Fallon Community Health Plan - WebMD POS Transaction Guide Eligibility & Benefits
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WebMD POS Transaction Guide
Fallon Community
Health Plan
Eligibility & Benefits
MEDIFAX MASS 1.00
October 11, 2004
Pub # 04-288:POSFALThis documentation is the confidential property of WebMD® Corporation.
Any unauthorized use, reproduction, or transfer of the
documentation is strictly prohibited.
WebMD is a registered Trademark of the WebMD Corporation.
WebMD Corporation
1283 Murfreesboro Road
Nashville, TN 37217
615 / 843-2500
© 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 • iii • 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 • 1Step 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 EligibilityResponses
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 • 3Time
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 EligibilityInformation 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 • 5Subscriber
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 EligibilitySuffix
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 • 7Subscriber 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 EligibilitySubscriber 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 • 9No 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 EligibilityNo 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 • 11No 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 EligibilityFor 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 • 13For 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 EligibilityValues
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 • 15Value 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 EligibilityService 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 • 17Value 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 EligibilityValue 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 • 19Value 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 EligibilityInsurance 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 • 21Value 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 EligibilityEntity 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 • 2324 • 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 • 2526 • 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 • 27No 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 EligibilityYou can also read
