health (Kansas) Centene-Sunshine State Health Plan Centene-Total Care Carolina CenterLight Healthcare Central California Alliance for Health Central Reserve Insurance Company Central Reserve Life Ins Co Medicare Supp Central Senior Care Central States Funds Central States Indemnity Cerner Health Plan 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 - MHNet Behavioral Health CHC OmniCare (Michigan) CHC PersonalCare/Coventry Health of Illinois CHC Southern Health s (SHS) CHC WellPath Select (Carolinas) CHC Coventry Health and Life (Tenn) CHC Advantra Savings CHC Vista (MCD, FHK, LTC) Stated Downtime Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 436

449 Payer CHC- CoventryCares Children's Mercy PCN Christian Brothers s CHRISTUS Health Plan NM CHRISTUS Health Plan NM Medicare Advantage CIGNA CHP Direct Claims Management Inc CMFG Life Insurance Colonial Penn Life Colorado Access Columbia United Providers Commerce Benefits Group Community Care of Oklahoma Community HealthFirst Medicare Advantage Community Health Plan of Washington (CHPW) Connecticare Consolidated Associates Railroad Consumers Life Continental General Ins Co Medicare Supp Cooperative Benefit Administrators (CBA) CoreSource (FMH) CoreSource (Little Rock) CoreSource (MD,PA,IL,NC,IN,AZ,MN) CoreSource (OH) Country Cupboard Country Life Insurance Company Covenant Administrators (TPA) Coventry Healthcare National Network Coventry Nebraska Medicaid Cox Health Plan CSA Fraternal Live Medicare Supp CTI Administrators Culinary Health Fund DakotaCare DeCare Dental Health Insurance Definity Health Delaware Physicians Care Delta Dental Ins. Co. - Alabama Delta Dental Ins. Co. - Florida Delta Dental Ins. Co. - Georgia Delta Dental Ins. Co. - Louisiana Delta Dental Ins. Co. - Mississippi Stated Downtime 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- Sat 12:00am to 6:00am, All Day Sunday Every Sunday Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 437

450 Payer Delta Dental Ins. Co. - Montana Delta Dental Ins. Co. - Nevada Delta Dental Ins. Co. - Texas Delta Dental Ins. Co. - Utah Delta Dental of California Delta Dental of Colorado Delta Dental of Delaware Delta Dental of Hawaii Delta Dental of Indiana Delta Dental of Maryland Delta Dental of Michigan Delta Dental of Minnesota Delta Dental of Nebraska Delta Dental of New Jersey Delta Dental of New Mexico Delta Dental of New York Delta Dental of North Carolina Delta Dental of North Dakota Delta Dental of Ohio Delta Dental of Pennsylvania Delta Dental of Rhode Island Delta Dental of Tennessee Delta Dental of Virginia Delta Dental of Washington DC Dental of Washington State Delta Dental of West Virginia DeltaCare USA - Encounters DeltaCare USA - Claims Denver Health Medical Plan Deseret Mutual (DMBA) Director's Guild Employee Benefit s EBMS EPIC Life Insurance EPSI, Inc. Essence Healthcare Evangelical Community Hospital Evercare Everence Financial Evergreen Health Co-Op Expert Benefit Solutions Fallon Community Health Plan FamilyCare FCE Benefit Administrators Inc Federated Insurance Company Fidelis Care New York Stated Downtime Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 438

451 Payer Fidelis SecureCare of Michigan FirstCare First Medical Network First United American Insurance Company Flex Compensation - Dental Florida Combined Life - Dental Florida Hospital Healthcare System Florida True Health Food Employers & Bakery Workers Benefit Food Employers & Bakery Confectionary Workers Benefit Fresenius Medical Care GHI - Group Health Incorporated Gilsbar Globe Life & Accident Insurance Company Government Employees Hospital Association GEHA Great-West Healthcare Group Health Cooperative of South Central Wisconsin - Dental Group Practice Affiliates Guardian Life Insurance Co. of America - Dental Harmony Health Plan Hawaii Medical Assurance Association - Dental Health Alliance Medical Plan (IL) Health Alliance Medical Plans (HAP) Health Choice Arizona Health Cost Solutions Health First Health Plan Health Net National Health Partners (Minnesota) Health Partners of Philadelphia Health Plan of San Mateo Health s for Children with Special Needs Health Share of Oregon Healthcare Solutions Group HealthComp Administrators HEALTHe Exchange HealthEase HealthEase Kids Healthfirst New Jersey Healthfirst New York Healthgram HealthMarkets (Chesapeake National Life) Stated Downtime 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) sat 8pm sun 4am (Mountain) Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) Mon 3am sun 3:15am (Central) Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 439

452 Payer HealthMarkets (Mega Life and Health Insurance) HealthMarkets (Mid-West National Life) HealthMarkets (TransAmerica Life) HealthNow HealthPlan of Nevada HealthPlans Inc HealthPlus of Michigan Healthsource Provident - Dental HealthSpring Healthy Texas Heritage Physician Network (Houston) Hershey Healthsmile - Dental HIPNY Hometown Health Horizon New Jersey Health Humana Humana CareSource (KY) Humana of Florida IBEW Local 508 Health Plan IBM Insurance Outsourcing s Ideal Life Insurance Independence Administrators Inland Empire Health Insurers Administrative Corporation (IAC) Integrated Mental Health s Inter Valley Health Plan International Medical Card Inc Island Home Insurance 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 Hawaii (DHMO Choice) Kaiser Foundation Health Plan of the Mid- Atlantic Kaiser Foundation Health Plan of the Northwest Kaiser Permanente of Georgia Kaiser Permanente of Northern CA Kaiser Permanente of Southern CA Kentucky Health Exchange Keystone Mercy Health Stated Downtime 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) 2 nd weekend of every month where unavailability will be between 1 hour and 2 days Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 440

453 Payer Kitsap Physician s KSKJ Life Leggett & Platt Leon Medical Centers Health Plan Liberty National Life Insurance Company Lifetime Benefit Solutions (RMSCO) Lifewise Arizona Lifewise Health Plan of Oregon Lifewise Health Plan of Washington Lincoln Heritage Lincoln Financial Local 1199 LoneStar TPA Loomis Company Louisiana Health Exchange Lovelace Health Plan Loyal American Life Ins Co Medicare Supp Magellan Behavioral Health Magnacare Managed Care of America Mail Handlers Benefit Plan Managed Health s Indiana Managed Health s Wisconsin MAPFRE Life Puerto Rico MAPFRE Medicare Excel Maricopa Care Advantage (Arizona) Maricopa Health Plan (Arizona) MDWise Hoosier Alliance MedBen - Newark OH MedCost Benefit s Medica Medica Health Plan Medical Card System Medical Mutual of Ohio Medicare (Part A & B) Medicare Advantage - Pennsylvania Medicare y Mucho Mas (INMEDIATA HEALTH GROUP) Med-Pay, Inc MedStar Family Choice Mega Life (Oklahoma City) Mercy Care Plan (Arizona) Mercy Health Plan Meritus Health Partners Stated Downtime Sunday 12am 11:59pm (Eastern) Sunday 12am 11:59pm (Eastern) Available 24/7 with regular maintenance scheduled the 2nd Sat of each month; outage may last from late Fri - Sun afternoon. Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) sun 10pm mon 3am (Eastern) Sat 9AM-5:59PM, Sun Unavailable (Central) Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 441

454 Payer MetLife Dental Family Metropolitan Health Plan (MHP) Michigan MI Child Mid Atlantic Medical s-mamsi Health Plan Mississippi State Employees and Teachers Missouri Care MMSI (Mayo Health) Moda Health Molina Healthcare of California Molina Healthcare of Florida Molina Healthcare of Illinois Molina Healthcare of Indiana Molina Healthcare of Michigan Molina Healthcare of Missouri Molina Healthcare of New Mexico Molina Healthcare of Ohio Molina Healthcare of South Carolina Molina Healthcare of Texas Molina Healthcare of Utah Molina Healthcare of Washington Municipal Health Benefit Fund Mutual Health s Mutual of Omaha MVP Health Care (New York) National Association of Letter Carriers (NALC) National Telecommunications Cooperative Association (NTCA) Nationwide Health Plans NEHEN Harvard Pilgrim Health Care NEHEN Neighborhood Health Plans NEHEN Tufts Associated Health Plan Network Health Plan of WI New Era Life Insurance Company NGS American North Carolina Medicaid Nova Healthcare Administrators NovaSys Health Ohana Health Plan Oklahoma Employees Group Insurance Division Operating Engineers Local No.428 Operating Engineers Local.428 Health and Welfare Optima/Sentara Orange County Fire Authority Stated Downtime mon 11pm 12am, tues fri 11am -3a, sat 4pm-5:30pm, sun 2am 9am, holiday times vary mon sun 3am 3:15am (Central) Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) mon 2am 4am (Central) sat 9pm mon 2:15am. (Central) Mon 11 pm - Tue 6 am; Tue 11 pm - Wed 6 am; Wed 11 pm - Thu 6 am and Thu 11 pm - Fri 6 am (Central) wed 9pm thur 2am (Eastern) Sun 4am 6am (Eastern) Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 442

455 Payer Oscar (NY) 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) Panamerican Life Puerto Rico Paramount Health Patriot Dental Partners National Health Plans of NC Partnership Health Plan of California Passport Advantage Passport Health Plan Peach State Health Plan People First Peoples Health Piedmont (GA) Preferred Health System of Kansas Preferred Medicare Choice (PMC) (INMEDIATA HEALTH GROUP) Premier Health Presbyterian Health Plan Pro-Claim Plus Phoenix Health Plan Physicians Health Plan Northern IN Physicians Health Plan of Mid-Michigan Physicians Mutual Insurance Company Physicians Plus Insurance Corp Piedmont Wellstar HealthPlans Pittman and Associates Plan de Salud Hospital Menonita Planned Administrators Inc. Plumbers and Pipefitters Local Union 525 Preferred Care Partners Preferred Health Systems PreferredOne Prestige Health Choice Principal Financial Group (Nippon Life) Stated Downtime 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) 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) Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 443

456 Payer Principal Financial Group (Principal Life) Priority Health Providence Health Plan Provident American Life & Health McareSupp Provident Preferred Network - Dental Public Employees Health Plan Puritan Life Insurance Qualchoice QuikTrip Corporation Boon-Chapman Benefit Admin Corporate Benefit Group & Pension Administrators JP Farley Corporation Professional Benefits Administrators Underwriters Safety & Claims Rocky Mountain Health Plan Royal Neighbors of America S and S Healthcare Strategies Sanford Health Plan San Francisco Health Plan San Joaquin Health Plan Santa Clara Family Health Plan Schaller Anderson Aetna Better Health of New York Schaller Anderson Aetna Better Health of OH Schaller Anderson Delaware Physicians, Inc. Schaller Anderson MajestaCare VA Schaller Anderson Maryland Physicians Care Schaller Anderson Mercy Care Schaller Anderson Missouri Care Schaller Anderson Texas CHRISTUS Scott & White Health Plan Secure Health Plans of Georgia Security Health Plan Securian Dental Securian/Patriot Dental Senior Health s Center Universal American Family of Companies Senior Whole Health Select Health SC Select Health Utah Senior Care Action Network (SCAN) HMO Shenandoah Life Insurance Sierra Health s Stated Downtime 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. Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 444

457 Payer Significa Benefit s Simply Healthcare Plans Special Agents Mutual Benefit Association SPJST Medicare Supplement Standard Life and Accident Insurance Company Star HRG State Mutual Med Supp. State Mutual (Lincoln Novation) StayWell StayWell Kids Sterling Investors Life Insurance Student Insurance SummaCare Health Plan Sunshine State Superior HealthPlan Texas TennDent TexanPlus North Texas Area TexanPlus Southeast Texas Area The Kempton Company Three Rivers Health Plans (Unison Health Plan) TMG Network Health Insurance Today s Health Today s Options Total Healthcare Tribute/SelectCare of Oklahoma TRICARE TRICARE for Life Triple-S Salud (BCBS Puerto Rico) Trustmark Insurance Ucare of Minnesota Ultimate Health Plans UMR UNICARE - Dental Unicare(Wellpoint) Union Pacific Railroad Employees Health Systems United American Insurance Company United Healthcare United Healthcare Community Plan - Tennessee United Healthcare Plan of River Valley United Healthcare SecureHorizons Stated Downtime 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 sun 3pm 10pm (Eastern) Thurs 5:30am-8:00am (MT) Sun 9:00am-12:00pm (MT) Thurs 5:30am-8:00am (MT) Sun 9:00am-12:00pm (MT) Thurs 5:30am-8:00am (MT) Sun 9:00am-12:00pm (MT) Thu 9:00pm 11:30pm (MST) Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 445

458 Payer United Teachers Associates Ins Co McareSupp United Concordia Federal Employees Program - Dental United Concordia Companies, Inc. - Dental UnitedHealthcare Community Plan Kansas UnitedHealthcare Facets Detroit Community and State UnitedHealthcare Facets Pittsburgh Community and State UnitedHealthcare Nevada Market United Healthcare SecureHorizons Unity Health Plans University Care Advantage Arizona University Family Care University of Arizona Health Plan - UHM University of Utah Health Plans University Physicians Care Advantage (AZ) University Physicians Healthcare Group (AZ) UPMC Health Plan (Tristate) USAA Life Insurance Company VA Fee Basis Program VA Health Administration Center VA Healthcare VA Health Administration Center Vantage Health Plan, Inc. VIVA Health VNS CHOICE VYTRA Washington National WEA Trust WEB-TPA, Inc. Well Sense Wellcare Health Plan Wells Fargo Third Party Administrators, Inc. (CHIP and PEIA) Western Health Advantage Wilson McShane - Dental Windsor Medicare Extra World Insurance (ARIC) WPS Health Insurance Stated Downtime 2nd Friday of the month brief outage at 4am VA Health Administration Center Sun 4:00p-5:00p, occasionally 8:00p-8:30p (EST) Xerox EDI Eligibility Gateway 270/ Payer Guide Commercial 446