Xerox EDI Eligibility Gateway 270/271 Payer Guide Commercial Version 5010 Technical Capital Support: egateway@xerox.com Updated November 12, 2014
2014 Xerox Corporation. All rights reserved. XEROX and XEROX and Design are trademarks of the Xerox Corporation in the United States and/or other countries. Other company trademarks are also acknowledged. Document Version: November 2014
Table of Contents Revision Table... 1 4010 and 5010 Compatibility... 9 Enrollment and Data Collection... 9 AARP 10431... 10 Absolute Total Care 10560... 11 Advantage by BridgewayHealthSolutions-10561... 12 Advantage by Buckeye Community Health Plan-10562... 13 Advantage by Managed Health s-10563... 14 Advantage by Superior Health Plan-10564... 15 Advantage Health Solutions 10954... 16 Aetna Administrator Medicare Supplement 10891... 17 Aetna AETNA... 18 Aetna Better Health (NE) 10976... 20 Aetna Better Health (IL) 10892... 21 Aetna Better Health (PA) 10894... 22 Aetna Better Health (TX) 10895... 23 Aetna Better Health (TX) CHIP 10896... 24 Aetna Senior Supplemental 10897... 25 Affinity Health Plan Medicare 10661... 26 Affinity Health Plan 10594... 27 AFLAC 10955... 28 AFLAC Medicare Supplemental -10663... 29 Alan Sturm and Associates Dental 10798... 30 Allegiance Benefit Plan Management 10654... 31 Allied Benefit Systems 10898... 32 Altus Dental 10786... 33 American FamilyInsurance Group- Medicare Supplement and PPO 10487... 34 American Medical Security (AMS) 10829... 35 American Network Ins. Medicare Supplement 10899... 36 American Postal Workers Union 00360... 37 American Republic Insurance Company (ARIC) 00224... 38 AmeriHealth (DE, NJ, PA) 10974... 39 AmeriHealth Administrators 10416... 40 AmeriHealth Caritas Louisiana (LaCare) 10640... 41 AmeriHealth Caritas Pennsylvania 10340... 42 Ameritas Group... 43 Arbor Health Plan 10641... 44 Arise Health Plan Medicare Select Policy 10868... 45 Arizona Physicians IPA (APIPA) 00322... 46 Associacion De Maestros Puerto Rico 10957... 47 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial i
Assurant Health... 48 Asuris Northwest Health- 10529... 49 Aultcare- 10472... 50 Automated Benefit s 10890... 51 Auxiant 10900... 52 Avera Health Plans 10869... 53 AvMed Health Plans AVMED... 54 Bankers Life and Casualty 10813... 55 Banner Health Plans 10707... 56 Benefit Management Inc. 10665... 57 Best Choice Health Plans 00000000820... 58 Better Health Plans (Unison Health Plan) 00199... 59 Blue Benefit Administrators of Mass 10803... 60 BlueChoice Health Plan South Carolina Medicaid 10504... 61 BMC HealthNet 10556... 62 Boon Group 10821... 63 Bravo Health 10399... 64 Bridgespan 10827... 65 Bridgeway Arizona 10901... 66 Brokers National Dental 10783... 67 Buckeye Community Health 10566... 68 Butler Benefit s, Inc. 10902... 69 Capitol Administrators 10903... 70 Capital District Physicians Health Plan 10458... 71 CAPROCK 10660... 72 CareSource Health (OH) 994... 73 Care Improvement Plus 10806... 74 CarePlus Health Plan 00324... 76 CarePoint Medicare Advantage 10822... 77 Carolina Care Plan, Inc. (CCP) 10762... 78 CDS Group Health 10667... 79 Celticare 10589... 80 Celtic Insurance 10668... 81 Cenpatico... 82 Centene Health Plans... 84 CenterLight Healthcare 10666... 85 Central California Alliance for Health 10884... 86 Central Reserve Life Insurance Company- 10450... 87 Central Senior Care 10904... 88 Central States Indemnity 10744... 89 CHAMPVA/Spina Bifida/Children of Women Vietnam Vets 00232... 90 Children s Mercy PCN 10906... 91 CHP Direct 10907... 92 Christian Brothers s 10908... 93 Cigna-GWH 00001... 94 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial ii
CMFG Life Insurance 10909... 95 Colonial Penn Life 10852... 96 Colorado Access- 0000002356... 97 Commerce Benefits Group 10910... 98 Community Health Plan of Washington (CHPW) 2641... 99 ConnectiCare 10303... 100 Consolidated Associates Railroad 10669... 101 Consumers Life 10911... 102 Continental General Insurance Company- 10454... 103 Cooperative Benefits Administrators 00223... 104 Cook Children s Health Plan- 10610... 105 CoreSource... 106 Country Cupboard 10912... 107 Country Life Insurance Company 10670... 108 Covenant Administrators (TPA) 10880... 109 Coventry Healthcare... 110 Cox Health Plan 10838... 112 CTI Administrators 10671... 113 DeCare Dental Health Insurance 10780... 114 Definity Health 10828... 115 Dental Benefit Providers 10787... 116 Delaware Physicians Care 10913... 117 Delta Dental... 118 Denver Health Medical Plan- 0000001321... 119 Deseret Mutual (DMBA) 10578... 120 Director s Guild 10077... 121 EBMS 10862... 122 Employee Benefit s Dental 10784... 123 EPIC Life Insurance 10914... 124 EssenceHealthcare- 10601... 125 Evangelical Community Hospital 10915... 126 Evercare 10807... 127 Everence Financial 10772... 128 Evergreen Health Co-Op 10860... 129 Family Care- 10427... 130 Federated Insurance Company- 00262... 131 Fidelis Care New York 10459... 132 Fidelis SecureCare of Michigan 10859... 133 FirstCare 10870... 134 First Medical Network 10916... 135 Flex Compensation Dental 10799... 136 Florida Combined Life Dental 10811... 137 Florida Health Care Plans- 10615... 138 Florida Hospital Healthcare System- 10333... 139 Florida True Health 10839... 140 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial iii
Food Employers & Bakery Confectionary Workers Benefit 10776... 141 Freedom Blue- 10502... 142 Fresenius Medical Care 10602... 143 Gateway Health Plan 10629... 144 Geisinger Health Plan 10611... 145 Geisinger Health Plan Gold 10612... 146 Generations Healthcare 10603... 147 Gerber Life Insurance* 10745... 148 GHI Group Health Incorporated 10808... 149 Gilsbar- 10509... 150 Great American Life Insurance Co Medicare Supplement- 10543... 151 Group Health Cooperative- 10608... 152 Group Health Cooperative of South Central Wisconsin Dental 10781... 153 Guardian Life Insurance Co. of America Dental 10788... 154 Harmony Health Plan 10514... 155 Hawaii Medical Assurance Association Dental 10785... 156 Health Alliance Medical Plan (IL) 10871... 157 Health Alliance Medical Plans (HAP) 00000002077... 158 Health Choice Arizona 00329... 159 Health First Health Plan 10673... 160 Health First New Jersey 10438... 161 Health First New York 00240... 162 Health Net National 10385... 163 Health New England 10627... 164 Health Partners (Minnesota) 10484... 165 Health Partners Philadelphia 00288... 166 Health Plan of San Mateo 10362... 167 Health Share of Oregon 10823... 168 Health s for Children with Special Needs 10584... 169 Healthcare Solutions Group 10463... 170 HealthEase 10510... 171 HealthEase Kids 10511... 172 Healthgram 10917... 173 HealthMarkets... 174 HealthPlan of Nevada 10804... 176 HealthPlans Inc. 10802... 177 HealthPlus of Michigan 1311... 178 HealthScope (Morris Assoc, Central Benefits, Employer s Health, Plan Handlers) 10621179 Healthsource Provident Dental 10789... 180 HealthSpring 10464... 181 Healthy Texas 10824... 182 Heritage Physician Network (Houston) 10918... 183 Hershey Healthsmile Dental 107935... 184 HIPNY 10406... 185 Horizon NJ Health 2840... 186 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial iv
Humana 00041... 187 Humana CareSource (KY) 10920... 188 IBM Insurance Outsourcing s 10861... 189 IBEW Local 508 Health Plan 10885... 190 Ideal Life Insurance 10747... 191 Independence Administrators 10417... 192 Island Home Insurance 10675... 193 John Hopkins Health Plan 00000002613... 194 Kaiser Foundation Health Plan of Colorado 00277... 195 Kaiser Foundation Health Plan of Hawaii 00278... 196 Kaiser Foundation Health Plan of Hawaii (DHMO Choice) 10676... 197 Kaiser Foundation Health Plan of the Mid Atlantic 00276... 198 Kaiser Foundation Health Plan of the Northwest 00279... 199 Kaiser Permanente of Georgia 00281... 200 Kaiser Permanente of Northern CA 00282... 201 Kaiser Permanente of Southern CA 00283... 202 Kentucky Health Exchange 10857... 203 Keystone Mercy Health 2232... 204 Kitsap Physician s 2644... 205 KSKJ Life 10748... 206 Leggett & Platt 10975... 207 Leon Medical Centers Health Plan 10677... 208 Lifewise Arizona 10843... 209 Lincoln Financial 10678... 210 Lincoln Heritage 10749... 211 Loomis Company 10755... 212 Louisiana Health Exchange 10830... 213 Magellan Behavioral Health 10649... 214 Magnacare 10867... 215 MAMSI Health Plan MAMSI... 216 Managed Care of America 10885... 217 Managed Health s Wisconsin 10587... 218 MAPFRE Medicare Excel 10680... 219 MAPFRE Life Puerto Rico 10679... 220 Maricopa Health Plan Arizona 10434... 221 MDWise Hoosier Alliance -10598... 222 MedBen Newark OH 10681... 223 MedCost Benefit s -10272... 224 Medica 00404... 225 Medical Associates Health Plan/Health Choices 10683... 226 Medical Card System 10952... 227 Medical Mutual of Ohio 00211... 228 Medicare CMS... 229 Medicare y Mucho Mas (INMEDIATA HEALTH GROUP) 10960... 230 Med-Pay, Inc. 10682... 231 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial v
MedStar Family Choice 10844... 232 MedStar Health Plan 10845... 233 Mercy Health Care Plan 10465... 234 Meritain Health 10635... 235 Michigan MI Child 10138... 236 Mississippi State Employees and Teachers 10142... 237 Missouri Care 10702... 238 MMSI (Mayo Health) 10144... 239 Molina Healthcare... 240 Municipal Health Benefit Fund 10687... 241 Mutual Assurance Administrators 10872... 242 Mutual Health s 10686... 243 Mutual of Omaha 10382... 244 National Association of Letter Carriers (NALC) 00214... 245 National Telecommunications Cooperative Association (NTCA) 10812... 246 NEHEN Harvard Pilgrim Health Care 10376... 247 NEHEN Harvard Pilgrim Health Care 00000002393... 248 NEHEN- Neighborhood Health Plans- 00000002395... 249 Neighborhood Health Plan (RI) 10630... 250 Network Health 10626... 251 Network Health Plan of WI 10706... 252 NGS American 10873... 253 North Carolina Medicaid 10156... 254 Nova Healthcare Administrators 10537... 255 Ohana 10515... 256 Operating Engineers Local.428 Health and Welfare 10777... 257 Optima/Sentara 10477... 258 Orange County Fire Authority 10951... 259 Oscar (NY) 10881... 260 Oxford Health Plans 00016... 261 Pacific Source Health Plan 2597... 262 Panamerican Life Puerto Rico 10689... 263 Paramount Health 10854... 264 Parkland Community Health Plan 10643... 265 Partners National Health Plans of NC 10383... 266 Passport Health Plan 2841... 267 Patriot Dental 10782... 268 Peoples Health 10636... 269 Physicians Health Plan Northern IN (PHPNI)-10658... 270 Physicians Mutual Insurance Company 00287... 271 Piedmont (GA) 10882... 272 Piedmont Wellstar HealthPlans 10825... 273 Plan de Salud Hospital Menonita 10958... 274 Planned Administrators Inc. 10886... 275 Preferred Care Partners 10691... 276 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial vi
Preferred Health System of Kansas 10847... 277 Preferred Medicare Choice (PMC) (INMEDIATA HEALTH GROUP) 10959... 278 Preferred One 00371... 279 Premier Health 10848... 280 Presbyterian Health Plan 10646... 281 Prestige Health Choice 10965... 282 Primary PhysicianCare Inc. 10692... 283 Principal Financial Group (Nippon Life)... 284 Priority Health 10490... 285 Providence Health Plan 2598... 286 Provident Preferred Network Dental 10790... 287 Puritan Life Insurance 10743... 288 Qualcare 10637... 289 Recall Systems... 290 Royal Neighbors of America 10751... 291 S and S Healthcare Strategies 10875... 292 Sanford Health Plan 10533... 293 Santa Clara Family Health Plan 10876... 294 Schaller Anderson... 295 Schaller Anderson... 296 Schaller Anderson Aetna Better Health of OH 10887... 297 Schaller Anderson Texas CHRISTUS 10696... 298 Scott & White Health Plan 00000002076... 299 Secure Health Plans of Georgia 10883... 300 Securian Dental 10792... 301 Securian/Patriot Dental 10793... 302 Security Health Plan -10864... 303 Senior Health s Center Universal American Family of Companies 10697... 304 Senior Whole Health 10962... 305 Select Health SC 10520... 306 Select Health Utah 10575... 307 Shenandoah Life Insurance 10752... 308 Sierra Health s 10282... 309 Significa 00191... 310 SPJST Medicare Supplement 10546... 311 Star HRG 10833... 312 State Mutual Med Supp. 10750... 313 Staywell 10512... 314 Staywell Kids 10513... 315 Sterling Investors Life Insurance 10753... 316 Student Insurance 00290... 317 SummaCare 00000002514... 318 Superior Health Plan Texas 10592... 319 TennDent 107934... 320 TexanPlus North Texas Area 10604... 321 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial vii
TexanPlusSoutheast Texas Area 10605... 322 The Kempton Company 10698... 323 Three Rivers Health Plans 00198... 324 TMG Network Health Insurance 10688... 325 Today s Health 10606... 326 Today s Option 10505... 327 Total Healthcare 10805... 328 TRICARE for Life 10879... 329 Triple-S Salud (BCBS Puerto Rico) 10953... 330 Trustmark 00233... 331 Tribute/Select Care of Oklahoma 10607... 332 Tricare TRICR... 333 Ucare of Minnesota 2596... 334 Ultimate Health Plans 10888... 335 UMR (Wausau) 10501... 336 UNICARE Dental 10791... 337 Unicare UCARE... 338 United Concordia (Dental)... 339 United Healthcare 00112... 340 United Healthcare Plan River Valley 00335... 342 UnitedHealthcare Community Plan Kansas 10835... 343 UnitedHealthcare Facets Detroit Community and State 10836... 344 UnitedHealthcare Facets Pittsburgh Community and State 10834... 345 United Healthcare SecureHorizons 10655... 346 UnitedHealthcare Nevada Market 10837... 347 Unity Health Plan 00000000780... 348 University Care Advantage Arizona 10699... 349 University Family Care 00353... 350 University of Arizona Health Plan-UHM 10889... 351 University of Utah Health Plans 10977... 352 University Physicians Care Advantage (AZ) 10433... 353 University Physicians Healthcare Group (Arizona) 10439... 354 UPMC Health Plan (Tristate) 00000001054... 355 USAA Life Insurance Company 10195... 356 VA Fee Basis Program 00231... 357 VA Healthcare 10850... 358 VA Health Administration Center 10956... 359 Vantage Health Plan, Inc. 10858... 360 VIVA Health 10468... 361 VYTRA 10407... 362 Washington National 10853... 363 Well Sense 10814... 364 Wellcare Health Plans 10488... 365 Western Health Advantage 10201... 366 Wilson McShane 10797... 368 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial viii
World Insurance (ARIC) 10386... 369 WPS Health Insurance 10878... 370 Zenith Administrators (MN) Dental 10796... 371 Payer Maintenance Schedule... 372 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial ix
Revision Table Change Origination of 5010 Payer Guide 11/25/2011 Aetna AETNA Added 11/25/2011 BMC HealthNet 10556 Added 11/25/2011 Coventry Healthcare Added 11/25/2011 Optima/Sentara 10477 Added 11/25/2011 AARP- 10431 added 4/30/2012 American Postal Workers Union- 00360 added 4/30/2012 AmeriHealth Mercy Health Plan- 2843 added 4/30/2012 Assurant Health- added 4/30/2012 Asuris Northwest Health- 10529 added 4/30/2012 AultCare- 10472 added 4/30/2012 AcMed Health Plans- AVMED added 4/30/2012 Capital District Health Plan- 10458 added 4/30/2012 Cigna- 00001 added 4/30/2012 Cook Children s Health Plan- 10610 added 4/30/2012 Family Care- 2594 added 4/30/2012 Federated Insurance Company- 00262 added 4/30/2012 Florida Health Care Plans- 10615 added 4/30/2012 Florida Hospital Healthcare System- 10333 added 4/30/2012 Freedom Blue- 10502 added 4/30/2012 Fresenius Medical Care-0 10602 added 4/30/2012 Geisinger Health Plan- 10611 added 4/30/2012 Geisinger Health Plan Gold- 10612 added 4/30/2012 Generations Healthcare- 10603 added 4/30/2012 Gilsbar- 10509 added 4/30/2012 Health Alliance Medical Plans (HAP)- 00000002077 added 4/30/2012 Healthcare Solutions Group- 10463 added 4/30/2012 Health Choice Arizona- 00329 added 4/30/2012 Health First New Jersey- 10438 added 4/30/2012 Health First New York- 00240 added 4/30/2012 HealthMarkets- added 4/30/2012 HealthNet National- 10385 added 4/30/2012 Health Partners MN- 10484 added 4/30/2012 HealthEase- 10510 added 4/30/2012 HealthEase Kids- 10511 added 4/30/2012 Horizon NJ Health- 2840 added 4/30/2012 Humana- 00041 added 4/30/2012 John Hopkins Health Plan- 00000002613 added 4/30/2012 Kaiser Foundation Health Plan of Colorado- 00277 added 4/30/2012 Kaiser Foundation Health Plan of Hawaii- 00278 added 4/30/2012 Kaiser Foundation Health Plan of Mid-Atlantic States- 00276 added 4/30/2012 Kaiser Foundation Health Plan of the Northwest- 00279 added 4/30/2012 Kaiser Foundation Health Plan of Ohio- 00280 added 4/30/2012 Kaiser Permanente of Georgia- 00281 added 4/30/2012 Kaiser Permanente of Northern CA- 00282 added 4/30/2012 Kaiser Permanente of Southern CA- 00283 added 4/30/2012 Keystone Mercy Health- 2232 added 4/30/2012 Medica- 00404 added 4/30/2012 Medical Mutual of Ohio- 00211 added 4/30/2012 Medicare (Part A & B)- CMS added 4/30/2012 Mercy Health Care Plan- 10465 added 4/30/2012 MMSI (Mayo Health)- 10144 added 4/30/2012 Mutual of Omaha- 10382 added 4/30/2012 National Association of Letter Carriers (NALC)- 00214 added 4/30/2012 NEHEN- Harvard Pilgrim Health Care- 00000002393 added 4/30/2012 Ohana- 10515 added 4/30/2012 Date Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 1
Oxford Health Plan- 00016 added 4/30/2012 Pacific Source Health Plan- 2597 added 4/30/2012 Passport Health Plan- 2841 added 4/30/2012 Physicians Mutual Insurance Company- 00287 added 4/30/2012 PreferredOne- 00371 added 4/30/2012 Recall Systems-added 4/30/2012 Select Health SC- 10520 added 4/30/2012 Staywell- 10512 added 4/30/2012 Staywell Kids- 10513 added 4/30/2012 TexanPlus North Texas Area- 10604 added 4/30/2012 TexanPlus Southeast Texas Area- 10605 added 4/30/2012 Today s Health- 10606 added 4/30/2012 Today s Option- 10505 added 4/30/2012 Trustmark- 00233 added 4/30/2012 Tribute/Select Care of Oklahoma- 10607 added 4/30/2012 UMR (Wausau)- 10501 added 4/30/2012 Unicare- UCARE added 4/30/2012 United Healthcare- 00112 added 4/30/2012 VA Fee Basis Program- 00231 added 4/30/2012 VIVA Health- 10468 added 4/30/2012 Wellcare Health Plans- 10488 added 4/30/2012 Windsor Medicare Extra- 10576 added 4/30/2012 Added new payer HealthScope 10621 5/29/2012 Added new payer Universal Healthcare 10625 5/29/2012 Added new payer- Network Health 10626 6/8/2012 Added Standard Insurance of New York- 00430 added 6/8/2012 Added Standard Insurance- 00429 added 6/8/2012 Added Reliance Standard Life 6/8/2012 Added First Reliance Standard Life- 00428 added 6/8/2012 Added First Ameritas of New York- 00426 added 6/8/2012 AARP- 10431 updated search options 6/8/2012 Added new payer- Health New England 10627 6/8/2012 Added Health Partners of Philadelphia- 00288 added 6/8/2012 Added Colorado Access- 00000002356 added 6/8/2012 Added Denver Health Plan- 00000001321 added 6/8/2012 Medicare- CMS updated search options 6/8/2012 Added Principal Financial Group (Nippon Life)- 00144 added 6/8/2012 Added CoreSource Little Rock- 00205 added 6/8/2012 Added CoreSource FMH- 00204 added 6/8/2012 Denver Health-00000001321 added note to 6/27/2012 Added Continental General Insurance Company 10454 7/5/2012 Added Central Reserve Life Insurance Company 10450 7/5/2012 Added American Family Insurance Group- Medicare Supplement and PPO 10487 7/5/2012 Added American Republic Insurance Company 00224 7/5/2012 Added Cooperative Benefit Administrators 00223 7/5/2012 Added World Insurance (ARIC) 10386 7/5/2012 Added Molina WI 10678, TX 10391, OH 00445, NM 10146, MO 10523, MI 00226, FL 10445, CA 00222 7/5/2012 Cigna 00001- corrected/updated search options 7/5/2012 Added Sanford Health Plan 10533 7/5/2012 Mutual of Omaha 10382- updated search options 7/5/2012 Added Unity Health Plans 00000000780 7/5/2012 Added Ucare of Minnesota 2596 7/5/2012 Added SummaCare Health Plan 00000002514 7/5/2012 Added Santa Clara Valley Health and Hospital 00000002805 7/5/2012 Added HealthPlus of Michigan 1311 7/5/2012 Added NEHEN Neighborhood Health Plans 00000002395 7/5/2012 Added Three Rivers Health Plans (Unison Health Plan) 00198 7/5/2012 Added Select Health Utah 10575 7/5/2012 Added Deseret Mutual (DMBA) 10578 7/5/2012 Added Better Health Plans 00199 7/5/2012 Added Group Health Cooperative 10608 8/1/2012 Added UPMC Health Plan 00000001054, notes, updated date restrictions and updated maintenance times 8/1/2012 Added AmeriHealth Administrators 10416 8/1/2012 Added Independence Administrators 10417 8/1/2012 Added USAA Life Insurance Company 10195 8/1/2012 Added Significa Benefit s 00191 8/1/2012 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 2
Updated downtimes for GEHA, Medica, Cigna, UHC, Oxford Health Plan, QualChoice, MAMSI, AARP and 8/1/2012 Great West Added Priority Health 10490 8/1/2012 Added Affinity Health Plan 10594 8/1/2012 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) 10630 8/27/2012 Added Managed Health s WI 10587 8/27/2012 Added Kentucky Spirit Health Plan 10620 8/27/2012 Added Cenpatico WI 10634, TX 10633, SC 10573, OH 10572, MA10588, KY 10632, KS 10571, IN 8/27/2012 10570, IL 10631, GA 10569, FL 10568, AZ 10567 Added CeltiCare 10589 8/27/2012 Added Buckeye Community Health 10566 8/27/2012 Added Bridgeway Arizona 10565 8/27/2012 Added Advantage by Superior Health Plan 10564 8/27/2012 Added Advantage by Managed Health s 10563 8/27/2012 Added Advantage by Buckeye Community Health Plan 10562 8/27/2012 Added Advantage by Bridgeway Health Solutions 10561 8/27/2012 Added Absolute Total Care 10560 8/27/2012 Added new payer Meritain Health 10635 8/27/2012 Added CarePlus Health Plan 00324 9/28/2012 Added Fidelis Care New York 10459 9/28/2012 Added Great-West 10089 9/28/2012 Added University Physicians Healthcare Group Arizona 10194 9/28/2012 Added University Family Care Arizona 10433 10/1/2012 Added Maricopa Health Plan Arizona 10434 10/1/2012 Principal Financial Group (Nippon Life) 10170 is now a parent plan under Nippon Life Benefits 10/1/2012 Added Scott & White Health Plan 10360 11/2/2012 Added new payer Qualcare 10637 11/2/2012 Removed payer Cenpatico Georgia 10569 database no longer available 11/2/2012 Added Superior Health Plan of Texas 10592 11/2/2012 Added Harmony Health Plan 10514 11/2/2012 Added MAMSI Health Plan 11/2/2012 Updated date option Ucare Minnesota 2596 11/2/2012 Added new payer Alameda Alliance Health Plan 10639 11/2/2012 Added note to subscriber ID section Sanford Health Plan 10533 11/2/2012 Added New Payer LACare 10640 11/2/2012 Added new payer Arbor Health Plan 10641 11/2/2012 Removed payer Alameda Alliance Health Plan 10639 1/16/2013 Updated search options for Geisinger Health Plan 10611 and Geisinger Health Plan Gold 10612 2/20/2013 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 10601 2/20/2013 Added MDWise Hoosier Alliance 10598 2/20/2013 Removed Alameda Alliance Health Plan 10639 2/20/2013 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 HealthSpring10464 4/03/2013 Removed SSN search option for Kaiser Foundation Health Plan for Mid-Atlantic States 00276 4/03/2013 Updated Search options for Kaiser Permanente of Georgia 00281 4/03/2013 Great West Healthcare 10089 deactivated due to Cigna merger 4/03/2013 Updated Cigna-GWH 00001 since merger with Great West Healthcare 4/03/2013 Removed payer Universal Healthcare 10625 4/15/2013 Added Community Health Plan of Washington 2641 6/17/2013 Added Best Choice Health Plans 00000000820 6/17/2013 Added ConnectiCare 10303 6/17/2013 Added Student Insurance 00290 6/17/2013 Added CHAMPVA/Spina Bifida/Children of Women Vietnam Vets 00232 12/6/2013 Added Providence Health Plan modified search options for 5010 12/6/2013 Best Choice Health Plan removed SSN, DOB search option 12/6/2013 Community Health Plan of Washington 2641 modified search options, removed dependent search option 12/6/2013 Added United Healthcare of River Valley 00335 12/6/2013 Reactivated Nova Healthcare Administrators 10537 12/6/2013 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 3
Added CoventryCares of Kentucky 10642 12/6/2013 Deactivated Mercy Health Care Plan 10465(split into payerid 10219 and 10449) 12/6/2013 Deactivated Kentucky Spirit Health Plan 10620 12/6//2013 Corrected service type code for Select Health UTAH 10575 12/6/2013 Modified search options for Independence Administrators 10417 12/6/2013 Added additional search options USAA Life Insurance Co.10195 12/6/2013 Updated Healthspring 10552 to reflect supported states TN, AL, MS, TX, AR, OK, WV & GA 12/6/2013 Modified search options for UMR Wausau 10501 12/6/2013 Modified search options for HealthNet National 10385 12/6/2013 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 10195 12/17/2013 Updated 4010 / 5010 compatibility note 12/17/2013 Added Great American Life Insurance Co Medicare Supp 10543 12/17/2013 Added Gateway Health Plan 10629 12/17/2013 Added Schaller Anderson Parkland Community Health Plan 10643 12/17/2013 Modified search options for Providence Health Plan 2598 12/17/2013 Deactivated Santa Clara Valley Health and Hospital System 00000002805 01/30/2014 Modified search options for Advantage by Superior Health Plan-10564 01/30/2014 Added search option for CHAMPVA/Spina Bifida/Children of Women Vietnam Vets 00232 01/30/2014 Added note to VIVA Health 10468 01/30/2014 Added note to NEHEN Harvard Pilgrim Health Care 00000002393 01/30/2014 Added Arizona Physicians IPA (APIPA) 00322 01/30/2014 Updated AARP search option # 6- payer ID 10431 01/30/2014 Added SPJST Medicare Supplement 10546 01/30/2014 Added new payer Physicians Health Plan Northern IN (PHPNI)-10658 01/30/2014 Added new payer MHNet Behavioral Health Payer ID 10659 01/30/2014 Added new payer CAPROCK 10660 01/30/2014 Modified search option for NEHEN Harvard Pilgrim Health Care 10376 under Coventry Healthcare 01/30/2014 Added Kitsap Physician s 10341 and Modified search options for Kitsap Physician s 10341 01/30/2014 Modified Absolute Total Care (payer ID: 10560) 5010 search options effective immediately. 01/30/2014 Added new payer Centene-Magnolia Health Plan payer ID: 10704 01/30/2014 Added new payer Easy Choice payer ID 10703 01/30/2014 Added new payer Missouri Care payer ID 10702 01/30/2014 Added new payer Med-Pay, Inc. 10682 01/30/2014 Added new payer Affinity Health Plan Medicare -:10661 02/28/2014 Added new payer AFLAC Medicare Supplemental -10663 02/28/2014 Added new payer Benefit Management Inc. 10665 02/28/2014 Added new payer CDS Group Health 10667 02/28/2014 Added new payer Health First Health Plan 10673 02/28/2014 Added new payer Leon Medical Centers Health Plan 10677 02/28/2014 Added new payer Lincoln Financial -10678 02/28/2014 Added new payer Senior Health s Center Universal American Family of Companies -10697 02/28/2014 Added new payer The Kempton Company 10698 02/28/2014 Added new payer University Care Advantage Arizona -10699 02/28/2014 Added new payer Mutual Health s 10686 02/28/2014 Added new payer Panamerican Life Puerto Rico 10689 02/28/2014 Added new payer Schaller Anderson Maryland Physicians Care 10693 02/28/2014 Added new payer Schaller Anderson Mercy Care 10694 02/28/2014 Added new payer Schaller Anderson Missouri Care 10695 02/28/2014 Added new payer Schaller Anderson Texas CHRISTUS 10696 02/28/2014 Modified search options for payer Cigna 10062 02/28/2014 Added new payer Banner Health Plans 10707 02/28/2014 Added new payer MedBen Newark OH 10681 02/28/2014 Added Mississippi State Employees and Teachers 10142 02/28/2014 Added new payer Celtic Insurance 10668 02/28/2014 Added new payer CenterLight Healthcare 10666 02/28/2014 Added new payer Consolidated Associates Railroad 10669 02/28/2014 Added new payer Country Life Insurance Company 10670 02/28/2014 Added new payer CTI Administrators 10671 02/28/2014 Added new payer FCE Benefit Administrators Inc. 10672 02/28/2014 Added new payer Island Home Insurance 10675 02/28/2014 Added new payer Kaiser Foundation Health Plan of Hawaii (DHMO Choice) 10676 02/28/2014 Added new payer MAPFRE Medicare Excel 10680 02/28/2014 Added new payer MAPFRE Life Puerto Rico 10679 02/28/2014 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 4
Added new payer Medical Associates Health Plan/Health Choices 10683 02/28/2014 Added new payer Molina Healthcare of Illinois 10685 02/28/2014 Added new payer Municipal Health Benefit Fund 10687 02/28/2014 Added new payer Network Health Plan of WI 10706 02/28/2014 Added new payer Primary PhysicianCare Inc. 10692 02/28/2014 Added new payer Preferred Care Partners 10691 02/28/2014 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 10755 03/31/2014 Added the new payer Magellan Behavioral Health 10649 03/31/2014 Added the new payer TMG Network Health Insurance 10688 03/31/2014 Added the following new payers for Cenpatico: 03/31/2014 Cenpatico Behavioral Health 10766 Cenpatico Mississippi 10769 Cenpatico Behavioral Health Texas 10767 Cenpatico Missouri 10768 Cenpatico Georgia 10569 Cenpatico New Hampshire 10770 Added the following new payers for Centene: 03/31/2014 Centene Advantage by Peach State 10763 Centene- IlliniCare Health Plan 10757 Centene Advantage by Sunshine State 10764 Centene-Kentucky Spirit Health Plan 10620 Centene Advantage Plans 10771 Centene-Louisiana Healthcare Connections 10756 Centene-Coordinated Care 10761 Centene-Magnolia Health Plan 10704 Centene-California Health & Wellness 10759 Centene-Peach State Health Plan 10590 Centene Granite State Health Plan 10765 Centene-Sunflower State Health (Kansas) 10758 Centene-Home State Health Plan 10760 Added the new payer Carolina Care Plan, Inc. (CCP) - 10762 03/31/2014 Added the new payer Everence Financial 10772 03/31/2014 Added the new payer Health Choice Insurance Company 10773 03/31/2014 Added the new payer Windsor Health Plan 10774 03/31/2014 Added the new payer BlueChoice Health Plan South Carolina Medicaid 10504 03/31/2014 Added the new payer Centene Sunshine State Health Plan 10451 03/31/2014 Added the new payer North Carolina Medicaid 10156 03/31/2014 Added the following new payer for United Concordia (Dental): 03/31/2014 United Concordia Federal Employees Program Dental 10809 United Concordia Companies, Inc. Dental 10810 Added the new payer Florida Combined Life Dental 10811 03/31/2014 Deactivated payer Windsor Health Plan 10774 03/31/2014 Modified search options for payer Windsor Medicare Extra 10576 03/31/2014 Modified search options for payer BlueChoice Health Plan South Carolina Medicaid 10504 03/31/2014 Added the new payer Blue Benefit Administrators of Mass 10803 03/31/2014 Added the new payer Care Improvement Plus 10806 03/31/2014 Added the new payer Evercare 10807 03/31/2014 Added the new payer GHI Group Health Incorporated 10808 03/31/2014 Added the new payer HealthPlans Inc. 10802 03/31/2014 Added the new payer HealthPlan of Nevada 10804 03/31/2014 Added the new payer Total Healthcare 10805 03/31/2014 Added the new payer Cariten Senior Health 10059 03/31/2014 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 5
Added the new payer Director s Guild 10077 03/31/2014 Added information multiple STCs in the Specific data requirements and/or for payer Humana- 03/31/2014 00041 Added the new payer HIPNY 10406 03/31/2014 Added the new payer National Telecommunications Cooperative Association (NTCA) 10812 03/31/2014 Added the new payer Sierra Health s 10282 03/31/2014 Added the new payer VYTRA 10407 03/31/2014 Added the following new payers for Dental: 03/31/2014 DeCare Dental Health Insurance 10780 Group Health Cooperative of South Central Wisconsin Dental 10781 Patriot Dental 10782 Brokers National Dental 10783 Employee Benefit s Dental 10784 Hawaii Medical Assurance Association Dental 10785 Altus Dental 10786 Dental Benefit Providers 10787 Guardian Life Insurance Co. of America Dental 10788 Healthsource Provident Dental 10789 Provident Preferred Network Dental 10790 UNICARE Dental 10791 Securian Dental 10792 Securian/Patriot Dental 10793 TennDent 10794 Hershey Healthsmile Dental 10795 Zenith Administrators (MN) Dental 10796 Wilson McShane Dental 10797 Alan Sturm and Associates Dental 10798 Flex Compensation Dental 10799 Added the new payer American Medical Security (AMS) 10829 04/30/2014 Added the new payer AmeriHealth Caritas Pennsylvania 10820 04/30/2014 Added the new payer Boon Group 10821 04/30/2014 Added the new payer CarePoint Medicare Advantage 10822 04/30/2014 Added the new payer Cox Health Plan 10838 04/30/2014 Added the new payer Definity Health 10828 04/30/2014 Added the new payer Florida True Health 10839 04/30/2014 Added the new payer Health Share of Oregon 10823 04/30/2014 Added the new payer Healthy Texas 10824 04/30/2014 Added the new payer Integral Quality Care Florida 10842 04/30/2014 Added the new payer Lifewise Arizona 10843 04/30/2014 Added the new payer Louisiana Health Exchange 10830 04/30/2014 Added the new payer MedStar Family Choice 10844 04/30/2014 Added the new payer Molina Healthcare of South Carolina 10815 04/30/2014 Added the new payer Piedmont Wellstar HealthPlans 10825 04/30/2014 Added the new payer Preferred Health System of Kansas 10847 04/30/2014 Added the new payer Premier Health 10848 04/30/2014 Added the following new payers for Schaller Anderson: 04/30/2014 Schaller Anderson Aetna Better Health of New York 10816 Schaller Anderson Delaware Physicians, Inc. 10817 Schaller Anderson MajestaCare VA 10818 Added the new payer Star HRG 10833 04/30/2014 Added the new payer UnitedHealthcare Community Plan Kansas 10835 04/30/2014 Added the new payer UnitedHealthcare Facets Detroit Community and State 10836 04/30/2014 Added the new payer UnitedHealthcare Facets Pittsburgh Community and State 10834 04/30/2014 Added the new payer UnitedHealthcare Nevada Market 10837 04/30/2014 Added the new payer VA Healthcare 10850 04/30/2014 Added the new payer Well Sense 10814 04/30/2014 Added the new payer Bridgespan 10827 04/30/2014 Deactivated payer Easy Choice 10703 04/30/2014 Deactivated payer Health Choice Insurance Company 10773 04/30/2014 Added the new payer Kentucky Health Exchange 10857 04/30/2014 Added the new payer Fidelis SecureCare of Michigan 10859 04/30/2014 Added the new payer Vantage Health Plan, Inc. 10858 04/30/2014 Reactivated payer Presbyterian Health Plan 10646 05/30/2014 Added the new payer Central States Indemnity 10744 05/30/2014 Added the new payer Gerber Life Insurance* 10745 05/30/2014 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 6
Added the new payer Heartland National Life 10746 05/30/2014 Added the new payer Ideal Life Insurance 10747 05/30/2014 Added the new payer KSKJ Life 10748 05/30/2014 Added the new payer Lincoln Heritage 10749 05/30/2014 Added the new payer Puritan Life Insurance 10743 05/30/2014 Added the new payer Royal Neighbors of America 10751 05/30/2014 Added the new payer Shenandoah Life Insurance 10752 05/30/2014 Added the new payer State Mutual Med Supp. 10750 05/30/2014 Added the new payer Sterling Investors Life Insurance 10753 05/30/2014 Added the new payer Evergreen Health Co-Op 10860 05/30/2014 Added the new payer IBM Insurance Outsourcing s 10861 05/30/2014 Deactivated payer Heartland National Life 10746 06/30/2014 Added the new payer Centene Total Care Carolina 10866 06/30/2014 Added the new payer Bravo Health 10399 06/30/2014 Added the new payer Bankers Life and Casualty 10813 06/30/2014 Added the new payer Colonial Penn Life 10852 06/30/2014 Added the new payer Washington National 10853 06/30/2014 Added the new payer Evergreen Health Co-Op 10860 06/30/2014 Added the new payer WPS Health Insurance 10878 06/30/2014 Added the new payer TRICARE for Life 10879 06/30/2014 Added the new payer FirstCare 10870 06/30/2014 Added the new payer S and S Healthcare Strategies 10875 06/30/2014 Added the new payer Covenant Administrators (TPA) 10880 06/30/2014 Added the new payer Secure Health Plans of Georgia 10883 06/30/2014 Added the new payer Oscar (NY) 10881 06/30/2014 Added the new payer Piedmont (GA) 10882 06/30/2014 Added the new payer NGS American 10873 06/30/2014 Added the new payer Health Alliance Medical Plan (IL) 10871 06/30/2014 Added the new payer Santa Clara Family Health Plan 10876 06/30/2014 Added the new payer Arise Health Plan Medicare Select Policy 10868 06/30/2014 Added the new payer Avera Health Plans 10869 06/30/2014 Changed payer AmeriHealth Mercy Health Plan 10340 to AmeriHealth Caritas Pennsylvania - 10340 06/30/2014 Added the new payer Central California Alliance for Health 10884 06/30/2014 Added the new payer Magnacare 10867 06/30/2014 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 10242 Recall Systems Underwriters Safety & Claims 10246 Added the new payer Schaller Anderson Aetna Better Health of OH 10887 06/30/2014 Added the new payer Managed Health s Wisconsin 10587 06/30/2014 Added the new payer Planned Administrators Inc. 10886 06/30/2014 Added the new payer University of Arizona Health Plan-UHM 10889 06/30/2014 Added the new payer Ultimate Health Plans 10888 06/30/2014 Deactivated payer Cariten Senior Health 10059 07/31/2014 Added the new payer Automated Benefit s 10890 07/31/2014 Added the payer Michigan MI Child 10138 07/31/2014 Added the new payer CareSource Health 10057 07/31/2014 Added the new payer MedCost Benefit s -10272 07/31/2014 Added the new payer Aetna Administrator Medicare Supplement 10891 07/31/2014 Added the new payer Aetna Better Health (IL) 10892 07/31/2014 Added the new payer Aetna Better Health (PA) 10894 07/31/2014 Added the new payer Aetna Better Health (TX) 10895 07/31/2014 Added the new payer Aetna Better Health (TX) CHIP 10896 07/31/2014 Added the new payer Aetna Senior Supplemental 10897 07/31/2014 Added the new payer Allied Benefit Systems 10898 07/31/2014 Added the new payer American Network Ins. Medicare Supplement 10899 07/31/2014 Added the new payer Auxiant 10900 07/31/2014 Added the new payer Bridgeway Arizona 10901 07/31/2014 Added the new payer Butler Benefit s, Inc. 10902 07/31/2014 Added the new payer Capitol Administrators 10903 07/31/2014 Added the new payer Central Senior Care 10904 07/31/2014 Added the new payer Children s Mercy PCN 10906 07/31/2014 Added the new payer CHP Direct 10907 07/31/2014 Added the new payer Christian Brothers s 10908 07/31/2014 Added the new payer CMFG Life Insurance 10909 07/31/2014 Added the new payer Commerce Benefits Group 10910 07/31/2014 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 7
Added the new payer Consumers Life 10911 07/31/2014 Added the new payer Country Cupboard 10912 07/31/2014 Added the new payer Delaware Physicians Care 10913 07/31/2014 Added the new payer EPIC Life Insurance 10914 07/31/2014 Added the new payer Evangelical Community Hospital 10915 07/31/2014 Added the new payer First Medical Network 10916 07/31/2014 Added the new payer Healthgram 10917 07/31/2014 Added the new payer Heritage Physician Network (Houston) 10918 07/31/2014 Added the new payer Humana CareSource (KY) 10920 07/31/2014 Added the new payer Health Net National 10385 07/31/2014 Added the new payer Health Plan of San Mateo 10362 07/31/2014 Added the new payer IBEW Local 508 Health Plan 10885 07/31/2014 Added the new payer Operating Engineers Local.428 Health and Welfare 10777 07/31/2014 Added the new payer Food Employers & Bakery Confectionary Workers Benefit 10776 07/31/2014 Added the new payer Triple-S Salud (BCBS Puerto Rico) 10953 07/31/2014 Added the new payer Preferred Medicare Choice (PMC) (INMEDIATA HEALTH GROUP) 10959 07/31/2014 Added the new payer Medicare y Mucho Mas (INMEDIATA HEALTH GROUP) 10960 07/31/2014 Added the new payer Associacion De Maestros Puerto Rico 10957 07/31/2014 Added the new payer VA Health Administration Center 10956 07/31/2014 Added the new payer Advantage Health Solutions 10954 07/31/2014 Added the new payer Health s for Children with Special Needs 10584 07/31/2014 Added the new payer AFLAC 10955 07/31/2014 Added the new payer Plan de Salud Hospital Menonita 10958 07/31/2014 Added the new payer Orange County Fire Authority 10951 07/31/2014 Added the new payer Medical Card System 10952 07/31/2014 Added the new payer Peoples Health 10636 07/31/2014 Added the new payer Prestige Health Choice 10965 07/31/2014 Updated LACare 10640 to AmeriHealth Caritas Louisiana (LaCare) 10640 07/31/2014 Changed payer name from United Healthcare Plan of River Valley 00335 to United Healthcare Plan 07/31/2014 River Valley 00335 Added the new payer Western Health Advantage 10201 08/29/2014 Added the new payer AmeriHealth (DE, NJ, PA) 10974 08/29/2014 Added the new payer Partners National Health Plans of NC 10383 08/29/2014 Added the new payer Security Health Plan -10864 08/29/2014 Added the new payer Leggett & Platt 10975 08/29/2014 Deactivated payer Integral Quality Care Florida 10842 09/9/2014 Changed search options payer Meritain Health 10635 09/9/2014 Added the new payer Allegiance Benefit Plan Management 10654 09/30/2014 Added the new payer Aetna Better Health (NE) 10976 09/30/2014 Added the new payer United Healthcare SecureHorizons 10655 09/30/2014 Added the new payer EBMS 10862 09/30/2014 Added the new payer Senior Whole Health 10962 09/30/2014 Added the new payer University of Utah Health Plans 10977 10/31/2014 Added the new payer Paramount Health 10854 10/31/2014 Deactivated payers Kaiser Foundation Health Plan of Ohio 00280 10/31/2014 Updated search option 6 CareSource Health 10057 and change to CareSource Health (OH) 994 10/31/2014 Deactivated payers Windsor Medicare Extra 10576 10/31/2014 Deactivated payers FCE Benefit Administrators Inc. 10672 10/31/2014 Corrected Delta Dental data requirements. 11/12/2014 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 8
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 5010. Even if your software moves to a 5010 only platform, you can continue sending to those 4010 payers using the existing search types and 270 requirements until they complete their conversions. Enrollment and Data Collection While Xerox EDI Direct does not require enrollment of your providers with us, some payers do require special enrollment. For those payers you can work with our customer support team and they will step you through the process of getting your providers enrolled. You can contact them at egateway@xerox.com. We can provide a full list of those payers. Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 9
AARP 10431 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Subscriber S3 First Subscriber S4 Subscriber S5 Last First Subscriber S6 Last First No No No and/or 10431 = [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 270/271 5010 Payer Guide Commercial 10
Absolute Total Care 10560 Option 1 2 3 4 Subscriber Last First No No No and/or 10560 = [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 270/271 5010 Payer Guide Commercial 11
Advantage by BridgewayHealthSolutions- 10561 Option 1 2 3 Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or 10561 = [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 270/271 5010 Payer Guide Commercial 12
Advantage by Buckeye Community Health Plan-10562 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or 10562 = [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 270/271 5010 Payer Guide Commercial 13
Advantage by Managed Health s- 10563 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or 10563 = [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 270/271 5010 Payer Guide Commercial 14
Advantage by Superior Health Plan-10564 Option 1 2 3 4 Subscriber Last First No No No and/or 10564 = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth Min/Max = 11 Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 15
Advantage Health Solutions 10954 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No and/or 10954 = [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 270/271 5010 Payer Guide Commercial 16
Aetna Administrator Medicare Supplement 10891 Option 1 2 3 4 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 = 10891 = [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 270/271 5010 Payer Guide Commercial 17
Aetna AETNA Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 18
(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. W123456789-01. 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 270/271 5010 Payer Guide Commercial 19
Aetna Better Health (NE) 10976 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last First Subscriber S3 Last First No End of current month No and/or 10976 = [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 270/271 5010 Payer Guide Commercial 20
Aetna Better Health (IL) 10892 Option 1 2 3 4 Subscriber Subscriber S2 Last First 1 year No 90 Day Date Ranges Required and/or 10892 = [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 270/271 5010 Payer Guide Commercial 21
Aetna Better Health (PA) 10894 Option 1 2 3 4 Subscriber Subscriber S2 Last First 1 year No 90 Day Date Ranges Required and/or 10894 = [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 270/271 5010 Payer Guide Commercial 22
Aetna Better Health (TX) 10895 Option 1 2 3 4 Subscriber Subscriber S2 Last First 1 year No 90 Day Date Ranges Required and/or 10895 = [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 270/271 5010 Payer Guide Commercial 23
Aetna Better Health (TX) CHIP 10896 Option 1 2 3 4 Subscriber Subscriber S2 Last First 1 year No 90 Day Date Ranges Required and/or 10896 = [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 270/271 5010 Payer Guide Commercial 24
Aetna Senior Supplemental 10897 Option 1 2 3 4 Subscriber Last First Subscriber S2 SSN Subscriber S3 Last First No No No Required and/or 10897 = [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 270/271 5010 Payer Guide Commercial 25
Affinity Health Plan Medicare 10661 Option 1 2 3 4 5 Subscriber Last First Gender and/or 10661 = [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 270/271 5010 Payer Guide Commercial 26
Affinity Health Plan 10594 Option 1 2 3 4 Subscriber Subscriber S2 SSN Subscriber S3 Last First Subscriber S4 Last First No and/or 10594 = [NM108=PI]NM109 Last or Organiza tion Last First Member ID Date of Birth 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 270/271 5010 Payer Guide Commercial 27
AFLAC - 10955 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: First Dep: No No No and/or 10955 = [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 270/271 5010 Payer Guide Commercial 28
AFLAC - Medicare Supplemental -10663 Option 1 2 3 4 5 6 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 = 10663 = [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 270/271 5010 Payer Guide Commercial 29
Alan Sturm and Associates - Dental 10798 Option 1 2 3 Subscriber Last First No No No and/or 10798 [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 270/271 5010 Payer Guide Commercial 30
Allegiance Benefit Plan Management 10654 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Subscriber S3 Last First No End of current month No and/or 10654 = [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 270/271 5010 Payer Guide Commercial 31
Allied Benefit Systems 10898 Option 1 2 3 4 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 = 10898 = [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 270/271 5010 Payer Guide Commercial 32
Altus Dental 10786 Option 1 2 3 Subscriber Last First No No No and/or 10786 [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 270/271 5010 Payer Guide Commercial 33
American FamilyInsurance Group- Medicare Supplement and PPO 10487 Option 1 2 3 4 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 10487 = [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 270/271 5010 Payer Guide Commercial 34
American Medical Security (AMS) 10829 Option 1 2 3 4 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 10829 = [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 270/271 5010 Payer Guide Commercial 35
American Network Ins. Medicare Supplement 10899 Option 1 2 3 4 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 = 10899 = [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 270/271 5010 Payer Guide Commercial 36
American Postal Workers Union 00360 Option 1 2 3 4 Subscriber Last First Dependent D1 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 = 00360 = [NM108=PI]NM109 Last or Last First Gender Dependent Last First S2 S2 S2 S2 D1 D1 D1 Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 37
American Republic Insurance Company (ARIC) 00224 Option 1 2 3 4 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 00224 = [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 270/271 5010 Payer Guide Commercial 38
AmeriHealth (DE, NJ, PA) 10974 Option 1 2 3 4 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 = 10974 = [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 270/271 5010 Payer Guide Commercial 39
AmeriHealth Administrators 10416 Option 1 2 3 4 Subscriber Dependent D1 Sub: Dep: and/or 10416 = [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 270/271 5010 Payer Guide Commercial 40
AmeriHealth Caritas Louisiana (LaCare) 10640 Option 1 2 3 4 Subscriber Subscriber S2 SSN Subscriber S3 Last First Area of coverage: Louisiana Yes No No Required and/or 10640 = [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 270/271 5010 Payer Guide Commercial 41
AmeriHealth Caritas Pennsylvania 10340 Option 1 2 3 4 Subscriber Subscriber S2 SSN Subscriber S3 Last First No No No and/or 10340 = [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 270/271 5010 Payer Guide Commercial 42
Ameritas Group Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Payers Payer Payer ID Payer Payer ID Ameritas Life Insurance Co. 00425 First Ameritas of New York 00426 First Reliance Standard Life 00428 Reliance Standard Life 00427 Standard Insurance 00429 Standard Insurance of New York 00430 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 270/271 5010 Payer Guide Commercial 43
Arbor Health Plan 10641 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 SSN Area of coverage: Nebraska Yes No No and/or 10641 = [NM108=PI]NM109 Last or Last First SSN S2 S2 S3 S2 Type and/or and/or 30 Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 44
Arise Health Plan Medicare Select Policy 10868 Option 1 2 3 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or 10868 = [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 270/271 5010 Payer Guide Commercial 45
Arizona Physicians IPA (APIPA) 00322 Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 46
Associacion De Maestros Puerto Rico 10957 Option 1 2 3 4 Subscriber No No No Required and/or 10957 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 47
Assurant Health Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: No Payers Payer Payer ID Payer Payer ID John Alden Insurance Company (JALIC) 00254 Time Insurance Company (FIC) 00252 Union Security Insurance Company (FBIC) 00253 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 270/271 5010 Payer Guide Commercial 48
Asuris Northwest Health- 10529 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: 24 mos 6 weeks Yes and/or 10529 = [NM108=PI]NM109 Last or Organizatio n Last First, D1 and/or Federal Tax ID and/or Situational. No Last Type Dependent Last First, D1 30 D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 49
Aultcare- 10472 Option 1 2 3 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 10472 = [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 270/271 5010 Payer Guide Commercial 50
Automated Benefit s 10890 Option 1 2 3 4 Subscriber Dependent D1 Subscriber Member ID Dep. Last Dep. First Dep. No No No and/or 10890 = [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 270/271 5010 Payer Guide Commercial 51
Auxiant 10900 Option 1 2 3 4 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 = 10900 = [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 270/271 5010 Payer Guide Commercial 52
Avera Health Plans 10869 Option 1 2 3 4 Subscriber Subscriber S2 SSN Last Subscriber S3 Last First Group Number 1 year No No and/or 10869 = [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 270/271 5010 Payer Guide Commercial 53
AvMed Health Plans AVMED Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 54
Bankers Life and Casualty 10813 Option 1 2 3 4 Subscriber Last First Subscriber S2 Subscriber S3 Last First 1 year End of current month Yes **Note: This a Medicare Supplemental Plan and/or 10813 = [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 270/271 5010 Payer Guide Commercial 55
Banner Health Plans 10707 Option 1 2 3 4 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 = 10707 = [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 270/271 5010 Payer Guide Commercial 56
Benefit Management Inc. - 10665 Option 1 2 3 4 5 6 Subscriber Dependent D1 Subscriber Subscriber Last Subscriber Last First Gender Dep. Last Dep. First Dep. Date of Birth Dep. Gender and/or 10665 = [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 270/271 5010 Payer Guide Commercial 57
Best Choice Health Plans 00000000820 Option 1 2 3 4 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 00000000820 = [NM108=PI]NM109 Last or required. Type and/or 30 required. and/or Last First,S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 58
Better Health Plans (Unison Health Plan) 00199 Option 1 2 3 4 Subscriber Last First 1 year No Yes and/or 00199 = [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 270/271 5010 Payer Guide Commercial 59
Blue Benefit Administrators of Mass 10803 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep. Last Dep. First Dep. No No No and/or 10803 = [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 270/271 5010 Payer Guide Commercial 60
BlueChoice Health Plan South Carolina Medicaid 10504 Option 1 2 3 4 5 Subscriber Last First No No No and/or 10504 = [NM108=PI]NM109 Type and/or 30 Federal Tax ID and/or Situational. No Last Situational. No First Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 61
BMC HealthNet 10556 Option 1 2 3 4 Subscriber Subscriber S2 Last First Gender No and/or 10556 = [NM108=PI]NM109 Type and/or 30 and/or Last S2 First S2 S2 Gender S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 62
Boon Group 10821 Option 1 2 3 4 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 10821 = [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 270/271 5010 Payer Guide Commercial 63
Bravo Health 10399 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or 10399 = [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 270/271 5010 Payer Guide Commercial 64
Bridgespan 10827 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Subscriber S3 Last First Subscriber S4 Last First Subscriber S5 1 year No No and/or 10827 = [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 270/271 5010 Payer Guide Commercial 65
Bridgeway Arizona 10901 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or 10901 = [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 270/271 5010 Payer Guide Commercial 66
Brokers National - Dental - 10783 Option 1 2 3 Subscriber Last First No No No and/or 10783 [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 270/271 5010 Payer Guide Commercial 67
Buckeye Community Health 10566 Option 1 2 3 4 Subscriber Subscriber Last First Subscriber Last First No and/or 10566 = [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 270/271 5010 Payer Guide Commercial 68
Butler Benefit s, Inc. 10902 Option 1 2 3 4 Subscriber Last First Subscriber S2 SSN Subscriber S3 Last First 1 year No No Required and/or 10902 = [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 270/271 5010 Payer Guide Commercial 69
Capitol Administrators 10903 Option 1 2 3 4 Subscriber Subscriber S2 Last First 1 year No 90 Day Date Ranges and/or 10903 = [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 270/271 5010 Payer Guide Commercial 70
Capital District Physicians Health Plan 10458 Option 1 2 3 4 Subscriber Subscriber S2 Last First 1 year Yes Required and/or 10458 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Last S2 First S2,S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 71
CAPROCK 10660 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep. Last Dep. First Dep. and/or 10589 = [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 270/271 5010 Payer Guide Commercial 72
CareSource Health (OH) 994 Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 73
Care Improvement Plus 10806 Option 1 2 3 4 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 name Dep. First Dep. Dependent D2 Dep. Last name Dep. First Dep. Dep. State 18 months End of current month Yes and/or 10806 = [NM108=PI]NM109 Last or Type and/or and/or All s accepted. Situational. No Federal Tax ID Situational. No Last S2 S3,S5,S6 First S2 S3,S5,S6,S2,S3,D1 SSN S3,S4 State S5,S3,S5,S6 Dependent Dep. Last Dep. First Dep. Date of Birth D1,D2 D1,D2 D1,D2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 74
Dep. State D2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 75
CarePlus Health Plan 00324 Option 1 2 3 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 00324 = [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 270/271 5010 Payer Guide Commercial 76
CarePoint Medicare Advantage 10822 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First No No No and/or 10822 = [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 270/271 5010 Payer Guide Commercial 77
Carolina Care Plan, Inc. (CCP) 10762 Option 1 2 3 4 Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep. Last Dep. First Dep. No No No and/or 10762 = [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 270/271 5010 Payer Guide Commercial 78
CDS Group Health 10667 Option 1 2 3 4 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 = 10667 = [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 270/271 5010 Payer Guide Commercial 79
Celticare 10589 Option 1 2 3 4 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 10589 = [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 270/271 5010 Payer Guide Commercial 80
Celtic Insurance 10668 Option 1 2 3 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 10668 = [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 270/271 5010 Payer Guide Commercial 81
Cenpatico Option 1 2 3 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Payers Payer Payer ID Payer Payer ID Cenpatico- Arizona 10567 Cenpatico- Massachusetts 10588 Cenpatico Behavioral Health 10766 Cenpatico - Mississippi 10769 Cenpatico Behavioral Health Texas 10767 Cenpatico - Missouri 10768 Cenpatico- Florida 10568 Cenpatico - New Hampshire 10770 Cenpatico - Georgia 10569 Cenpatico- Ohio 10572 Cenpatico- Illinois 10631 Cenpatico- South Carolina 10573 Cenpatico- Indiana Cenpatico- Kansas Cenpatico- Kentucky 10570 Cenpatico- Texas 10633 10571 Cenpatico- Wisconsin 10634 10632 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 270/271 5010 Payer Guide Commercial 82
,S3 S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 83
Centene Health Plans Option 1 2 3 4 5 Subscriber Last First No No No Payers Payer Payer ID Payer Payer ID Centene - Advantage by Peach State 10763 Centene-Kentucky Spirit Health Plan 10620 Centene - Advantage by Sunshine State 10764 Centene-Louisiana Healthcare Connections 10756 Centene Advantage Plans 10771 Centene-Magnolia Health Plan 10704 Centene-Coordinated Care 10761 Centene-Peach State Health Plan 10590 Centene-California Health & Wellness 10759 Centene-Sunflower State Health (Kansas) 10758 Centene - Granite State Health Plan 10765 Centene-Sunshine State Health Plan 10451 Centene-Home State Health Plan 10760 Centene-Total Care Carolina 10866 Centene- IlliniCare Health Plan 10757 and/or See above table = [NM108=PI]NM109 Type and/or 30 Federal Tax ID and/or Situational. No Last Situational. No First Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 84
CenterLight Healthcare 10666 Option 1 2 3 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First Required and/or 10666 = [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 270/271 5010 Payer Guide Commercial 85
Central California Alliance for Health 10884 Option 1 2 3 4 Subscriber Last First No No No and/or 10884 = [NM108=PI]NM109 Type and/or 30 Federal Tax ID and/or Situational. No Last Situational. No First Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 86
Central Reserve Life Insurance Company- 10450 Option 1 2 3 Subscriber Subscriber S2 Last First Subscriber S3 Last First Required and/or 10450 = [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 270/271 5010 Payer Guide Commercial 87
Central Senior Care 10904 Option 1 2 3 4 Subscriber Last First Up to 3 Years in Past No Yes and/or 10904 = [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 270/271 5010 Payer Guide Commercial 88
Central States Indemnity 10744 Option 1 2 3 4 Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan and/or 10744 = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 89
CHAMPVA/Spina Bifida/Children of Women Vietnam Vets - 00232 Option 1 2 3 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 00232 = [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 270/271 5010 Payer Guide Commercial 90
Children's Mercy PCN 10906 Option 1 2 3 4 Subscriber Subscriber S2 SSN Subscriber S3 Last First No No No Required and/or 10906 = [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 270/271 5010 Payer Guide Commercial 91
CHP Direct 10907 Option 1 2 3 4 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 10907 = [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 270/271 5010 Payer Guide Commercial 92
Christian Brothers s 10908 Option 1 2 3 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 10908 = [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 270/271 5010 Payer Guide Commercial 93
Cigna-GWH - 00001 Option 1 2 3 4 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 00001 = [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 270/271 5010 Payer Guide Commercial 94
CMFG Life Insurance 10909 Option 1 2 3 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 10909 = [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 3) 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 270/271 5010 Payer Guide Commercial 95
Colonial Penn Life 10852 Option 1 2 3 4 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 10852 = [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 270/271 5010 Payer Guide Commercial 96
Colorado Access- 0000002356 Option 1 2 3 4 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 00000002356 = [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,S5,S2,S4,S5,S4,S5 30 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 97
Commerce Benefits Group 10910 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No and/or 10910 = [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 270/271 5010 Payer Guide Commercial 98
Community Health Plan of Washington (CHPW) 2641 Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 99
ConnectiCare 10303 Option 1 2 3 4 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 10458 = [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 270/271 5010 Payer Guide Commercial 100
Consolidated Associates Railroad 10669 Option 1 2 3 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 10669 = [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 270/271 5010 Payer Guide Commercial 101
Consumers Life 10911 Option 1 2 3 4 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 10911 = [NM108=PI]NM109 Last or Type and/or and/or 4) 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 270/271 5010 Payer Guide Commercial 102
Continental General Insurance Company- 10454 Option 1 2 3 4 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 10454 = [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 270/271 5010 Payer Guide Commercial 103
Cooperative Benefits Administrators 00223 Option 1 2 3 4 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 00223 = [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 270/271 5010 Payer Guide Commercial 104
Cook Children s Health Plan- 10610 Option 1 2 3 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 10610 = [NM108=PI]NM109 Last or Required. No Last First SSN Required. No S2,S3 S2 S2 S3 Type 30 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 105
CoreSource Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Payers Payer Payer ID Payer Payer ID FMH 00204 Little Rock 00205 MD/PA/IL/NC/IN/AZ/MN 00236 Ohio 00239 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 270/271 5010 Payer Guide Commercial 106
Country Cupboard 10912 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No and/or 10912 = [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 270/271 5010 Payer Guide Commercial 107
Country Life Insurance Company 10670 Option 1 2 3 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 10670 = [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 270/271 5010 Payer Guide Commercial 108
Covenant Administrators (TPA) 10880 Option 1 2 3 4 Subscriber Last First Subscriber S2 Subscriber S3 Last First Subscriber S4 Last Subscriber S5 Last First 1 year No No and/or 10880 = [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 270/271 5010 Payer Guide Commercial 109
Coventry Healthcare Option 1 2 3 4 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) 10447 Healthcare USA(HCUSA) 00186 Altius Health Plans 00364 Iowa 00170 Advantra Freedom 10307 Kansas 10208 Coventry Health &Life Nevada 10448 Louisiana 00158 Coventry Health and Life (Oklahoma) 00441 Missouri 10449 Coventry HealthCare Carelink (Advantra) 00160 Nebraska 00176 Coventry Health Care Carelink Medicaid 00182 OmniCare (Michigan) 00284 Coventry Health Care Carenet 00190 PersonalCare/Coventry Health of Illinois 00179 Delaware 00166 Southern Health s (SHS) 00156 Diamond Plan (Maryland Medicaid) 00177 WellPath Select (Carolinas) 00164 Georgia 00154 Coventry Health and Life (Tenn) 10405 Group Health Plan (GHP) 00184 Advantra Savings 10419 HealthAmerica&HealthAssurance 00148 Mail Handlers Benefit Plan 00251 HealthCare Inc. (Promina) 00193 Coventry Healthcare National Network 10084 University of Missouri 10428 Coventry Health Care Federal 10481 CoventryOne 10440 Coventry Nebraska Medicaid 10548 Vista (MCD, FHK, LTC) 10483 CoventryCares 10614 Florida/Vista/Summit 10551 CoventryCares of Kentucky 10642 MHNet Behavioral Health 10659 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 110
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 270/271 5010 Payer Guide Commercial 111
Cox Health Plan 10838 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Frist 12 months 60 days No and/or 10838 = [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 270/271 5010 Payer Guide Commercial 112
CTI Administrators 10671 Option 1 2 3 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 10671 = [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 270/271 5010 Payer Guide Commercial 113
DeCare Dental Health Insurance - 10780 Option 1 2 3 Subscriber Last First No No No and/or 10780 [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 270/271 5010 Payer Guide Commercial 114
Definity Health 10828 Option 1 2 3 4 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 10828 = [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 270/271 5010 Payer Guide Commercial 115
Dental Benefit Providers 10787 Option 1 2 3 Subscriber Last First No No No and/or 10787 [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 270/271 5010 Payer Guide Commercial 116
Delaware Physicians Care 10913 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No and/or 10913 = [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 270/271 5010 Payer Guide Commercial 117
Delta Dental Option 1 2 3 4 Subscriber Last First No No No Payers Payer Payer ID Payer Payer ID 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 Colorado 10718 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 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 270/271 5010 Payer Guide Commercial 118
Denver Health Medical Plan- 0000001321 Option 1 2 3 4 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 00000001321 = [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 270/271 5010 Payer Guide Commercial 119
Deseret Mutual (DMBA) 10578 Option 1 2 3 4 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 10578 = [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 270/271 5010 Payer Guide Commercial 120
Director's Guild 10077 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last First Dependent D1 Sub: Dep. Last Dep. Dependent D2 Sub: Dep. No No No and/or 10077 = [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 270/271 5010 Payer Guide Commercial 121
EBMS 10862 Option 1 2 3 4 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 = 10862 = [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 270/271 5010 Payer Guide Commercial 122
Employee Benefit s - Dental 10784 Option 1 2 3 Subscriber Last First No No No and/or 10784 [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 270/271 5010 Payer Guide Commercial 123
EPIC Life Insurance 10914 Option 1 2 3 4 Subscriber Last First No No No and/or 10914 = [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 270/271 5010 Payer Guide Commercial 124
EssenceHealthcare- 10601 Option 1 2 3 4 Subscriber Last First Subscriber S2 Subscriber S3 Last First Required and/or 10601 = [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 270/271 5010 Payer Guide Commercial 125
Evangelical Community Hospital 10915 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No and/or 10915 = [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 270/271 5010 Payer Guide Commercial 126
Evercare 10807 Option 1 2 3 4 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 10807 = [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 270/271 5010 Payer Guide Commercial 127
Everence Financial 10772 Option 1 2 3 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 10772 = [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 270/271 5010 Payer Guide Commercial 128
Evergreen Health Co-Op 10860 Option 1 2 3 4 Subscriber Last First Subscriber Member Subscriber Last Subscriber First Dependent D1 Dep. ID No No No and/or 10860 = [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 270/271 5010 Payer Guide Commercial 129
Family Care- 10427 Option 1 2 3 4 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 10427 = [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 270/271 5010 Payer Guide Commercial 130
Federated Insurance Company- 00262 Option 1 2 3 4 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 00262 = [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 270/271 5010 Payer Guide Commercial 131
Fidelis Care New York 10459 Option 1 2 3 4 Subscriber Last First Subscriber S2 Subscriber S3 SSN Subscriber S4 SSN Last First Subscriber S5 Last First No No No and/or 10459 = [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 270/271 5010 Payer Guide Commercial 132
Fidelis SecureCare of Michigan 10859 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or 10859 = [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 270/271 5010 Payer Guide Commercial 133
FirstCare 10870 Option 1 2 3 4 Subscriber Last First Subscriber S2 Subscriber S3 Last First Subscriber S4 Last Subscriber S5 Last First 1 year No No and/or 10870 = [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 270/271 5010 Payer Guide Commercial 134
First Medical Network 10916 Option 1 2 3 4 Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Dependent D2 Dep: Last Dep: First Dep: 3 years No Yes and/or 10916 = [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 270/271 5010 Payer Guide Commercial 135
Flex Compensation - Dental 10799 Option 1 2 3 Subscriber Last First No No No and/or 10799 [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 270/271 5010 Payer Guide Commercial 136
Florida Combined Life Dental 10811 Option 1 2 3 4 Subscriber Last First No No No and/or 10811 [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 270/271 5010 Payer Guide Commercial 137
Florida Health Care Plans- 10615 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: 24 mos 12 mos No and/or 10615 = [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 270/271 5010 Payer Guide Commercial 138
Florida Hospital Healthcare System- 10333 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First 1 year No 90 days and/or 10333 = [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 270/271 5010 Payer Guide Commercial 139
Florida True Health 10839 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 SSN Past Date allowed: unrestricted 60 days No and/or 10839 = [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 270/271 5010 Payer Guide Commercial 140
Food Employers & Bakery Confectionary Workers Benefit 10776 Option 1 2 3 4 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 = 10776 = [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 270/271 5010 Payer Guide Commercial 141
Freedom Blue- 10502 Option 1 2 3 4 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 10502 = [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 270/271 5010 Payer Guide Commercial 142
Fresenius Medical Care 10602 Option 1 2 3 4 Subscriber Last First and/or 10602 = [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 270/271 5010 Payer Guide Commercial 143
Gateway Health Plan 10629 Option 1 2 3 4 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 10629 = [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 270/271 5010 Payer Guide Commercial 144
Geisinger Health Plan 10611 Option 1 2 3 4 Subscriber Subscriber S2 Last First Note: Lines of business: Pennsylvania/Commercial. 1 year No Required and/or 10611 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Min/Max=12 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 145
Geisinger Health Plan Gold 10612 Option 1 2 3 4 Subscriber Subscriber S2 Last First Note: Lines of business: Pennsylvania/Medicare. 1 year No Required and/or 10612 = [NM108=PI]NM109 Last or Required. No Required. No Optional Type and/or 30 Min/Max=12 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 146
Generations Healthcare 10603 Option 1 2 3 4 Subscriber Last First and/or 10603 = [NM108=PI]NM109 Last or R and/or Type 23, 24, 25, 26, 27, 28, 35, 36, 37, 38, 39, 40, 41, 88, 89, 90, 91, 92 First and/or Required is entity is a person Last First R Min/Max=12 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 147
Gerber Life Insurance* 10745 Option 1 2 3 4 Subscriber Last First No No No and/or 10745 = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 148
GHI - Group Health Incorporated 10808 Option 1 2 3 4 Subscriber Last First and/or 10808 = [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 270/271 5010 Payer Guide Commercial 149
Gilsbar- 10509 Option 1 2 3 4 Subscriber Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: First Required and/or 10509 = [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 270/271 5010 Payer Guide Commercial 150
Great American Life Insurance Co Medicare Supplement- 10543 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or 10543 = [NM108=PI]NM109 Last or Required. No Optional Type Required. No Federal Tax ID Optional and/or 30, S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 151
Group Health Cooperative- 10608 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required and/or 10608 = [NM108=PI]NM109 Last or Required. No Required. No Last First Type, D1 30 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 152
Group Health Cooperative of South Central Wisconsin - Dental 10781 Option 1 2 3 Subscriber Last First No No No and/or 10781 [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 270/271 5010 Payer Guide Commercial 153
Guardian Life Insurance Co. of America Dental 10788 Option 1 2 3 Subscriber Last First No No No and/or 10788 [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 270/271 5010 Payer Guide Commercial 154
Harmony Health Plan - 10514 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last First Subscriber S3 1 Year No No Required and/or 10514 = [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 270/271 5010 Payer Guide Commercial 155
Hawaii Medical Assurance Association Dental 10785 Option 1 2 3 Subscriber Last First No No No and/or 10785 [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 270/271 5010 Payer Guide Commercial 156
Health Alliance Medical Plan (IL) 10871 Option 1 2 3 Subscriber Subscriber S2 Subscriber S3 SSN Subscriber S4 Last First 2 years No No and/or 10871 = [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 270/271 5010 Payer Guide Commercial 157
Health Alliance Medical Plans (HAP) 00000002077 Option 1 2 3 4 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 00000002077 = [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 270/271 5010 Payer Guide Commercial 158
Health Choice Arizona 00329 Option 1 2 3 4 Subscriber Subscriber S2 Last First 1 year No No and/or 00329 = [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 270/271 5010 Payer Guide Commercial 159
Health First Health Plan 10673 Option 1 2 3 4 5 6 Subscriber Dependent D1 Subscriber Subscriber Last Subscriber Last First Gender Dep. Last Dep. First Dep. Date of Birth Dep. Gender and/or 10673 = [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 270/271 5010 Payer Guide Commercial 160
Health First New Jersey 10438 Option 1 2 3 4 Subscriber Last First and/or 10438 = [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 270/271 5010 Payer Guide Commercial 161
Health First New York 00240 Option 1 2 3 4 Subscriber Last First and/or 00240 = [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 270/271 5010 Payer Guide Commercial 162
Health Net National 10385 Option 1 2 3 4 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 11-12 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 7/1/2013 1 year End of current month Yes Required and/or 10385 = [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 270/271 5010 Payer Guide Commercial 163
Health New England 10627 Option 1 2 3 4 Subscriber Subscriber S2 Last First and/or 10627 = [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 270/271 5010 Payer Guide Commercial 164
Health Partners (Minnesota) 10484 Option 1 2 3 4 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 10484 = [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 270/271 5010 Payer Guide Commercial 165
Health Partners Philadelphia 00288 Option 1 2 3 4 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 00288 = [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 270/271 5010 Payer Guide Commercial 166
Health Plan of San Mateo 10362 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year 60 days 60 days Required Optional and/or and/or 10362 = [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 270/271 5010 Payer Guide Commercial 167
Health Share of Oregon 10823 Option 1 2 3 4 Subscriber Subscriber S2 Last Subscriber S3 Last First Subscriber S4 Last No No No and/or 10823 = [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 270/271 5010 Payer Guide Commercial 168
Health s for Children with Special Needs 10584 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 SSN No No No and/or 10584 = [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 270/271 5010 Payer Guide Commercial 169
Healthcare Solutions Group 10463 Option 1 2 3 4 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 10463 = [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 270/271 5010 Payer Guide Commercial 170
HealthEase 10510 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year No No Required and/or 10510 = [NM108=PI]NM109 Optional Type and/or 30 Last First Required. No,S2,S2,S3 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 171
HealthEase Kids 10511 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year No No Required and/or 10511 = [NM108=PI]NM109 Optional Type and/or 30 Last First Required. No,S2,S2,S3 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 172
Healthgram 10917 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or 10917 = [NM108=XX]NM109 Optional Type and/or 30 Last First Required. No S2,S3 S2,S3,S2 Min/Max=12 S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 173
HealthMarkets Option 1 2 3 4 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 00207 Mid-West National Life 00206 TransAmerica Life 00208 Mega Life and Health Insurance 00248 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 270/271 5010 Payer Guide Commercial 174
Last First D2,D3,D4 D2,D3,D4 D1,D3,D4 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 175
HealthPlan of Nevada 10804 Option 1 2 3 4 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 10807 = [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 270/271 5010 Payer Guide Commercial 176
HealthPlans Inc. 10802 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or 10802 = [NM108=PI]NM109 Optional Type and/or 30 Last First Required. No,S2,S2,S2 Min/Max=12 S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 177
HealthPlus of Michigan 1311 Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 178
HealthScope (Morris Assoc, Central Benefits, Employer s Health, Plan Handlers) 10621 Option 1 2 3 4 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 10621 = [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 270/271 5010 Payer Guide Commercial 179
Healthsource Provident - Dental 10789 Option 1 2 3 Subscriber Last First No No No and/or 10789 [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 270/271 5010 Payer Guide Commercial 180
HealthSpring 10464 Option 1 2 3 4 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 10464 = [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 270/271 5010 Payer Guide Commercial 181
Healthy Texas 10824 Option 1 2 3 4 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 10821 = [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 270/271 5010 Payer Guide Commercial 182
Heritage Physician Network (Houston) 10918 Option 1 2 3 4 Subscriber Last First 3 years No 5) 90 day Date Ranges and/or 10918 = [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 270/271 5010 Payer Guide Commercial 183
Hershey Healthsmile - Dental 107935 Option 1 2 3 Subscriber Last First No No No and/or 10795 [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 270/271 5010 Payer Guide Commercial 184
HIPNY 10406 Option 1 2 3 4 Subscriber Last First No No No and/or 10406 = [NM108=PI]NM109 Type and/or 30 Federal Tax ID and/or Situational. No Last Situational. No First Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 185
Horizon NJ Health 2840 Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 186
Humana 00041 Option 1 2 3 4 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 00041 = [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 270/271 5010 Payer Guide Commercial 187
Humana CareSource (KY) 10920 Option 1 2 3 4 Subscriber Subscriber S2 Last First 1 year Up to end of current month Yes and/or 10920 = [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 270/271 5010 Payer Guide Commercial 188
IBM Insurance Outsourcing s 10861 Option 1 2 3 4 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 10861 = [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 270/271 5010 Payer Guide Commercial 189
IBEW Local 508 Health Plan 10885 Option 1 2 3 4 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 = 10885 = [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 270/271 5010 Payer Guide Commercial 190
Ideal Life Insurance 10747 Option 1 2 3 4 Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan and/or 10747 = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 191
Independence Administrators 10417 Option 1 2 3 4 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 10417 = [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 270/271 5010 Payer Guide Commercial 192
Island Home Insurance 10675 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No and/or 00000002613 = [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 270/271 5010 Payer Guide Commercial 193
John Hopkins Health Plan 00000002613 Option 1 2 3 4 Subscriber 1 year 1 year No Note: Employee Health Plan This connection does not support members whose ID start with U. and/or 00000002613 = [NM108=PI]NM109 Last or Min/Max=12 Type and/or and/or 30 Situational. No Provider ID Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 194
Kaiser Foundation Health Plan of Colorado 00277 Option 1 2 3 4 Subscriber Last First Subscriber S2 SSN Last First Subscriber S3 Last First Gender No No No Required and/or 00277 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Federal Tax ID Last First SSN Gender Required. No Required. No,S2,S3,S2,S3 Min/Max=12 S2 S3,S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 195
Kaiser Foundation Health Plan of Hawaii 00278 Option 1 2 3 4 Subscriber Last First Subscriber S2 SSN Last First Subscriber S3 Last First Gender No Required and/or 00278 = [NM108=PI]NM109 Optional Type and/or 30 Federal Tax ID Last First SSN Gender Required. No Required. No,S2,S3,S2,S3 Min/Max=12 S2 S3,S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 196
Kaiser Foundation Health Plan of Hawaii (DHMO Choice) 10676 Option 1 2 3 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 Required and/or 10676 = [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 30 D2,D3 D2,D3 D1,D3 30 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 197
Kaiser Foundation Health Plan of the Mid Atlantic 00276 Option 1 2 3 4 Subscriber Subscriber S3 Last First No Required and/or 00276 = [NM108=PI]NM109 Optional Type and/or 30 Federal Tax ID Last First SSN Required. No Required. No S3 S3 Min/Max=12 S2 S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 198
Kaiser Foundation Health Plan of the Northwest 00279 Option 1 2 3 4 Subscriber Last First Subscriber S2 SSN Last First Subscriber S3 Last First Gender No Required and/or 00279 = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Last First SSN Gender Required. No,S2,S3,S2,S3 Min/Max=12 S2 S3,S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 199
Kaiser Permanente of Georgia 00281 Option 1 2 3 4 Subscriber Subscriber S2 Last First No Required and/or 00281 = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Last First SSN Gender Required. No,S2,S3,S2,S3 Min/Max=12 S2 S3,S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 200
Kaiser Permanente of Northern CA 00282 Option 1 2 3 4 Subscriber Subscriber S2 SSN Subscriber S3 Last First No Required and/or 00282 = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Last First SSN Required. No S3 S3 Min/Max=12 S2 S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 201
Kaiser Permanente of Southern CA 00283 Option 1 2 3 4 Subscriber Subscriber S2 SSN Subscriber S3 Last First No Required and/or 00283 = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Last First SSN Required. No S3 S3 Min/Max=12 S2 S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 202
Kentucky Health Exchange 10857 Option 1 2 3 4 Subscriber Last First Dependent D1 Subscriber Member ID Dep Last Dep. First Dep. No No No and/or 10857 = [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 270/271 5010 Payer Guide Commercial 203
Keystone Mercy Health 2232 Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 204
Kitsap Physician s 2644 Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 205
KSKJ Life 10748 Option 1 2 3 4 Subscriber Last First Np No No *Note: This is a Medicare Supplemental Plan and/or 10748 = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 206
Leggett & Platt 10975 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 SSN 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 = 10975 = [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 270/271 5010 Payer Guide Commercial 207
Leon Medical Centers Health Plan 10677 Option 1 2 3 4 5 Subscriber Last First Gender Required and/or 10640 = [NM108=PI]NM109 Last or Required. No Required. No Optional Type and/or 30 Last First Gender Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 208
Lifewise Arizona 10843 Option 1 2 3 4 Subscriber Last First and/or 10820 = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 209
Lincoln Financial 10678 Option 1 2 3 4 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 = 10678 = [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 270/271 5010 Payer Guide Commercial 210
Lincoln Heritage 10749 Option 1 2 3 4 Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan Optional Situational Required and/or and/or and/or 10749 = [NM108=PI]NM109 Type 30 Federal Tax ID Situational. No Last or Last First Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 211
Loomis Company 10755 Option 1 2 3 4 Subscriber Last First Dependent D1 Subscriber Subscriber Last Dep. First Dep. No No No and/or 10775 = [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 270/271 5010 Payer Guide Commercial 212
Louisiana Health Exchange 10830 Option 1 2 3 4 Subscriber Last First Subscriber Member Subscriber Last Subscriber First Dependent D1 Dep. ID No No No and/or 10830 = [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 270/271 5010 Payer Guide Commercial 213
Magellan Behavioral Health 10649 Option 1 2 3 4 Subscriber Last First Subscriber Member Subscriber Last Subscriber First Dependent D1 Dep. Last ID Option (cont.) 5 6 Dependent D1 Dep. First Dep. No No No and/or 10649 = [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 270/271 5010 Payer Guide Commercial 214
Magnacare 10867 Option 1 2 3 4 Subscriber Last First Subscriber S2 SSN Last First No No No Required and/or 10867 = [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 270/271 5010 Payer Guide Commercial 215
MAMSI Health Plan MAMSI Option 1 2 3 4 Subscriber Subscriber S2 SSN 1 Year No No and/or MAMSI = [NM108=PI]NM109 SSN Min=2 Max=20 S2 Min/Max=9 Type and/or 30 Min=1 Max=2 Last or Organizatio n and/or Situational. No Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 216
Managed Care of America 10885 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First 1 year No No and/or 10885 = [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 270/271 5010 Payer Guide Commercial 217
Managed Health s Wisconsin 10587 Option 1 2 3 Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or 10587 = [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 270/271 5010 Payer Guide Commercial 218
MAPFRE Medicare Excel 10680 Option 1 2 3 4 Subscriber Required and/or 10680 = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Type Required. No Min/Max=12 30 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 219
MAPFRE Life Puerto Rico 10679 Option 1 2 3 4 Subscriber No No No Required and/or 10679 = [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 270/271 5010 Payer Guide Commercial 220
Maricopa Health Plan Arizona 10434 Option 1 2 3 4 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 10434 = [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 270/271 5010 Payer Guide Commercial 221
MDWise Hoosier Alliance -10598 Option 1 2 3 4 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 10598 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,S4 6 12 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 270/271 5010 Payer Guide Commercial 222
MedBen - Newark OH 10681 Option 1 2 3 4 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 = 10681 = [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 270/271 5010 Payer Guide Commercial 223
MedCost Benefit s -10272 Option 1 2 3 4 Subscriber Last First Subscriber Dependent Last Dependent Date of Dependent D1 Dependent First Birth and/or 10272 = [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 270/271 5010 Payer Guide Commercial 224
Medica 00404 Option 1 2 3 4 Subscriber Subscriber S2 SSN Subscriber S3 Last First Subscriber S4 Last First State Dependent D1 Sub: Sub: Group Number Dep: First Dep: Last Option 5 Dep: Dependent D2 Dep: Last Dep: First Dep: Dep: State 1 year No No and/or 00404 = [NM108=PI]NM109 Last or Federal Tax ID Type and/or 30 Provider ID and/or Situational. No Situational. No Last First SSN Group Number S3,S4 S3,S4,S3,D1 Min=10 Max=12 S2 D1 Min=1 Max=17,S2,S4 CCYYMMDD Dependent Last First D1,D2 D1,D2 D1,D2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 225
Medical Associates Health Plan/Health Choices 10683 Option 1 2 3 4 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 10683 = [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 270/271 5010 Payer Guide Commercial 226
Medical Card System 10952 Option 1 2 3 4 Subscriber No No No Required and/or 10952 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 227
Medical Mutual of Ohio 00211 Option 1 2 3 4 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 00211 = [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 270/271 5010 Payer Guide Commercial 228
Medicare CMS Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 229
Medicare y Mucho Mas (INMEDIATA HEALTH GROUP) 10960 Option 1 2 3 4 Subscriber No No No Required and/or 10960 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 230
Med-Pay, Inc. 10682 Option 1 2 3 4 Subscriber Last First No No No Required and/or 10682 = [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 270/271 5010 Payer Guide Commercial 231
MedStar Family Choice 10844 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First Subscriber S6 SSN Last and/or 10844 = [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 270/271 5010 Payer Guide Commercial 232
MedStar Health Plan 10845 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last and/or 10845 = [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 270/271 5010 Payer Guide Commercial 233
Mercy Health Care Plan 10465 Option 1 2 3 4 Subscriber Last First Option 5 Subscriber S2 Gender SSN Required and/or 10465 = [NM108=PI]NM109 Last or Required. No Required. No Optional Type and/or 30 Last First SSN Min=10 Max=12 S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 234
Meritain Health 10635 Option 1 2 3 4 Subscriber Last Subscriber S2 Last First Dependent D1 Subscriber Dep. Last Dep. Dependent D2 Subscriber Dep. Last Dep. First Required and/or 10635 = [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 270/271 5010 Payer Guide Commercial 235
Michigan MI Child 10138 Option 1 2 3 4 Subscriber Subscriber S2 SSN Subscriber S3 SSN Last First Subscriber S4 Last First 1 year End of the current month Yes and/or 10138 = [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 270/271 5010 Payer Guide Commercial 236
Mississippi State Employees and Teachers 10142 Option 1 2 3 4 Subscriber Dependent D1 Subscriber Subscriber Last Subscriber Last First Dep. Last Dep. First Dep. Date of Birth and/or 10142 = [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 270/271 5010 Payer Guide Commercial 237
Missouri Care 10702 Option 1 2 3 4 Subscriber Last First Subscriber Subscriber S2 Last First Subscriber S3 Subscriber and/or 10702 = [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 270/271 5010 Payer Guide Commercial 238
MMSI (Mayo Health) 10144 Option 1 2 3 4 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 10144 = [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 270/271 5010 Payer Guide Commercial 239
Molina Healthcare Option 1 2 3 4 Subscriber Subscriber S2 Last First 1 year No No Payers Payer Payer ID Payer Payer ID Molina Healthcare of California 00222 Molina Healthcare of Ohio 00445 Molina Healthcare of Florida 10445 Molina Healthcare of South Carolina 10815 Molina Healthcare of Illinois 10685 Molina Healthcare of Texas 10391 Molina Healthcare of Michigan 00226 Molina Healthcare of Utah 00227 Molina Healthcare of Missouri 10523 Molina HealthCare of Washington 10253 Molina Healthcare of New Mexico 10146 Molina Healthcare of Wisconsin 10628 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 270/271 5010 Payer Guide Commercial 240
Municipal Health Benefit Fund 10687 Option 1 2 3 4 Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Dependent D2 Dep: Last Dep: First Dep: No No No and/or 10687 = [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 270/271 5010 Payer Guide Commercial 241
Mutual Assurance Administrators 10872 Option 1 2 3 4 5 Subscriber Last First Gender and/or 10872 = [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 270/271 5010 Payer Guide Commercial 242
Mutual Health s 10686 Option 1 2 3 4 Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Dependent D2 Dep: Last Dep: First Dep: 18 months Current Month No and/or 10686 = [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 270/271 5010 Payer Guide Commercial 243
Mutual of Omaha 10382 Option 1 2 3 4 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 10382 = [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 270/271 5010 Payer Guide Commercial 244
National Association of Letter Carriers (NALC) 00214 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required Situational and/or and/or 00214 = [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 270/271 5010 Payer Guide Commercial 245
National Telecommunications Cooperative Association (NTCA) 10812 Option 1 2 3 4 Subscriber Last First Subscriber S2 SSN Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required Situational and/or and/or 10812 = [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 270/271 5010 Payer Guide Commercial 246
NEHEN Harvard Pilgrim Health Care 10376 Option 1 2 3 4 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 10376 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:,s2 1 11 AN NM103 [NM108= XX] NM109 [NM108= MI] NM109 Last S2,S3 1 60 AN NM103 First S2,S3 1 35 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 270/271 5010 Payer Guide Commercial 247
NEHEN Harvard Pilgrim Health Care 00000002393 Option 1 2 3 4 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 00000002393 = [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 270/271 5010 Payer Guide Commercial 248
NEHEN- Neighborhood Health Plans- 00000002395 Option 1 2 3 4 Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Last Dep: First Required and/or 00000002395 = [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 270/271 5010 Payer Guide Commercial 249
Neighborhood Health Plan (RI) 10630 Option 1 2 3 4 Subscriber Subscriber S2 Last First 1 year No 60 days Required and/or 10630 = [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 270/271 5010 Payer Guide Commercial 250
Network Health 10626 Option 1 2 3 4 Subscriber Subscriber S2 Last First 1 year 1 year No Required and/or 10626 = [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 270/271 5010 Payer Guide Commercial 251
Network Health Plan of WI 10706 Option 1 2 3 4 Subscriber Subscriber S2 Last First Yes No No Required and/or 10626 = [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 270/271 5010 Payer Guide Commercial 252
NGS American 10873 Option 1 2 3 4 5 Subscriber Last First Gender 2 years No No and/or 10873 = [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 270/271 5010 Payer Guide Commercial 253
North Carolina Medicaid 10156 Option 1 2 3 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 10156 = [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 270/271 5010 Payer Guide Commercial 254
Nova Healthcare Administrators 10537 Option 1 2 3 4 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 10537 = [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 270/271 5010 Payer Guide Commercial 255
Ohana 10515 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year No No Required and/or 10515 = [NM108=PI]NM109 indicated. Optional Type and/or 30 Last First,S2,S2,S3 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 256
Operating Engineers Local.428 Health and Welfare 10777 Option 1 2 3 4 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 = 10777 = [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 270/271 5010 Payer Guide Commercial 257
Optima/Sentara 10477 Option 1 2 3 4 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 10477 = [NM108=PI]NM109 indicated. Optional Type and/or 30 Last First SSN Min/Max=12 S3 S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 258
Orange County Fire Authority 10951 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or 10951 = [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 270/271 5010 Payer Guide Commercial 259
Oscar (NY) 10881 Option 1 2 3 4 Subscriber Last First Subscriber S2 Subscriber S3 Last First Subscriber S4 Last Subscriber S5 Last First 1 year No No and/or 10881 = [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 270/271 5010 Payer Guide Commercial 260
Oxford Health Plans 00016 Option 1 2 3 4 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 00016 = [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 270/271 5010 Payer Guide Commercial 261
Pacific Source Health Plan 2597 Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 262
Panamerican Life Puerto Rico 10689 Option 1 2 3 Subscriber No No No and/or 10689 = [NM108=PI]NM109 Last or Type and/or and/or Full code set Provider ID Min/Max=7 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 263
Paramount Health 10854 Option 1 2 3 4 Subscriber Last First 1 year No No and/or 10854 = [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 270/271 5010 Payer Guide Commercial 264
Parkland Community Health Plan 10643 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last First No No yes Required and/or 10643 = [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 270/271 5010 Payer Guide Commercial 265
Partners National Health Plans of NC 10383 Option 1 2 3 4 Subscriber Last Subscriber S2 Last First Dependent D1 Sub: Dep. Last Dep. First Dep. No No No and/or 10383 = [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 270/271 5010 Payer Guide Commercial 266
Passport Health Plan 2841 Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 267
Patriot Dental - 10782 Option 1 2 3 Subscriber Last First No No No and/or 10782 [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 270/271 5010 Payer Guide Commercial 268
Peoples Health 10636 Option 1 2 3 4 5 Subscriber Last First and/or 10636 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 269
Physicians Health Plan Northern IN (PHPNI)-10658 Option 1 2 3 4 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 10658 = [NM108=PI]NM109 Last or indicated. indicated. Optional Type and/or 30 Last First Min/Max=12 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 270
Physicians Mutual Insurance Company 00287 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required and/or 00287 = [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 270/271 5010 Payer Guide Commercial 271
Piedmont (GA) 10882 Option 1 2 3 4 Subscriber Last First Subscriber S2 Subscriber S3 Last First Subscriber S4 Last Subscriber S5 Last First 1 year No No and/or 10882 = [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 270/271 5010 Payer Guide Commercial 272
Piedmont Wellstar HealthPlans 10825 Option 1 2 3 4 Subscriber Last First Subscriber S2 and/or 10825 = [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 270/271 5010 Payer Guide Commercial 273
Plan de Salud Hospital Menonita 10958 Option 1 2 3 4 Subscriber Group Number No No No Required and/or 10958 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Group Number Required. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 274
Planned Administrators Inc. 10886 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First 1 year No No and/or 10886 = [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 270/271 5010 Payer Guide Commercial 275
Preferred Care Partners 10691 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or s and Values = 10691 = [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 270/271 5010 Payer Guide Commercial 276
Preferred Health System of Kansas 10847 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 SSN No No No and/or 10847 = [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 270/271 5010 Payer Guide Commercial 277
Preferred Medicare Choice (PMC) (INMEDIATA HEALTH GROUP) 10959 Option 1 2 3 4 Subscriber Subscriber S2 No No No Required and/or 10959 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No.S2 S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 278
Preferred One 00371 Option 1 2 3 4 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 00371 = [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 270/271 5010 Payer Guide Commercial 279
Premier Health 10848 Option 1 2 3 4 Subscriber Last First Subscriber S2 No No No and/or 10848 = [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 270/271 5010 Payer Guide Commercial 280
Presbyterian Health Plan 10646 Option 1 2 3 4 Subscriber Last First No No No and/or 10646 = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 281
Prestige Health Choice 10965 Option 1 2 3 4 5 Subscriber Last First Yes No No and/or 10965 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 282
Primary PhysicianCare Inc. 10692 Option 1 2 3 4 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 = 10692 = [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 270/271 5010 Payer Guide Commercial 283
Principal Financial Group (Nippon Life) Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required and/or 10170 = [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 270/271 5010 Payer Guide Commercial 284
Priority Health 10490 Option 1 2 3 4 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 10490 = [NM108=PI]NM109 Last or Min=1 Max=24 Optional Type and/or 30 Last First indicated. Min/Max=12 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 285
Providence Health Plan - 2598 Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 286
Provident Preferred Network - Dental 10790 Option 1 2 3 Subscriber Last First No No No and/or 10790 [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 270/271 5010 Payer Guide Commercial 287
Puritan Life Insurance 10743 Option 1 2 3 4 Subscriber Last First *Note: This is a Medicare Supplemental Plan and/or 10743 = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 288
Qualcare - 10637 Option 1 2 3 4 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 10637 = [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 270/271 5010 Payer Guide Commercial 289
Recall Systems Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: First Dep: Yes Payers Payer Payer ID Payer Payer ID Boon Chapman Benefit Admin 10414 Professional Benefits Administrators 10242 Corporate Benefit 10411 Underwriters Safety and Claims 10246 Group and Pension Administrators 10174 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 270/271 5010 Payer Guide Commercial 290
Royal Neighbors of America 10751 Option 1 2 3 4 Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan and/or 10751 = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 291
S and S Healthcare Strategies 10875 Option 1 2 3 4 Subscriber Last First Subscriber S2 Subscriber S3 Last First Subscriber S4 Last Subscriber S5 Last First 1 year No No and/or 10875 = [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 270/271 5010 Payer Guide Commercial 292
Sanford Health Plan 10533 Option 1 2 3 4 Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required and/or 10533 = [NM108=PI]NM109 Last or indicated. Last First indicated. S2 S2,D1 Min=10 Max=12 Dependent inquiries must always include the subscriber ID ending with 02 suffix Type Dependent Last First,S2 30 D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 293
Santa Clara Family Health Plan 10876 Option 1 2 Subscriber 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 10876 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX.. Federal Tax ID Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 294
Schaller Anderson Option 1 2 3 4 Subscriber Subscriber S2 Last First 1 year No No Payers Payer Payer ID Payer Payer ID Schaller Anderson Aetna Better Health of Schaller Anderson Maryland 10816 New York Physicians Care 10693 Schaller Anderson Delaware Physicians, Inc. 10817 Schaller Anderson Mercy Care 10694 Schaller Anderson MajestaCare VA 10818 Schaller Anderson Texas CHRISTUS 10696 and/or See table above = [NM108=PI]NM109 Last or Last Either Tax ID or is required S2, S3 Type and/or 30 Federal Tax ID and/or Either Tax ID or is required First,S3 S2, S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 295
Schaller Anderson Option 1 2 3 4 Subscriber Subscriber S2 Last First 1 year No No Payers Payer Payer ID Payer Payer ID Schaller Anderson Missouri Care 10695 Schaller Anderson Parkland Community Health Plan 10643 and/or See table above = [NM108=PI]NM109 Last or Last Either Tax ID or is required S2 Type and/or 1, 30, 33, 35, 47, 48, 50, 52,86, 88, 98, A4, AL, MH, UC Federal Tax ID and/or Either Tax ID or is required First S2 S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 296
Schaller Anderson Aetna Better Health of OH 10887 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First 1 year No No and/or 10887 = [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 270/271 5010 Payer Guide Commercial 297
Schaller Anderson Texas CHRISTUS 10696 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No Required and/or 10696 = [NM108=PI]NM109 Last or indicated. Optional Type indicated. Federal Tax ID and/or 30 Optional Last First S2 S2 S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 298
Scott & White Health Plan 00000002076 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First 1 Year 60 days 60 days and/or 00000002076 = [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 270/271 5010 Payer Guide Commercial 299
Secure Health Plans of Georgia 10883 Option 1 2 3 4 Subscriber Last First Subscriber S2 Subscriber S3 Last First Subscriber S4 Last Subscriber S5 Last First 1 year No No and/or 10883 = [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 270/271 5010 Payer Guide Commercial 300
Securian - Dental 10792 Option 1 2 3 Subscriber Last First No No No and/or 10792 [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 270/271 5010 Payer Guide Commercial 301
Securian/Patriot - Dental 10793 Option 1 2 3 Subscriber Last First No No No and/or 10793 [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 270/271 5010 Payer Guide Commercial 302
Security Health Plan -10864 Option 1 2 3 4 5 Subscriber Last First Gender No No No and/or s and Values = 10564 = [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 270/271 5010 Payer Guide Commercial 303
Senior Health s Center Universal American Family of Companies 10697 Option 1 2 3 4 5 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 = 10697 = [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 Dep. First Dep. D3 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 304
Senior Whole Health 10962 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First 1 year No No and/or 10962 = [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 270/271 5010 Payer Guide Commercial 305
Select Health SC 10520 Option 1 2 3 4 Subscriber Subscriber S2 SSN Subscriber S3 Last First 4 years No No Required and/or 10520 = [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 270/271 5010 Payer Guide Commercial 306
Select Health Utah 10575 Option 1 2 3 4 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 after the claim has been received in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions. Required and/or 10575 = [NM108=PI]NM109 Last or Federal Tax ID indicated. indicated. Last First Type,D1 Min=10, Max=12 2, 4, 5, 7, 12, 18, 30, 33, 35, 42, 48, 50, 52, 54, 56, 59, 69, 80, 82, 86, 88, 98, A4, AD, AE, AI, AL Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 307
Shenandoah Life Insurance 10752 Option 1 2 3 4 Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan and/or 10752 = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 308
Sierra Health s 10282 Option 1 2 3 4 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 10282 = [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 270/271 5010 Payer Guide Commercial 309
Significa 00191 Option 1 2 3 4 Subscriber Dependent D1 Sub: Dep: Yes and/or 00191 = [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 270/271 5010 Payer Guide Commercial 310
SPJST Medicare Supplement 10546 Option 1 2 3 4 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. Use Min Max Type s and Values Payer Information Source Level: 2100A Payer ID R 5 5 AN 10546 [NM108=PI] NM109 Transunion Payer ID Provider Federal Tax ID S 9 9 N S 10 10 N Subscriber Information Receiver Level: 2100B [NM108=FI] NM109 [NM108=XX] NM109 Subscriber Level: 2100C Last S2,S3 1 35 AN NM103 First S2,S3 1 25 AN NM104,S3 2 80 AN [NM108=MI] NM109 S2,S3 8 8 DT CCYYMMDD DMG02 Type O 1 2 ID 30 EQ01 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 311
Star HRG 10833 Option 1 2 3 4 Subscriber Last First Subscriber Member Subscriber Last Subscriber First Dependent D1 Dep. ID No No No and/or 10833 = [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 270/271 5010 Payer Guide Commercial 312
State Mutual Med Supp. 10750 Option 1 2 3 4 Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan and/or 10750 = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 313
Staywell 10512 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year No No Required and/or 10512 = [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 270/271 5010 Payer Guide Commercial 314
Staywell Kids 10513 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year No No Required and/or 10513 = [NM108=PI]NM109 Optional Type and/or 30 Last First indicated.,s2,s2,s3 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 315
Sterling Investors Life Insurance 10753 Option 1 2 3 4 Subscriber Last First No No No *Note: This is a Medicare Supplemental Plan and/or 10753 = [NM108=PI]NM109 Last or Last First Type and/or 30 Federal Tax ID and/or Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 316
Student Insurance 00290 Option 1 2 3 4 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 00290 = [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 270/271 5010 Payer Guide Commercial 317
SummaCare 00000002514 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First No No No Required and/or 00000002514 = [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 270/271 5010 Payer Guide Commercial 318
Superior Health Plan Texas - 10592 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First and/or 10592 = [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 270/271 5010 Payer Guide Commercial 319
TennDent 107934 Option 1 2 3 Subscriber Last First No No No and/or 10794 [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 270/271 5010 Payer Guide Commercial 320
TexanPlus North Texas Area 10604 Option 1 2 3 4 Subscriber Last First and/or 10604 = [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 270/271 5010 Payer Guide Commercial 321
TexanPlusSoutheast Texas Area 10605 Option 1 2 3 4 Subscriber Last First and/or 10605 = [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 270/271 5010 Payer Guide Commercial 322
The Kempton Company 10698 Option 1 2 3 4 5 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 = 10698 = [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 270/271 5010 Payer Guide Commercial 323
Three Rivers Health Plans 00198 Option 1 2 3 4 Subscriber Last First Yes and/or 00198 = [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 270/271 5010 Payer Guide Commercial 324
TMG Network Health Insurance 10688 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No and/or 10688 = [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 270/271 5010 Payer Guide Commercial 325
Today s Health 10606 Option 1 2 3 4 Subscriber Last First and/or 10606 = [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 270/271 5010 Payer Guide Commercial 326
Today s Option 10505 Option 1 2 3 4 Subscriber Last First and/or 10505 = [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 270/271 5010 Payer Guide Commercial 327
Total Healthcare 10805 Option 1 2 3 Subscriber Subscriber S2 Card Control Number Subscriber S3 SSN Subscriber S4 SSN Last First Subscriber S5 Last First No No No Required and/or 10805 = [NM108=PI]NM109 Optional Type indicated. SSN S3, S4 and/or 30 Last First S4, S5 S4,S5,S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 328
TRICARE for Life 10879 Option 1 2 3 4 5 Subscriber Last First Gender and/or 10879 = [NM108=PI]NM109 Last or Type and/or and/or All Situational. No Federal Tax ID Situational. No Last First Subscriber Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 329
Triple-S Salud (BCBS Puerto Rico) 10953 Option 1 2 3 4 Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Last Dep: First Dep: No No No and/or 10953 = [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 270/271 5010 Payer Guide Commercial 330
Trustmark 00233 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Required and/or 00233 = [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 270/271 5010 Payer Guide Commercial 331
Tribute/Select Care of Oklahoma 10607 Option 1 2 3 4 Subscriber Last First and/or 10607 = [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 270/271 5010 Payer Guide Commercial 332
Tricare TRICR Option 1 2 3 4 5 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 270/271 5010 Payer Guide Commercial 333
UCare of Minnesota 2596 Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 334
Ultimate Health Plans 10888 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No and/or 10888 = [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 270/271 5010 Payer Guide Commercial 335
UMR (Wausau) 10501 Option 1 2 3 4 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 10501 = [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 270/271 5010 Payer Guide Commercial 336
UNICARE - Dental 10791 Option 1 2 3 Subscriber Last First No No No and/or 10791 [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 270/271 5010 Payer Guide Commercial 337
Unicare UCARE Option 1 2 3 4 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 270/271 5010 Payer Guide Commercial 338
United Concordia (Dental) Option 1 2 3 Subscriber Last First No No No Payers Payer Payer ID Payer Payer ID United Concordia Federal Employees Program 10809 United Concordia Companies, Inc. 10810 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 270/271 5010 Payer Guide Commercial 339
United Healthcare 00112 Option 1 2 3 4 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 00112 = [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 270/271 5010 Payer Guide Commercial 340
First State D1,D2 D2 D1,D2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 341
United Healthcare Plan River Valley 00335 Option 1 2 3 4 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 00335 = [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 270/271 5010 Payer Guide Commercial 342
UnitedHealthcare Community Plan Kansas 10835 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Subscriber S3 First Subscriber S4 Subscriber S5 Last First Subscriber S6 Last First No No No and/or 10835 = [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 270/271 5010 Payer Guide Commercial 343
UnitedHealthcare Facets Detroit Community and State 10836 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Dependent D1 Sub. Dep. Last name Dep. First name Dependent D2 Sub. Dep. First Dep. and/or 10836 = [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 270/271 5010 Payer Guide Commercial 344
UnitedHealthcare Facets Pittsburgh Community and State 10834 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Dependent D1 Sub. Dep. Last name Dep. First name Dependent D2 Sub. Dep. First Dep. and/or 10834 = [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 270/271 5010 Payer Guide Commercial 345
United Healthcare SecureHorizons 10655 Option 1 2 3 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 = 10655 = [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 270/271 5010 Payer Guide Commercial 346
UnitedHealthcare Nevada Market 10837 Option 1 2 3 4 Subscriber Last First and/or 10837 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 347
Unity Health Plan 00000000780 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last 12 months 60 days 60 days Required and/or 00000000780 = [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 270/271 5010 Payer Guide Commercial 348
University Care Advantage Arizona 10699 Option 1 2 3 4 5 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 = 10699 = [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 270/271 5010 Payer Guide Commercial 349
University Family Care 00353 Option 1 2 3 Subscriber Subscriber S2 SSN Subscriber S3 SSN Last First Subscriber S4 Last First 1 Year No No and/or 10194 = [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 270/271 5010 Payer Guide Commercial 350
University of Arizona Health Plan-UHM 10889 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First 1 year No No and/or 10889 = [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 270/271 5010 Payer Guide Commercial 351
University of Utah Health Plans 10977 Option 1 2 3 4 Subscriber Last First 1 year No No and/or 10977 = [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 270/271 5010 Payer Guide Commercial 352
University Physicians Care Advantage (AZ) 10433 Option 1 2 3 4 Subscriber Subscriber S2 SSN Subscriber S3 SSN Last First Subscriber S4 Last First 1 Year No No and/or 10433 = [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 270/271 5010 Payer Guide Commercial 353
University Physicians Healthcare Group (Arizona) 10439 Option 1 2 3 Subscriber Subscriber S2 SSN Subscriber S3 SSN Last First Subscriber S4 Last First 1 Year No No and/or 10439 = [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 270/271 5010 Payer Guide Commercial 354
UPMC Health Plan (Tristate) 00000001054 Option 1 2 3 4 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 00000001054 = [NM108=PI]NM109 Last or No Optional Type and/or 30 Last First No,S2,S2 Min/Max=12,S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 355
USAA Life Insurance Company 10195 Option 1 2 3 4 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 10195 = [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 270/271 5010 Payer Guide Commercial 356
VA Fee Basis Program 00231 Option 1 2 3 4 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 00231 = [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 270/271 5010 Payer Guide Commercial 357
VA Healthcare 10850 Option 1 2 3 4 Subscriber Last First and/or 10850 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last First Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 358
VA Health Administration Center 10956 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No and/or 10956 = [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 270/271 5010 Payer Guide Commercial 359
Vantage Health Plan, Inc. 10858 Option 1 2 3 4 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 10858 = [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 270/271 5010 Payer Guide Commercial 360
VIVA Health 10468 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last First Note: Drummond Plan format is Alpha prefix + 9 digits Required and/or 10468 = [NM108=PI]NM109 Last or No Optional Type and/or 30 Last First No,S2,S2 Min/Max=12,S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 361
VYTRA 10407 Option 1 2 3 4 Subscriber Last First Required and/or 10407 = [NM108=PI]NM109 Last or No Optional Type and/or 30 Last First No Min/Max=12 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 362
Washington National 10853 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Subscriber S3 Last First 1 year End of current month No and/or 10853 = [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 270/271 5010 Payer Guide Commercial 363
Well Sense 10814 Option 1 2 3 4 Subscriber Last First Subscriber and/or 10814 = [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 270/271 5010 Payer Guide Commercial 364
Wellcare Health Plans 10488 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last First Subscriber S3 1 year No No Required and/or 10488 = [NM108=PI]NM109 Optional Type and/or 30 Last First No,S2,S2,S3 Min/Max=12,S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 365
Western Health Advantage 10201 Option 1 2 3 4 5 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 = 10201 = [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 270/271 5010 Payer Guide Commercial 366
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Wilson McShane 10797 Option 1 2 3 Subscriber Last First No No No and/or 10797 [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 270/271 5010 Payer Guide Commercial 368
World Insurance (ARIC) 10386 Option 1 2 3 4 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 10386 = [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 270/271 5010 Payer Guide Commercial 369
WPS Health Insurance 10878 Option 1 2 3 4 5 Subscriber Last First Gender and/or 10878 = [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 270/271 5010 Payer Guide Commercial 370
Zenith Administrators (MN) - Dental 10796 Option 1 2 3 Subscriber Last First No No No and/or 10796 [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 270/271 5010 Payer Guide Commercial 371
Payer Maintenance Schedule Payer AARP Absolute Total Care 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 (NE) Aetna Better Health (PA) Aetna Better Health (TX) Aetna Better Health (TX) CHIP Aetna Senior Supplemental 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 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 Medical Security (AMS) American National Insurance Company American National Life Insurance Company TX American Network Ins. Medicare Supplement American Postal Workers Union (APWU) American Republic Insurance Company (ARIC) American Retirement Life Ins Co McareSupp AmericChoice of New Jersey (Commercial) AMERIGROUP Stated Downtime Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) Sunday 4:00 am 12:00 pm (Eastern) Sunday 4:00 am 12:00 pm (Eastern) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 372
Payer 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 Arise Health Plan Medicare Select Policy Arizona Physicians IPA (APIPA) 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 (Unison Health Plans) BlueChoice Health Plan South Carolina Medicaid Bluegrass Family Health Blue Benefit Administrators of Mass BMC HealthNet Plan Boon Group Bridgespan Bravo Health Bridgestone Americas Inc. Bridgeway Arizona Brokers National - Dental Buckeye Community Health Butler Benefit s, Inc. Capitol Administrators Capital District Physicians Health Plan (CDPHP) 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 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 270/271 5010 Payer Guide Commercial 373
Payer CAPROCK 10660 Carefirst Federal Employee Program Carefirst Blue Cross Blue Shield CarePoint Medicare Advantage CareSource Health (OH) Care Improvement Plus 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) 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 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 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 374
Payer 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) CHC- CoventryCares Children's Mercy PCN Christian Brothers s CIGNA CHP Direct CMFG Life Insurance Colonial Penn Life Colorado Access Columbia United Providers Commerce Benefits Group 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) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 375
Payer 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 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 Stated Downtime Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 376
Payer 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 Essence Healthcare Evangelical Community Hospital Evercare Everence Financial Evergreen Health Co-Op Fallon Community Health Plan FamilyCare FCE Benefit Administrators Inc Federated Insurance Company Fidelis Care New York Fidelis SecureCare of Michigan FirstCare First Medical Network 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 Gerber Life Insurance* Generations Healthcare GHI - Group Health Incorporated Gilsbar Government Employees Hospital Association GEHA Great American Life Assurance Co McareSupp 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) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 377
Payer Great American Life Insurance Co McareSupp 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 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 HEALTHe Exchange HealthEase HealthEase Kids Healthfirst New Jersey Healthfirst New York Healthgram HealthMarkets (Chesapeake National Life) 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) Stated Downtime sat 8pm sun 4am (Mountain) Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) Mon 3am sun 3:15am (Central) 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) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 378
Payer Humana of Florida IBEW Local 508 Health Plan IBM Insurance Outsourcing s Ideal Life Insurance Independence Administrators Inland Empire Health Integrated Mental Health s Inter Valley Health Plan 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 Kitsap Physician s KSKJ Life Leggett & Platt Leon Medical Centers Health Plan Lifewise Arizona Lincoln Heritage Lincoln Financial 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) Stated Downtime 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 270/271 5010 Payer Guide Commercial 379
Payer Maricopa Health Plan (Arizona) MDWise Hoosier Alliance MedBen - Newark OH MedCost Benefit s Medica Medical Card System Medical Mutual of Ohio Medicare (Part A & B) Medicare y Mucho Mas (INMEDIATA HEALTH GROUP) Med-Pay, Inc MedStar Family Choice Mega Life (Oklahoma City) Mercy Care Plan (Arizona) Mercy Health Plan 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) 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 Stated Downtime 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) 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 thru fri 11pm 6am (Central) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 380
Payer NEHEN Neighborhood Health Plans NEHEN Tufts Associated Health Plan Network Health Plan of WI NGS American North Carolina Medicaid Nova Healthcare Administrators NovaSys Health Ohana Health Plan Operating Engineers Local No.428 Operating Engineers Local.428 Health and Welfare Optima/Sentara Orange County Fire Authority 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 Peoples Health Piedmont (GA) Preferred Health System of Kansas Preferred Medicare Choice (PMC) (INMEDIATA HEALTH GROUP) Premier Health Presbyterian Health Plan Phoenix Health Plan Physicians Mutual Insurance Company Piedmont Wellstar HealthPlans Pittman and Associates Plan de Salud Hospital Menonita Stated Downtime wed 9pm thur 2am (Eastern) Sun 4am 6am (Eastern) mon fri 2am 4am sat 11pm 6am (Eastern) Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 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) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 381
Payer Planned Administrators Inc. Plumbers and Pipefitters Local Union 525 Preferred Care Partners Preferred Health Systems PreferredOne Prestige Health Choice Primary PhysicianCare Inc Principal Financial Group (Nippon Life) 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 Recall Systems Boon-Chapman Benefit Admin Recall Systems Corporate Benefit Recall Systems Group & Pension Administrators Recall Systems JP Farley Corporation Recall Systems Professional Benefits Administrators Recall Systems 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 Stated Downtime 11pm- 5:45 am mon-fri 7pm 5:45 am weekends (Central) 11pm- 5:45 am mon-fri 7pm 5:45 am weekends (Central) mon sun 3am to 3:15am (Central) Sun 4:00p-5:00p, occasionally 8:00p-8:30p (EST) Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) mon sun 3am 3:15am (Central) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 382
Payer 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 Significa Benefit s Special Agents Mutual Benefit Association SPJST Medicare Supplement Standard Life and Accident Insurance Company Star HRG State Mutual Med Supp. 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 10698 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 Stated Downtime Every second weekend of the month from 1hour to 2 days. sun 11:30pm mon 4am mon 11:30pm tue 4am tue 11:30pm wed 4am wed 11:30pm thu 4am thu 11:30pm fri 4am fri 11:30pm sat 4am sat 11:30pm sun 4am sun 3pm 10pm (Eastern) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 383
Payer United Healthcare United Healthcare Plan of River Valley 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 Zenith Administrators (MN) - Dental Stated Downtime Tues - Fri: 2:00 a.m. until 5:59 a.m., 6:00pm Sat until 6:00am Mon ET Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) 2nd Friday of the month brief outage at 4am VA Health Administration Center Sun 4:00p-5:00p, occasionally 8:00p-8:30p (EST) Zenith Administrators (MN) - Dental Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 384
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