Fallon Community Health Plan - WebMD POS Transaction Guide Eligibility & Benefits

 
WebMD POS Transaction Guide

     Fallon Community
            Health Plan
               Eligibility & Benefits

                   MEDIFAX MASS 1.00
                     October 11, 2004
                         Pub # 04-288:POSFAL
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 © 2004, WebMD Corporation. All rights reserved. Printed in the USA.
Contents
                Requests                                                                                                                              1
                         Overview.......................................................................................................................1
                                Disclaimer........................................................................................................1
                         Running Transactions ...................................................................................................1
                                Eligibility Verification.....................................................................................1
                                Entering Letters on Your POS .........................................................................2

                Responses                                                                                                                             3
                         About Your Responses .................................................................................................3
                                Input Information.............................................................................................3
                                Fallon HealthPln Information ..........................................................................3
                                Information Source ..........................................................................................4
                                Information Source Contact.............................................................................5
                                Information Receiver .......................................................................................5
                                Subscriber ........................................................................................................6
                                Subscriber Contact...........................................................................................8
                                Subscriber Additional ID .................................................................................8
                                Subscriber Date................................................................................................9
                                Eligibility/Benefit ............................................................................................9
                         Error Messages ...........................................................................................................13

                Values                                                                                                                              15
                         Eligibility/Benefit Values ...........................................................................................15
                         Service Types..............................................................................................................17
                         Insurance Types ..........................................................................................................21
                         Entity Types................................................................................................................23

                Customer Service                                                                                                                    25
                         WebMD/Medifax EDI Customer Service ..................................................................25

                Index                                                                                                                               27

Fallon Community Health Plan Eligibility                                                                                              Contents • i
ii • Contents   Fallon Community Health Plan Eligibility
Requests

Overview
                                 A WebMD Fallon Community Health Plan (Fallon) eligibility transaction
                                 allows you to verify a member's eligibility status for a date of service of up to
                                 one year in the past. Future dates of service are not allowed.

                                 Disclaimer
                                 Your response may contain a disclaimer. Please review the response for any
                                 disclaimer information.

Running Transactions
                             Eligibility Verification

                              Step   You See:                     Do This:

                                1     multipayer idle prompt:     - Press key 1 to start the Massachusetts payer program.
                                      MEDIFAX MAV                 MEDIFAX MASS 1.00 displays briefly.
                                2     ENTER PASSWORD              - Enter the six- to eight-digit password you have set for
                                                                    your POS device.
                                                                  - Press FUNC/ENTER.
                                                                  Asterisks will appear as you type to ensure privacy.
                                                                  For information on creating or changing your password, see
                                           to update passwords:
                                                                  the POS Basics Guide - Massachusetts Multipayer.

                                3     PRESS A KEY 1-7             - Press 3.
                                                                  ELIGIBILITY displays briefly.
                                4     PAYER ID?                   - Press 4.
                                                                  FALLON HEALTHPLN displays briefly.

Fallon Community Health Plan Eligibility                                                                       Requests • 1
Step    You See:                     Do This:

                  5    SERVICE PROV ID              - Enter the one- to two-digit provider ID code assigned to
                                                      the inquiring provider on your POS device.
                                                    - Press FUNC/ENTER.
                                                    The provider’s name displays briefly.
                                                    To print a list of provider codes and associated providers,
                        to print provider codes:    press CLEAR to cancel your transaction and return to the
                                                    idle prompt. Press FUNC/ENTER, then 5.
                  6    MEMBER ID                    - Swipe the member’s Fallon member ID card.
                                                    or
                                                    - Enter member’s Fallon member ID exactly as it appears
                                                      on the hard card.
                                                    - Press FUNC/ENTER.

                                to enter letters:   See “Entering Letters on Your POS” on page 2.
                  7    DATE OF BIRTH                - Enter the patient’s date of birth, in MMDDCCYY
                                                      format.
                                                    - Press FUNC/ENTER.
                  8    GROUP NUMBER                 - Enter the member’s Fallon group number.
                                                    or
                                                    - Just press FUNC/ENTER to skip to the next prompt.
                  9    DATE OF SERVICE              - Enter the date of service, in MMDDCCYY format.
                                                    - Press FUNC/ENTER.
                                                    or
                                                    - Just press FUNC/ENTER for today’s date.

               Entering Letters on Your POS
               If you do not have a keyboard attachment, enter letters as follows:
                           1. Press the key on which the letter appears.
                           2. Press ALPHA once, twice, or three times to display the correct
                              letter.
               If you pass the letter you want to enter, you can continue to press ALPHA to
               cycle through the letters again.
               Special characters are found on the * and 0 keys. The letters Q and Z are found
               on key 1.

2 • Requests                                                     Fallon Community Health Plan Eligibility
Responses

About Your Responses
                                 All of the items described in this response explanation may not appear in
                                 every response. The database will return only the information that is
                                 applicable to your query.
                                 If the database does not return a particular piece or section of information in
                                 a specific response, the headings for that information will not print. Items
                                 will shift position to fill the vacancy.

                                 Note: To reprint a response, press FUNC then 1.

                                 Input Information
                                 The Input Information section lists the input prompts in the query and the
                                 data you entered in response to them.

                                 Fallon HealthPln Information
                                 The Fallon Community Health Plan Information section returns reference
                                 information for this particular transaction. This section occurs once.

                                 Submit ID
                                    The submitter transaction identifier is used to trace a transaction from
                                    point to point.

                                 Date
                                     The transaction set creation date is the date the transaction is generated
                                     by the payer/fiscal intermediary (in MM/DD/CCYY format).

Fallon Community Health Plan Eligibility                                                         Responses • 3
Time
                    The transaction set creation time is the time the transaction is generated
                    by the payer/fiscal intermediary (in HH:MM:SS format). Based on a
                    24-hour clock (e.g., 13:12:00 = 1:12:00 PM).

                Benefit Ind
                   Indicates the presence or type of benefit information in the response.
                        Y = Benefit information exists
                        N = No benefit information exists

                Medicare Ind
                    Indicates the member’s Medicare coverage.
                        NA = Unable to determine if Medicare information is present in the
                         response from the payer.

                Other Payer Ind
                    Indicates the member’s Other Payer coverage.
                        NA = Unable to determine if Other/Additional Payer information is
                         present in the response sent from the payer.

                Information Source
                The Information Source section identifies the source of the information being
                returned. This section occurs once.

                Primary ID
                    The primary identification number for the information source.

                Name
                   The last name or the organization name of the information source.

                First
                     If the information source is a person and data is provided, the person's
                     first name.

                Middle
                    If the information source is a person and data is provided, the person's
                    middle initial.

                Suffix
                     If the information source is a person and data is provided, the suffix to
                     the person's name.

4 • Responses                                          Fallon Community Health Plan Eligibility
Information Source Contact
                                 The Information Source Contact section returns a contact name and up to
                                 three telephone numbers or e-mail addresses to use when contacting the
                                 information source. This section can occur up to three times.

                                 No Heading (Name)
                                     The name of an individual or group contact to use when contacting the
                                     information source.

                                 No Heading (Contact Information)
                                     The type of contact information and either the telephone number (in
                                     9999999 or 999-999-9999 format) or e-mail address for the individual
                                     or group named in the previous field. Up to three contact telephone
                                     numbers or e-mail addresses can occur for each contact.

                                 Information Receiver
                                 The Information Receiver section identifies the receiver of the eligibility and
                                 benefit information (for example, a provider, medical group, IPA, or
                                 hospital). This section occurs once.

                                 Primary ID
                                     The primary identification number for the information receiver.

                                 Name
                                    The last name or the organization name of the information receiver.

                                 First
                                      If the information receiver is a person and data is provided, the person's
                                      first name.

                                 Middle
                                     If the information receiver is a person and data is provided, the person’s
                                     middle initial.

                                 Suffix
                                      If the information receiver is a person and data is provided, the suffix to
                                      the person’s name.

Fallon Community Health Plan Eligibility                                                         Responses • 5
Subscriber
                The Subscriber section returns a unique trace or reference number assigned
                to identify the transaction. It may also return personal information about the
                member. This section occurs once.

                Trce1
                    A number assigned by Medifax to identify the transaction.

                No Heading (Origin 1)
                    The originator of the preceding trace number. The value returned will
                    be 9MEDIFAX.

                No Heading (Origin 1 Description)
                    Any additional information about the originator of the preceding trace
                    number.

                Trce2
                    A number assigned by WebMD to identify the transaction.

                No Heading (Origin 2)
                    The originator of the preceding trace number. The value returned will
                    be 9WEBMD.

                No Heading (Origin 2 Description)
                    Any additional information about the originator of the preceding trace
                    number.

                Primary ID
                    The member’s Fallon primary identification number.

                Last
                       The member’s last name.

                First
                     The member’s first name.

                Middle
                    The member’s middle initial.

                Prefix
                     The prefix to the member’s name. This field is only used to return
                     military rank.

6 • Responses                                          Fallon Community Health Plan Eligibility
Suffix
                                      The suffix to the member’s name.

                                 DOB
                                    The member’s date of birth in MM/DD/CCYY format.

                                 Gender
                                    The member’s gender.
                                           Female
                                           Male
                                           Unknown

                                 No Heading (Subscriber's Address)
                                     The member’s address.

                                 No Heading (Location)
                                     The type of location and the location of the member’s address.

                                 Student Sts
                                     A code indicating the patient's student status if he/she is 19 years of age
                                     or older, is not handicapped, and is not the insured.
                                           F = Full-time
                                           N = Not a student
                                           P = Part-time.

                                 Hcap Ind
                                     Indicates the handicapped status of the member.
                                           Y = Member is handicapped
                                           N = Member is not handicapped.

                                 Birth Seq
                                      A number assigned to each family member who is born with the same
                                      birth date.

                                 Chng
                                    Indicates whether any identifying elements for the member have
                                    changed from those submitted in the request. Y or N.

Fallon Community Health Plan Eligibility                                                        Responses • 7
Subscriber Contact
                The Subscriber Contact section returns a contact name and up to three
                telephone numbers or e-mail addresses to use when contacting the member.
                This section can occur up to three times.

                No Heading (Name)
                    The name of the individual or group to use when contacting the
                    member.

                No Heading (Contact Information)
                    The type of contact information and either the telephone number (in
                    9999999 or 999-999-9999 format) or e-mail address for the individual
                    or group named in the previous field. Up to three contact telephone
                    numbers or e-mail addresses can occur for each contact.

                Subscriber Additional ID
                The Subscriber Additional ID section returns an identification number other
                than or in addition to the member identification number for the member. If
                the member's Medicaid ID number or Medicare Health Insurance Claim
                (HIC) number is different than the Primary ID number given in the
                Subscriber section, then the Medicaid ID or Medicare HIC number will be
                returned here.
                This section can occur up to nine times.

                No Heading (Supplemental Identifier)
                    The type of identification number followed by the identification
                    number.

                No Heading (Supplemental ID Description)
                    Free-form text further describing the supplemental identifier in the
                    previous field.

8 • Responses                                         Fallon Community Health Plan Eligibility
Subscriber Date
                                 The Subscriber Date section returns a date relating to the member’s
                                 eligibility/benefits. This section can occur up to nine times.

                                 No Heading (Date)
                                     The type of date, followed by the date (in MM/DD/CCYY or
                                     MM/DD/CCYY-MM/DD/CCYY format).
                                      If the type of date returned in this section is Eligibility, Eligibility
                                      Begin, Eligibility End, Admission, or Service, it is implied that the
                                      date applies to all Eligibility/Benefit sections that follow unless there is
                                      a specific date in the Eligibility/Benefit section.

                                 Eligibility/Benefit
                                 The Eligibility/Benefit section returns specific eligibility and benefit
                                 information for the subscriber or patient. This section can occur up to 999
                                 times.

                                 No Heading (Eligibility/Benefit Type Description)
                                     The type of eligibility or benefit being reported. See
                                     “Eligibility/Benefit Values” on page 15.

                                 No Heading (Coverage Description)
                                     A description of the level of coverage of benefits.

                                 No Heading (Service Type Description)
                                     A description of the classification of service. See “Service Types” on
                                     page 17.

                                 No Heading (Insurance Type Description)
                                     A description of the type of insurance policy. See “Insurance Types”
                                     on page 21.

                                 Plan Cvg
                                     Free-form text further describing the plan or coverage.

                                 Period
                                     A code and/or description which identifies the time period category for
                                     the benefits being described.

                                 No Heading (Amount)
                                     The amount associated with the benefit (in $9,999.99 format).

Fallon Community Health Plan Eligibility                                                          Responses • 9
No Heading (Percent)
                     A percentage associated with the benefit (in 99% format).

                 No Heading (Quantity)
                     The benefit quantity.

                 Auth/Cert
                     Indicates if authorization or certification is required.
                         Yes
                         No
                         Unknown

                 In Ntwk
                      Indicates if benefits are considered in- or out-of-plan network.
                         Yes
                         No
                         Unknown

                 No Heading (Product/Svc ID)
                     A description of the product/service ID, followed by the product/service
                     ID code.

                 Proc Mod1 through Proc Mod4
                     A modifier for the product/service ID. Up to four modifiers may
                     appear.

                 No Heading (Health Care Service Delivery)
                     A delivery or usage pattern that is associated with the service type or
                     product/service ID returned in this Eligibility/Benefits section.
                      Health care service delivery information can occur up to nine times and
                      can include the following types of data:

                         •   The service or product quantity; e.g., Units: 5.
                         •   The service or product frequency, in terms of the unit of
                             measure; e.g., Week: 3 (three per week).
                         •   The type and number of periods of delivery; e.g., Mo: 2 (two
                             months).
                         •   Text description of the frequency of delivery; e.g., Mon thru
                             Fri.
                         •   Text description of the delivery time; e.g., A.M.

10 • Responses                                           Fallon Community Health Plan Eligibility
No Heading (Additional Identification)
                                     Additional identification type and identification relating to the benefit
                                     reported in this Eligibility/Benefit section. A free-form text description
                                     can follow.
                                      Up to nine additional identifiers and free form text descriptions can
                                      appear.

                                 No Heading (Patient Dates)
                                     Additional type of date and date (in MM/DD/CCYY or
                                     MM/DD/CCYY-MM/DD/CCYY format) relating to the benefit in this
                                     Eligibility/Benefit section.
                                      Up to 20 additional date types and dates can appear.

                                 No Heading (Message)
                                     Free-form text message relating to the benefit reported in this
                                     Eligibility/Benefit section. Up to ten messages can appear.

                                 No Heading (Eligibility or Benefit Additional Information)
                                     A code and description that identifies either:

                                           •   Information used to determine eligibility.
                                           •   Limitations to service at a particular facility.
                                      Up to ten codes and descriptions can appear.

                                 No Heading (Benefit Related Entity)
                                     Identifies a type of entity related to the benefit returned in this
                                     Eligibility/Benefit section. May be used to identify the member by
                                     name and/or identification number, a provider (for example, the
                                     primary care provider), an individual, another payer, or another
                                     information source.
                                      Benefit-related entity information appears once and can include the
                                      following lines of data:

                                           •   The type of entity; see “Entity Types” on page 23.
                                           •   The last name of the related entity or the organization name.
                                           •   The first name, middle name, and suffix, if the entity is a person.
                                           •   The related entity’s ID code.
                                           •   The type of provider, if applicable.
                                           •   The provider identifier, if applicable.
                                           •   The related entity’s address.
                                           •   The Department of Defense Health Service Region, if applicable.

Fallon Community Health Plan Eligibility                                                          Responses • 11
No Heading (Related Entity Contact)
                     Additional contact information for the benefit related entity identified
                     by the data described by the benefit related entity information above.
                      Up to three contacts can appear with the following lines of data:

                         •   The name of the contact.
                         •   The type of contact information and either the telephone number
                             (in 9999999 or 999-999-9999 format) or e-mail address for the
                             contact. Up to three contact numbers or e-mail addresses can
                             appear for each contact.

12 • Responses                                          Fallon Community Health Plan Eligibility
For support, call 1-800-333-0263

Error Messages
                                 WebMD Announcement
                                    Occasionally you will see this message, followed by a line or so of text.
                                    Such messages are used to convey pertinent information about
                                    WebMD/Medifax EDI products, such as program changes, new
                                    product releases, or additional databases that are available to you. Call
                                    your sales representative or WebMD/Medifax EDI Customer Service if
                                    you would like more information.

                                 CL0001 – Medifax Account Suspended – Please Call Customer
                                 Service
                                     Your customer account has been turned off. Call WebMD/Medifax
                                     EDI Customer Service.

                                 CL0002 – Incomplete Customer Information – Please Call
                                 Customer Service
                                     Your customer account information is incomplete. Call
                                     WebMD/Medifax EDI Customer Service.

                                 CL0003 – Insufficient Information To Complete A Search – Please
                                 Call Customer Service
                                      Call WebMD/Medifax EDI Customer Service.

                                 CL0004 – Please Call Customer Service For Program Update
                                    Call WebMD/Medifax EDI Customer Service.

                                 CL0005 – Unknown Transaction Request – Please Call Customer
                                 Service
                                     Retry the transaction. If the problem repeats, call WebMD/Medifax
                                     EDI Customer Service.

                                 CL0006 – Invalid APPLID
                                    Call WebMD/Medifax EDI Customer Service.

                                 CL997 – Please Call 1-800-333-0263
                                    An invalid autograph (the first three bytes of the request) was sent with
                                    your request. Call WebMD/Medifax EDI Customer Service.

                                 HT0015 – Invalid Date Of Birth
                                    You entered a date of birth that is the wrong length, is not an actual
                                    date, or contains invalid characters.

Fallon Community Health Plan Eligibility                                                      Responses • 13
For support, call 1-800-333-0263

                               HT0031 – Provider Not On File
                                  The provider you entered is not on file in the payer’s database.

                               HT0103 – Invalid Recipient ID Card
                                  The recipient ID card number you entered or that was read from the
                                  card’s magnetic strip is the wrong length or contains invalid characters.

                               HT0108 – Invalid Recipient ID
                                  You entered a recipient ID that is the wrong length or contains invalid
                                  characters.

                               HT0499 – Invalid/Missing Date Of Birth
                                  Your request did not include a date of birth, or the date of birth you
                                  entered is the wrong length, is not a real date, or contains invalid
                                  characters.

                               HT0502 – Invalid/Missing Provider ID
                                  The provider ID was invalid or missing.

                               HT0641 – Group Number Invalid
                                  You entered a group number that is the wrong length or contains invalid
                                  characters.

                               RH0085 – Unable To Respond At Current Time
                                  The payer’s database is unable to respond at the current time. Wait a
                                  short period of time; and then retry the transaction. If the problem
                                  persists, call WebMD/Medifax EDI Customer Service.

                               RH0252 – Invalid/Missing Subscriber/Insured ID
                                  The subscriber/insured ID was invalid or missing.

                               RH0502 – Invalid/Missing Provider ID
                                  The provider ID was invalid or missing.

                               RH0547 – Subscriber/Insured Not Found
                                  The subscriber/insured was not found in the payer’s database using the
                                  information you entered.

                               SM0001 – Stand-In Message
                                  The payer has been placed in stand-in mode.

14 • Responses                                                       Fallon Community Health Plan Eligibility
Values

Eligibility/Benefit Values
                                 The payer can return any of the values listed below.

                                  Value in Response                     Description
                                  Actv Cvg                              Active Coverage
                                  Actv – Full Risk Capitation           Active - Full Risk Capitation
                                  Actv – Srvcs Capitated                Active - Services Capitated
                                  Actv – Srvcs Capitated to PCP         Active - Services Capitated to Primary Care
                                                                        Physician
                                  Actv – Pend Investigation             Active - Pending Investigation
                                  Inactv                                Inactive
                                  Inactv – Pend Elig Updte              Inactive - Pending Eligibility Update
                                  Inactv – Pend Investigation           Inactive - Pending Investigation
                                  Co-Ins                                Co-Insurance
                                  Co-Pay                                Co-Payment
                                  Ded                                   Deductible
                                  Cvg Basis                             Coverage Basis
                                  Bene Descrip                          Benefit Description
                                  Exclusions                            Exclusions
                                  Limitations                           Limitations
                                  Out of Pckt (Stop Loss)               Out of Pocket (Stop Loss)
                                  Unlim                                 Unlimited
                                  Non-Cvd                               Non-Covered
                                  Cost Containment                      Cost Containment
                                  Rsv                                   Reserve
                                  PCP                                   Primary Care Provider
                                  Pre-existing Cond                     Pre-existing Condition
                                  MC Coord                              Managed Care Coordinator

Fallon Community Health Plan Eligibility                                                                 Values • 15
Value in Response                           Description
              Svces Restricted to Following Prov           Services Restricted to Following Provider
              Not Deemed a Med Necessity                  Not Deemed a Medical Necessity
              Bene Disclmr                                Benefit Disclaimer
              2nd Surg Opinion Reqd                       Second Surgical Opinion Required
              Other/Addl Payer                            Other or Additional Payer
              Prior Year(s) History                       Prior Year(s) History
              Card(s) Rptd Lost/Stolen                    Card(s) Reported Lost/Stolen
              Contact Following Entity for Elig or Bene   Contact Following Entity for Eligibility or
              Info                                        Benefit Information
              Cannot Process                              Cannot Process
              Other Sce of Data                           Other Source of Data
              Health Care Facility                         Health Care Facility
              Spend Down                                  Spend Down

16 • Values                                               Fallon Community Health Plan Eligibility
Service Types
                                 The payer can return any of the values listed below.

                                  Value in Response                     Description
                                  Med Care                              Medical Care
                                  Surg                                  Surgical
                                  Consultation                          Consultation
                                  Dx X-Ray                              Diagnostic X-Ray
                                  Dx Lab                                Diagnostic Lab
                                  Radiation Thrpy                       Radiation Therapy
                                  Anesth                                Anesthesia
                                  Surg Asstnce                          Surgical Assistance
                                  Other Medcl                           Other Medical
                                  Blood Charges                         Blood Charges
                                  Used DME                              Used Durable Medical Equipment
                                  DME Purchase                          Durable Medical Equipment Purchase
                                  ASC Facility                          Ambulatory Service Center Facility
                                  Renal Supplies in the Home            Renal Supplies in the Home
                                  Alternate Method Dial                 Alternate Method Dialysis
                                  CRD Equipment                         Chronic Renal Disease (CRD) Equipment
                                  Pre-Admin Testing                     Pre–Admission Testing
                                  DME Rent                              Durable Medical Equipment Rental
                                  Pneumonia Vaccine                     Pneumonia Vaccine
                                  Second Surg Opinion                   Second Surgical Opinion
                                  Third Surg Opinion                    Third Surgical Opinion
                                  Social Work                           Social Work
                                  Dx Dntl                               Diagnostic Dental
                                  Periodontics                          Periodontics
                                  Restorative                           Restorative
                                  Endodontics                           Endodontics
                                  MFP                                   Maxillofacial Prosthetics
                                  Adjunctive Dntl Svcs                  Adjunctive Dental Services
                                  Health Bene Plan Cvg                  Health Benefit Plan Coverage
                                  Plan Waiting Period                   Plan Waiting Period
                                  Chiropractic                          Chiropractic
                                  Chiropractic Office Visits            Chiropractic Office Visits
                                  Dntl Care                             Dental Care
                                  Dntl Crowns                           Dental Crowns
                                  Dntl Accident                         Dental Accident

Fallon Community Health Plan Eligibility                                                               Values • 17
Value in Response                  Description
              Orthodontics                       Orthodontics
              Prosthodontics                     Prosthodontics
              Oral Surg                          Oral Surgery
              Routine (Preventive) Dntl          Routine (Preventive) Dental
              HHC                                Home Health Care
              HH Rxs                             Home Health Prescriptions
              HH Visits                          Home Health Visits
              Hspc                               Hospice
              Respite Care                       Respite Care
              Hosp                               Hospital
              Hosp – IP                           Hospital – Inpatient
              Hosp – Room/Board                   Hospital – Room and Board
              Hosp – OP                          Hospital – Outpatient
              Hosp – Emergency Accident          Hospital – Emergency Accident
              Hosp – Emergency Medical           Hospital – Emergency Medical
              Hosp – Ambulatory Surg             Hospital – Ambulatory Surgical
              LTC                                Long Term Care
              Major Medical                      Major Medical
              Medically Related Transportation   Medically Related Transportation
              Air Transportation                 Air Transportation
              Cabulance                          Cabulance
              Licensed Ambulance                 Licensed Ambulance
              General Benefits                   General Benefits
              IVF                                In–vitro Fertilization
              MRI/CAT Scan                       MRI/CAT Scan
              Donor Procedures                   Donor Procedures
              Acupuncture                        Acupuncture
              Newborn Care                       Newborn Care
              Pa                                 Pathology
              Smoking Cessation                  Smoking Cessation
              Well Baby Care                     Well Baby Care
              Maternity                          Maternity
              Transplants                        Transplants
              Audiology Exam                     Audiology Exam
              Inhalation Thrpy                   Inhalation Therapy
              Dx Medical                         Diagnostic Medical
              Private Duty Nursing               Private Duty Nursing
              Prosthetic Device                  Prosthetic Device
              Dial                               Dialysis
              Otological Exam                    Otological Exam
              CH                                 Chemotherapy

18 • Values                                      Fallon Community Health Plan Eligibility
Value in Response                         Description
                                  Allergy Testing                           Allergy Testing
                                  Immunizations                             Immunizations
                                  Routine Physical                          Routine Physical
                                  FP                                        Family Planning
                                  Infertility                               Infertility
                                  Abortion                                  Abortion
                                  AIDS                                      AIDS
                                  Emergency Svcs                            Emergency Services
                                  Cancer                                    Cancer
                                  Pharm                                     Pharmacy
                                  Free Standing Rx Drg                      Free Standing Prescription Drug
                                  Mail Order Rx Drg                         Mail Order Prescription Drug
                                  Brand Name Rx Drg                         Brand Name Prescription Drug
                                  Generic Rx Drg                            Generic Prescription Drug
                                  Podiatry                                  Podiatry
                                  Podiatry – Office Visits                  Podiatry – Office Visits
                                  Podiatry – Nursing Home Visits            Podiatry – Nursing Home Visits
                                  Professional (PHY)                        Professional (Physician)
                                  Anesthesiologist                          Anesthesiologist
                                  Professional (PHY) Visit – Office         Professional (Physician) Visit – Office
                                  Professional (PHY) Visit – IP             Professional (Physician) Visit – Inpatient
                                  Professional (PHY) Visit – OP             Professional (Physician) Visit – Outpatient
                                  Professional (PHY) Visit – Nursing Home   Professional (Physician) Visit – Nursing
                                                                            Home
                                  Professional (PHY) Visit – SNF            Professional (Physician) Visit – Skilled
                                                                            Nursing Facility
                                  Professional (PHY) Visit – Home           Professional (Physician) Visit – Home
                                  PC                                        Psychiatric
                                  PC – Room/Board                           Psychiatric – Room and Board
                                  Psychotherapy                             Psychotherapy
                                  PC – IP                                   Psychiatric – Inpatient
                                  PC – OP                                   Psychiatric – Outpatient
                                  Rehab                                     Rehabilitation
                                  Rehab – Room/Board                        Rehabilitation – Room and Board
                                  Rehab – IP                                Rehabilitation – Inpatient
                                  Rehab – OP                                Rehabilitation – Outpatient
                                  OT                                        Occupational Therapy
                                  Physical Medicine                         Physical Medicine
                                  Spch Thrpy                                Speech Therapy
                                  Skilled Nursing Care                      Skilled Nursing Care
                                  Skilled Nursing Care – Room and Board     Skilled Nursing Care – Room and Board

Fallon Community Health Plan Eligibility                                                                    Values • 19
Value in Response                 Description
              SA                                Substance Abuse
              Alcoholism                        Alcoholism
              Drg Addiction                     Drug Addiction
              Vision (Optometry)                Vision (Optometry)
              Frames                            Frames
              Routine Exam                      Routine Exam
              Lenses                            Lenses
              Nonmedically Necessary Physical   Nonmedically Necessary Physical
              Experimental Drg Thrpy            Experimental Drug Therapy
              Independent Medical Eval          Independent Medical Evaluation
              Prtl Hospitalization (PC)          Partial Hospitalization (Psychiatric)
              Day Care (PC)                     Day Care (Psychiatric)
              Cognitive Thrpy                   Cognitive Therapy
              Massage Thrpy                     Massage Therapy
              Pulmonary Rehab                   Pulmonary Rehabilitation
              Cardiac Rehab                     Cardiac Rehabilitation
              Peds                              Pediatric
              Nursery                           Nursery
              Skin                              Skin
              Orthopedic                        Orthopedic
              Cardiac                           Cardiac
              Lymphatic                         Lymphatic
              GI                                Gastrointestinal
              Endocrine                         Endocrine
              Neuro                             Neurology
              Eye                               Eye
              Invasive Procs                    Invasive Procedures

20 • Values                                     Fallon Community Health Plan Eligibility
Insurance Types
                                 The payer can return any of the values listed below.

                                  Value in Response                             Description
                                  Mcare 2ndary Working Aged Beneficiary or      Medicare Secondary Working Aged
                                  Spouse with EGHP                              Beneficiary or Spouse with Employer Group
                                                                                Health Plan
                                  Mcare 2ndary ESRD Beneficiary in the 12       Medicare Secondary End-Stage Renal
                                  mo coordination period with an EGHP           Disease Beneficiary in the 12 month
                                                                                coordination period with an employer group
                                                                                health plan
                                  Mare 2ndary, No-fault Ins including Auto is   Medicare Secondary, No-fault Insurance
                                  Primary                                       including Auto is Primary
                                  Mcare 2ndary Work Comp                        Medicare Secondary Workers Compensation
                                  Mcare 2ndary PHS or Other Federal Agency      Medicare Secondary Public Health Service
                                                                                (PHS) or Other Federal Agency
                                  Mcare 2ndary Black Lung                       Medicare Secondary Black Lung
                                  Mcare 2ndary Vets Admin                       Medicare Secondary Veterans
                                                                                Administration
                                  Mcare 2ndary Disabled Beneficiary Under       Medicare Secondary Disabled Beneficiary
                                  Age 65 with LGHP                              Under Age 65 with Large Group Health Plan
                                                                                (LGHP)
                                  Mcare 2ndary, Other Liability Ins is Primary Medicare Secondary, Other Liability
                                                                               Insurance is Primary
                                  Auto Ins Pol                                  Auto Insurance Policy
                                  Comm                                          Commercial
                                  COBRA                                         Consolidated Omnibus Budget
                                                                                Reconciliation Act (COBRA)
                                  Mcare Conditionally Primary                   Medicare Conditionally Primary
                                  Disability                                    Disability
                                  Disability Benes                              Disability Benefits
                                  Exclusive Provider Organization               Exclusive Provider Organization
                                  Fam or Friends                                Family or Friends
                                  Grp Pol                                       Group Policy
                                  HMO                                           Health Maintenance Organization (HMO)
                                  HMO – Mcare Risk                              Health Maintenance Organization (HMO) –
                                                                                Medicare Risk
                                  Spcl Low Income Medicare Beneficiary          Special Low Income Medicare Beneficiary
                                  Indemnity                                     Indemnity
                                  Indiv Pol                                     Individual Policy
                                  LTC                                           Long Term Care
                                  Long Term Pol                                 Long Term Policy
                                  Life Ins                                      Life Insurance

Fallon Community Health Plan Eligibility                                                                      Values • 21
Value in Response                  Description
              Litigation                         Litigation
              Mcare A                            Medicare Part A
              Mcare B                            Medicare Part B
              Mcaid                              Medicaid
              Mgap A                             Medigap Part A
              Mgap B                             Medigap Part B
              Mcare Primary                      Medicare Primary
              Other                              Other
              Property Ins – Personal            Property Insurance – Personal
              Personal                           Personal
              Personal Payment (Cash - No Ins)    Personal Payment (Cash - No Insurance)
              PPO                                Preferred Provider Organization (PPO)
              POS                                Point of Service (POS)
              QMB                                Qualified Medicare Beneficiary
              Property Ins – Real                Property Insurance – Real
              Supplemental Pol                   Supplemental Policy
              TEFRA                              Tax Equity Fiscal Responsibility Act
                                                 (TEFRA)
              Work Comp                          Workers Compensation
              Wrap Up Pol                        Wrap Up Policy

22 • Values                                      Fallon Community Health Plan Eligibility
Entity Types
                                 The payer can return any of the values listed below.

                                  Value in Response                     Description
                                  Contracted Svc Prov                   Contracted Service Provider
                                  Prov                                  Provider
                                  Third-Party Admin                     Third-Party Administrator
                                  Employer                              Employer
                                  Other PHY                             Other Physician
                                  Hosp                                  Hospital
                                  Facility                              Facility
                                  Gateway Prov                          Gateway Provider
                                  Insured or Sub                        Insured or Subscriber
                                  Legal Rep                             Legal Representative
                                  PCP                                   Primary Care Provider
                                  Prior Ins Carrier                     Prior Insurance Carrier
                                  Plan Sponsor                          Plan Sponsor
                                  Payer                                 Payer
                                  Primary Payer                         Primary Payer
                                  2ndary Payer                          Secondary Payer
                                  Tertiary Payer                        Tertiary Payer
                                  Vendor                                Vendor
                                  Utilization Management Org            Utilization Management Organization

Fallon Community Health Plan Eligibility                                                              Values • 23
24 • Values   Fallon Community Health Plan Eligibility
Customer Service

WebMD/Medifax EDI Customer Service

                                 Eastern Time:            8:00 AM - 7:00 PM

                                 Central Time:            7:00 AM - 6:00 PM

                                 Mountain Time:           6:00 AM - 5:00 PM

                                 Pacific Time:            5:00 AM - 4:00 PM

                                 Voice:    800.333.0263

                                 Fax:      615.843.2539

                                 E-mail: customer.service@medifax.com

Fallon Community Health Plan Eligibility                                      Customer Service • 25
26 • Customer Service   Fallon Community Health Plan Eligibility
Eligibility/Benefit Values 15
                                                  ENTER PASSWORD 1
                                                  Entering Letters on Your POS 2
                                                  Entity Types 23
                                                  Error Messages 13
Index                                             F
                                                  Fallon HealthPln Information 3
                                                  First 4, 5, 6

                                                  G
                                                  Gender 7
                                                  GROUP NUMBER 2
A
About Your Responses 3                            H
Auth/Cert 10                                      Hcap Ind 7
                                                  HT0015 - Invalid Date Of Birth 13
B                                                 HT0031 - Provider Not On File 14
                                                  HT0103 - Invalid Recipient ID Card 14
Benefit Ind 4
                                                  HT0108 - Invalid Recipient ID 14
Birth Seq 7
                                                  HT0499 - Invalid/Missing Date Of Birth 14
                                                  HT0502 - Invalid/Missing Provider ID 14
C                                                 HT0641 - Group Number Invalid 14
Chng 7
CL0001 - Medifax Account Suspended - Please       I
    Call Customer Service 13
                                                  In Ntwk 10
CL0002 - Incomplete Customer Information -
                                                  Information Receiver 5
    Please Call Customer Service 13
                                                  Information Source 4
CL0003 - Insufficient Information To Complete A
                                                  Information Source Contact 5
    Search - Please Call Customer Service 13
                                                  Input Information 3
CL0004 - Please Call Customer Service For
                                                  Insurance Types 21
    Program Update 13
CL0005 - Unknown Transaction Request - Please
    Call Customer Service 13                      L
CL0006 - Invalid APPLID 13                        Last 6
CL997 - Please Call 1-800-333-0263 13
                                                  M
D
                                                  Medicare Ind 4
Date 3                                            MEMBER ID 2
DATE OF BIRTH 2                                   Middle 4, 5, 6
DATE OF SERVICE 2
Disclaimer 1                                      N
DOB 7
                                                  Name 4, 5
E                                                 No Heading (Additional Identification) 11
                                                  No Heading (Amount) 9
Eligibility Verification 1                        No Heading (Benefit Related Entity) 11
Eligibility/Benefit 9                             No Heading (Contact Information) 5, 8

Fallon Community Health Plan Eligibility                                                Index • 27
No Heading (Coverage Description) 9                 Service Types 17
No Heading (Date) 9                                 SM0001 - Stand-In Message 14
No Heading (Eligibility or Benefit Additional       Student Sts 7
    Information) 11                                 Submit ID 3
No Heading (Eligibility/Benefit Type Description)   Subscriber 6
    9                                               Subscriber Additional ID 8
No Heading (Health Care Service Delivery) 10        Subscriber Contact 8
No Heading (Insurance Type Description) 9           Subscriber Date 9
No Heading (Location) 7                             Suffix 4, 5, 7
No Heading (Message) 11
No Heading (Name) 5, 8                              T
No Heading (Origin 1 Description) 6
No Heading (Origin 1) 6                             Time 4
No Heading (Origin 2 Description) 6                 Trce1 6
No Heading (Origin 2) 6                             Trce2 6
No Heading (Patient Dates) 11
No Heading (Percent) 10                             W
No Heading (Product/Svc ID) 10                      WebMD Announcement 13
No Heading (Quantity) 10                            WebMD/Medifax EDI Customer Service 25
No Heading (Related Entity Contact) 12
No Heading (Service Type Description) 9
No Heading (Subscriber's Address) 7
No Heading (Supplemental ID Description) 8
No Heading (Supplemental Identifier) 8

O
Other Payer Ind 4
Overview 1

P
PAYER ID? 1
Period 9
Plan Cvg 9
Prefix 6
PRESS A KEY 1-7 1
Primary ID 4, 5, 6
Proc Mod1 through Proc Mod4 10

R
RH0085 - Unable To Respond At Current Time 14
RH0252 - Invalid/Missing Subscriber/Insured ID
    14
RH0502 - Invalid/Missing Provider ID 14
RH0547 - Subscriber/Insured Not Found 14
Running Transactions 1

S
SERVICE PROV ID 2

28 • Index                                                    Fallon Community Health Plan Eligibility
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