Xerox EDI Eligibility Gateway 270/271 Payer Guide Commercial Version 5010 Technical Capital Support: egateway@xerox.com Updated May 22, 2015
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Table of Contents Revision Table... 1 4010 and 5010 Compatibility... 11 Enrollment and Data Collection... 11 AARP 10431... 12 Absolute Total Care 10560... 13 ACS Benefit s - 11009... 14 Advantage by BridgewayHealthSolutions-10561... 15 Advantage by Buckeye Community Health Plan-10562... 16 Advantage by Managed Health s-10563... 17 Advantage by Superior Health Plan-10564... 18 Advantage Health Solutions 10954... 19 Aetna Administrator Medicare Supplement 10891... 20 Aetna AETNA... 21 Aetna Better Health (IL) 10892... 23 Aetna Better Health (LA) - 11008... 24 Aetna Better Health (MI) - 11026... 25 Aetna Better Health (NE) 10976... 26 Aetna Better Health (NJ) - 10994... 27 Aetna Better Health (PA) 10894... 28 Aetna Better Health (TX) 10895... 29 Aetna Better Health (TX) CHIP 10896... 30 Aetna Senior Supplemental 10897... 31 Aetna Signature Administrators 10983... 32 Affinity Health Plan Medicare 10661... 33 Affinity Health Plan 10594... 34 AFLAC - 10955... 35 AFLAC - Medicare Supplemental -10663... 36 Alan Sturm and Associates - Dental 10798... 37 All Savers Life Insurance 11027... 38 Allegiance Benefit Plan Management 10654... 39 Allied Benefit Systems 10898... 40 AlohaCare 11017... 41 Alternative Insurance Resources, Inc 11002... 42 Altus Dental 10786... 43 American FamilyInsurance Group- Medicare Supplement and PPO 10487... 44 American Income Life Insurance Company 10986... 45 American Medical Security (AMS) 10829... 46 American Network Ins. Medicare Supplement 10899... 47 American Postal Workers Union (APWU) 00360... 48 American Republic Insurance Company (ARIC) 00224... 49 AmeriBen 10985... 50 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial i
AmeriHealth (DE, NJ, PA) 10974... 51 AmeriHealth Administrators 10416... 52 AmeriHealth Caritas Louisiana (LaCare) 10640... 53 AmeriHealth Caritas Pennsylvania 10340... 54 Ameritas Group... 55 Anthem Vivity 10993... 56 Arbor Health Plan 10641... 57 Arise Health Plan Medicare Select Policy 10868... 58 Arizona Physicians IPA (APIPA) 00322... 59 ASR Health Benefits 10984... 60 Associacion De Maestros Puerto Rico 10957... 61 Assurant Health... 62 Asuris Northwest Health- 10529... 63 Aultcare- 10472... 64 Automated Benefit s 10890... 65 Auxiant 10900... 66 Avera Health Plans 10869... 67 AvMed Health Plans AVMED... 68 Bankers Life and Casualty 10813... 69 Banner Health Plans 10707... 70 Benefit Management Inc. - 10665... 71 Best Choice Health Plans 00000000820... 72 Better Health Plans of Florida 10999... 73 Better Health Plans (Unison Health Plan) 00199... 74 Blue Benefit Administrators of Mass 10803... 75 BlueChoice Health Plan South Carolina Medicaid 10504... 76 BMC HealthNet 10556... 77 Boon Chapman Benefit Admin 10414... 78 Boon Group 10821... 79 Bravo Health 10399... 80 Bridgespan 10827... 81 Bridgeway Arizona 10901... 82 Brokers National - Dental - 10783... 83 Buckeye Community Health 10566... 84 Butler Benefit s, Inc. 10902... 85 Capitol Administrators 10903... 86 Capital District Physicians Health Plan 10458... 87 CAPROCK 10660... 88 Care1st Health Plan Arizona 10981... 89 CarePlus Health Plan 00324... 90 CarePoint Medicare Advantage 10822... 91 CareSource Health (OH) 994... 92 Carolina Care Plan, Inc. (CCP) 10762... 93 CDS Group Health 10667... 94 Celticare 10589... 95 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial ii
Celtic Insurance 10668... 96 Cenpatico... 97 Centene Health Plans... 99 CenterLight Healthcare 10666... 101 Central California Alliance for Health 10884... 102 Central Reserve Life Insurance Company- 10450... 103 Central Senior Care 10904... 104 Central States Indemnity 10744... 105 Cerner Health Plan 11018... 106 CHAMPVA/Spina Bifida/Children of Women Vietnam Vets - 00232... 107 Children's Mercy PCN 10906... 108 CHP Direct 10907... 109 Christian Brothers s 10908... 110 CHRISTUS Health Plan New Mexico- 11006... 111 CHRISTUS Health Plan NM Medicare Advantage- 11007... 112 Cigna-GWH - 00001... 113 Claims Management Inc.- 11001... 114 CMFG Life Insurance 10909... 115 Colonial Penn Life 10852... 116 Colorado Access 00000002356... 117 Commerce Benefits Group 10910... 118 Community Health Plan of Washington (CHPW) 2641... 119 ConnectiCare 10303... 120 Consolidated Associates Railroad 10669... 121 Consumers Life 10911... 122 Continental General Insurance Company- 10454... 123 Cooperative Benefits Administrators 00223... 124 Cook Children s Health Plan- 10610... 125 CoreSource... 126 Corporate Benefit - 10411... 127 Country Cupboard 10912... 128 Country Life Insurance Company 10670... 129 Covenant Administrators (TPA) 10880... 130 Coventry Healthcare... 131 Cox Health Plan 10838... 133 CTI Administrators 10671... 134 Culinary Health Fund UNITE HERE Health- 10775... 135 Dean Health Plan 10653... 136 DeCare Dental Health Insurance - 10780... 137 Definity Health 10828... 138 Dental Benefit Providers 10787... 139 Delaware Physicians Care 10913... 140 Delta Dental... 141 Denver Health Medical Plan- 0000001321... 142 Deseret Mutual (DMBA) 10578... 143 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial iii
Director's Guild 10077... 144 EBMS 10862... 145 Elderplan 11010... 146 Employee Benefit s - Dental 10784... 147 EPIC Life Insurance 10914... 148 EPSI, Inc. 11011... 149 EssenceHealthcare- 10601... 150 Evangelical Community Hospital 10915... 151 Evercare 10807... 152 Everence Financial 10772... 153 Evergreen Health Co-Op 10860... 154 Expert Benefit Solutions 11019... 155 Family Care- 10427... 156 FCE Benefit Administrators 11003... 157 Federated Insurance Company- 00262... 158 Fidelis Care New York 10459... 159 Fidelis SecureCare of Michigan 10859... 161 FirstCare 10870... 162 First Medical Network 10916... 163 First United American Insurance Company 10987... 164 Flex Compensation - Dental 10799... 165 Florida Combined Life Dental 10811... 166 Florida Health Care Plans- 10615... 167 Florida Hospital Healthcare System- 10333... 168 Florida True Health 10839... 169 Food Employers & Bakery Confectionary Workers Benefit 10776... 170 Freedom Blue- 10502... 171 Fresenius Medical Care 10602... 172 Gateway Health Plan 10629... 173 Geisinger Health Plan 10611... 174 Geisinger Health Plan Gold 10612... 175 GHI - Group Health Incorporated 10808... 176 Gilsbar- 10509... 177 Globe Life & Accident Insurance Company 10988... 178 Group & Pension Administrators - 10174... 179 Group Health Cooperative- 10608... 180 Group Health Cooperative of South Central Wisconsin - Dental 10781... 181 Guardian Life Insurance Co. of America Dental 10788... 182 Harmony Health Plan - 10514... 183 Hawaii Medical Assurance Association Dental 10785... 184 Health Alliance Medical Plan (IL) 10871... 185 Health Alliance Medical Plans (HAP) 00000002077... 186 Health Choice Arizona 00329... 187 Health Cost Solutions 11012... 188 Health First Health Plan 10673... 189 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial iv
Health First New Jersey 10438... 190 Health First New York 00240... 191 Health Net National 10385... 192 Health New England 10627... 193 Health Partners (Minnesota) 10484... 194 Health Partners Philadelphia 00288... 195 Health Plan of San Mateo 10362... 196 Health Share of Oregon 10823... 197 Health s for Children with Special Needs 10584... 198 Healthcare Solutions Group 10463... 199 HealthComp Administrators 11020... 200 HealthEase 10510... 201 HealthEase Kids 10511... 202 Healthgram 10692... 203 HealthMarkets... 204 HealthPlan of Nevada 10804... 206 HealthPlans Inc. 10802... 207 HealthPlus of Michigan 1311... 208 HealthScope (Morris Assoc, Central Benefits, Employer s Health, Plan Handlers) 10621209 Healthsource Provident - Dental 10789... 210 HealthSpring 10464... 211 Healthy Texas 10824... 212 Heritage Physician Network (Houston) 10918... 213 Hershey Healthsmile - Dental 107935... 214 HIPNY 10406... 215 Horizon NJ Health 2840... 216 Humana 00041... 217 Humana CareSource (KY) 10920... 218 IBM Insurance Outsourcing s 10861... 219 IBEW Local 508 Health Plan 10885... 220 Ideal Life Insurance 10747... 221 Independence Administrators 10417... 222 Insurers Administrative Corporation (IAC) 11021... 223 International Medical Card Inc 11028... 224 Island Home Insurance 10675... 225 John Hopkins Health Plan 00000002613... 226 Kaiser Foundation Health Plan of Colorado 00277... 227 Kaiser Foundation Health Plan of Hawaii 00278... 228 Kaiser Foundation Health Plan of Hawaii (DHMO Choice) 10676... 229 Kaiser Foundation Health Plan of the Mid Atlantic 00276... 230 Kaiser Foundation Health Plan of the Northwest 00279... 231 Kaiser Permanente of Georgia 00281... 232 Kaiser Permanente of Northern CA 00282... 233 Kaiser Permanente of Southern CA 00283... 234 Kentucky Health Exchange 10857... 235 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial v
Keystone Mercy Health 2232... 236 Kitsap Physician s 2644... 237 KSKJ Life 10748... 238 Leggett & Platt 10975... 239 Leon Medical Centers Health Plan 10677... 240 Liberty National Life Insurance Company 10989... 241 Lifetime Benefit Solutions (RMSCO) 10978... 242 Lifewise Arizona 10843... 243 Lifewise Health Plan of Oregon 10651... 244 Lifewise Health Plan of Washington 10650... 245 Lincoln Financial 10678... 246 Lincoln Heritage 10749... 247 Local 1199 10979... 248 LoneStar TPA 11013... 249 Loomis Company 10755... 250 Louisiana Health Exchange 10830... 251 Magellan Behavioral Health 10649... 252 Magnacare 10867... 253 Mid Atlantic Medical s, LLC MAMSI... 254 Managed Care of America 10885... 256 Managed Health s Wisconsin 10587... 257 MAPFRE Medicare Excel 10680... 258 MAPFRE Life Puerto Rico 10679... 259 Maricopa Health Plan Arizona 10434... 260 MDWise Hoosier Alliance -10598... 261 MedBen - Newark OH 10681... 262 MedCost Benefit s -10272... 263 Medica 00404... 264 Medica Health Plans 11029... 265 Medical Associates Health Plan/Health Choices 10683... 266 Medical Card System 10952... 267 Medical Mutual of Ohio 00211... 268 Medicare CMS... 269 Medicare Advantage - Pennsylvania- 11000... 270 Medicare y Mucho Mas (INMEDIATA HEALTH GROUP) 10960... 271 Med-Pay, Inc. 10682... 272 MedStar Family Choice 10844... 273 MedStar Health Plan 10845... 274 Meritain Health 10635... 275 Meritus Health Partners 10980... 276 Michigan MI Child 10138... 277 Mississippi State Employees and Teachers 10142... 278 Missouri Care 10702... 279 MMSI (Mayo Health) 10144... 280 Moda Health 11005... 281 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial vi
Molina Healthcare... 282 Municipal Health Benefit Fund 10687... 283 Mutual Health s 10686... 284 Mutual of Omaha 10382... 285 MVP Health Care (New York) 10148... 286 National Association of Letter Carriers (NALC) 00214... 287 National Telecommunications Cooperative Association (NTCA) 10812... 288 NEHEN Harvard Pilgrim Health Care 10376... 289 NEHEN Harvard Pilgrim Health Care 00000002393... 290 NEHEN- Neighborhood Health Plans- 00000002395... 291 Neighborhood Health Plan (RI) 10630... 292 Network Health 10626... 293 Network Health Plan of WI 10706... 294 New Era Life Insurance Company 10991... 295 NGS American 10873... 296 North Carolina Medicaid 10156... 297 Nova Healthcare Administrators 10537... 298 Ohana 10515... 299 Oklahoma Employees Group Insurance Division- 10995... 300 Operating Engineers Local.428 Health and Welfare 10777... 301 Optima/Sentara 10477... 301 Orange County Fire Authority 10951... 303 Oscar (NY) 10881... 304 Oxford Health Plans 00016... 305 Pacific Source Health Plan 2597... 306 Panamerican Life Puerto Rico 10689... 307 Paramount Health 10854... 308 Parkland Community Health Plan 10643... 309 Partners National Health Plans of NC 10383... 310 Passport Health Plan 2841... 311 Patriot Dental - 10782... 312 People First 11022... 313 Peoples Health 10636... 314 Personal Insurance Administrators (PIA) - 10492... 315 Physicians Health Plan Northern IN (PHPNI)-10658... 316 Physicians Health Plan of Mid-Michigan 11015... 317 Physicians Mutual Insurance Company 00287... 318 Physicians Plus Insurance Corp 11004... 319 Piedmont (GA) 10882... 320 Piedmont Wellstar HealthPlans 10825... 321 Plan de Salud Hospital Menonita 10958... 322 Planned Administrators Inc. 10886... 323 Plumbers and Pipefitters Local Union 525 Health & Welfare Trust-10778... 324 Preferred Care Partners 10691... 325 Preferred Health System of Kansas 10847... 326 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial vii
Preferred Medicare Choice (PMC) (INMEDIATA HEALTH GROUP) 10959... 327 Preferred One 00371... 328 Premier Health 10848... 329 Presbyterian Health Plan 10646... 330 Prestige Health Choice 10965... 331 Principal Financial Group (Nippon Life)... 332 Priority Health 10490... 333 Pro-Claim Plus 11014... 334 Professional Benefits Administrators- 10242... 335 Providence Health Plan - 2598... 336 Provident Preferred Network - Dental 10790... 337 Puritan Life Insurance 10743... 338 Qualcare - 10637... 339 Royal Neighbors of America 10751... 340 S and S Healthcare Strategies 10875... 341 Santa Clara Family Health Plan 10876... 342 Schaller Anderson Aetna Better Health of New York 10816... 343 Schaller Anderson Aetna Better Health of OH 10887... 344 Schaller Anderson Delaware Physicians Care, Inc. 10817... 345 Schaller Anderson MajestaCare VA 10818... 346 Schaller Anderson Maryland Physicians Care 10693... 347 Schaller Anderson Mercy Care 10694... 348 Schaller Anderson Mercy Maricopa- 10996... 349 Schaller Anderson Missouri Care 10695... 350 Schaller Anderson Parkland Community Health Plan 10643... 351 Schaller Anderson Texas CHRISTUS 10696... 352 Scott & White Health Plan 00000002076... 353 Secure Health Plans of Georgia 10883... 354 Securian - Dental 10792... 355 Security Health Plan -10864... 357 Select Health SC 10520... 358 Select Health Utah 10575... 359 Senior Care Action Network (SCAN) HMO 00350... 360 Senior Dimensions 11023... 361 Senior Health s Center Universal American Family of Companies 10697... 362 Senior Whole Health 10962... 363 Shenandoah Life Insurance 10752... 365 Sierra Health s 10282... 366 Significa 00191... 367 Simply Healthcare Plans 10826... 368 Soundpath Health 10935... 369 Spectrum Health 10936... 370 SPJST Medicare Supplement 10546... 371 Star HRG 10833... 372 State Mutual (Lincoln Novation) 10982... 373 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial viii
State Mutual Med Supp. 10750... 374 Staywell 10512... 375 Staywell Kids 10513... 376 Sterling Investors Life Insurance 10753... 377 Student Insurance 00290... 378 SummaCare 00000002514... 379 Superior Health Plan Texas - 10592... 380 TennDent 107934... 381 TexanPlus North Texas Area 10604... 382 TexanPlusSoutheast Texas Area 10605... 383 The Kempton Company 10698... 384 Three Rivers Health Plans 00198... 385 TMG Network Health Insurance 10688... 386 Today s Health 10606... 387 Today s Option 10505... 388 Triple-S Salud (BCBS Puerto Rico) 10953... 389 Trustmark 00233... 390 Tribute/Select Care of Oklahoma 10607... 391 Tricare TRICR... 392 UCare of Minnesota 2596... 393 Ultimate Health Plans 10888... 394 UMR (Wausau) 10501... 395 Underwriters Safety & Claims - 10246... 396 UNICARE - Dental 10791... 397 Unicare UCARE... 398 United American Insurance Company 10990... 399 United Concordia (Dental)... 400 United Healthcare 00112... 401 United Healthcare Community Plan Kansas 10835... 403 United Healthcare Community Plan River Valley 00335... 404 United Healthcare Community Plan Tennessee 11025... 405 United Healthcare Facets Detroit Community and State 10836... 406 United Healthcare Facets Pittsburgh Community and State 10834... 407 United Healthcare Nevada Market 10837... 408 United Healthcare SecureHorizons 10655... 409 Unity Health Plan 00000000780... 410 University Care Advantage Arizona 10699... 411 University Family Care 00353... 412 University of Arizona Health Plan-UHM 10889... 413 University of Utah Health Plans 10977... 414 University Physicians Care Advantage (AZ) 10433... 415 University Physicians Healthcare Group (Arizona) 10439... 416 UPMC Health Plan (Tristate) 00000001054... 417 USAA Life Insurance Company 10195... 418 VA Fee Basis Program 00231... 419 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial ix
VA Healthcare 10850... 420 VA Health Administration Center 10956... 421 Vantage Health Plan, Inc. 10858... 422 VIVA Health 10468... 423 VYTRA 10407... 424 Washington National 10853... 425 Well Sense 10814... 426 Wellcare Health Plans 10488... 427 Western Health Advantage 1043... 428 Wilson McShane 10797... 429 Windsor Medicare Extra 10576... 430 World Insurance (ARIC) 10386... 431 WPS Health Insurance 10878... 432 Payer Maintenance Schedule... 433 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial x
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
Change Date 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 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 2
Change Date Added Significa Benefit s 00191 8/1/2012 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 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 3
Change Date Added United Healthcare of River Valley 00335 12/6/2013 Reactivated Nova Healthcare Administrators 10537 12/6/2013 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 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 4
Change Date 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 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 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 5
Change Date 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 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 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 6
Change Date 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 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 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 7
Change Date 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 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 payer 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 payer Windsor Medicare Extra 10576 10/31/2014 Deactivated payer FCE Benefit Administrators Inc. 10672 10/31/2014 Corrected Delta Dental data requirements. 11/12/2014 Renamed payer Primary PhysicianCare Inc. 10692 to Healthgram 10692 11/30/2014 Deactivated payer Healthgram 10917 11/30/2014 Reactivated payer Windsor Medicare Extra 10576 11/30/2014 Modified search options for payer American Postal Workers Union (APWU) 00360 11/30/2014 Deactivated payer Great American Life Insurance Co Medicare Supp 10543 11/30/2014 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 8
Change Date Added the new payer Lifetime Benefit Solutions (RMSCO) 10978 11/30/2014 Deactivated payer Gerber Life Insurance* 10745 11/30/2014 Deactivated payer Colorado Access- 0000002356 11/30/2014 Deactivated payer Mutual Assurance Administrators 10872 11/30/2014 Added the new payer Local 1199 10979 11/30/2014 Added the new payer Care1st Health Plan Arizona 10981 11/30/2014 Added the new payer Meritus Health Partners 10980 11/30/2014 Updated search option for the following payers: 11/30/2014 Kaiser Foundation Health Plan of Colorado 00277 Kaiser Foundation Health Plan of Hawaii 00278 Kaiser Foundation Health Plan of Hawaii (DHMO Choice) 10676 Kaiser Foundation Health Plan of the Mid Atlantic 00276 Kaiser Foundation Health Plan of the Northwest 00279 Kaiser Permanente of Georgia 00281 Kaiser Permanente of Northern CA 00282 Kaiser Permanente of Southern CA 00283 Added the new payer State Mutual (Lincoln Novation) 10982 12/31/2014 Added the new payer Aetna Signature Administrators 10983 12/31/2014 Added the new payer ASR Health Benefits 10984 12/31/2014 Added the new payer Lifewise Health Plan of Washington 10650 12/31/2014 Added the new payer Lifewise Health Plan of Oregon 10651 12/31/2014 Added the new payer Dean Health Plan 10653 12/31/2014 Deactivated payer Zenith Administrators (MN) - Dental 10796 12/31/2014 Added the new payer AmeriBen 10985 12/31/2014 Added the new payer United American Insurance Company 10990 12/31/2014 Added the new payer First United American Insurance Company 10987 12/31/2014 Added the new payer Globe Life & Accident Insurance Company 10988 12/31/2014 Added the new payer United American Insurance Company 10990 12/31/2014 Added the new payer Liberty National Life Insurance Company 10989 12/31/2014 Added the new payer New Era Life Insurance Company 10991 12/31/2014 Added the new payer American Income Life Insurance Company 10986 12/31/2014 Added the new payer Simply Healthcare Plans 10826 1/31/2015 Deactivated payer Generations Healthcare 10603 1/31/2015 Added the new payer MVP Health Care (New York) 10148 1/31/2015 Added Senior Care Action Network (SCAN) HMO 00350. Formerly 4010 payer. 4/15/2015 Added Oklahoma Employees Group Insurance Division- 10995 4/15/2015 Added Plumbers and Pipefitters Local Union 525 Health & Welfare Trust-10778 4/20/2015 Added Culinary Health Fund UNITE HERE Health-10775 4/20/2015 Added Aetna Better Health (NJ) (payer ID: 10994) 4/20/2015 Reactivated Personal Insurance Administrators (payer ID: 10492) 4/21/2015 Deactivated Total Healthcare Payer ID10805 4/21/2015 Edited for Geisinger Health Plan (Payer ID: 10611) and Geisinger Health Plan Gold 4/23/2015 (Payer ID: 10612). Remove search option of Subscriber ID only this is not permitted. Deactivated Care Improvement Plus Payer ID 10806 4/23/2015 Removed Recall Systems name from the following payers. They are are now listed independently. 4/24/2015 Boon-Chapman Benefit Admin 10414 Group & Pension Administrators 10174 Underwriters Safety & Claims 10246 Corporate Benefit 10411 Professional Benefits Administrators 10242 Added Anthem Vivity 10993 4/29/2015 Deactivated TRICARE for Life (payer ID: 10879) 5/5/2015 Added Better Health Plans of Florida (Payer ID: 10999) 5/5/2015 Added Medicare Advantage - Pennsylvania (Payer ID: 11000) 5/5/2015 Added Claims Management Inc. (Payer ID: 11001) 5/5/2015 Deactivated Sanford Health Plan (payer ID: 10533). Payer was returning innacurate data. 5/5/2015 Deactivated Molina Healthcare of Missouri, payer ID 10523 5/5/2015 Added Alternative Insurance Resources, Inc. (Payer ID: 11002) 5/5/3015 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 9
Change Date Added ACS Benefit s 11009 5/11/2015 Added AlohaCare - 11017 5/11/2015 Added Cerner Health Plan - 11018 5/11/2015 Added Elderplan 11010 5/11/2015 Added EPSI, Inc. 11011 5/11/2015 Added Expert Benefit Solutions 11019 5/11/2015 Added Health Cost Solutions 11012 5/11/2015 Added HealthComp Administrators 11020 5/11/2015 Added Insurers Administrative Corporation (IAC) 11021 5/11/2015 Added LoneStar TPA 11013 5/11/2015 Added Physicians Health Plan of Mid-Michigan 11015 5/13/2015 Added Pro-Claim Plus 11014 5/13/2015 Added Senior Dimensions 11023 5/13/2015 Added Moda Health (Payer ID: 11005) 5/14/2015 Added UnitedHealthcare Community Plan TN (Payer ID: 11025) 5/14/2015 Added Aetna Better Health (MI) (Payer ID: 11026) 5/14/2015 Added All Savers Life Insurance 11027 5/14/2015 Added International Medical Card Inc. (Payer ID: 11028) 5/14/2015 Added CHRISTUS Health Plan New Mexico- 11006 5/14/2015 Added CHRISTUS Health Plan NM Medicare Advantage- 11007 5/15/2015 Modified search options for Santa Clara Family Health Plan 10876 5/15/2015 Added Medica Health Plans 11029 5/15/2015 Reactivated Colorado Access (payer ID: 0000002356) 5/15/2015 Updated search options for Mid Atlantic Medical s, LLC - MAMSI (Payer ID: MAMSI) 5/18/2015 Updated search options for Oklahoma Employees Group Insurance Division- 10995 5/18/2015 Added Centene - Michigan Fidelis Secure Care (payer ID: 11034) 5/18/2015 Corrected Search options for Health First Health Plan 10673 5/18/2015 Added Spectrum Health (Payer ID 10936) 5/18/2015 Added Soundpath Health - 10935 5/18/2015 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 10
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 11
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 12
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 13
ACS Benefit s - 11009 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last name Dep: First name Dep: No No No and/or 11009 = [NM108=PI]NM109 Last or Organizatio n Last First Dependent Dep. Last Dep. First Dep. Date of Birth,D1 Min/Max = 16 D1 D1 D1 Type and/or 30 Federal Tax ID and/or Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 14
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 15
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 16
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 17
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 Last First Min/Max = 11 Type and/or and/or 30 Federal Tax ID Either Tax ID or is required Either Tax ID or is required Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 18
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 19
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 20
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 21
(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 22
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 23
Aetna Better Health (LA) - 11008 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or 11008 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Last First Required. No S2,S3 S2,S3,S2 Min\Max=24,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 24
Aetna Better Health (MI) - 11026 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or 11026 = [NM108=PI]NM109 Last or Required. No Situational Type and/or Operating set Last First Required. No S2,S3 S2,S3,S2 Min\Max=24,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 25
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 26
Aetna Better Health (NJ) - 10994 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or 10994 = [NM108=PI]NM109 Last or Type and/or 1, 30,33,35, 47,86, 88, 98,AL,MH,UC,A4 and/or Situational. National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Last First S2,S3 S2,S3,S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 27
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 28
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 29
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 30
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 31
Aetna Signature Administrators 10983 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: No No No and/or 10983 = [NM108=FI]NM109 = XX Last or Last First, D1 Type and/or 1,2,4,5,6,7,8,12,13,18,20,3 0,33,35,40,42,47,49,50,51, 52,53,62,65,68,73,76,78,8 0,81,82,86,88,93,98,99,A0,A3,A6,A7,A8,AD,AE,AF,A G,AI,AL,BG,BH,MH,UC Federal Tax ID, and/or Situational. Federal Tax ID if NM108 = FI if NM108 = XX. Last Dependent Last First, D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 32
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 33
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 Last First SSN S3,S4 S3,S4,S4 Min= 10 Max = 12 S2,S3,S4 S2 Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 34
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 35
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 36
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 37
All Savers Life Insurance 11027 Option 1 2 3 Subscriber Last Subscriber S2 First Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First Dependent D1 Sub: Dep: Last Dep: Dependent D2 Sub: Dep: First Dep: Dependent D3 Sub: Dep: Dependent D4 Sub: Dep: Last Dep: First Dependent D5 Dep: Last Dep: First Dep: No No Date Ranges are allowed Required Situational and/or and/or 11027 [NM108=PI]NM109 Last or Required. No Type Operating Set Last First Dependent Last First Required. No,S4,S5 S2,S4,S5,S2,S3,S4,D1,D2,D3,D4,S2,S3,S5 D1,D4,D5 D2,D4,D5 D1,D2,D3,D5 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 38
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 39
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 40
AlohaCare 11017 Option 1 2 3 4 Subscriber Last Subscriber S2 Subscriber S3 Last Subscriber S4 Last First No No No Required and/or 11017 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Last,S3 First S4,S2,S4 Min/Max=24 S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 41
Alternative Insurance Resources, Inc 11002 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Dependent D4 Sub: SSN Dep: No No No Required and/or 11002 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Last S2 S3 First S2 S3,S2,D1,D2,S3,D3,D4 Dependent Dep. Last Dep. First Dep. Dep. SSN D2,D3 D2,D3 D1,D4 D4 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 42
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 43
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 44
American Income Life Insurance Company 10986 Option 1 2 3 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or 10986 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2 S2, S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 45
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 46
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 47
American Postal Workers Union (APWU) 00360 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. and/or s and Values = 00360 = [NM108=PI]NM109 Last or Last First Dependent Last First S2, S3, S4 S2, S3, S4, S2, S4, D1, D2, D4, S3, S4 D2, D3, D4 D2, D3, D4 D1, D3, D4 Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 48
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 49
AmeriBen 10985 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 = 10985 = [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 50
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 51
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 52
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 53
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 54
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 55
Anthem Vivity 10993 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: No No No and/or 10993 = [NM108=PI]NM109 Last or Last First, D1, D1, D1, D1 Type and/or 1,2,4,5,6,7,8,9,10 11,12,13,14,15,16 17,18,19,20,21,22 23,24,25,26,27,28 30,32,33,34,35,36 37,38,39,40,41,42 43,44,45,46,47,48 49,50,51,52,53,54 55,56,57,60,61,62 65,68,69,73,76,78 80,81,82,83,84,86 88,93,98,99,A0,A3 A6,A7,A8,AD,AE AF,AG,AI,AL,BG BH,MH,UC / Federal Tax ID and/or Situational. National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 56
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 57
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 58
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 59
ASR Health Benefits 10984 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: No No No and/or s and Values = 10984 = [NM108= FI, XX NM109 Last or Last First Required. No, D1 Type and/or 1,2,4,5,6,7,8,12,13,18,2 0,30,33,35,40,42,47,49, 50,51,52,53,62,65,68,7 3,76,78,80,81,82,86, 88,93,98,99,A0,A3,A6, A7,A8,AD,AE,AF,AG,AI,AL,BG,BH,MH,UC Federal Tax ID, and/or Federal Tax ID if NM108 = FI if NM108 = XX. Last Dependent Last First, D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 60
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 61
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 62
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 Type and/or 30 Federal Tax ID and/or Situational. No Last Dependent Last First, D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 63
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 64
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 65
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 66
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 67
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 68
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 69
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 70
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 71
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 72
Better Health Plans of Florida 10999 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First No No No Required and/or 10999 = [NM108=PI]NM109 Last or required. Optional Type and/or 30 required. Last S3, S4 First S3, S4, S2, S3 Min/Max=20 S2, S4 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 73
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 74
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 75
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 76
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 77
Boon Chapman Benefit Admin 10414 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: First Dep: Yes and/or See table above = [NM108=SV]NM109 Type and/or and/or 30 Situational. No notes indicated. Last Provider ID Situational. No notes indicated. First,D1 Max=9 Dependents First D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 78
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 79
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 80
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 81
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 82
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 83
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 84
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 85
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 86
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 87
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 88
Care1st Health Plan Arizona 10981 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or 10981 = [NM108=PI]NM109 Last or Type and/or 30 Federal Tax ID and/or No No No Last First S2,S3 S2,S3,S2 Min/Max=12,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 89
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 90
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 91
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 92
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 93
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 94
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 95
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 96
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 97
,S3 S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 98
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 - Michigan Fidelis Secure Care 11034 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 Centene-Sunshine State Health Plan 10451 Centene- IlliniCare Health Plan 10757 Centene-Total Care Carolina 10866 and/or See above table = [NM108=PI]NM109 Type and/or All code types accepted Federal Tax ID and/or Situational. National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Last Situational. National Provider ID if NM108=XX. First Federal Tax ID if NM108=FI. Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 99
Min/Max=20 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 100
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 101
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 102
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 103
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 104
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 105
Cerner Health Plan 11018 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Last Dep: First Dependent D2 Sub: Dep: Dependent D3 Dep: Last Dep: First Dep: No No No Required and/or 11018 = [NM108=PI]NM109 Last or Required. No Situational Type and/or 30 Last First No, S2, D1,D2 Min/Max=24 S2,S3 S2,S3,S3 Dependent Last First D1 D1 D2,D3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 106
CHAMPVA/Spina Bifida/Children of Women Vietnam Vets - 00232 Option 1 2 3 4 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 107
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 108
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 109
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 110
CHRISTUS Health Plan New Mexico- 11006 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: No No No Required and/or 11006 = [NM108=PI]NM109 Last or Required. No Situational Type and/or The operating rule code set. Last First Required. No Min/Max=9,S2,D1,D2 S2,S3 S2,S3,S3 Dependent Last First D2,D3 D2,D3 D1,D3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 111
CHRISTUS Health Plan NM Medicare Advantage- 11007 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or 11007 = [NM108=PI]NM109 Last or Last Required. No Max=80,S2 S2,S3 Situational Federal Tax ID, Type and/or Federal Tax ID if NM108 = FI if NM108 = XX The operating rule codeset. First S2,S3,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 112
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 113
Claims Management Inc.- 11001 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: First Dep: 3 Years in the Past. No 90 Day Required and/or 11001 = [NM108=PI]NM109 Last or Required. No Situational Type and/or 30 Last First Required. No Min/Max=24, D1 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 114
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 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 115
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 116
Colorado Access 00000002356 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Subscriber S3 Subscriber S4 Last First Subscriber S5 Last First Last 1 year End of current month No Required Optional and/or and/or 10852 = [NM108=PI]NM109 Last or Required. No Type 30 Last First Required. No,S2,S4,S5,S4,S5,S2,S3,S4 Min=2 Max=80 S3,S3,S5 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 117
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 118
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 119
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 120
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 121
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 3) 30 Situational. No Federal Tax ID Situational. No Subscriber Last Subscriber First Subscriber Subscriber S2 S2, D1 S2 Dependent Subscriber Dep. Last Dep. First Dep. Date of Birth, D1 D2 D2 D2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 122
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 123
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 124
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 125
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 126
Corporate Benefit - 10411 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: First Dep: Yes and/or See table above = [NM108=SV]NM109 Type and/or and/or 30 Situational. No notes indicated. Last Provider ID Situational. No notes indicated. First,D1 Max=9 Dependents First D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 127
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 128
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 129
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 130
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 131
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 132
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 133
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 134
Culinary Health Fund UNITE HERE Health- 10775 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: No No No and/or 10775 = [NM108=PI]NM109 Last or Type and/or 1, 30,33,35, 47,86, 88,98,AL,MH,UC,A4 and/or Either Tax ID or is required Last S2,S3 First S2,S3,S2, D1, D2 Dependent Dep. Last Dep. First Dep. Date of Birth,S3 D2, D3 D2, D3 D1, D2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 135
Dean Health Plan 10653 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last First Subscriber S3 Last Yes Future dates allowed up to 7 days Yes and/or 10653 = [NM108=PI]NM109 Last or Type and/or 1,2,4,5,6,7,8,12,18,20, 33,35,40,42,45,47,48, 50,51,52,53,62,65,68, 73,76,78,80,81,82,86, 88,93,98,99,A0,A3,A6, A7,A8,AD,AE,AF,AG, AI,AL,BG,BH,MH,UC and/or Situational. No Last S2,S3 First S2,S3 S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 136
DeCare Dental Health Insurance - 10780 Option 1 2 3 Subscriber Last First No No No and/or 10780 [NM108=PI]NM109 Last or Federal Tax ID Last First Provider Tax ID Required Type and/or 30 and/or if NM108 = XX Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 137
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 138
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 139
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 140
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 141
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 142
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 143
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 144
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 145
Elderplan 11010 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First No No No Required and/or 11010 = [NM108=PI]NM109 Last or Required. No Situational Type and/or 30 Last First Required. No, S2, S3 Min =2 Max=80 S3,S4 S3,S4 S2,S4 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 146
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 147
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 148
EPSI, Inc. 11011 Option 1 2 3 4 Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: Required and/or 11011 = [NM108=PI]NM109 Last or No Optional Type and/or 30 Last First No Min/Max=16,D2 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 149
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 150
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 151
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 152
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 153
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 154
Expert Benefit Solutions 11019 Option 1 2 3 4 Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: Required and/or 11019 = [NM108=PI]NM109 Last or No Optional Type and/or 30 Last First No Min/Max=16,D2 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 155
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 156
FCE Benefit Administrators 11003 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or 11003 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Last First Required. No Min/Max=24,S2,S3 S2,S3 S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 157
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 158
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 159
Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 160
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 161
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 162
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 163
First United American Insurance Company 10987 Option 1 2 3 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or 10987 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2 S2, S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 164
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 165
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 166
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 167
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 168
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 169
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 170
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 171
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 172
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 173
Geisinger Health Plan 10611 Option 1 2 3 4 Subscriber 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 Last First Required. No Min/Max=12 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 174
Geisinger Health Plan Gold 10612 Option 1 2 3 4 Subscriber 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 Last First Min/Max=12 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 175
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 176
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 177
Globe Life & Accident Insurance Company 10988 Option 1 2 3 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or 10988 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2 S2, S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 178
Group & Pension Administrators - 10174 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: First Dep: Yes and/or See table above = [NM108=SV]NM109 Type and/or and/or 30 Situational. No notes indicated. Last Provider ID Situational. No notes indicated. First,D1 Max=9 Dependents First D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 179
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 180
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 181
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 182
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 183
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 184
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 185
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 186
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 187
Health Cost Solutions 11012 Option 1 2 3 4 Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: Required Optional and/or and/or 11012 = [NM108=PI]NM109 Last or No Last First Type Dependent Last First No Min/Max=16,D2 The operating rule codeset D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 188
Health First Health Plan 10673 Option 1 2 3 4 5 Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep: Date of Birth Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: Date of Birth No No No Required and/or 10673 = [NM108=PI]NM109 Last or Identification Subscriber Subscriber Last Subscriber First Subscriber Dependent Required. No or Tax ID required Min/Max=9,D1,D2 S2 S2 S2 Situational Type and/or 1, 2, 4, 5, 6, 7, 8, 12, 13, 18, 20, 30, 33, 35, 40, 42, 45, 47, 48, 50, 51, 52, 53, 62, 65, 68, 69, 73, 76, 78, 80, 81, 82, 86, 88, 93, 96, 98, 99, A0, A3, A6, A7, A8, AD, AE, AF, AG, AI, AL, BG, BH, MH, UC Dep. Last Dep. First Dep. Date of Birth D2,D3 D2,D3 D1,D3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 189
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 190
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 191
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 192
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 193
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 194
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 195
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 196
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 197
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 198
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 199
HealthComp Administrators 11020 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Last Dep: First Dependent D2 Sub: Dep: Dependent D3 Dep: Last Dep: First Dep: No No No Required and/or 11020 = [NM108=PI]NM109 Last or No No Optional Type and/or 30 Last First Dependent Last First,S2,S2,S2,D1,D2 Min/Max=24,S3 D1,D3 D1,D3 D2,D3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 200
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 201
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 202
Healthgram 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 203
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 204
Last First D2,D3,D4 D2,D3,D4 D1,D3,D4 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 205
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 206
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 207
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 208
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 209
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 210
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 211
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 212
Heritage Physician Network (Houston) 10918 Option 1 2 3 4 Subscriber Last First 3 years No 4) 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 213
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 214
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 215
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 216
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 217
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 218
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 219
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 220
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 221
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 222
Insurers Administrative Corporation (IAC) 11021 Option 1 2 3 4 Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: No No No Required and/or 11021 = [NM108=PI]NM109 Last or No No Optional Type and/or 30 Last First Dependent Last First,D1 Min/Max=16 D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 223
International Medical Card Inc 11028 Option 1 2 3 4 Subscriber Last First No No No Required and/or 11028 = [NM108=PI]NM109 Last or Identification Last No Tax ID or required. Optional Type and/or The operating rule codeset First Min/Max=24 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 224
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 225
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 226
Kaiser Foundation Health Plan of Colorado 00277 Option 1 2 3 4 Subscriber Subscriber S2 Last First Gender No No No Required and/or 00277 = [NM108=PI]NM109 Last or Federal Tax ID Last First Gender Type Required. No Required. No Required. No,S2,S2 Min/Max=12 S2,S2 The operating rule codeset Optional Type and/or 30 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 227
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 No No Required and/or 00278 = [NM108=PI]NM109 Federal Tax ID Last First Gender SSN Type Required. No Required. No,S2, S3,S2, S3 Min/Max=12 S2 S2,S2, S3 The operating rule codeset Optional Type and/or 30 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 228
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 No 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 The operating rule codeset D2,D3 D2,D3 D1,D3 The operating rule codeset Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 229
Kaiser Foundation Health Plan of the Mid Atlantic 00276 Option 1 2 3 4 Subscriber Subscriber S2 Last First Gender No No No Required and/or 00276 = [NM108=PI]NM109 Optional Type and/or 30 Federal Tax ID Last First Gender Type Required. No Required. No S2 S2 Min/Max=12 S2 S2 The operating rule codeset Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 230
Kaiser Foundation Health Plan of the Northwest 00279 Option 1 2 3 4 Subscriber Subscriber S2 Last First Gender No No No Required and/or 00279 = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Last First Gender Type Required. No S2 S2 Min/Max=12 S2 S2 The operating rule codeset Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 231
Kaiser Permanente of Georgia 00281 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last No No No Required and/or 00281 = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Last First Type Required. No S2,S3 S2, S2,S3 Min/Max=12,S2 The operating rule codeset Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 232
Kaiser Permanente of Northern CA 00282 Option 1 2 3 4 Subscriber Subscriber S2 Last First Gender No No No Required and/or 00282 = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Last First Gender Type Required. No S2 S2 Min/Max=12 California s are a total of 12 digits. The ID numbers are left zero filled to 10 digits and then a prefix is added for the region (11 for Northern California and 00 for Southern California members). An ID that is 1234567 would be 110001234567 for Northern California and 000001234567 for Southern California S2 S2 The operating rule codeset Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 233
Kaiser Permanente of Southern CA 00283 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No Required and/or 00283 = [NM108=PI]NM109 Required. No Optional Type and/or 30 Federal Tax ID Last First Type Required. No S2 S2 Min/Max=12 California s are a total of 12 digits. The ID numbers are left zero filled to 10 digits and then a prefix is added for the region (11 for Northern California and 00 for Southern California members). An ID that is 1234567 would be 110001234567 for Northern California and 000001234567 for Southern California S2 The operating rule codeset Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 234
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 235
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 236
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 237
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 238
Leggett & Platt 10975 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 SSN Subscriber S5 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Dep. Last name Dep. First Dep. No No No and/or s and Values = 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 239
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 240
Liberty National Life Insurance Company 10989 Option 1 2 3 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or 10989 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2 S2, S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 241
Lifetime Benefit Solutions (RMSCO) 10978 Option 1 2 3 4 Subscriber Last First No No No and/or 10978 = [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 242
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 243
Lifewise Health Plan of Oregon 10651 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: 1 Year No No and/or 10651 = [NM108=PI]NM109 Last or Last First, D1 Type and/or All valid service types are supported Only (1) EQ01 segment per transaction and/or National Provider ID. Last Dependent Last First, D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 244
Lifewise Health Plan of Washington 10650 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: 1 Year No No and/or 10651 = [NM108=PI]NM109 Last or Last First, D1 Type and/or All valid service types are supported Only (1) EQ01 segment per transaction and/or National Provider ID. Last Dependent Last First, D1 D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 245
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 246
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 247
Local 1199 10979 Option 1 2 3 4 Subscriber Subscriber S2 Last First Dependent D1 Sub: Dep. Last Dep. First Dep. No No No and/or 10979 = [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 248
LoneStar TPA 11013 Option 1 2 3 4 Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: Required and/or 11013 = [NM108=PI]NM109 Last or Required. No No Optional Type and/or 30 Last First,D1 Min/Max=16 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 249
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 250
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 251
Magellan Behavioral Health 10649 Option 1 2 3 4 5 6 Subscriber Dependent D1 Last First Subscriber Subscriber Last Subscriber First Dep. Last Dep. First Dep. Date of Birth 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 252
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 253
Mid Atlantic Medical s, LLC MAMSI Option 1 2 3 4 5 Subscriber Subscriber S2 Last First Subscriber S3 SSN Subscriber S4 SSN Last First Subscriber S5 Last First State Subscriber S6 Last First Dependent D1 Sub: Dep: Last Dep: First Dep: Date of Birth Dependent D2 Sub: Dep: Last Dep: First Dep: Date of Birth Dep: State Up to 18 months in the Past Up to the end of the current month in the Future End date of date range must be no greater than the end of the current month and/or MAMSI = [NM108=PI]NM109 Group Number and/or Min/Max=7 Optional, but recommended. / Federal Tax ID/Provider ID and/or National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Last or Org Member ID No,S2,S6,D1,D2 Min/Max=9 Type Provider ID if NM108=SV. 1,2,3,4,5,6,7,8,10, 12,13,18,20,23,24, 25,26,27,28,33,35, 36,37,38,39,40,41,42,45,4 7,48,49,50,51,52,53,62,65,68,73,76,78,80,81,82,83, 86,88,,89,90,91,92,93,98, 99,A0,A3,A4,A5,A6,A7,A8, AD,AE,AF,AG,AI,,AJ,AK,A L,BG,BH,BT,BU,BV,BW,B X,BY,BZ,DM,GF,GN,MH, UC Last S2,S4,S5,S6 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 254
First S2,S4,S5,S6 SSN State Date of Birth S3,S4 S5,S3,S5,S6 Dependent Last First Date Of Birth State D1,D2 D1,D2 D1,D2 D2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 255
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 256
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 257
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 258
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 259
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 260
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 261
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 262
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 263
Medica 00404 Option 1 2 3 4 Subscriber Subscriber S2 SSN Subscriber S3 Last First Subscriber S4 Last First Dependent D1 Sub: Dep: First Dep: Last Dep: Dependent D2 Dep: Last Dep: First Dep: 1 year No No Required and/or 00404 = [NM108=PI]NM109 Situational /Federal Tax ID and/or National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Provider ID (legacy) if NM108=SV. Last or Required. No Type All services type codes accepted. Last S3,S4 First S3,S4,S3,D1 Min/Max=9 SSN S2 Group Number D1 Min=1 Max=17,S2,S4 CCYYMMDD Dependent Last D1,D2 First D1,D2 D1,D2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 264
Medica Health Plans 11029 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No and/or 11029 = [NM108=PI]NM109 Last or and/or Gender M,F Type and/or The operating rule codeset. Last First Min/Max=12,S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 265
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 266
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 267
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 268
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 269
Medicare Advantage - Pennsylvania- 11000 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: First Dep: 2 Years in the Past. 18 Months in the Future. No Date Ranges allowed. Required Optional and/or and/or 11000 = [NM108=PI]NM109 Last or Required. No Required. No Type 30 Last First Dependent Dep. Last Dep. First Min\Max = 24 D1 D2 D2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 270
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 271
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 272
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 273
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 274
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 275
Meritus Health Partners 10980 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: No Yes No and/or s and Values = 10980 = [NM108=PI]NM109 Last or Last First Dependent Last First S2, S3 S2, S3, S2, S4, D1, D2, S3 D2, D3 D2, D3 D1, D3 Type and/or 30 Federal Tax ID and/or Situational. No Situational. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 276
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 277
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 278
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 279
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 280
Moda Health 11005 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Subscriber S3 Last First Subscriber S4 Last First Up to 1 year in the Past Future Dates allowed up to end of current month Date Ranges allowed Required and/or 11005 = [NM108=PI]NM109 Required. No Situational Type and/or Operating Set Last First,S2,S3,S4,S3,S4,S2,S3 Min=12 Max=80,S2,S4 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 281
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 South Carolina 10815 Molina Healthcare of Florida 10445 Molina Healthcare of Texas 10391 Molina Healthcare of Illinois 10685 Molina Healthcare of Utah 00227 Molina Healthcare of Michigan 00226 Molina HealthCare of Washington 10253 Molina Healthcare of New Mexico 10146 Molina Healthcare of Wisconsin 10628 Molina Healthcare of Ohio 00445 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 282
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 283
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 284
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 285
MVP Health Care (New York) 10148 Option 1 2 3 4 Subscriber First First Subscriber S2 Last Subscriber S3 Last First No No No and/or 10148 = [NM108=PI]NM109 Last or Required. Must match the name associated with the in the NPPES database. Type and/or 1,30,35 Federal Tax ID and/or Either Tax ID or is required Last First Required. S3,S4 S3,S4,S2,S3 MVP Preferred Care is not included and any member ID s not beginning with 8 is not going to be matched or returned. S2, S4 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 286
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 287
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 288
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 289
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 290
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 291
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 292
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 293
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 294
New Era Life Insurance Company 10991 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 SSN Subscriber S5 Last First Dependent D1 Sub. Dep. Dependent D2 Sub. Dep. Last name Dep. First name Dependent D3 Sub. SSN Dep. Dependent D4 Dep. Last name Dep. First Dep. No No No and/or s and Values = 10991 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. No Federal Tax ID Situational. No Last S2,S5 First SSN S2,S5,S2,S3.D1.D2 S4,D3 S2,S4,S5 Dependent Dep. Last Dep. First Dep. D2,D4 D2,D4 D1, D3,D4 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 295
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 296
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 297
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 298
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 299
Oklahoma Employees Group Insurance Division- 10995 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First Dependent D5 Sub: Dep: Dependent D6 Sub: Dep: Last Dep: First Dependent D7 Dep: Last Dep: First Dep: No No No and/or 10995 = [NM108=PI]NM109 Last or Type and/or 1, 2, 4, 5, 6, 7, 8, 12, 13, 18, 20, 30, 33, 35, 40, 42, 45, 47, 48, 50, 51, 52, 53, 62, 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 Federal Tax ID and/or Situational. No notes Situational. No notes Last First Dependent Dep. Last Dep. First Dep. Date of Birth S3, S4 S3, S4,S2, S3,D5,D6 S2, S4 D6,D7 D6,D7 D1, D3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 300
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 Optima/Sentara 10477 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 301
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 302
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 303
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 304
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 305
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 306
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 307
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 308
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 309
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 310
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 311
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 312
People First 11022 Option 1 2 3 4 Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: Required and/or 11022 = [NM108=PI]NM109 Last or Required. No No Optional Type and/or 30 Last First Dependent Last First,D1 Min/Max=16 D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 313
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 314
Personal Insurance Administrators (PIA) - 10492 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: No No No and/or 10492 = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 1, 30,33,35, 47,86, 88,98,AL,MH,UC,A4 Federal Tax ID and/or Either Tax ID or is required Last First Dependent Dep. Last Dep. First Dep. Date of Birth S2,S3 S2,S3,S2,D1, D2, S3 D2, D3 D2, D3 D1, D2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 315
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 316
Physicians Health Plan of Mid-Michigan 11015 Option 1 2 3 4 5 Subscriber Subscriber S2 SSN Subscriber S3 Last First Dependent D1 Dep: Date of Birth Dependent D2 Sub: SSN Dep: Date of Birth Dependent D3 Dep: Last Dep: First Dep: No No No Required and/or 11015 = [NM108=PI]NM109 Last or No notes indicated. No notes indicated. Optional Type and/or 30 Last First SSN Min/Max=9,D1 S3,S2 S2 Dependent Last First SSN D3 D3 D1,D2,D3 D2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 317
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 318
Physicians Plus Insurance Corp 11004 Option 1 2 3 4 5 Subscriber SSN Last First Subscriber S2 SSN Subscriber S3 Last First No No No Required and/or 11004 = [NM108=PI]NM109 Last or /Federal Tax ID indicated. National Provider ID Optional Type and/or 30 Last First SSN,S3,S3,S2,S3 Min\Max=14,S2, S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 319
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 320
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 321
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 322
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 323
Plumbers and Pipefitters Local Union 525 Health & Welfare Trust-10778 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First Dependent D1 Sub: Dep: Dependent D2 Sub: Dep: Last Dep: First Dependent D3 Dep: Last Dep: First Dep: No No No and/or 10778 = [NM108=PI]NM109 Last or Either Tax ID or is required Type and/or 1, 30,33,35, 47,86, 88,98,AL,MH,UC,A4 Federal Tax ID and/or Either Tax ID or is required Last First Dependent Dep. Last Dep. First Dep. Date of Birth S2,S3 S2,S3,S2,D1, D2, S3 D2, D3 D2, D3 D1, D2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 324
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 325
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 326
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 327
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 328
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 329
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 330
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 331
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 332
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 333
Pro-Claim Plus 11014 Option 1 2 3 4 Subscriber Last First Dependent D1 Dep:Last Dep:First Dep: Required and/or 11014 = [NM108=PI]NM109 Last or No notes indicated. Optional Type and/or 30 Last First No notes indicated. Min/Max=16, D2 Dependent Last First D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 334
Professional Benefits Administrators- 10242 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: First Dep: Yes and/or See table above = [NM108=SV]NM109 Type and/or and/or 30 Situational. No notes indicated. Last Provider ID Situational. No notes indicated. First,D1 Max=9 Dependents First D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 335
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 336
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 337
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 338
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 339
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 340
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 341
Santa Clara Family Health Plan 10876 Option 1 2 e 3 4 5 Subscriber Last First 1 year Up to 60 days 60 day NOTE: Eligibility is available only for: Medi Cal Managed Care, Healthy Families, Healthy Kids, and Healthy Workers as delegated to Valley Health Plan Network. and/or 10876 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX.. Max=20 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 342
Schaller Anderson Aetna Better Health of New York 10816 Option 1 2 3 4 Subscriber Subscriber S2 Last First Required and/or 10816 = [NM108=PI]NM109 Last or indicated. indicated. Situational Type and/or The operating rule codeset Last First S2 S2 Min/Max=20 S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 343
Schaller Anderson Aetna Better Health of OH 10887 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First Required and/or 10887 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Last First Required. No S3,S4 S3,S4,S2,S3 S2, S4 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 344
Schaller Anderson Delaware Physicians Care, Inc. 10817 Option 1 2 3 4 Subscriber Subscriber S2 Last First Required and/or 10817 = [NM108=PI]NM109 Last or Required. No Situational Type and/or The operating rule codeset Last First Required. No S2 S2 Min/Max=20 S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 345
Schaller Anderson MajestaCare VA 10818 Option 1 2 3 4 Subscriber Subscriber S2 Last First Required and/or 10818 = [NM108=PI]NM109 Last or Required. No Situational Type and/or The operating rule codeset Last First Required. No S2 S2 Min/Max=20 S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 346
Schaller Anderson Maryland Physicians Care 10693 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No Required and/or 10693 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Last First Required. No S2 S2 Min/Max=9 S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 347
Schaller Anderson Mercy Care 10694 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No Required and/or 10694 = [NM108=PI]NM109 Last or Required. No Situational Type and/or The operating rule codeset Last First Required. No S2 S2 Min/Max=9 S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 348
Schaller Anderson Mercy Maricopa- 10996 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No Required and/or 10996 = [NM108=PI]NM109 Last or Identification Required. No Tax ID or required. Situational Type and/or 1,30,33,35, 47,86, 88, 98,AL,MH,UC,A4,A5 Last First S2,S3 S2,S3 Min=2 Max=80,S2,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 349
Schaller Anderson Missouri Care 10695 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No No Required and/or 10695 = [NM108=PI]NM109 Last or Required. No Required. No Situational Type and/or 1,30,33,35, 47,86, 88, 98,AL,MH,UC,A4,A5 Last First S2 S2 Min/Max=9 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 350
Schaller Anderson Parkland Community Health Plan 10643 Option 1 2 3 4 Subscriber Subscriber S2 Last First No No Date Ranges are allowed. Required and/or 10643 = [NM108=PI]NM109 Last or Required. No Situational / Federal Tax ID Type and/or National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. The operating rule codeset. Last First Either Tax ID or is required S2 S2 Min/Max=20 S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 351
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. indicated. Situational Type and/or The operating rule codeset Last First S2 S2 Min\Max=9 S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 352
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 353
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 354
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 355
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 356
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 357
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 358
Select Health Utah 10575 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: Last Dep: First Dep: No No Yes and/or 10575 = [NM108=PI]NM109 Last or Last First,D1 Type and/or 1,2,4,5,7,11,12,13,18,23 24,25,26,27,28,30,33,34 35,36,37,38,39,40,41,42, 44,47,48,49,,50,52,53,54 56,59,62,66,68,69, 73 75,77,80,81,82,86,88,94 97,98,A4,A6,A8,AD,AF AI,AL,AM,AN,AO,B1,BT BU,BV,CC,CD,CF,CH, CJ,CP,DG,DM,IC,MH,NI PT,RT,UC /Federal Tax ID and/or National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Dependent Dep. Last Dep. First Dep. Date Of Birth D1 D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 359
Senior Care Action Network (SCAN) HMO 00350 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Subscriber S3 Last First Up to 2 years No Yes Required and/or 00350 = [NM108=PI]NM109 Last or indicated. Required. Not notes indicated Situational Type and/or 30, 47, 86, 88, 98, AL, MH, UC Last First, S2, S3, S3,S2, S3,S2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 360
Senior Dimensions 11023 Option 1 2 3 4 Subscriber Last First 1 year No No Required and/or 11023 = [NM108=PI]NM109 Last or No notes indicated. Optional Type and/or 30 Last First No notes indicated. Min/Max=16 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 361
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 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 362
Dep. First Dep. D3 D1 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 363
Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 364
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 365
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 366
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 367
Simply Healthcare Plans 10826 Option 1 2 3 4 Subscriber Subscriber S2 Subscriber S3 Last First Subscriber S4 Last First 1 year No No Required and/or 10826 = [NM108=PI]NM109 Last or Required. No Situational Type and/or The operating rule codeset Last First Required. No S3,S4 S3,S4,S2,S3 S2, S4 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 368
Soundpath Health 10935 Option 1 2 3 4 Subscriber No No No Required and/or 10935 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Required. No Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 369
Spectrum Health 10936 Option 1 2 3 4 Subscriber Subscriber S2 Last First Up to 1 year in Past No No Required and/or 10935 = [NM108=PI]NM109 Last or Required. No Optional Type and/or 30 Last First Required. No S2 S2 S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 370
SPJST Medicare Supplement 10546 Option 1 2 3 4 Subscriber Last First 1 Year 60 Days 60 Days : Data updated twice weekly. Required and/or 10935 = [NM108=PI]NM109 Last or Required. No Situational Type and/or if NM108 = XX The operating rule codset Last First Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 371
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 372
State Mutual (Lincoln Novation) 10982 Option 1 2 3 4 Subscriber Last First No No No and/or 10982 = [NM108=PI]NM109 Last or Last First Type and/or 30 /Federal Tax ID and/or National Provider ID if NM108=XX. Federal Tax ID if NM108=FI. Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 373
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 374
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 375
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 376
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 377
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 378
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 379
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 380
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 381
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 382
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 383
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 384
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 385
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 386
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 387
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 388
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 389
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 390
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 391
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 392
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 393
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 394
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 395
Underwriters Safety & Claims - 10246 Option 1 2 3 4 Subscriber Last First Dependent D1 Sub: Dep: First Dep: Yes and/or See table above = [NM108=SV]NM109 Type and/or and/or 30 Situational. No notes indicated. Last Provider ID Situational. No notes indicated. First,D1 Max=9 Dependents First D1 D1 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 396
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 397
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 398
United American Insurance Company 10990 Option 1 2 3 Subscriber Subscriber S2 Last First Subscriber S3 Last First No No No and/or 10990 = [NM108=PI]NM109 Last or Type and/or and/or 30 Situational. National Provider ID if NM108=XX. Federal Tax ID Situational. No Last S2, S3 First S2, S3,S2 S2, S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 399
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 400
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 401
First State D1,D2 D2 D1,D2 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 402
United Healthcare 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 403
United Healthcare Community 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 404
United Healthcare Community Plan Tennessee 11025 Option 1 2 3 4 Subscriber Last First Subscriber S2 Last Subscriber S3 First Subscriber S4 Subscriber S5 Last First Subscriber S6 Last First Up to 6 months in the Past Up to the end of the current month in the Future Date Ranges allowed - End date of date range must be no greater than the end of the current month Required and/or 11025 = [NM108=PI]NM109 Last or /Federal Tax ID/Provider ID No National Provider ID Situational Type and/or 1,2,3,4,5,6,7,8,10, 12,13,18,20,23,24, 25,26,27,28,33,35,36,37,38,39,40,41,4 2,45,47, 48,49,50,51,52,53, 62,65,68,73,76,78,80,81,82,83,86,88,, 89,90,91,92,93,98,99,A0,A3,A4,A5,A6, A7,A8,AD,AE,AF,AG,AI,,AJ,AK,AL,BG,BH,BT, BU,BV,BW,BX,BY,BZ, DM,GF,GN,MH,UC Last First,S2,S5,S6,S3,S5,S6,S2,S3,S4,S5 Min=2 Max=80,S2,S3,S4,S6 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 405
United Healthcare 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 406
United Healthcare 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 407
United Healthcare 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 408
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 409
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 410
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 411
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 412
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 413
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 414
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 415
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 416
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 417
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 418
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 419
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 420
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 421
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 422
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 423
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 424
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 425
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 426
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 427
Western Health Advantage 1043 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 428
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 429
Windsor Medicare Extra 10576 Option 1 2 3 4 Subscriber Subscriber S2 Last First Subscriber S3 Last First 1 year No No Note: Medicare Part A and Medicare Part B. Termination Date of is a valid day of member eligibility. and/or 10386 = [NM108=PI]NM109 Last or Type and/or 30 Federal Tax ID and/or No No No Last First S2,S3 S2,S3,S2 Min/Max=12,S3 Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 430
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 431
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 432
Payer Maintenance Schedule Payer AARP Absolute Total Care ACS Benefit s Advantage by Bridgeway Health Solutions Advantage by Buckeye Community Health Plan Advantage by Managed Health s Advantage by Superior Care Improvement Advantage Health Solutions Aetna Aetna Administrator Medicare Supplement Aetna Better Health (IL) Aetna Better Health (LA) Aetna Better Health (MI) Aetna Better Health (NE) Aetna Better Health (PA) Aetna Better Health (TX) Aetna Better Health (TX) CHIP Aetna Senior Supplemental Aetna Signature Administrators Aetna Long Term Care Affinity Health Plan Affinity Health Plan Medicare AFLAC AFLAC Dental AFLAC - Medicare Supplemental Aftra Health Fund Alan Sturm and Associates - Dental Allegiance Benefit Plan Management Allied Benefit Systems AlohaCare Alternative Insurance Resources, Inc 11002 Altus Dental AMC Alaska Electrical Health & Welfare Fund AMC American General Life and Accident AMC Health Future AMC Poly America AMC Touchstone AMC Touchstone PSO American Community Mutual American Family Insurance Group-Medicare Supplemental and PPO Policies American Income Life Insurance Company American Medical Security (AMS) American National Insurance Company American National Life Insurance Company TX Stated Downtime Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) Sunday 4:00 am 12:00 pm (Eastern) Mon- Fri 12am 5:00 am (Central) Sunday 4:00 am 12:00 pm (Eastern) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 433
Payer American Network Ins. Medicare Supplement American Postal Workers Union (APWU) American Republic Insurance Company (ARIC) American Retirement Life Ins Co McareSupp AmeriBen AmericChoice of New Jersey (Commercial) AMERIGROUP Amerigroup Corporation AmeriHealth Administrators AmeriHealth Caritas Pennsylvania AmeriHealth (DE, NJ, PA) Ameritas Group Ameritas Life Insurance Co. Ameritas Group First Ameritas of New York Ameritas Group First Reliance Standard Life Ameritas Group Reliance Standard Life Ameritas Group Standard Insurance Ameritas Group Standard Insurance of New York Antares Anthem Vivity Arise Health Plan Medicare Select Policy Arizona Physicians IPA (APIPA) ASR Health Benefits Associacion De Maestros Puerto Rico Assurant Health John Alden Insurance Company (JALIC) Assurant Health Time Insurance Company (FIC) Assurant Health Union Security Insurance Company (FBIC) AultCare Automated Benefit s Auxiant Avera Health Plans AvMed Health Plans Bankers Life and Casualty Banner Health Plans Benefit Management Inc. Best Choice Health Plan Best Life and Health Better Health Plans of Florida Better Health Plans (Unison Health Plans) BlueChoice Health Plan South Carolina Medicaid Bluegrass Family Health Blue Benefit Administrators of Mass BMC HealthNet Plan Stated Downtime sat 11:45pm sun 12pm (Eastern) 1:30 am 6:30am, daily 1:30 am 6:30am, daily 1:30 am 6:30am, daily 1:30 am 6:30am, daily 1:30 am 6:30am, daily 1:30 am 6:30am, daily mon sun 3am 3:15am (Central) Mon- Fri 12am 5:00 am (Central) mon- fri 9pm 5:45am (Central) mon- fri 12am 5:00 am (Central) mon- fri 12am 5:00 am (Central) 12:00 AM Friday to 12:00 AM Saturday of the third weekend every month mon 7pm tue 6am, tue 7pm wed 6am (Central) s s Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 434
Payer Boon Group Bridgespan Bravo Health Bridgeway Arizona Brokers National - Dental Buckeye Community Health Butler Benefit s, Inc. Capitol Administrators Capital District Physicians Health Plan (CDPHP) CAPROCK Care Improvement Plus Care1st Health Plan Arizona Carefirst Federal Employee Program Carefirst Blue Cross Blue Shield CarePoint Medicare Advantage CareSource Health (OH) Carolina Care Plan, Inc. (CCP) Carpenter s Health and Welfare Trust Fund of St. Louis CDS Group Health Celticare Celtic Insurance Cenpatico - Arizona Cenpatico Behavioral Health Cenpatico Behavioral Health Texas Cenpatico Florida Cenpatico Georgia Cenpatico Indiana Cenpatico Kansas Cenpatico - Massachusetts Cenpatico - Mississippi Cenpatico - New Hampshire Cenpatico Ohio Cenpatico South Carolina Centene - Advantage by Peach State Centene - Advantage by Sunshine State Centene Advantage Plans Centene-Coordinated Care Centene-California Health & Wellness Centene - Granite State Health Plan Centene-Home State Health Plan Centene- IlliniCare Health Plan Centene-Kentucky Spirit Health Plan Centene-Louisiana Healthcare Connections Centene-Magnolia Health Plan Centene-Peach State Health Plan Stated Downtime mon fri 9pm 7am, sat 4pm mon 7am (Pacific) mon fri 9pm 7am, sat 4pm mon 7am (Pacific) mon sun 3am 3:15am (Central) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 435
Payer Centene-Sunflower State Health (Kansas) Centene-Sunshine State Health Plan Centene-Total Care Carolina CenterLight Healthcare Central California Alliance for Health Central Reserve Insurance Company Central Reserve Life Ins Co Medicare Supp Central Senior Care Central States Funds Central States Indemnity Cerner Health Plan CHAMPVA/Spina Bifida/Children of Women Vietnam Vets CHC Advantra (TX, NM, AZ Only) CHC Altius Health Plans CHC Advantra Freedom CHC Coventry Health and Life (Nevada) CHC Coventry Health and Life (Oklahoma) CHC Coventry Health Care Carelink (Advantra) CHC Coventry Health Care Carelink Medicaid CHC Coventry Health Care Carenet CHC Coventry Missouri CHC CoventryOne CHC Delaware CHC Diamond Plan (Maryland Medicaid) CHC Florida/Vista/Summit CHC Georgia CHC Group Health Plan (GHP) CHC HealthAmerica&HealthAssurance CHC HealthCare Inc. (Promina) CHC-Coventry Health Care Federal CHC University of Missouri CHC HealthCare USA (HCUSA) CHC Iowa CHC Kansas CHC Louisiana CHC Nebraska CHC - MHNet Behavioral Health CHC OmniCare (Michigan) CHC PersonalCare/Coventry Health of Illinois CHC Southern Health s (SHS) CHC WellPath Select (Carolinas) CHC Coventry Health and Life (Tenn) CHC Advantra Savings CHC Vista (MCD, FHK, LTC) Stated Downtime Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 436
Payer CHC- CoventryCares Children's Mercy PCN Christian Brothers s CHRISTUS Health Plan NM CHRISTUS Health Plan NM Medicare Advantage CIGNA CHP Direct Claims Management Inc CMFG Life Insurance Colonial Penn Life Colorado Access Columbia United Providers Commerce Benefits Group Community Care of Oklahoma Community HealthFirst Medicare Advantage Community Health Plan of Washington (CHPW) Connecticare Consolidated Associates Railroad Consumers Life Continental General Ins Co Medicare Supp Cooperative Benefit Administrators (CBA) CoreSource (FMH) CoreSource (Little Rock) CoreSource (MD,PA,IL,NC,IN,AZ,MN) CoreSource (OH) Country Cupboard Country Life Insurance Company Covenant Administrators (TPA) Coventry Healthcare National Network Coventry Nebraska Medicaid Cox Health Plan CSA Fraternal Live Medicare Supp CTI Administrators Culinary Health Fund DakotaCare DeCare Dental Health Insurance Definity Health Delaware Physicians Care Delta Dental Ins. Co. - Alabama Delta Dental Ins. Co. - Florida Delta Dental Ins. Co. - Georgia Delta Dental Ins. Co. - Louisiana Delta Dental Ins. Co. - Mississippi Stated Downtime mon fri: 10pm 7am, sat 8pm sun 2pm, sun 8pm mon 7am (Eastern), Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) Mon- Sat 12:00am to 6:00am, All Day Sunday Every Sunday Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 437
Payer Delta Dental Ins. Co. - Montana Delta Dental Ins. Co. - Nevada Delta Dental Ins. Co. - Texas Delta Dental Ins. Co. - Utah Delta Dental of California Delta Dental of Colorado Delta Dental of Delaware Delta Dental of Hawaii Delta Dental of Indiana Delta Dental of Maryland Delta Dental of Michigan Delta Dental of Minnesota Delta Dental of Nebraska Delta Dental of New Jersey Delta Dental of New Mexico Delta Dental of New York Delta Dental of North Carolina Delta Dental of North Dakota Delta Dental of Ohio Delta Dental of Pennsylvania Delta Dental of Rhode Island Delta Dental of Tennessee Delta Dental of Virginia Delta Dental of Washington DC Dental of Washington State Delta Dental of West Virginia DeltaCare USA - Encounters DeltaCare USA - Claims Denver Health Medical Plan Deseret Mutual (DMBA) Director's Guild Employee Benefit s EBMS EPIC Life Insurance EPSI, Inc. Essence Healthcare Evangelical Community Hospital Evercare Everence Financial Evergreen Health Co-Op Expert Benefit Solutions Fallon Community Health Plan FamilyCare FCE Benefit Administrators Inc Federated Insurance Company Fidelis Care New York Stated Downtime Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 438
Payer Fidelis SecureCare of Michigan FirstCare First Medical Network First United American Insurance Company Flex Compensation - Dental Florida Combined Life - Dental Florida Hospital Healthcare System Florida True Health Food Employers & Bakery Workers Benefit Food Employers & Bakery Confectionary Workers Benefit Fresenius Medical Care GHI - Group Health Incorporated Gilsbar Globe Life & Accident Insurance Company Government Employees Hospital Association GEHA Great-West Healthcare Group Health Cooperative of South Central Wisconsin - Dental Group Practice Affiliates Guardian Life Insurance Co. of America - Dental Harmony Health Plan Hawaii Medical Assurance Association - Dental Health Alliance Medical Plan (IL) Health Alliance Medical Plans (HAP) Health Choice Arizona Health Cost Solutions Health First Health Plan Health Net National Health Partners (Minnesota) Health Partners of Philadelphia Health Plan of San Mateo Health s for Children with Special Needs Health Share of Oregon Healthcare Solutions Group HealthComp Administrators HEALTHe Exchange HealthEase HealthEase Kids Healthfirst New Jersey Healthfirst New York Healthgram HealthMarkets (Chesapeake National Life) Stated Downtime mon-sun 11:30pm-2:30am (CST) mon - fri 5:20am-6am, 5:25pm-6:55pm, sat 5:20am- 6:35am, sun 12:15pm-2:30pm, 6pm-10:00pm (Central) Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) sat 8pm sun 4am (Mountain) Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) Mon 3am sun 3:15am (Central) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 439
Payer HealthMarkets (Mega Life and Health Insurance) HealthMarkets (Mid-West National Life) HealthMarkets (TransAmerica Life) HealthNow HealthPlan of Nevada HealthPlans Inc HealthPlus of Michigan Healthsource Provident - Dental HealthSpring Healthy Texas Heritage Physician Network (Houston) Hershey Healthsmile - Dental HIPNY Hometown Health Horizon New Jersey Health Humana Humana CareSource (KY) Humana of Florida IBEW Local 508 Health Plan IBM Insurance Outsourcing s Ideal Life Insurance Independence Administrators Inland Empire Health Insurers Administrative Corporation (IAC) Integrated Mental Health s Inter Valley Health Plan International Medical Card Inc Island Home Insurance Jackson Memorial Hospital Health Plan John Hopkins Health Plan Kaiser Foundation Health Plan of Colorado Kaiser Foundation Health Plan of Hawaii Kaiser Foundation Health Plan of Hawaii (DHMO Choice) Kaiser Foundation Health Plan of the Mid- Atlantic Kaiser Foundation Health Plan of the Northwest Kaiser Permanente of Georgia Kaiser Permanente of Northern CA Kaiser Permanente of Southern CA Kentucky Health Exchange Keystone Mercy Health Stated Downtime Sat evening 6pm until Sunday evening 6pm 2 nd weekend of every month where unavailability will be between 1 hour and 2 days sun 2am sun 3am (Central) No Information Available sat 11:45pm sun 12pm (Eastern) mon sun 3am 3:15am (Central) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) Mon-Fri 11:30pm 2:00am (PST). Sat-Sun 12:00am 4:00am (PST) 2 nd weekend of every month where unavailability will be between 1 hour and 2 days Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 440
Payer Kitsap Physician s KSKJ Life Leggett & Platt Leon Medical Centers Health Plan Liberty National Life Insurance Company Lifetime Benefit Solutions (RMSCO) Lifewise Arizona Lifewise Health Plan of Oregon Lifewise Health Plan of Washington Lincoln Heritage Lincoln Financial Local 1199 LoneStar TPA Loomis Company Louisiana Health Exchange Lovelace Health Plan Loyal American Life Ins Co Medicare Supp Magellan Behavioral Health Magnacare Managed Care of America Mail Handlers Benefit Plan Managed Health s Indiana Managed Health s Wisconsin MAPFRE Life Puerto Rico MAPFRE Medicare Excel Maricopa Care Advantage (Arizona) Maricopa Health Plan (Arizona) MDWise Hoosier Alliance MedBen - Newark OH MedCost Benefit s Medica Medica Health Plan Medical Card System Medical Mutual of Ohio Medicare (Part A & B) Medicare Advantage - Pennsylvania Medicare y Mucho Mas (INMEDIATA HEALTH GROUP) Med-Pay, Inc MedStar Family Choice Mega Life (Oklahoma City) Mercy Care Plan (Arizona) Mercy Health Plan Meritus Health Partners Stated Downtime Sunday 12am 11:59pm (Eastern) Sunday 12am 11:59pm (Eastern) Available 24/7 with regular maintenance scheduled the 2nd Sat of each month; outage may last from late Fri - Sun afternoon. Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) sun 10pm mon 3am (Eastern) Sat 9AM-5:59PM, Sun Unavailable (Central) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 441
Payer MetLife Dental Family Metropolitan Health Plan (MHP) Michigan MI Child Mid Atlantic Medical s-mamsi Health Plan Mississippi State Employees and Teachers Missouri Care MMSI (Mayo Health) Moda Health Molina Healthcare of California Molina Healthcare of Florida Molina Healthcare of Illinois Molina Healthcare of Indiana Molina Healthcare of Michigan Molina Healthcare of Missouri Molina Healthcare of New Mexico Molina Healthcare of Ohio Molina Healthcare of South Carolina Molina Healthcare of Texas Molina Healthcare of Utah Molina Healthcare of Washington Municipal Health Benefit Fund Mutual Health s Mutual of Omaha MVP Health Care (New York) National Association of Letter Carriers (NALC) National Telecommunications Cooperative Association (NTCA) Nationwide Health Plans NEHEN Harvard Pilgrim Health Care NEHEN Neighborhood Health Plans NEHEN Tufts Associated Health Plan Network Health Plan of WI New Era Life Insurance Company NGS American North Carolina Medicaid Nova Healthcare Administrators NovaSys Health Ohana Health Plan Oklahoma Employees Group Insurance Division Operating Engineers Local No.428 Operating Engineers Local.428 Health and Welfare Optima/Sentara Orange County Fire Authority Stated Downtime mon 11pm 12am, tues fri 11am -3a, sat 4pm-5:30pm, sun 2am 9am, holiday times vary mon sun 3am 3:15am (Central) Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) mon 2am 4am (Central) sat 9pm mon 2:15am. (Central) Mon 11 pm - Tue 6 am; Tue 11 pm - Wed 6 am; Wed 11 pm - Thu 6 am and Thu 11 pm - Fri 6 am (Central) wed 9pm thur 2am (Eastern) Sun 4am 6am (Eastern) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 442
Payer Oscar (NY) Oxford Health Plans Pacific Source Health Plan PacifiCare (PPO) PacifiCare of California (HMO) Pacificare of Oklahoma (HMO) Pacificare of Oregon (HMO) Pacificare of Texas (HMO) Pacificare of Washington (HMO) Pacificare of Arizona (HMO) Pacificare of Colorado (HMO) Pacificare of Nevada (HMO) Panamerican Life Puerto Rico Paramount Health Patriot Dental Partners National Health Plans of NC Partnership Health Plan of California Passport Advantage Passport Health Plan Peach State Health Plan People First Peoples Health Piedmont (GA) Preferred Health System of Kansas Preferred Medicare Choice (PMC) (INMEDIATA HEALTH GROUP) Premier Health Presbyterian Health Plan Pro-Claim Plus Phoenix Health Plan Physicians Health Plan Northern IN Physicians Health Plan of Mid-Michigan Physicians Mutual Insurance Company Physicians Plus Insurance Corp Piedmont Wellstar HealthPlans Pittman and Associates Plan de Salud Hospital Menonita Planned Administrators Inc. Plumbers and Pipefitters Local Union 525 Preferred Care Partners Preferred Health Systems PreferredOne Prestige Health Choice Principal Financial Group (Nippon Life) Stated Downtime mon fri 2am 4am sat 11pm 6am (Eastern) Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 3 rd Friday of every month 12am 5am (Pacific) 2 nd weekend of every month where unavailability will be between 1 hour and 2 days 2 nd weekend of every month where unavailability will be between 1 hour and 2 days sun 3am to 3:15am (Central) 11pm- 5:45 am mon-fri 7pm 5:45 am weekends (Central) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 443
Payer Principal Financial Group (Principal Life) Priority Health Providence Health Plan Provident American Life & Health McareSupp Provident Preferred Network - Dental Public Employees Health Plan Puritan Life Insurance Qualchoice QuikTrip Corporation Boon-Chapman Benefit Admin Corporate Benefit Group & Pension Administrators JP Farley Corporation Professional Benefits Administrators Underwriters Safety & Claims Rocky Mountain Health Plan Royal Neighbors of America S and S Healthcare Strategies Sanford Health Plan San Francisco Health Plan San Joaquin Health Plan Santa Clara Family Health Plan Schaller Anderson Aetna Better Health of New York Schaller Anderson Aetna Better Health of OH Schaller Anderson Delaware Physicians, Inc. Schaller Anderson MajestaCare VA Schaller Anderson Maryland Physicians Care Schaller Anderson Mercy Care Schaller Anderson Missouri Care Schaller Anderson Texas CHRISTUS Scott & White Health Plan Secure Health Plans of Georgia Security Health Plan Securian Dental Securian/Patriot Dental Senior Health s Center Universal American Family of Companies Senior Whole Health Select Health SC Select Health Utah Senior Care Action Network (SCAN) HMO Shenandoah Life Insurance Sierra Health s Stated Downtime 11pm- 5:45 am mon-fri 7pm 5:45 am weekends (Central) mon sun 3am to 3:15am (Central) Sun 4:00p-5:00p, occasionally 8:00p-8:30p (EST) Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm (MT) mon sun 3am 3:15am (Central) Every second weekend of the month from 1hour to 2 days. Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 444
Payer Significa Benefit s Simply Healthcare Plans Special Agents Mutual Benefit Association SPJST Medicare Supplement Standard Life and Accident Insurance Company Star HRG State Mutual Med Supp. State Mutual (Lincoln Novation) StayWell StayWell Kids Sterling Investors Life Insurance Student Insurance SummaCare Health Plan Sunshine State Superior HealthPlan Texas TennDent TexanPlus North Texas Area TexanPlus Southeast Texas Area The Kempton Company Three Rivers Health Plans (Unison Health Plan) TMG Network Health Insurance Today s Health Today s Options Total Healthcare Tribute/SelectCare of Oklahoma TRICARE TRICARE for Life Triple-S Salud (BCBS Puerto Rico) Trustmark Insurance Ucare of Minnesota Ultimate Health Plans UMR UNICARE - Dental Unicare(Wellpoint) Union Pacific Railroad Employees Health Systems United American Insurance Company United Healthcare United Healthcare Community Plan - Tennessee United Healthcare Plan of River Valley United Healthcare SecureHorizons Stated Downtime sun 11:30pm mon 4am mon 11:30pm tue 4am tue 11:30pm wed 4am wed 11:30pm thu 4am thu 11:30pm fri 4am fri 11:30pm sat 4am sat 11:30pm sun 4am sun 3pm 10pm (Eastern) Thurs 5:30am-8:00am (MT) Sun 9:00am-12:00pm (MT) Thurs 5:30am-8:00am (MT) Sun 9:00am-12:00pm (MT) Thurs 5:30am-8:00am (MT) Sun 9:00am-12:00pm (MT) Thu 9:00pm 11:30pm (MST) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 445
Payer United Teachers Associates Ins Co McareSupp United Concordia Federal Employees Program - Dental United Concordia Companies, Inc. - Dental UnitedHealthcare Community Plan Kansas UnitedHealthcare Facets Detroit Community and State UnitedHealthcare Facets Pittsburgh Community and State UnitedHealthcare Nevada Market United Healthcare SecureHorizons Unity Health Plans University Care Advantage Arizona University Family Care University of Arizona Health Plan - UHM University of Utah Health Plans University Physicians Care Advantage (AZ) University Physicians Healthcare Group (AZ) UPMC Health Plan (Tristate) USAA Life Insurance Company VA Fee Basis Program VA Health Administration Center VA Healthcare VA Health Administration Center Vantage Health Plan, Inc. VIVA Health VNS CHOICE VYTRA Washington National WEA Trust WEB-TPA, Inc. Well Sense Wellcare Health Plan Wells Fargo Third Party Administrators, Inc. (CHIP and PEIA) Western Health Advantage Wilson McShane - Dental Windsor Medicare Extra World Insurance (ARIC) WPS Health Insurance Stated Downtime 2nd Friday of the month brief outage at 4am VA Health Administration Center Sun 4:00p-5:00p, occasionally 8:00p-8:30p (EST) Xerox EDI Eligibility Gateway 270/271 5010 Payer Guide Commercial 446