all payers eligibility guide pc - emdeon payers eligibility guide pc ... bcbs north dakota ......
TRANSCRIPT
PC Products
Input Guide for Eligibility/Benefit
Transactions
Emdeon MAX®, Emdeon Assistant®, and Emdeon NetDirect®
Version 18.29
6.1.2018
All Payers Eligibility Guide PC
This publication is the proprietary property of Emdeon and is furnished solely for use pursuant to a license agreement giving the user
the right to use the Emdeon product(s) referenced in this document. All uses of this document are subject to the terms of such license
agreement. This document may not be used except as permitted by such license agreement or changed, copied, photocopied,
reproduced, translated, or reduced to any electronic medium or machine readable form without the prior consent of Emdeon.
Copyright is held by Emdeon Business Services, LLC.
Emdeon is not liable for any losses or damages that result from the use of this material, including loss of profit or indirect, special, or
consequential damages.
© 2018, Emdeon Business Services LLC, 3055 Lebanon Pike Suite 1000, Nashville, TN 37214.
All Rights Reserved. Printed in the USA.
All Payers Eligibility Guide PC Table of Contents
© 2018 Emdeon Business Services LLC. All rights reserved. Page i
Table of Contents
Overview --------------------------------------------------------------------------------------------------------------- 1
About This Guide -------------------------------------------------------------------------------------------------- 1 Customer Support ------------------------------------------------------------------------------------------------- 1
General Information --------------------------------------------------------------------------------------------------- 2
Requests ----------------------------------------------------------------------------------------------------------- 2 Determine the Transaction Type ----------------------------------------------------------------------------- 2 Determine the Search Types --------------------------------------------------------------------------------- 2 Enter the Search Data ---------------------------------------------------------------------------------------- 3
Responses --------------------------------------------------------------------------------------------------------- 5
Payer-Specific Information -------------------------------------------------------------------------------------------- 6
Payer Details ------------------------------------------------------------------------------------------------------ 6 1199 National Benefit Fund ------------------------------------------------------------------------------ 6 AARP ------------------------------------------------------------------------------------------------------ 6 Absolute Total Care (CTOTL) ---------------------------------------------------------------------------- 6 Administrative Services, Inc. ---------------------------------------------------------------------------- 6 Advantage by Bridgeway Health Solutions -------------------------------------------------------------- 6 Advantage by Buckeye Community Health Plan -------------------------------------------------------- 6 Advantage by Managed Health Services ---------------------------------------------------------------- 6 Advantage by Superior HealthPlan ---------------------------------------------------------------------- 6 Aetna ------------------------------------------------------------------------------------------------------ 7 Aetna Administrator − Medicare Supplemental --------------------------------------------------------- 7 Aetna Better Health of CA ------------------------------------------------------------------------------- 7 Aetna Better Health of FL -------------------------------------------------------------------------------- 7 Aetna Better Health of NJ -------------------------------------------------------------------------------- 7 Aetna Better Health of KY -------------------------------------------------------------------------------- 7 Aetna Better Health of LA -------------------------------------------------------------------------------- 7 Aetna Better Health of MD ------------------------------------------------------------------------------- 7 Aetna Better Health of MI -------------------------------------------------------------------------------- 7 Aetna Better Health of MO ------------------------------------------------------------------------------- 7 Aetna Better Health of NV ------------------------------------------------------------------------------- 8 Aetna Better Health of PA -------------------------------------------------------------------------------- 8 Aetna Better Health of VA ------------------------------------------------------------------------------- 8 Aetna Better Health of WV ------------------------------------------------------------------------------- 8 Aetna Long Term Care ----------------------------------------------------------------------------------- 8 Aetna Senior Supplemental Insurance ------------------------------------------------------------------ 8 Affinity Essentials ---------------------------------------------------------------------------------------- 8 Affinity Health Plan --------------------------------------------------------------------------------------- 8 Affinity Health Plan Medicare ---------------------------------------------------------------------------- 8 AGIA Inc -------------------------------------------------------------------------------------------------- 8 Aflac Dental Insurance ----------------------------------------------------------------------------------- 8 Aflac - Medicare Supplemental -------------------------------------------------------------------------- 9 Alabama Medicaid ---------------------------------------------------------------------------------------- 9 All Savers Life Insurance Company --------------------------------------------------------------------- 9 Alliant Health Plans --------------------------------------------------------------------------------------- 9 Allied Benefit Systems, Inc. ----------------------------------------------------------------------------- 9 Alternative Insurance Resources, Inc. ------------------------------------------------------------------ 9 AmeriBen ------------------------------------------------------------------------------------------------- 9 American Behavioral Benefit Managers ----------------------------------------------------------------- 9 American Community Mutual -------------------------------------------------------------------------- 10 American General Life and Accident ------------------------------------------------------------------- 10 American Health Medicare (Inmediata Health) ------------------------------------------------------- 10 American Income Life Insurance Company ----------------------------------------------------------- 10 American National Insurance Company --------------------------------------------------------------- 10
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American National Life Insurance Company of Texas ------------------------------------------------ 10 American Network Insurance (REHAB) − Medicare Supplemental ---------------------------------- 11 American Postal Workers Union ----------------------------------------------------------------------- 11 American Retirement Life Insurance Company – Medicare Supplement ---------------------------- 11 Americhoice of New Jersey ---------------------------------------------------------------------------- 11 Amerigroup --------------------------------------------------------------------------------------------- 11 AmeriHealth Caritas Delaware ------------------------------------------------------------------------- 11 AmeriHealth Caritas Iowa ------------------------------------------------------------------------------ 11 AmeriHealth Caritas Louisiana ------------------------------------------------------------------------- 11 AmeriHealth Caritas Pennsylvania --------------------------------------------------------------------- 11 AmeriHealth Caritas VIP Care Plus -------------------------------------------------------------------- 12 AmeriHealth District of Columbia ---------------------------------------------------------------------- 12 AmeriHealth VIP Care ---------------------------------------------------------------------------------- 12 Ameritas Dental Group --------------------------------------------------------------------------------- 12 Anthem BlueCross of California ------------------------------------------------------------------------ 12 APS ------------------------------------------------------------------------------------------------------ 12 Archbold Medical Center ------------------------------------------------------------------------------- 12 Arise Health Plan --------------------------------------------------------------------------------------- 12 Arise Health Plan − Medicare Select Policy ----------------------------------------------------------- 12 Arizona Medicaid (AHCCCS) --------------------------------------------------------------------------- 13 Arizona Physicians IPA --------------------------------------------------------------------------------- 13 Arkansas Medicaid -------------------------------------------------------------------------------------- 13 Associacion de Maestros Puerto Rico ------------------------------------------------------------------ 13 AVMed -------------------------------------------------------------------------------------------------- 13 Banner Health Plans ------------------------------------------------------------------------------------ 13 Banner University Family Care ------------------------------------------------------------------------ 13 Baptist Health Plan Advantage ------------------------------------------------------------------------ 13 BC Complete of Michigan ------------------------------------------------------------------------------ 13 BC Idaho ------------------------------------------------------------------------------------------------ 14 BC Medicare Advantage -------------------------------------------------------------------------------- 14 BCBS Alabama (Benefits) ------------------------------------------------------------------------------ 14 BCBS Alabama (Eligibility) ----------------------------------------------------------------------------- 14 BCBS Arizona ------------------------------------------------------------------------------------------- 15 BCBS Arkansas ----------------------------------------------------------------------------------------- 15 BCBS Colorado ----------------------------------------------------------------------------------------- 15 BCBS Connecticut -------------------------------------------------------------------------------------- 15 BCBS Delaware (Highmark) --------------------------------------------------------------------------- 15 BCBS District of Columbia ----------------------------------------------------------------------------- 15 BCBS Florida -------------------------------------------------------------------------------------------- 16 BCBS Georgia ------------------------------------------------------------------------------------------- 16 BCBS Illinois -------------------------------------------------------------------------------------------- 16 BCBS Indiana ------------------------------------------------------------------------------------------- 16 BCBS Iowa ---------------------------------------------------------------------------------------------- 16 BCBS Kansas ------------------------------------------------------------------------------------------- 16 BCBS Kansas City -------------------------------------------------------------------------------------- 16 BCBS Kentucky ----------------------------------------------------------------------------------------- 17 BCBS LA Medicare Advantage ------------------------------------------------------------------------- 17 BCBS Louisiana ----------------------------------------------------------------------------------------- 17 BCBS Maine --------------------------------------------------------------------------------------------- 17 BCBS Maryland ----------------------------------------------------------------------------------------- 17 BCBS Massachusetts ----------------------------------------------------------------------------------- 17 BCBS Michigan ----------------------------------------------------------------------------------------- 18 BCBS Minnesota ---------------------------------------------------------------------------------------- 18 BCBS Mississippi ---------------------------------------------------------------------------------------- 19 BCBS Missouri ------------------------------------------------------------------------------------------ 19 BCBS Nebraska ----------------------------------------------------------------------------------------- 19 BCBS Nevada ------------------------------------------------------------------------------------------- 19 BCBS New Hampshire ---------------------------------------------------------------------------------- 19 BCBS New Jersey (Horizon) --------------------------------------------------------------------------- 19 BCBS New Mexico -------------------------------------------------------------------------------------- 19 BCBS New York Empire -------------------------------------------------------------------------------- 20 BCBS North Carolina ----------------------------------------------------------------------------------- 20
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BCBS North Dakota ------------------------------------------------------------------------------------ 20 BCBS Ohio ---------------------------------------------------------------------------------------------- 20 BCBS Oklahoma ---------------------------------------------------------------------------------------- 20 BCBS Oregon (Regence) ------------------------------------------------------------------------------- 20 BCBS Pennsylvania (Highmark) ----------------------------------------------------------------------- 21 BCBS Rhode Island ------------------------------------------------------------------------------------- 21 BCBS South Carolina ----------------------------------------------------------------------------------- 21 BCBS South Carolina ----------------------------------------------------------------------------------- 22 BCBS South Dakota ------------------------------------------------------------------------------------ 22 BCBS Tennessee --------------------------------------------------------------------------------------- 22 BCBS Texas --------------------------------------------------------------------------------------------- 23 BCBS Texas-Medicaid ---------------------------------------------------------------------------------- 23 BCBS Vermont ------------------------------------------------------------------------------------------ 23 BCBS Virginia ------------------------------------------------------------------------------------------- 23 BCBS Wisconsin ---------------------------------------------------------------------------------------- 23 BCBS Wyoming ----------------------------------------------------------------------------------------- 23 Behavioral Health Systems ---------------------------------------------------------------------------- 23 Benefit Management Inc. ------------------------------------------------------------------------------ 24 Better Health ------------------------------------------------------------------------------------------- 24 Better Health Plans of Tennessee --------------------------------------------------------------------- 24 BlueChoice HealthPlan of South Carolina Medicaid --------------------------------------------------- 24 BlueCross BlueShield of Western New York Medicaid/CHP ------------------------------------------- 24 Bluegrass Family Health ------------------------------------------------------------------------------- 24 Boon Group --------------------------------------------------------------------------------------------- 24 Bridgeway Health Solutions (Arizona)----------------------------------------------------------------- 24 BS California -------------------------------------------------------------------------------------------- 24 BS Washington (Regence) ----------------------------------------------------------------------------- 24 Buckeye Community Health --------------------------------------------------------------------------- 25 California Medicaid (Medi-Cal) ------------------------------------------------------------------------- 25 Capital BlueCross --------------------------------------------------------------------------------------- 25 Capital District Physician’s Health Plan ---------------------------------------------------------------- 25 Care1st Health Plan Arizona --------------------------------------------------------------------------- 25 Care Improvement Plus -------------------------------------------------------------------------------- 25 CareFirst Administrators ------------------------------------------------------------------------------- 26 CarePlus Health Plan ----------------------------------------------------------------------------------- 26 CarePoint Medicare Advantage ------------------------------------------------------------------------ 26 CareSource Health ------------------------------------------------------------------------------------- 26 Carpenters Health and Welfare Trust Fund of St Louis ----------------------------------------------- 26 CareSource --------------------------------------------------------------------------------------------- 26 CDS Group Health -------------------------------------------------------------------------------------- 26 Celtic Insurance ---------------------------------------------------------------------------------------- 26 CeltiCare ------------------------------------------------------------------------------------------------ 26 Cenpatico ----------------------------------------------------------------------------------------------- 27 Central Reserve Life Insurance Company ― Medicare Supplement --------------------------------- 27 Central States Funds ----------------------------------------------------------------------------------- 27 Chesterfield Resources Inc ----------------------------------------------------------------------------- 27 Christian Brothers Services ---------------------------------------------------------------------------- 27 Christie Student Health Plans -------------------------------------------------------------------------- 27 CHRISTUS Health Plan Medicaid ----------------------------------------------------------------------- 27 CHRISTUS Health Plan New Mexico Health Insurance Exchange ------------------------------------ 27 CHRISTUS Health Plan NM MA ------------------------------------------------------------------------- 28 Cigna ---------------------------------------------------------------------------------------------------- 28 CMFG Life Insurance ----------------------------------------------------------------------------------- 28 Colorado Access ---------------------------------------------------------------------------------------- 28 Colorado Medicaid -------------------------------------------------------------------------------------- 29 Community Care of Oklahoma ------------------------------------------------------------------------- 29 Community Health Plan of Washington --------------------------------------------------------------- 29 Concentrix Insurance Solutions ----------------------------------------------------------------------- 29 Connecticare Inc --------------------------------------------------------------------------------------- 29 Connecticut Medicaid ----------------------------------------------------------------------------------- 29 Consolidated Associates Railroad ---------------------------------------------------------------------- 29 Consumer Mutual of Michigan ------------------------------------------------------------------------- 29
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Continental General Insurance Company ― Medicare Supplement --------------------------------- 30 Cooperative Benefit Administrators ------------------------------------------------------------------- 30 CoreSource --------------------------------------------------------------------------------------------- 30 CountyCare --------------------------------------------------------------------------------------------- 30 Coventry ------------------------------------------------------------------------------------------------ 30 Coventry/Dentex Dental ------------------------------------------------------------------------------- 30 CREATE ------------------------------------------------------------------------------------------------- 30 Crystal Run Health Plan -------------------------------------------------------------------------------- 30 CSA Fraternal Life ― Medicare Supplement ---------------------------------------------------------- 31 Dean Health Plan --------------------------------------------------------------------------------------- 31 Delaware Medicaid ------------------------------------------------------------------------------------- 31 Dell Childrens Health Plan ----------------------------------------------------------------------------- 31 Dentaquest Government Payer WI -------------------------------------------------------------------- 31 District No. 9, I. A. of M. & A. W. Welfare Trust ------------------------------------------------------ 31 District of Columbia Medicaid -------------------------------------------------------------------------- 31 Diversified Administration Corp ----------------------------------------------------------------------- 31 Driscoll Health Plan ------------------------------------------------------------------------------------- 31 EBMS ---------------------------------------------------------------------------------------------------- 31 Elderplan ------------------------------------------------------------------------------------------------ 32 Emblem Health ----------------------------------------------------------------------------------------- 32 Epic Life Insuranace ------------------------------------------------------------------------------------ 32 Essence Healthcare------------------------------------------------------------------------------------- 32 Evergreen Health --------------------------------------------------------------------------------------- 32 Everence Financial ------------------------------------------------------------------------------------- 32 Excellus BlueCross BlueShield ------------------------------------------------------------------------- 32 Fallon Community Health Plan ------------------------------------------------------------------------- 32 Farm Bureau Health Plans ----------------------------------------------------------------------------- 32 Federated Insurance Company ------------------------------------------------------------------------ 32 Fidelis Care New York ---------------------------------------------------------------------------------- 33 First Carolina Care ------------------------------------------------------------------------------------- 33 First Choice VIP Care Plus ----------------------------------------------------------------------------- 33 First Community Health Plan -------------------------------------------------------------------------- 33 First United American Insurance Company ----------------------------------------------------------- 33 Florida Medicaid ---------------------------------------------------------------------------------------- 34 Florida Medicaid ---------------------------------------------------------------------------------------- 35 Food Employers & Bakery & Confectionery Workers Benefit Fund of Southern California --------- 35 Fresenius Health Partners------------------------------------------------------------------------------ 35 Georgia Medicaid --------------------------------------------------------------------------------------- 36 Globe Life and Accident Insurance Company --------------------------------------------------------- 36 G.M.P. Employers Retiree Trust ----------------------------------------------------------------------- 36 Golden Rule --------------------------------------------------------------------------------------------- 36 Government Employees Hospital Association (GEHA) ------------------------------------------------ 36 Great American Life Assurance Company ― Medicare Supplement --------------------------------- 36 Great American Life Insurance Company ― Medicare Supplement --------------------------------- 36 Great-West Healthcare --------------------------------------------------------------------------------- 37 Group and Pension Administrators Inc. --------------------------------------------------------------- 37 Group Dental Service ---------------------------------------------------------------------------------- 37 Harmony Health Plan (WellCare of Florida) ----------------------------------------------------------- 37 Harvard Pilgrim Health Care --------------------------------------------------------------------------- 37 Hawaii Medicaid ---------------------------------------------------------------------------------------- 37 Hawaii Medical Service Association -------------------------------------------------------------------- 38 Health Alliance of Illinois ------------------------------------------------------------------------------- 38 Health Alliance Plan ------------------------------------------------------------------------------------ 38 Health Choice of Arizona ------------------------------------------------------------------------------- 38 Health First Health Plan -------------------------------------------------------------------------------- 38 Health First Insurance --------------------------------------------------------------------------------- 38 Health Partners MN ------------------------------------------------------------------------------------- 38 Health Partners of Philadelphia ------------------------------------------------------------------------ 38 Health Services for Children with Special Needs ----------------------------------------------------- 38 Health Share of Oregon -------------------------------------------------------------------------------- 38 HEALTHe Exchange ------------------------------------------------------------------------------------ 39 HealthEase (WellCare of Florida) ---------------------------------------------------------------------- 39
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HealthEase Kids (WellCare of Florida) ----------------------------------------------------------------- 39 HealthEZ ------------------------------------------------------------------------------------------------ 39 Healthfirst of New Jersey ------------------------------------------------------------------------------ 39 Healthfirst of New York -------------------------------------------------------------------------------- 39 HealthNet National ------------------------------------------------------------------------------------- 39 HealthPlus of Michigan --------------------------------------------------------------------------------- 39 HealthSmart Benefit Solutions ------------------------------------------------------------------------- 39 HealthSmart Benefit Solutions − WV ----------------------------------------------------------------- 39 HealthSpring -------------------------------------------------------------------------------------------- 40 Healthy Blue Louisiana --------------------------------------------------------------------------------- 40 Highmark BCBSD Health Options ---------------------------------------------------------------------- 40 HMA (Hawaii Mainland Admin) ------------------------------------------------------------------------ 40 Horizon New Jersey Health ---------------------------------------------------------------------------- 40 HSBS Oklahoma City ----------------------------------------------------------------------------------- 40 Humana ------------------------------------------------------------------------------------------------- 40 IBEW Local 508 Health Plan --------------------------------------------------------------------------- 40 Idaho Medicaid ----------------------------------------------------------------------------------------- 40 IlliniCare Health Plan ----------------------------------------------------------------------------------- 40 Illinois Medicaid ---------------------------------------------------------------------------------------- 41 Illinois Medicaid ---------------------------------------------------------------------------------------- 42 Independence Blue Cross ------------------------------------------------------------------------------ 42 Indiana Medicaid --------------------------------------------------------------------------------------- 42 Inland Empire Health Plan ----------------------------------------------------------------------------- 42 Inter Valley Health Plan -------------------------------------------------------------------------------- 43 International Medical Card ----------------------------------------------------------------------------- 43 Iowa Medicaid ------------------------------------------------------------------------------------------ 43 Island Home Insurance -------------------------------------------------------------------------------- 43 Johns Hopkins HealthCare ----------------------------------------------------------------------------- 43 Johns Hopkins HealthCare LLC ------------------------------------------------------------------------ 43 Johns Hopkins US Family Health Plan ----------------------------------------------------------------- 43 Kaiser Foundation Health Plan of Colorado ----------------------------------------------------------- 43 Kaiser Foundation Health Plan of Hawaii -------------------------------------------------------------- 43 Kaiser Foundation Health Plan of Hawaii (DHMO/CHOICE) ------------------------------------------ 44 Kaiser Foundation Mid-Atlantic ------------------------------------------------------------------------ 44 Kaiser Foundation Health Plan of Northwest ---------------------------------------------------------- 44 Kaiser NW Dental --------------------------------------------------------------------------------------- 44 Kaiser Permanente Insurance Company KPIC -------------------------------------------------------- 44 Kaiser Permanente of Georgia ------------------------------------------------------------------------- 44 Kaiser Permanente of Northern California ------------------------------------------------------------ 44 Kaiser Permanente of Southern California ------------------------------------------------------------ 44 KanCare-UnitedHealthcare Community Plan Kansas ------------------------------------------------- 44 Kansas Medicaid ---------------------------------------------------------------------------------------- 44 Kempton Company ------------------------------------------------------------------------------------- 45 Kentucky Medicaid ------------------------------------------------------------------------------------- 45 Kentucky Spirit Health Plan ---------------------------------------------------------------------------- 45 Key Benefit Administrators ---------------------------------------------------------------------------- 45 Key Benefit Administrators (Indianapolis, IN) -------------------------------------------------------- 45 Keystone First ------------------------------------------------------------------------------------------ 45 Keystone VIP Choice ----------------------------------------------------------------------------------- 45 L.A. Care. ----------------------------------------------------------------------------------------------- 45 Leon Medical Centers Health Plan, Inc. --------------------------------------------------------------- 45 Liberty National Life Insurance Company ------------------------------------------------------------- 46 LifeCare Assurance Company -------------------------------------------------------------------------- 46 Lincoln Financial ---------------------------------------------------------------------------------------- 46 Louisiana Healthcare Connections --------------------------------------------------------------------- 46 Louisiana Medicaid ------------------------------------------------------------------------------------- 47 Loyal American Life ― Medicare Supplement --------------------------------------------------------- 47 Maine Community Health Options --------------------------------------------------------------------- 47 Magnolia Health Plan ----------------------------------------------------------------------------------- 47 MagnaCare ---------------------------------------------------------------------------------------------- 48 MaineCare (Maine Medicaid) --------------------------------------------------------------------------- 48 Managed Care of America------------------------------------------------------------------------------ 48
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Managed Health Network (MHN) ---------------------------------------------------------------------- 48 Managed Health Services - Indiana ------------------------------------------------------------------- 48 MAPFRE Life Puerto Rico ------------------------------------------------------------------------------- 48 MAPFRE Medicare Excel -------------------------------------------------------------------------------- 48 Maricopa Care Advantage ------------------------------------------------------------------------------ 48 Maricopa Health Plan (Arizona) ------------------------------------------------------------------------ 48 Maryland Medicaid-------------------------------------------------------------------------------------- 48 Maryland Physicians Care ------------------------------------------------------------------------------ 49 Massachusetts Medicaid (MassHealth) ---------------------------------------------------------------- 49 MDWISE Exchange ------------------------------------------------------------------------------------- 49 MDWISE Medicaid Health Plans ------------------------------------------------------------------------ 49 Med-Pay, Inc. ------------------------------------------------------------------------------------------- 49 Medi-Share --------------------------------------------------------------------------------------------- 49 MedBen Newark OH ------------------------------------------------------------------------------------ 49 Medica -------------------------------------------------------------------------------------------------- 49 Medica Health Plans ------------------------------------------------------------------------------------ 49 Medica2 ------------------------------------------------------------------------------------------------- 49 Medical Associates Health Plan/Health Choices ------------------------------------------------------- 49 Medical Card System ----------------------------------------------------------------------------------- 50 Medical Mutual of Ohio (MMO) ------------------------------------------------------------------------- 50 Medicare Part A & B ------------------------------------------------------------------------------------ 51 Medicare Part A & B ------------------------------------------------------------------------------------ 52 Medicare y Mucho Mas --------------------------------------------------------------------------------- 52 Meridian Health Plan of Illinois ------------------------------------------------------------------------ 52 Meritain Health ----------------------------------------------------------------------------------------- 52 Meritus Health Partners -------------------------------------------------------------------------------- 53 MetLife -------------------------------------------------------------------------------------------------- 53 MetroPlus Health Plan ---------------------------------------------------------------------------------- 53 Michigan Medicaid -------------------------------------------------------------------------------------- 53 Michigan MIChild --------------------------------------------------------------------------------------- 53 Minnesota Medicaid ------------------------------------------------------------------------------------ 53 Mississippi Medicaid ------------------------------------------------------------------------------------ 53 Mississippi State Employees’ Health Plan (SEHP) ---------------------------------------------------- 54 Missouri Medicaid --------------------------------------------------------------------------------------- 54 MMSI ---------------------------------------------------------------------------------------------------- 55 Molina Healthcare -------------------------------------------------------------------------------------- 55 Molina Healthcare of New Mexico --------------------------------------------------------------------- 55 Molina Healthcare of Virginia -------------------------------------------------------------------------- 55 Montana Medicaid -------------------------------------------------------------------------------------- 55 Molina of Puerto Rico ----------------------------------------------------------------------------------- 55 Mountain State ----------------------------------------------------------------------------------------- 55 Municipal Health Benefit Fund ------------------------------------------------------------------------- 55 Mutual Health Services --------------------------------------------------------------------------------- 55 Mutual of Omaha --------------------------------------------------------------------------------------- 55 MVP Health Care (New York) -------------------------------------------------------------------------- 56 National Association of Letter Carriers (NALC) ------------------------------------------------------- 56 National Claims Admin Services ----------------------------------------------------------------------- 56 Nebraska Medicaid ------------------------------------------------------------------------------------- 56 Network Health Plan ----------------------------------------------------------------------------------- 56 Nevada Medicaid --------------------------------------------------------------------------------------- 56 New Era Life Insurance Company --------------------------------------------------------------------- 56 New Hampshire Medicaid ------------------------------------------------------------------------------ 56 New Jersey Medicaid ----------------------------------------------------------------------------------- 57 New Mexico Health Connections ----------------------------------------------------------------------- 57 New Mexico Medicaid ----------------------------------------------------------------------------------- 57 New York Medicaid ------------------------------------------------------------------------------------- 58 Nippon Life Benefits ------------------------------------------------------------------------------------ 59 NMPSIA ------------------------------------------------------------------------------------------------- 59 NMRHCA ------------------------------------------------------------------------------------------------ 59 North Carolina Medicaid -------------------------------------------------------------------------------- 59 North Dakota Medicaid --------------------------------------------------------------------------------- 59 Northwest Administrators, Inc. ------------------------------------------------------------------------ 59
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NovaSys Health----------------------------------------------------------------------------------------- 59 ‘Ohana Health Plan (WellCare of Hawaii) ------------------------------------------------------------- 59 Ohio Medicaid ------------------------------------------------------------------------------------------- 59 Oklahoma Employees Group Insurance Division ----------------------------------------------------- 60 Oklahoma Medicaid ------------------------------------------------------------------------------------ 60 Operating Engineers Local No. 428 Health and Welfare Trust Fund --------------------------------- 60 Optima Health ------------------------------------------------------------------------------------------ 60 Orange County Fire Authority ------------------------------------------------------------------------- 60 Oregon Medicaid ---------------------------------------------------------------------------------------- 60 Oregon’s Health CO-OP -------------------------------------------------------------------------------- 60 Oxford Health Plans ------------------------------------------------------------------------------------ 60 Oxford Life Insurance Company ----------------------------------------------------------------------- 60 PacificSource Administrators -------------------------------------------------------------------------- 61 PacificSource Health Plans ----------------------------------------------------------------------------- 61 PacificSource Community Solutions ------------------------------------------------------------------- 61 PacificSource Medicare --------------------------------------------------------------------------------- 61 Pan-American Life Insurance -------------------------------------------------------------------------- 61 Panamerican Life Puerto Rico (PALIC) ---------------------------------------------------------------- 61 Partnership Health Plan of California ------------------------------------------------------------------ 61 Passport Health Plan ----------------------------------------------------------------------------------- 61 Pekin Life Insurance ------------------------------------------------------------------------------------ 61 Penn Treaty Network America Insurance (REHAB) − Medicare Supplemental ---------------------- 62 Pennsylvania Medical Assistance ---------------------------------------------------------------------- 62 Peoples Health ------------------------------------------------------------------------------------------ 62 PerformCare -------------------------------------------------------------------------------------------- 62 Personal Insurance Administrators -------------------------------------------------------------------- 62 PHCS Savility Payers ----------------------------------------------------------------------------------- 62 Physicians Mutual -------------------------------------------------------------------------------------- 62 Piedmont Wellstar HealthPlans ------------------------------------------------------------------------ 62 Pittman and Associates -------------------------------------------------------------------------------- 62 Plan de Salud Hospital Menonita ---------------------------------------------------------------------- 62 Planned Administrators, Inc. -------------------------------------------------------------------------- 63 Plumbers and Pipefitters Local 525 Health & Welfare Trust ------------------------------------------ 63 Preferred Care Partners -------------------------------------------------------------------------------- 63 Preferred Health Systems ------------------------------------------------------------------------------ 63 PreferredOne ------------------------------------------------------------------------------------------- 63 Premera Blue Cross ------------------------------------------------------------------------------------ 63 Prestige Health Choice --------------------------------------------------------------------------------- 63 Primary PhysicianCare, Inc. --------------------------------------------------------------------------- 64 Principal Financial -------------------------------------------------------------------------------------- 64 Priority Health ------------------------------------------------------------------------------------------ 64 Prominence Health Plan -------------------------------------------------------------------------------- 64 Providence Health Plan --------------------------------------------------------------------------------- 64 Provident American Life & Health Insurance Company ― Medicare Supplement ------------------- 64 Puerto Rico Medicaid (ODSI) -------------------------------------------------------------------------- 64 Quartz ASO --------------------------------------------------------------------------------------------- 64 QuikTrip Corporation ----------------------------------------------------------------------------------- 64 RightCare from Scott and White Health Plan --------------------------------------------------------- 65 Rocky Mountain Health Plan (HMO) ------------------------------------------------------------------- 65 SAMBA Health Benefit Plan ---------------------------------------------------------------------------- 65 San Joaquin Health Plan ------------------------------------------------------------------------------- 65 Santa Clara Family Health Plan ------------------------------------------------------------------------ 65 Schaller Anderson Health Plans ----------------------------------------------------------------------- 65 Schaller Anderson Mercy Maricopa -------------------------------------------------------------------- 65 Select Health of South Carolina ----------------------------------------------------------------------- 65 Selman & Company ------------------------------------------------------------------------------------ 65 Senior Care Action Network (SCAN) Health Maintenance Organization (HMO) --------------------- 66 Senior Health Services Center – Universal American Family of Companies------------------------- 66 Senior Whole Health ----------------------------------------------------------------------------------- 66 Significa Benefit Services ------------------------------------------------------------------------------ 66 Silver Summit Health Plan ----------------------------------------------------------------------------- 66 Simply Healthcare Plans ------------------------------------------------------------------------------- 66
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South Carolina Medicaid ------------------------------------------------------------------------------- 66 South Dakota Medicaid--------------------------------------------------------------------------------- 66 SPJST ― Medicare Supplement ------------------------------------------------------------------------ 67 Standard Life and Accident Insurance Company ----------------------------------------------------- 67 Star HRG ------------------------------------------------------------------------------------------------ 67 StayWell (WellCare of Florida) ------------------------------------------------------------------------- 67 StayWell Kids (WellCare of Florida) ------------------------------------------------------------------- 67 Stonebridge Life Insurance Company ----------------------------------------------------------------- 67 Summit America Insurance Service ------------------------------------------------------------------- 67 Sunflower State Health Plan --------------------------------------------------------------------------- 67 Sunshine State Health Plan ---------------------------------------------------------------------------- 67 Tennessee Medicaid (TennCare) ----------------------------------------------------------------------- 68 TexanPlus (North Texas Area) ------------------------------------------------------------------------- 68 TexanPlus (Southeast Texas Area) -------------------------------------------------------------------- 68 Texas Childrens Health Plan --------------------------------------------------------------------------- 68 Texas Medicaid ----------------------------------------------------------------------------------------- 68 The Ullico Family of Companies ----------------------------------------------------------------------- 68 Three Rivers Health Plan ------------------------------------------------------------------------------- 68 Today’s Options ---------------------------------------------------------------------------------------- 69 TransactRX Infusion and Specialty -------------------------------------------------------------------- 69 Transamerica Financial Life Insurance Company ----------------------------------------------------- 69 Transamerica Life Insurance Company --------------------------------------------------------------- 69 Transamerica Premier Life Insurance Company ------------------------------------------------------ 69 TRICARE ------------------------------------------------------------------------------------------------ 69 TRICARE East Region ---------------------------------------------------------------------------------- 69 Tricare For Life ----------------------------------------------------------------------------------------- 69 Tricare Overseas --------------------------------------------------------------------------------------- 69 Triple-S Salud (BCBS of Puerto Rico) ----------------------------------------------------------------- 70 Trillium Community Health Plan ----------------------------------------------------------------------- 70 True Health New Mexico Inc --------------------------------------------------------------------------- 70 Trustmark ----------------------------------------------------------------------------------------------- 70 Tufts Health Plan --------------------------------------------------------------------------------------- 70 Ucare of Minnesota ------------------------------------------------------------------------------------- 70 Ultimate Health Plans ---------------------------------------------------------------------------------- 70 UMR Wausau ------------------------------------------------------------------------------------------- 70 UMWA Health and Retirement Funds ------------------------------------------------------------------ 70 UniCare ------------------------------------------------------------------------------------------------- 70 Union Pacific Railroad Employes Health Systems ----------------------------------------------------- 70 United American Insurance Company ----------------------------------------------------------------- 71 United Healthcare Dental ------------------------------------------------------------------------------ 71 United Healthcare Nevada Market --------------------------------------------------------------------- 71 UnitedHealthcare Shared Services -------------------------------------------------------------------- 71 UnitedHealthcare StudentResources ------------------------------------------------------------------ 71 UnitedHealthcare (UHC) ------------------------------------------------------------------------------- 71 UnitedHealthcare Community Plan − Tennessee ----------------------------------------------------- 71 United Healthcare Securehorizons − Medicare Supplemental --------------------------------------- 72 United Teacher Associates Insurance Company ― Medicare Supplement -------------------------- 72 Unity Health Insurance --------------------------------------------------------------------------------- 72 Universal Benefit Corp --------------------------------------------------------------------------------- 72 Universal Care of California ---------------------------------------------------------------------------- 72 University Care Advantage (Arizona) ----------------------------------------------------------------- 72 University Family Care (Arizona) ---------------------------------------------------------------------- 72 University of Arizona Health Plans − UHM ------------------------------------------------------------ 72 University Physicians Care Advantage ---------------------------------------------------------------- 73 UnitedHealthCare Life Insurance Company (UHCLIC) ------------------------------------------------ 73 UPMC Health Plan -------------------------------------------------------------------------------------- 73 USAA – Medicare Supplemental ----------------------------------------------------------------------- 73 USFHP – St. Vincent Catholic Medical Centers of New York ----------------------------------------- 73 Vantage Health Plan ------------------------------------------------------------------------------------ 73 Vermont Medicaid -------------------------------------------------------------------------------------- 73 Veterans Affairs Fee Basis Programs ------------------------------------------------------------------ 74 Veterans Affairs Health Administration Center ------------------------------------------------------- 74
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Virginia Medicaid --------------------------------------------------------------------------------------- 74 Viva Health Inc. ---------------------------------------------------------------------------------------- 74 VNS CHOICE Medicare --------------------------------------------------------------------------------- 74 Washington Medicaid ----------------------------------------------------------------------------------- 75 WEB-TPA, Inc. ------------------------------------------------------------------------------------------ 75 WellCare Health Plans ---------------------------------------------------------------------------------- 75 Wells Fargo Third Party Administrators --------------------------------------------------------------- 75 West Virginia Family Health Plan ---------------------------------------------------------------------- 75 West Virginia Medicaid --------------------------------------------------------------------------------- 75 Western Health Advantage ---------------------------------------------------------------------------- 75 Western Southern Financial Group -------------------------------------------------------------------- 75 Windsor Health Plan ------------------------------------------------------------------------------------ 76 Wisconsin Chronic Disease Program ------------------------------------------------------------------ 76 Wisconsin Medicaid ------------------------------------------------------------------------------------- 76 Wisconsin Well Woman Program ---------------------------------------------------------------------- 76 Wyoming Medicaid ------------------------------------------------------------------------------------- 76
Plan Network IDs ------------------------------------------------------------------------------------------------ 77 Ameritas Dental Group Plans ------------------------------------------------------------------------------ 77
Ameritas Life Insurance Company--------------------------------------------------------------------- 77 First Ameritas of New York ---------------------------------------------------------------------------- 77 First Reliance Standard Life Insurance Company ----------------------------------------------------- 77 Reliance Standard Life Insurance Company ---------------------------------------------------------- 77 Standard Insurance Company ------------------------------------------------------------------------- 77 Standard Insurance Company of New York ----------------------------------------------------------- 77
Cenpatico Plans --------------------------------------------------------------------------------------------- 77 Cenpatico Behavioral Health Arizona ------------------------------------------------------------------ 77 Cenpatico Behavioral Health Florida------------------------------------------------------------------- 77 Cenpatico Behavioral Health Illinois ------------------------------------------------------------------- 77 Cenpatico Behavioral Health Indiana ------------------------------------------------------------------ 77 Cenpatico Behavioral Health Kansas ------------------------------------------------------------------ 77 Cenpatico Behavioral Health Kentucky ---------------------------------------------------------------- 77 Cenpatico Behavioral Health Massachusetts ---------------------------------------------------------- 77 Cenpatico Behavioral Health Ohio --------------------------------------------------------------------- 77 Cenpatico Behavioral Health South Carolina ---------------------------------------------------------- 77 Cenpatico Behavioral Health Texas-------------------------------------------------------------------- 77 Cenpatico Behavioral Health Wisconsin --------------------------------------------------------------- 77 Cenpatico – Managed Health Services (Indiana) ----------------------------------------------------- 77 CMHIN -------------------------------------------------------------------------------------------------- 77 Cenpatico – Managed Health Services (Wisconsin) -------------------------------------------------- 77 CMHWI -------------------------------------------------------------------------------------------------- 77 Cenpatico – Superior Health Plan --------------------------------------------------------------------- 77 CHSPT --------------------------------------------------------------------------------------------------- 77
CoreSource Plans ------------------------------------------------------------------------------------------- 78 CoreSource – FMH-------------------------------------------------------------------------------------- 78 CoreSource – Little Rock ------------------------------------------------------------------------------- 78 CoreSource – Maryland, Pennsylvania, and Illinois -------------------------------------------------- 78 CoreSource – Ohio ------------------------------------------------------------------------------------- 78
Coventry Plans ---------------------------------------------------------------------------------------------- 78 Health America of PA ----------------------------------------------------------------------------------- 78 CHC Georgia -------------------------------------------------------------------------------------------- 78 CHC Virginia -------------------------------------------------------------------------------------------- 78 CHC Louisiana ------------------------------------------------------------------------------------------ 78 CHC West Virginia* ------------------------------------------------------------------------------------ 78 CHC of Carolinas --------------------------------------------------------------------------------------- 78 CHC Delaware ------------------------------------------------------------------------------------------ 78 CHC Iowa ----------------------------------------------------------------------------------------------- 78 CHC Kansas / CHC Oklahoma ------------------------------------------------------------------------- 78 CHC Nebraska ------------------------------------------------------------------------------------------ 78 CHC Illinois --------------------------------------------------------------------------------------------- 78 CoventryCares of West Virginia ----------------------------------------------------------------------- 78 CHC of MO, MS, AK , TN ------------------------------------------------------------------------------- 78 CHC Healthcare USA* ---------------------------------------------------------------------------------- 78
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CoventryCares of Virginia* ---------------------------------------------------------------------------- 78 CvtyNatnlAccts/UofMO/CvtyOne ----------------------------------------------------------------------- 78 Mail Handlers & FEHBP --------------------------------------------------------------------------------- 78 CHC Altius Health Plan/CHC Nevada ------------------------------------------------------------------ 78 CoventryCares of Michigan ---------------------------------------------------------------------------- 78 CHC Texas ---------------------------------------------------------------------------------------------- 78 Vista ----------------------------------------------------------------------------------------------------- 78 CoventryCares of Pennsylvania ------------------------------------------------------------------------ 78 CoventryCares of Nebraska* -------------------------------------------------------------------------- 78 CHC Florida --------------------------------------------------------------------------------------------- 78 MHNET Behavioral Health ------------------------------------------------------------------------------ 78 Aetna Better Health of Kentucky ---------------------------------------------------------------------- 78 *Medicaid Plans ---------------------------------------------------------------------------------------- 78
Glassman Plans --------------------------------------------------------------------------------------------- 79 AFTRA Health Fund ------------------------------------------------------------------------------------- 79 Best Life and Health ------------------------------------------------------------------------------------ 79
Molina Healthcare Plans ------------------------------------------------------------------------------------ 79 Molina CA (California) ---------------------------------------------------------------------------------- 79 Molina FL (Florida) ------------------------------------------------------------------------------------- 79 Molina ID (Idaho) -------------------------------------------------------------------------------------- 79 Molina MI (Michigan) ----------------------------------------------------------------------------------- 79 Molina NM (New Mexico) ------------------------------------------------------------------------------- 79 Molina OH (Ohio) --------------------------------------------------------------------------------------- 79 Molina TX (Texas) -------------------------------------------------------------------------------------- 79 Molina UT (Utah) --------------------------------------------------------------------------------------- 79 Molina WA (Washington) ------------------------------------------------------------------------------- 79 Molina WI (Wisconsin) --------------------------------------------------------------------------------- 79
Principal Financial Plans ------------------------------------------------------------------------------------ 79 Principal Financial Life Insurance Company of America ---------------------------------------------- 79 Nippon Life Insurance Company of America ---------------------------------------------------------- 79
Schaller Anderson Health Plans ---------------------------------------------------------------------------- 80 Schaller Anderson Aetna Better Health of New York ------------------------------------------------- 80 Schaller Anderson Aetna Better Health of Ohio ------------------------------------------------------- 80 Schaller Anderson Aetna Better Health – PA Medicaid ----------------------------------------------- 80 Schaller Anderson Aetna IL Medicaid ----------------------------------------------------------------- 80 Schaller Anderson Aetna TX Medicaid & CHIP -------------------------------------------------------- 80 Schaller Anderson Delaware Physicians Care, Inc. --------------------------------------------------- 80 Schaller Anderson MajestaCare VA -------------------------------------------------------------------- 80 Schaller Anderson Maryland Physicians Care --------------------------------------------------------- 80 Schaller Anderson Mercy Care ------------------------------------------------------------------------- 80 Schaller Anderson Missouri Care ---------------------------------------------------------------------- 80 Schaller Anderson Parkland Community Health Plan ------------------------------------------------- 80 Schaller Anderson TX Christus ------------------------------------------------------------------------- 80
Appendices ----------------------------------------------------------------------------------------------------------- 81
Appendix A: Reference Guides --------------------------------------------------------------------------------- 81 Appendix B: Service Types ------------------------------------------------------------------------------------- 81
Index ----------------------------------------------------------------------------------------------------------------- 88
All Payers Eligibility Guide PC Overview
© 2018 Emdeon Business Services LLC. All rights reserved. Page 1
Overview
About This Guide This guide provides:
• General instructions for entering an eligibility request.
• Payer-specific input requirements and special considerations. The section “Payer Details” beginning on page 6 lists each eligibility transaction by payer name, including any date of service
restrictions, special considerations, and a hyperlink to the appropriate response guide.
This guide has these appendices: “Appendix A: Reference Guides” on page 81, lists additional reference materials. “Appendix B:
Service Types” on page 81 lists Service Types and abbreviated descriptions used in the requests and responses.
For transactions other than eligibility (for example, claim status, referral inquiry, credit report, etc.), see the guides specific to those
transactions.
Customer Support
Emdeon Customer Support
800.333.0263
All Payers Eligibility Guide PC General Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 2
General Information
Requests
Determine the Transaction Type
If all members of a plan have a unique member ID, regardless of their relationship to other family members covered under the same
plan, you will have only one option as the eligibility transaction type: Eligibility. If plan dependents have the same member ID as the
plan subscriber, select Subscriber Eligibility if the claim is for the plan subscriber or Dependent Eligibility if the claim is for a plan
dependent.
Determine the Search Types
Before you can submit a query, you must make sure that you enter enough information to complete at least one type of search in the
database you select.
Most databases can be queried using any one of several different combinations of information. Emdeon provides input fields for all of
the possible search types by which you can search the selected database. Search types are database-specific; however, common search
types include:
• Plan member ID and date(s) of service.
• Plan member ID, date of birth, and date(s) of service.
• Plan member ID, name, and date(s) of service.
• Plan member ID, Social Security number, name, date of birth, and date(s) of service.
• Social Security number and date(s) of service.
• Social Security number, date of birth, and date(s) of service.
• Social Security number, name, and date(s) of service.
• Social Security number, name, date of birth, and date(s) of service.
• Name, date of birth, and date(s) of service. Most payers require that you enter the provider identification number of the inquiring provider. For more information, see “Provider
IDs” on page 4.
You must make sure that at least one query set is complete by verifying that there is data in every input box underscored by one single
color (for example, all boxes underscored by a black bar). If you want the Emdeon server to automatically initiate another search if the
first search does not find the patient's file, make sure that you enter enough data to perform more than one type of query. (For
example, make sure there is data in input boxes underscored by both black and red bars.)
The query may also contain optional fields (for example, middle initial, gender, or group number). In certain cases, these optional
fields may help the payer find the patient’s file.
If you enter data for more than one type of search:
If you enter data for more than one search type, you enable Emdeon’s SmartSearchTM feature. This feature causes the software to
resend the query, using each different search type, until the patient’s record is found. This process is referred to as a search cascade.
The SmartSearch cascade process works like this:
1. When the query is processed, the software sends the combination of data that is most likely to
locate the patient’s file.
2. If the database responds that the data file was not found, the software sends the combination
of data which is the next most likely to locate the file.
3. If again the file is not found, the process repeats until one of the following occurs:
• The record is found.
All Payers Eligibility Guide PC General Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 3
• All search combinations from the query have been sent.
• Certain types of errors occur.
• You cancel processing.
Enter the Search Data
Data Input Area
The data input area contains the information Emdeon will use to query the payer's database. You can manually enter or change
information, if necessary.
Color Bars
The color bars beneath input boxes identify the input data required to complete each type of search. All data elements with the same
color bar compose a search type or query set. For example, to complete entries for a subscriber ID search, you would need to make an
entry in each field that has a black color bar.
Note the following:
• The position of the color bar beneath an input field indicates the sequence in which the search
will be conducted in the event of a SmartSearchTM search cascade. The left-most position
indicates that the data element is used in the highest-priority search type. The next position
from the left is for the second-priority search type, and so on.
• The colors themselves also indicate the priority of the search type, in this sequence:
Black
Red
Yellow
Light green
Blue Optional input fields do not have a color bar. The Account# and Amount fields are always optional fields that are not sent to the
payer in the request. These fields may be used for your internal use only. The account number is the number you have assigned to the
account. The amount is the dollar amount applicable to the inquiry.
Text Color in Input Fields The initial entry you make in a field in a new query will be blue if it is valid or red if it is invalid (for example, letters in a numeric
field or the wrong length).
Black type indicates that you changed the original entry, but that the change is valid.
Help Line For information about a field in which the cursor is resting, consult the help line at the bottom of the window. See the following
example.
All Payers Eligibility Guide PC General Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 4
Special Considerations
The payer may have guidelines for the information that you enter. For example, the patient’s group
number may be an optional entry field, but the payer may recommend that you enter the group number
to narrow your search. To determine if there are any special considerations for the transaction, see the
“Payer Details” on page 6.
Provider IDs Most searches require that you enter the provider identification number of the inquiring provider. A payer may require that you enter
your National Provider Identifier (NPI) as the provider ID, your federal taxpayer ID, a payer-assigned ID, or a combination of any of
these identifiers. Rest your cursor in the field, and note the entry requirements listed on the help line at the bottom of the screen.
In order for you to use your NPI, the following conditions must exist:
• The payer must be ready to accept NPI. Consult our payer lists at
https://access.emdeon.com/PayerLists/ for this payer’s NPI-readiness status.
• The inquiring provider must have fulfilled all of the payer’s NPI registration requirements. You can set up a default provider ID number or a drop-down list of frequently used provider IDs. For more information, see your
product’s user guide.
Date Entries You can enter either a six-digit (mmddyy) or an eight-digit (mmddyyyy) date of service.
If you enter a two-digit year, the software will convert the century, as follows, when you move off the date of service field:
• If the figure you enter is equal to or less than 20, the century converts to a date in the 2000s.
For example, if you enter 03, the system converts the century to 2003.
• If the figure you enter is greater than 20, the century converts to a date in the 1900s. For
example, if you enter 50, the system converts the century to 1950. You must enter all eight digits for a date of birth.
All Payers Eligibility Guide PC General Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 5
Date of Service Restrictions The current date appears on the date(s) of service input prompt(s) for each payer. To send the current date in your request, press the
Tab key to go to the next input prompt.
However, if you want to enter another date, be aware that your payer may or may not have restrictions on the date(s) of service. For
example, many payers do not allow you to enter future dates of service. Some payers let you inquire about eligibility for a date of
service range, but may limit the span between the service dates. To determine your payer’s date of service requirements, see the
“Payer Details” on page 6.
Card Swipe Some payers allow you to run an eligibility transaction using the data provided on the member’s magnetic swipe card. You must have
a card reader set up on your computer in order to use the card swipe feature.
To run a transaction using the magnetic swipe card:
1. From a new record, choose the payer and query type of the card in question.
2. Swipe the card through the card reader attached to your computer.
Emdeon MAX reads the data from the card and inserts it into the appropriate input fields.
3. Enter any additional required information, for example, the provider ID.
4. Submit the transaction as usual. See the “Payer Details” on page 6 to see which payers support magnetic swipe card searches.
Dollar Amounts An input field for a dollar amount places a static decimal point two decimal places to the left of the right-most two digits. Therefore,
you must enter a cent value, even for whole dollar amounts.
Add New Button In some cases, a query will allow you to enter several occurrences of an input field or group of fields (such as up to 12 diagnosis codes
or up to 10 procedure codes and dates), but only one instance of the field is initially displayed. The presence of an Add New button
beside the field indicates that the additional input fields are hidden.
You can display additional occurrences of the field by clicking the Add New button.
Responses There are three types of eligibility responses available through your product:
• A response using version 4 of Emdeon’s standard response format.
• A response using version 5 of Emdeon’s standard response format.
• A response that uses a non-standard format. For information on the response used for each payer, see the “Payer Details” on page 6. Here, the Response Guide column provides a
hyperlink to the appropriate response guide.
The response guides are also available on your installation CD or on the Emdeon resource library at
www.emdeon.com/resourcelibrary/#84; choose User Manuals.
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 6
Payer-Specific Information
Payer Details
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
1199 National Benefit
Fund
Eligibility v1.0
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer requires use of the National
Provider Identifier (NPI) the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
AARP
Eligibility v1.3
Any past date on file; future dates up to the end of the current month.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Absolute Total Care (CTOTL)
Eligibility v1.1
If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Administrative Services, Inc.
Eligibility v1.0
If no date is entered, the date of service will default to the current
date.
This payer permits use of a provider ID or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
Advantage by Bridgeway Health Solutions
Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Advantage by Buckeye Community Health Plan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Advantage by Managed Health Services
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Advantage by Superior HealthPlan
Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 7
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Aetna
Subscriber Eligibility v3.2 Dependent Eligibility v3.2
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the provider ID or the tax ID as the provider identifier.
Entry of the subscriber’s or dependent’s date
of birth is required for all subscriber ID searches, unless an eight-character HMO ID was entered as the subscriber ID.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will
be sent with your request. For dental inquiries, enter ADA codes in the Svc/Proc Code field rather than a service type.
PC-v4-Standard-Eligibility-Response.pdf
Aetna Administrator − Medicare Supplemental
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Aetna Better Health of CA
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the
provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Aetna Better Health of FL
Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Aetna Better Health of NJ
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Aetna Better Health of KY
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Aetna Better Health of LA
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Aetna Better Health of MD
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Aetna Better Health of MI
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Aetna Better Health of MO
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 8
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Aetna Better Health of NV
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Aetna Better Health of PA
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Aetna Better Health of VA
Eligibility v1.0
Any date on file. If no date is
entered, the date of service will
default to the current date.
This payer permits use of a National Provider
Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Aetna Better Health of WV
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Aetna Long Term Care
Eligibility v1.4
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Aetna Senior
Supplemental Insurance
Eligibility v1.1
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of a National Provider
Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Affinity Essentials
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Affinity Health Plan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Affinity Health Plan
Medicare
Eligibility v1.0
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of a National Provider
Identifier (NPI), provider ID, or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
AGIA Inc
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Aflac Dental Insurance
Subscriber Eligibility v1.2 Dependent Eligibility v1.2
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the
provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will
be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 9
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Aflac - Medicare Supplemental
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Alabama Medicaid
Eligibility v2.4
Up to 3 years in the past, future dates not allowed, date span of up to 90 days.
Entry of the patient’s middle initial is required if on file in the payer’s database.
This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
All Savers Life Insurance Company
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Alliant Health Plans
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
If no date is entered, the date of service will default to the current date.
This payer permits use of the provider ID or the tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Allied Benefit Systems, Inc.
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
If no date is entered, the date of service will default to the current
date.
This payer permits use of the provider ID or the tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
Alternative Insurance Resources, Inc.
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier. Entry if the tax ID is preferred,
but if the NPI is submitted instead, it will be used.
PC-v5-Standard-Eligibility-Response.pdf
AmeriBen
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the
provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
American Behavioral Benefit Managers
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 10
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
American Community Mutual
Subscriber Eligibility v1.2
Dependent Eligibility v1.2
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a provider ID or a tax ID as the provider identifier. This payer has no date of service restrictions, but if a date range is submitted and the member does not have eligibility for the entire range, the response will be Inactive. This payer does not return service types in the response. If a member is active for the
service type requested, the response will indicate that the member has active coverage for 30 (Health Benefit Plan Coverage). The response received is for the service type entered only. For example, if the service type in the request was 35, then the response would apply to dental coverage and
not to medical coverage.
All requests for vision service types will
return the message: “Contact the following Entity for Benefits Information.” Contact
information will follow the message.
PC-v4-Standard-Eligibility-Response.pdf
American General Life and Accident
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
American Health Medicare (Inmediata Health)
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
American Income Life Insurance Company
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
American National Insurance Company
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the provider ID or the tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
American National Life Insurance Company of
Texas
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
If no date is entered, the date of service will default to the current
date.
This payer permits use of the provider ID or the tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 11
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
American Network Insurance (REHAB) − Medicare Supplemental
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
American Postal Workers Union
Subscriber Eligibility v1.4 Dependent Eligibility v1.4
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of the provider ID or the tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will
be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
American Retirement Life Insurance Company –
Medicare Supplement
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the
provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will
be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Americhoice of New
Jersey
Eligibility v2.0
Any date on file. If no date is
entered, the date of service will
default to the current date.
This payer permits use of the National
Provider Identifier (NPI) or tax ID as the
provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Amerigroup
Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
AmeriHealth Caritas
Delaware
Eligibility v1.0
Up to 1,461 days in the past (four
years). Future dates of service are allowed.
This payer permits use of the National
Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
AmeriHealth Caritas Iowa
Eligibility v1.0
Up to 1,461 days in the past (four years). Future dates of service are allowed.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
AmeriHealth Caritas Louisiana
Eligibility v1.0
Up to 1,461 days in the past (four years). Future dates of service are allowed.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
AmeriHealth Caritas
Pennsylvania
Eligibility v1.3i
Any past date that is on file, future
dates not allowed.
None. PC-v4-Standard-Eligibility-
Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 12
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
AmeriHealth Caritas VIP Care Plus
Eligibility v1.0
Up to 1,461 days in the past (four years). Future dates of service are allowed.
This payer permits use of the National Provider Identifier (NPI) or Service Provider ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
AmeriHealth District of Columbia
Eligibility v1.0
Up to 1,461 days in the past (four years). Future dates of service are allowed.
This payer permits use of the National Provider Identifier (NPI) or Service Provider ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
AmeriHealth VIP Care
Eligibility v1.0
Up to 1,461 days in the past (four
years). Future dates of service are allowed.
This payer permits use of the National
Provider Identifier (NPI) or Service Provider ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Ameritas Dental Group
Subscriber Eligibility v1.4
Dependent Eligibility v1.4
Any date on file. If no date is entered, the date of service will default to the current date.
This payer supports multiple plans; see “Ameritas Dental Group Plans” on page 77.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Anthem BlueCross of California
Subscriber Eligibility v2.5
Dependent Eligibility v2.5
Future dates not allowed. This payer supports inquiries to out-of-state plans participating in Blue Exchange.
PC-v4-Standard-Eligibility-Response.pdf
APS
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Archbold Medical Center
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Arise Health Plan
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Arise Health Plan − Medicare Select Policy
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 13
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Arizona Medicaid (AHCCCS)
Eligibility v5.0
• The Begin Date of Service must be less than or equal to the current date, and can be 24 months prior to the current date.
• The End Date of Service can be in the past and 30 days in the future from current date.
• Begin Date of Service to End Date of Service span cannot exceed 24 months.
This payer permits use of the National Provider Identifier (NPI), or provider ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Arizona Physicians IPA
Eligibility v2.1
Up to six months in the past, up to 30 days in the future.
This payer permits use of the National Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Arkansas Medicaid
Eligibility v3.4
Up to one year in the past, future dates not allowed, begin and end dates can span up to one year and may cross year-end.
Responses are specific both to the date of service and to the provider; for example, long-term care providers may receive different and/or additional data than
providers who are not long-term care
providers.
PC-v4-Standard-Eligibility-Response.pdf
Associacion de Maestros Puerto Rico
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
AVMed
Eligibility v1.3
Up to one year in the past, future dates not allowed.
None. PC-v4-Standard-Eligibility-Response.pdf
Banner Health Plans
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is
entered, the date of service will
default to the current date.
This payer permits use of the National
Provider Identifier (NPI), provider ID, or tax
ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Banner University Family Care
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
Baptist Health Plan Advantage
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
BC Complete of Michigan
Eligibility v1.3
Up to 1,461 days (4 years) in the past, future dates not allowed.
This payer permits use of a National Provider Identifier (NPI) or provider ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 14
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
BC Idaho
Subscriber Eligibility v1.3 Dependent Eligibility v1.3
Any date on file. If no date is entered, the date of service will default to the current date.
This payer supports inquiries to out-of-state plans participating in Blue Exchange.
Blue Cross of Idaho strongly recommends
not sending service type 30 (Health Benefit Plan Coverage) with your request. It is recommended that you select a specific service type instead, for example, 1 (Medical Care), 35 (Dental Care), or AL (Vision
[Optometry]). When service type 30 is submitted, the payer returns copay and
deductible information for every service type supported.
PC-v4-Standard-Eligibility-Response.pdf
BC Medicare Advantage
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or Tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
BCBS Alabama (Benefits)
Benefits v1.6
Up to one year in the past, future dates not allowed.
This transaction returns details about benefits for which the provider is contracted.
The benefit information that is returned in
the response is customized to the provider’s
area of specialization. For example, an orthopedic physician may receive information related to fractures, casts, and equipment. A general practitioner may receive detail on many benefits.
BCBS-Alabama-Benefits-PC.pdf
BCBS Alabama (Eligibility)
Subscriber Eligibility v2.5
Dependent Eligibility v2.5
Up to one year in the past, future dates not allowed.
This payer supports inquiries to out-of-state plans participating in Blue Exchange.
Dental providers must enter a procedure
code or a dental service type; hospitals and Shield providers must enter a service type.
The benefit information that is returned in the response is customized to the provider’s area of specialization. For example, an orthopedic physician may receive information
related to fractures, casts and equipment. A general practitioner may receive data on all of the patient’s benefits.
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 15
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
BCBS Arizona
Subscriber Eligibility v2.1 Dependent Eligibility v2.2
Past date back to the plan enrollment date, up to 14 days in the future.
This payer supports inquiries to out-of-state plans participating in Blue Exchange.
If you submit your Legacy provider ID and
not your National Provider Identifier (NPI), you must enter the provider’s tax ID. If you submit your NPI, the tax ID is optional.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Arkansas
Subscriber Eligibility v1.3 Dependent Eligibility v1.3
Date of inquiry only. This payer supports inquiries to out-of-state plans participating in Blue Exchange.
Response information is for the date of
inquiry only.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Colorado
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Up to 18 months in the past, future dates not allowed, date span of up
to 18 months.
This payer supports inquiries to out-of-state plans participating in Blue Exchange.
Dependents may not be submitted as a subscriber, or vice versa.
Include the alpha characters in the member ID.
Open-ended eligibility/benefit periods are
returned with an end date 99991231.
Unlimited quantities are returned as 99999.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Connecticut
Subscriber Eligibility v1.3 Dependent Eligibility v1.3
Up to 18 months in the past, future dates not allowed, date span of up to 18 months.
This payer supports inquiries to out-of-state plans participating in Blue Exchange.
Dependents may not be submitted as a subscriber, or vice versa.
This payer requires entry of full first and last names where possible. For hyphenated names, the hyphen can be removed. Do not replace the hyphen with a space.
Open-ended eligibility/benefit periods are returned with an end date 99991231.
Unlimited quantities are returned as 99999.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Delaware (Highmark)
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
BCBS District of Columbia
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Up to one year in the past, future dates not allowed.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 16
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
BCBS Florida
Subscriber Eligibility v4.2 Dependent Eligibility v4.2
Date of inquiry only. This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
The last and first names are recommended
for out-of-state plans.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Georgia
Subscriber Eligibility v1.3 Dependent Eligibility v1.3
Up to one year in the past, future dates not allowed.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
Entry of the inquiring provider’s Q-Care
License Number or National Provider Identifier (NPI) is required.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Illinois
Subscriber Eligibility v2.4 Dependent Eligibility v2.4
Up to two years in the past, future dates not allowed.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
This payer responds with eligibility/benefit information for the current date only. If the date of service submitted is prior to the most recent policy change, this payer responds
with the error message RH0629 - Date of Service Not Within Allowable Inquiry
Period.
For more detailed benefit responses, enter the provider type and facility type.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Indiana
Subscriber Eligibility v1.2
Dependent Eligibility v1.2
Any date on file. If no date is entered, the date of service will default to the current date.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
Dependents may not be submitted as a subscriber, or vice versa.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Iowa
Subscriber Eligibility v2.0
Dependent Eligibility v2.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
This payer permits use of the National Provider Identifier (NPI), provider ID, or tax
ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
BCBS Kansas
Subscriber Eligibility v1.4 Dependent Eligibility v1.4
Up to two years in the past, future dates up to the end of the current
month.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Kansas City
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Up to two years in the past, future dates up to the end of the current month.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 17
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
BCBS Kentucky
Subscriber Eligibility v1.2 Dependent Eligibility v1.2
Up to 18 months in the past, future dates not allowed, date span of up to 18 months.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
Dependents may not be submitted as a
subscriber, or vice versa.
PC-v4-Standard-Eligibility-Response.pdf
BCBS LA Medicare Advantage
Subscriber Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
This payer supports entry of the National
Provider ID or the Federal Tax ID.
PC-v5-Standard-Eligibility-Response.pdf
BCBS Louisiana
Subscriber Eligibility v2.2 Dependent Eligibility v2.2
Up to two years in the past, future dates not allowed.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
The patient’s first name is optional. However, if a patient has siblings with the same birth date (twins, triplets, etc.), it is recommended that the child’s first name be entered. This will help to retrieve a response that shows
the amount of the deductible that has been met by this specific patient.
BCBS-Louisiana-Eligibility-PC.pdf
BCBS Maine
Subscriber Eligibility v1.2 Dependent Eligibility v1.2
Up to 18 months in the past, future dates not allowed, date span of up to 18 months.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Maryland
Subscriber Eligibility v1.3 Dependent Eligibility v1.3
Up to one year in the past, future dates not allowed.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
This payer supports entry of the provider ID or the tax ID.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Massachusetts
Subscriber Eligibility v2.0 Dependent Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
This payer permits use of a National Provider Identifier (NPI) or provider ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 18
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
BCBS Michigan
Subscriber Eligibility v1.4 Dependent Eligibility v1.4
Date of inquiry only. This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
Entry of the patient’s first and last names is
required for non-BCBS of Michigan members. Entry of the group number is required if there are multiple policies on file for the patient; otherwise, it is optional.
The Payer ID that you use is dependent upon
which of the two Emdeon Submitter IDs you registered with your BCBS of Michigan Provider ID with the payer. If you registered your BCBS MI Provider ID under Emdeon
Submitter ID C0DOQ (Professional), you may use the following Payer IDs:
Professional – 00710P
Vision – 00710V Hearing – 00710H FEP – 00710W
If you registered your BCBS MI Provider ID under Emdeon Submitter ID 521409791 (Institutional), you may use the following Payer IDs:
Institutional – 00210I Dental – 00710D
If you use the wrong Payer ID for your registration with BCBS of Michigan, error messages Invalid Provider Number Was Submitted On Request and RH0502 -
Invalid/Missing Provider ID are returned in the response. You will need to confirm with BCBS Michigan whether you are registered under Emdeon’s Submitter ID(s) as a Professional or as an Institutional Provider. BCBS Michigan Provider Enrollment can be reached at 800-822-2761 for
Professional Providers or at 800-777-2118 for Institutional Providers.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Minnesota
Subscriber Eligibility v2.2 Dependent Eligibility v2.2
Up to one year in the past, future
dates not allowed.
This payer supports inquiries to out-of-state
plans accessing the Blue Exchange network.
PC-v4-Standard-Eligibility-
Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 19
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
BCBS Mississippi
Subscriber Eligibility v3.0 Dependent Eligibility v2.0
Up to one year in the past, future dates not allowed, date span of up to 31 days.
The subscriber ID is printed on the patient’s card with a three-character prefix. Do not enter the prefix in the Subscriber ID field.
PC-v5-Standard-Eligibility-Response.pdf
BCBS Missouri
Subscriber Eligibility v1.2 Dependent Eligibility v1.2
Up to 18 months in the past, future dates not allowed, date span of up to 18 months.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
Dependents may not be submitted as a subscriber, or vice versa. Include the alpha
characters in the member ID.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Nebraska
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Up to 24 months in the past, future dates not allowed, date span of up to 90 days.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
Entry of the facility type is optional but highly recommended.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Nevada
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Up to 18 months in the past, future dates not allowed, date span of up to 18 months.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
Dependents may not be submitted as a subscriber, or vice versa.
Include the alpha characters in the member
ID. Open-ended eligibility/benefit periods are returned with an end date 99991231.
PC-v4-Standard-Eligibility-Response.pdf
BCBS New Hampshire
Subscriber Eligibility v1.2
Dependent Eligibility v1.2
Up to 18 months in the past, future dates not allowed, date span of up to 18 months.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
Dependents may not be submitted as a subscriber, or vice versa.
PC-v4-Standard-Eligibility-Response.pdf
BCBS New Jersey (Horizon)
Subscriber Eligibility v1.4
Dependent Eligibility v1.4
Up to two years in the past to January 1, future dates not allowed.
For example, if the current year is
2011, you can inquire back to January 1, 2009.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
This payer permits use of a National Provider
Identifier (NPI) only as the provider
identifier.
PC-v4-Standard-Eligibility-Response.pdf
BCBS New Mexico
Subscriber Eligibility v2.3 Dependent Eligibility v2.3
Up to two years in the past, future dates not allowed.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
This payer responds with eligibility/benefit information for the current date only. If the
date of service submitted is prior to the most recent policy change, this payer responds with the error message RH0629 - Date of Service Not Within Allowable Inquiry
Period.
For more detailed benefit responses, enter the provider type and facility type.
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 20
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
BCBS New York Empire
Subscriber Eligibility v1.3 Dependent Eligibility v1.3
Up to two years in the past to January 1, future dates not allowed. For example, if the current year is 2010, you can inquire back to January 1, 2008.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
PC-v4-Standard-Eligibility-Response.pdf
BCBS North Carolina
Subscriber Eligibility v1.1
Dependent Eligibility v1.1
Up to three years in the past. Date of inquiry will be used if a future date is submitted.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
For subscriber or dependent searches, the
Subscriber ID must be submitted exactly as it appears on the patient’s membership ID card, including alpha prefixes and numeric suffixes. Numeric suffixes are used to uniquely identify dependents who share
some portion of the Subscriber ID.
Dependents may not be submitted as a subscriber, or vice versa.
PC-v4-Standard-Eligibility-Response.pdf
BCBS North Dakota
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Up to 30 days in the past. If the current date is the first through the
fifteenth of the month, the payer
allows inquiries up to the last day of the current month. If the current date is the sixteenth to the end of the month, the payer allows inquiries through to the last day of the next month.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Ohio
Subscriber Eligibility v1.3
Dependent Eligibility v1.3
Up to 18 months in the past, future dates not allowed, date span of up to 18 months.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Oklahoma
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
BCBS Oregon (Regence)
Subscriber Eligibility v1.5 Dependent Eligibility v1.5
Any date on file. If no date is entered, the date of service will
default to the current date.
None. PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 21
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
BCBS Pennsylvania (Highmark)
Subscriber Eligibility v1.2
Dependent Eligibility v1.2
Up to two years in the past, up to six months in the future, although date of inquiry will be used for future dates.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
The following service types entered in the
request produce eligibility/benefit response information under the service type 1 (Medical Care):
10, 23, 24, 25, 26, 27, 28, 32, 35, 36, 37, 38, 39, 41, 60, 85, 87, AA, BA, BJ, BK, BL,
BM, BN, BP, BQ, BR
See Appendix B: Service Types for descriptions and abbreviations.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Rhode Island
Subscriber Eligibility v1.2
Dependent Eligibility v1.2
Up to one year in the past Date of inquiry will be used if a future date is submitted.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
Entry of the gender is optional but highly recommended.
PC-v4-Standard-Eligibility-Response.pdf
BCBS South Carolina
Subscriber Eligibility v1.1
Dependent Eligibility v1.1 Subscriber Detailed Benefits
v1.1 Dependent Detailed Benefits v1.1
Up to three years in the past, up to one year in the future.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
Eligibility:
The Eligibility inquiries return general responses indicating a status of Active or Inactive for Medical, Dental, Pharmacy, or
Vision coverage.
Detailed Benefits:
The Detailed Benefits inquiries return extensive benefit details based on a specific service type or procedure code. If detailed
benefits cannot be determined, the payer will
return a general eligibility response for Medical, Dental, Pharmacy, or Vision coverage. This does not necessarily indicate that the specific service is covered.
(Continued)
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 22
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
BCBS South Carolina
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Subscriber Detailed Benefits v1.1 Dependent Detailed Benefits v1.1
(Continued)
Up to three years in the past, up to one year in the future.
This payer uses the Billing Provider ID to determine if the provider is part of the BCBS network. If network matching occurs, the response may display only the applicable in-network or out-of-network benefits. If the performing and billing providers are the same, then the provider should be submitted as both performing and billing for network
matching to occur. If network matching does not occur, benefits for both billing and performing providers are returned.
Entry of the Performing Provider Specialty (taxonomy code) is recommended to ensure network matching occurs and detailed benefits are returned.
If the performing provider is not on file at the payer, and the performing provider’s specialty is invalid or omitted, this payer
attempts to provide detailed benefits based
on the service type, procedure code, diagnosis code, and/or facility type.
The performing provider must be on file at the payer as the patient's primary care physician in order to receive PCP level benefits in managed care.
Misspelled names can prevent patient matching even if the date of birth is correct. Entry of the patient name is not required for
local inquiries, but may be required for Blue Exchange transactions.
PC-v4-Standard-Eligibility-Response.pdf
BCBS South Dakota
Subscriber Eligibility v2.0 Dependent Eligibility v2.0
Up to one year in the past, up to 30 days in the future.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
BCBS Tennessee
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Up to 30 days in the future. This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
First character of the subscriber ID is
alphabetic.
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 23
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
BCBS Texas
Subscriber Eligibility v2.3 Dependent Eligibility v2.3
Up to two years in the past, future dates not allowed.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
This payer responds with eligibility/benefit
information for the current date only. If the date of service submitted is prior to the most recent policy change, this payer responds with the error message RH0629 - Date of Service Not Within Allowable Inquiry
Period.
For more detailed benefit responses, enter the provider type and facility type.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Texas-Medicaid
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
BCBS Vermont
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Date of inquiry only. This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
BCBS Virginia
Subscriber Eligibility v1.3 Dependent Eligibility v1.3
Up to 18 months in the past, future dates not allowed, date span of up to 18 months.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Wisconsin
Subscriber Eligibility v1.3 Dependent Eligibility v1.3
Up to 18 months in the past, future dates not allowed, date span of up to 18 months.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
Dependents may not be submitted as a subscriber, or vice versa.
PC-v4-Standard-Eligibility-Response.pdf
BCBS Wyoming
Subscriber Eligibility v1.1
Dependent Eligibility v1.1
Up to 30 days in the past. If the current date is the first through the
fifteenth of the month, the payer allows inquiries up to the last day of the current month. If the current date is the sixteenth to the end of the month, the payer allows
inquiries through to the last day of the next month.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
This payer permits use of a provider ID or a
tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Behavioral Health Systems
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 24
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Benefit Management Inc.
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Better Health
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Better Health Plans of
Tennessee
Eligibility v1.3
Up to one year in the past, future
dates not allowed.
Emdeon MAX users with a modem connection
can have the system automatically query this payer following TennCare eligibility transaction when this payer is identified as
the patient’s MCO in the TennCare response. See the Auto MCO topic your Emdeon MAX User’s Guide or online help for details.
PC-v4-Standard-Eligibility-
Response.pdf
BlueChoice HealthPlan of South Carolina Medicaid
Eligibility v1.1
Up to 18 months in the past, future dates not allowed.
Entry of the patient’s gender is optional but highly recommended.
This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
BlueCross BlueShield of
Western New York Medicaid/CHP
Eligibility v1.0
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of a National Provider
Identifier (NPI) only as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Bluegrass Family Health
Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) only as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Boon Group
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Bridgeway Health Solutions (Arizona)
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
BS California
Subscriber Eligibility v3.0 Dependent Eligibility v3.0
Up to one year in the past, future dates not allowed.
This payer supports inquiries to out-of-state plans accessing the Blue Exchange network.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
BS Washington (Regence)
Subscriber Eligibility v1.6
Dependent Eligibility v1.6
Any date on file. If no date is entered, the date of service will
default to the current date.
None. PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 25
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Buckeye Community Health
Eligibility v2.0
If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
California Medicaid (Medi-Cal)
Eligibility v2.3
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
When a patient presents a Medi-Cal Benefits
Identification Card, you must verify the patient’s eligibility status before you submit a
claim. (Benefits Identification Cards are not a guarantee of Medi-Cal eligibility because they are a permanent form of identification and patients retain the card even if they are not eligible for Medi-Cal during the current month.)
When you submit an eligibility transaction, Emdeon accesses the Medi-Cal Eligibility Data System (MEDS) to determine patient
eligibility information. Once you have correctly verified patient eligibility and used the same provider number, subscriber ID, and date of service for the claim as used for the eligibility inquiry, the claim will not suspend or be denied for eligibility.
This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
Capital BlueCross
Subscriber Eligibility v1.1
Dependent Eligibility v1.1
Up to one year in the past, up to six months in the future.
This payer permits use of a National Provider Identifier (NPI) only as the provider identifier.
This payer supports inquiries to out-of-state plans participating in Blue Exchange.
PC-v4-Standard-Eligibility-Response.pdf
Capital District Physician’s Health Plan
Eligibility v1.0
Date cannot be greater than current day and 1 year in the past.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Care1st Health Plan Arizona
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Care Improvement Plus
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 26
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
CareFirst Administrators
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
CarePlus Health Plan
Eligibility v1.3
Up to one year in the past, future dates not allowed.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
CarePoint Medicare
Advantage
Eligibility v1.0
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of a National Provider
Identifier (NPI)or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
CareSource Health
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Carpenters Health and Welfare Trust Fund of St Louis
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
CareSource
Eligibility v3.2
Up to one year in the past, future dates not allowed, date span of up to 92 days.
None. CareSource-Eligibility-PC.pdf
CDS Group Health
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or the tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Celtic Insurance
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or the tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
CeltiCare
Eligibility v1.1
If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 27
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Cenpatico
Eligibility v1.1
Any date on file. You may enter a range of service dates, but the payer uses the current date of service in the request.
This payer supports multiple plans; see “Cenpatico Plans” on page 77.
This payer permits use of a National Provider
Identifier (NPI), provider ID, or the tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Central Reserve Life Insurance Company ―
Medicare Supplement
Eligibility v2.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of the provider ID or the tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will
be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Central States Funds
Subscriber Eligibility v2.0 Dependent Eligibility v2.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the
provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will
be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Chesterfield Resources
Inc
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is
entered, the date of service will
default to the current date.
This payer permits use of a National Provider
Identifier (NPI), or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Christian Brothers Services
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
Christie Student Health Plans
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
CHRISTUS Health Plan Medicaid
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
CHRISTUS Health Plan New Mexico Health Insurance Exchange
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 28
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
CHRISTUS Health Plan NM MA
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Cigna
Subscriber Eligibility v3.2 Dependent Eligibility v3.2
Up to 18 months in the past and 30 days in the future.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
The service type entered must be appropriate for the line of business (medical,
dental, or behavioral) for which you are inquiring, per the following
Medical Line of Business Codes
1, 2, 3, 4, 6, 7, 8, 10, 12, 13, 17, 19, 20, 30, 33, 42, 45, 46, 47, 48, 49, 50, 51, 52, 53,
56, 61, 62, 64, 67, 68, 69, 70, 71, 72, 73,
74, 75, 76, 78, 79, 80, 81, 82, 83, 84, 88, 90, 91, 92, 93, 96, 97, 98, A0, A3, A9, AC, AD, AF, AG, AL, AM, AN, AO, AR, BD, BF, BG, BH, BK, BL, BN, BQ, BR
Dental Line of Business Code
35
Behavioral Line of Business Codes
5, 9, 22, 49, 59, 86, 99, A2, A4, A5, A6, A7,
A8, AA, AI, AJ, AK, BB, BC
See Appendix B: Service Types for code
descriptions and abbreviations.
This payer has card swipe capabilities.
PC-v5-Standard-Eligibility-Response.pdf
CMFG Life Insurance
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Colorado Access
Subscriber Eligibility v2.1 Dependent Eligibility v2.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or a tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 29
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Colorado Medicaid
Eligibility v2.4
Up to one year in the past, future dates not allowed.
This payer has card swipe capabilities. PC-v4-Standard-Eligibility-Response.pdf
Community Care of Oklahoma
Subscriber Eligibility v3.0 Dependent Eligibility v3.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Community Health Plan of
Washington
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of a National Provider
Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-
Response.pdf
Concentrix Insurance Solutions
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, Social Security number, or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Connecticare Inc
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Connecticut Medicaid
Eligibility v1.4
Up to one year in the past, future dates not allowed.
None. PC-v4-Standard-Eligibility-Response.pdf
Consolidated Associates Railroad
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Consumer Mutual of Michigan
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 30
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Continental General Insurance Company ― Medicare Supplement
Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Cooperative Benefit Administrators
Subscriber Eligibility v1.3
Dependent Eligibility v1.3
Any date on file. If no date is entered, the date of service will
default to the current date.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will
be sent with your request.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
CoreSource
Subscriber Eligibility v3.0 Dependent Eligibility v3.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer supports multiple plans; see “CoreSource Plans” on page 77.
This payer permits use a National Provider Identifier (NPI), provider ID, or tax ID as the
provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
CountyCare
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Coventry
Eligibility v2.1
Up to 18 months in the past, up to three months in the future, date span of up to 21 months.
This payer supports multiple plans; see “Coventry Plans” on page 78.
PC-v4-Standard-Eligibility-Response.pdf
Coventry/Dentex Dental
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is
entered, the date of service will
default to the current date.
This payer permits use of a National Provider
Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-
Response.pdf
CREATE
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Crystal Run Health Plan
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 31
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
CSA Fraternal Life ― Medicare Supplement
Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the provider ID or the tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
DAKOTACARE Administrative ServicesEligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Dean Health Plan
Eligibility v1.1
Up to seven days in the future. If no date is entered, the date of
service will default to the current date.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
Delaware Medicaid
Eligibility v1.0
Payer accepts a date of service range. No future dates.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
Dell Childrens Health Plan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
Dentaquest Government Payer WI
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
District No. 9, I. A. of M. & A. W. Welfare Trust
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
District of Columbia Medicaid
Eligibility v3.4
Up to one year in the past, future dates not allowed.
None. PC-v4-Standard-Eligibility-Response.pdf
Diversified Administration Corp
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Driscoll Health Plan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
EBMS
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 32
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Elderplan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Emblem Health
Eligibility v2.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of the National Provider Identifier (NPI) as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Epic Life Insuranace
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is
entered, the date of service will
default to the current date.
This payer permits use of a National Provider
Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Essence Healthcare
Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Evergreen Health
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the
provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Everence Financial
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Excellus BlueCross BlueShield
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. Future dates not allowed.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
Fallon Community Health Plan
Eligibility v2.0
Current date of service only. This payer permits use of the tax ID only.
This payer has card swipe capabilities.
PC-v5-Standard-Eligibility-Response.pdf
Farm Bureau Health Plans
Subscriber Eligibility v1.1
Dependent Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
Federated Insurance Company
Subscriber Eligibility v1.4 Dependent Eligibility v1.4
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 33
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Fidelis Care New York
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
First Carolina Care
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer requires use of the National Provider Identifier (NPI) the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
First Choice VIP Care Plus
Eligibility v1.0
Date cannot be greater than current
day & 1461 days in the past (4
years).
This payer permits use of the National
Provider Identifier (NPI) or Service Provider
ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
First Community Health Plan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the
provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
First United American Insurance Company
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 34
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Florida Medicaid
Eligibility v3.4
Up to one year in the past, future dates not allowed, date span of up to 365 days.
The dates of service you enter in the request determine the type of response you will receive.
If you inquire for a single date of service (beginning and end dates are the same), the Eligibility/Benefits segment will contain details about the patient’s eligibility on the date of service.
If you inquire for a date of service range, Florida Medicaid will return up to nine Eligibility/Benefit segments, one for each period of eligibility within the date of service
span. The Eligibility/Benefit segments will be summarized. For those users who are familiar with the Florida Medicaid proprietary transactions, this type of response will resemble the Span transaction.
In short, use date spans to identify periods of
eligibility, and a single date of service to retrieve detailed eligibility and benefit information for a specific date.
This payer has card swipe capabilities.
Response Details
Benefit and Utilization Limit Information
For single date of service inquiries, the following benefit utilization and limit information will be returned (if in the patient’s file):
(Continued)
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 35
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Florida Medicaid
Eligibility v3.4
(Continued)
Up to one year in the past, future dates not allowed, date span of up to 365 days.
Inpatient days limit
Inpatient days used
Outpatient dollar limit
Outpatient dollars used
Last hearing aid date
Last glasses date
Child Health Check-Up (CHCUP) screen
date
Applicable Dollar Amount or Percentage
With a service type of Hospital—Outpatient, an insurance type of Medicaid, and a time period of Service Year, the dollar amount
shown is the approved amount.
With a service type of Hospital—Outpatient, an insurance type of Medicaid, and a time
period of Exceeded or Not Exceeded, the dollar amount shown is the amount used.
For spenddowns, the patient’s remaining share of cost will appear.
Benefit-Specific Eligibility Dates
In the case of the last CHCUP screen date,
the most recent screen date appears.
In the case of the last hearing aid date or
last glasses date, the date represents the most recent date of issue.
PC-v4-Standard-Eligibility-Response.pdf
Food Employers & Bakery
& Confectionery Workers
Benefit Fund of Southern California
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is
entered, the date of service will
default to the current date.
This payer permits use of the National
Provider Identifier (NPI) or tax ID as the
provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Fresenius Health Partners
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 36
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Georgia Medicaid
Eligibility v5.4
Up to one year in the past, future dates not allowed.
Entry of the provider ID is optional if you are using your payer-assigned ID; entry is required if you are using your NPI and have registered the number with Georgia Medicaid. This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
Globe Life and Accident Insurance Company
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the
provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
G.M.P. Employers Retiree Trust
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Golden Rule
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Up to six months in the past, up to 30 days in the future.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Government Employees
Hospital Association (GEHA)
Subscriber Eligibility v2.1 Dependent Eligibility v2.1
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of the National
Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
Entry of the Member ID field can be either the patient’s GEHA member ID number or the patient’s Social Security number.
PC-v5-Standard-Eligibility-
Response.pdf
Great American Life Assurance Company ― Medicare Supplement
Eligibility v1.0
If no date is entered, the date of service will default to the current date.
This payer permits use of the provider ID or the tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
Great American Life Insurance Company ― Medicare Supplement
Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 37
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Great-West Healthcare
Eligibility v1.3
Up to 18 months in the past, future dates not allowed.
This payer permits use of a provider ID or a tax ID as the provider identifier.
This payer recommends that you use one of
the following service type codes in your request:
1, 35, AL
See Appendix B: Service Types for code descriptions and abbreviations.
PC-v4-Standard-Eligibility-Response.pdf
Group and Pension Administrators Inc.
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Group Dental Service
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Harmony Health Plan (WellCare of Florida)
Eligibility v1.0
Up to two years in the past. This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Harvard Pilgrim Health Care
Eligibility v1.2
Up to two years in the past, future dates not allowed.
You can enter a partial first name. For example, a partial first name of Jo will match Joe, Joseph, or Josephine. However, an
exact first name of Joe will not match a first name of Joey or a combined first name and middle initial of Joe B.
The last name must match exactly, including any suffix, hyphen, or apostrophe. For
example, Smithers Jackson will not match Smithers-Jackson and James will not match James Sr.
PC-v4-Standard-Eligibility-Response.pdf
Hawaii Medicaid
Eligibility v1.7
Future dates not allowed, date span of up to 30 days.
Hospital providers can search for dates of service further back than one year in the past.
Non-hospital providers must search for dates of service within the past
year.
Entry of the patient’s middle initial is required if on file in the payer’s database. If the patient’s first or last names have a special character such as an apostrophe, a
hyphen, or a space (for example, O’Hara, Smith-Jones, La Toya), try searching with and without the special characters or space.
This payer has card swipe capabilities.
Hawaii-Medicaid-Eligibility-PC.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 38
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Hawaii Medical Service Association
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file, up to 90 days in the future.
If no date is entered, the date of
service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) only as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Health Alliance of Illinois
Eligibility v1.0
Payer accepts a date of service range. No future dates.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
Health Alliance Plan
Eligibility v1.3
In the past to 1996, future dates not allowed.
None. PC-v4-Standard-Eligibility-Response.pdf
Health Choice of Arizona
Eligibility v2.2
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of the National Provider Identifier (NPI) or the tax ID as the
provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Health First Health Plan
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is
entered, the date of service will
default to the current date.
This payer permits use of the National
Provider Identifier (NPI) or the tax ID as the
provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Health First Insurance
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI), provider ID, or the tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Health Partners MN
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or provider ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Health Partners of
Philadelphia
Eligibility v1.3
Any date on file. If no date is
entered, the date of service will default to the current date.
None. PC-v4-Standard-Eligibility-
Response.pdf
Health Services for Children with Special Needs
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will
be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Health Share of Oregon
Eligibility v3.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 39
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
HEALTHe Exchange
Subscriber Eligibility v2.0 Dependent Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
HealthEase (WellCare of Florida)
Eligibility v1.0
Up to two years in the past. This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
HealthEase Kids
(WellCare of Florida)
Eligibility v1.0
Up to two years in the past. This payer permits use of a provider ID or a
tax ID as the provider identifier.
PC-v4-Standard-Eligibility-
Response.pdf
HealthEZ
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Any date on file. If no date is entered, the date of service will
default to the current date.
None. PC-v4-Standard-Eligibility-Response.pdf
Healthfirst of New Jersey
Eligibility v2.2
Any date on file. If no date is entered, the date of service will default to the current date.
None. PC-v5-Standard-Eligibility-Response.pdf
Healthfirst of New York
Eligibility v2.2
Any date on file. If no date is
entered, the date of service will default to the current date.
None. PC-v5-Standard-Eligibility-
Response.pdf
HealthNet National
Eligibility v1.2
Up to 12 months in the past, future dates up to the last day of the current month, date span of up to 12 months in the past to the last day of the current month.
You must enter the suffix for an ID search. If you do not enter the ID suffix, you will receive error message CL0003 – Insufficient Information to Complete a Search.
If you do not know the suffix, perform an ID/Social Security number/date of birth or an ID/name/date of birth search instead.
PC-v4-Standard-Eligibility-Response.pdf
HealthPlus of Michigan
Eligibility v1.3
Up to one year in the past, up to 60 days in the future, date span of up to 60 days.
None. PC-v4-Standard-Eligibility-Response.pdf
HealthSmart Benefit Solutions
Subscriber Eligibility v2.0 Dependent Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
HealthSmart Benefit Solutions − WV
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 40
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
HealthSpring
Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or the tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Healthy Blue Louisiana
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Highmark BCBSD Health
Options
Eligibility v1.0
Any date on file. If no date is
entered, the date of service will
default to the current date.
This payer permits use of a National Provider
Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
HMA (Hawaii Mainland Admin)
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Horizon New Jersey Health
Eligibility v1.3
Any date in the past on file, future dates not allowed.
None. PC-v4-Standard-Eligibility-Response.pdf
HSBS Oklahoma City
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or the tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Humana
Eligibility v2.3
Up to two years in the past, future dates up to one year based on the member’s date of renewal restriction.
This payer permits use of a provider ID or a tax ID as the provider identifier.
Information on as many as five family members can be returned in a single response.
PC-v4-Standard-Eligibility-Response.pdf
IBEW Local 508 Health
Plan
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of a National Provider
Identifier (NPI) or the tax ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Idaho Medicaid
Eligibility v1.2
Up to one year in the past, future dates not allowed, date span of up to one year.
Patient eligibility is determined on a month-to-month basis. For example, a patient may be eligible during the months of April and June, but ineligible during May.
This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
IlliniCare Health Plan
Eligibility v1.1
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 41
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Illinois Medicaid
Eligibility v6.2
Any date on file, date span of up to 94 days.
This payer has combined the former eligibility and pending eligibility transactions into a single eligibility transaction. The service type code is used in the request to differentiate between eligibility and pending eligibility: enter 30 for an eligibility request and 32 for a pending eligibility request.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
Once a recipient has been assigned a recipient ID, the recipient’s record will no
longer be in the pending eligibility database. If you search by recipient ID and service type of 32 (pending eligibility), the recipient’s record will not be found. You will receive the following error message: RH0247 – Patient Not Found. Search for the recipient’s
eligibility status using a service type of 30.
Pending Eligibility Responses
Application Still Pending
If a patient’s application for Medicaid is still pending, the Eligibility/Benefit portion of the response will appear as follows:
First Eligibility/Benefit Segment:
Eligibility type Inactv Coverage type Individual Service type Health Bene Plan Cvg
Second Eligibility/Benefit Segment:
Eligibility type Inactv – Pending Elig Update Coverage type Individual Service type Plan Waiting Period Date of the last update to the record
(Continued)
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 42
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Illinois Medicaid
Eligibility v6.2
(Continued)
Any date on file, date span of up to 94 days.
Application No Longer Pending
If a patient’s application for Medicaid is no longer pending—for example, it has been
approved or denied—the Eligibility/Benefit portion of the response will appear as follows::
First Eligibility/Benefit Segment:
Eligibility type Inactv
Coverage type Individual Service type Health Bene Plan Cvg Second Eligibility/Benefit Segment:
Eligibility type Non-Cvd Coverage type Individual Service type Plan Waiting Period Date of the last update to the record
You must submit the transaction using service type 30 to determine whether the patient has become Medicaid-eligible.
PC-v4-Standard-Eligibility-Response.pdf
Independence Blue Cross
Subscriber Eligibility v1.3 Dependent Eligibility v1.3
Up to two years in the past, future dates not allowed.
This payer supports inquiries to out-of-state plans participating in Blue Exchange.
The provider ID can be either the provider’s NPI or the provider’s federal tax ID with a leading zero (0).
PC-v4-Standard-Eligibility-Response.pdf
Indiana Medicaid
Eligibility v3.5
Future dates not allowed. Date span of up to 31 days, within the same month and year.
Entry of the service type is optional. However, entry of a service type allows you to whether benefit limits have been exceeded. For example, a provider wishing to
confirm Durable Medical Purchase would
enter a service type code of 12. If the benefit limit has been exceeded, the response will include a Limitations Eligibility/Benefit type. If benefit limits have not been exceeded, this payer will return basic Health Benefit Plan Coverage information.
This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
Inland Empire Health
Plan
Eligibility v2.2
Up to one year in the past, future
dates not allowed.
None. PC-v4-Standard-Eligibility-
Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 43
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Inter Valley Health Plan
Eligibility v2.2
Up to one year in the past, future dates not allowed.
When searching by name/date of birth, you must enter the patient’s full last name. If the patient’s last name has more than 13 characters, you will not find a matching record in the database. You must use a different search type.
PC-v4-Standard-Eligibility-Response.pdf
International Medical Card
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Iowa Medicaid
Eligibility v2.4
Up to three years in the past, future dates not allowed.
None. PC-v4-Standard-Eligibility-Response.pdf
Island Home Insurance
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Johns Hopkins HealthCare
Eligibility v1.2
Up to two years in the past, future dates not allowed. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) only as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Johns Hopkins HealthCare LLC
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Johns Hopkins US Family Health Plan
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) only as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Kaiser Foundation Health
Plan of Colorado
Eligibility v2.1
Any date on file. If no date is
entered, the date of service will
default to the current date.
This payer permits use of the provider’s
National Provider Identifier (NPI), provider
ID, or tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-
Response.pdf
Kaiser Foundation Health Plan of Hawaii
Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 44
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Kaiser Foundation Health Plan of Hawaii (DHMO/CHOICE)
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Kaiser Foundation Mid-Atlantic
Eligibility v2.1
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use a National Provider Identifier (NPI), provider ID, or tax ID as the
provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Kaiser Foundation Health Plan of Northwest
Eligibility v2.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Kaiser NW Dental
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Kaiser Permanente Insurance Company KPIC
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Kaiser Permanente of Georgia
Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Kaiser Permanente of Northern California
Eligibility v2.1
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of the provider’s National Provider Identifier (NPI), provider
ID, or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Kaiser Permanente of
Southern California
Eligibility v2.1
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of the provider’s
National Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
KanCare-UnitedHealthcare Community Plan Kansas
Eligibility v1.0
Up to 18 months in the past. End date of date range must be no greater than the end of the current month.
This payer permits use of the provider’s National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Kansas Medicaid
Eligibility v3.5
Up to one year in the past, future dates not allowed.
This payer has card swipe capabilities. PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 45
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Kempton Company
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the provider’s National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Kentucky Medicaid
Eligibility v5.3
Up to one year in the past, future dates not allowed.
This payer has card swipe capabilities. PC-v4-Standard-Eligibility-Response.pdf
Kentucky Spirit Health Plan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
Key Benefit Administrators
Subscriber Eligibility v1.1
Dependent Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Key Benefit Administrators (Indianapolis, IN)
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
Keystone First
Eligibility v1.3
Future dates not allowed. None. PC-v4-Standard-Eligibility-
Response.pdf
Keystone VIP Choice
Eligibility v1.0
Date cannot be greater than current day & 1461 days in the past (4 years).
This payer permits use of a National Provider Identifier (NPI) or Service Provider ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
L.A. Care.
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Leon Medical Centers Health Plan, Inc.
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 46
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Liberty National Life Insurance Company
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
LifeCare Assurance Company
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a Federal Tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Lincoln Financial
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Louisiana Healthcare Connections
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will
be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 47
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Louisiana Medicaid
Eligibility v2.4
Up to one year in the past, future dates up to and including the last day of the current month.
When performing searches that involve the patient’s name, you must enter the name exactly as it is spelled on the Louisiana plastic swipe card, so that it will match the state’s files. The first and last name entries must include any special characters such as hyphens, commas, apostrophes, and spaces (excluding asterisks).
Some patients may be currently covered by one of the following programs but have not
been issued a Louisiana plastic swipe card (hard card):
SOBRA presumptive eligible.
Illegal/ineligible aliens (emergency services).
Long term care (type-case 16-Certification of Long Term Care eligible applicants who
die before their certification can be
processed).
Since these patients do not have a hard card, you can verify their eligibility status by using other search methods, such as a name and date of birth search or a Social Security number and date of birth search.
This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
Loyal American Life ― Medicare Supplement
Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Maine Community Health Options
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Magnolia Health Plan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of the provider’s National Provider Identifier (NPI) or a tax ID
as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 48
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
MagnaCare
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
MaineCare (Maine Medicaid)
Eligibility v2.0
Up to two years in the past, future dates not allowed.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Managed Care of America
Subscriber Eligibility v1.1
Dependent Eligibility v1.1
Past dates of service up to January
1, 2011. Future dates and date spans are not allowed.
Entry of the provider’s National Provider
Identifier (NPI) is required.
PC-v5-Standard-Eligibility-
Response.pdf
Managed Health Network (MHN)
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Managed Health Services - Indiana
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
MAPFRE Life Puerto Rico
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
MAPFRE Medicare Excel
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Maricopa Care Advantage
Eligibility v1.2
Up to one year in the past, future dates not allowed.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Maricopa Health Plan (Arizona)
Subscriber Eligibility v2.1 Dependent Eligibility v2.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the provider’s National Provider Identifier (NPI) or a tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Maryland Medicaid
Eligibility v2.2
Up to one year in the past, future dates not allowed.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 49
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Maryland Physicians Care
Eligibility v1.0
A range of dates is acceptable, but Centene only looks up based on current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Massachusetts Medicaid (MassHealth)
Eligibility v1.4
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer’s member ID can be found on the patient’s hard card and consists of the first
nine characters of the number to the right of the patient’s name.
PC-v4-Standard-Eligibility-Response.pdf
MDWISE Exchange
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
MDWISE Medicaid Health Plans
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Med-Pay, Inc.
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Medi-Share
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
MedBen Newark OH
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Payer supports a single date of service only. Any date on file can be submitted.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Medica
Subscriber Eligibility v1.4 Dependent Eligibility v1.4
Up to one year in the past. None. PC-v4-Standard-Eligibility-Response.pdf
Medica Health Plans
Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Medica2
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Medical Associates Health Plan/Health Choices
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 50
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Medical Card System
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Medical Mutual of Ohio (MMO)
Subscriber Eligibility v2.2 Dependent Eligibility v2.2
Up to two years in the past, up to one year in the future. If no date is
entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or a tax ID as the provider
identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will
be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 51
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Medicare Part A & B
Eligibility v2.8
Up to 12 months in the past, future dates up to four months, based upon the date the transaction was received. If no dates are entered, the dates of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) only as the provider identifier.
General Information
This transaction returns both Part A and Part B information. Part A and B providers can
access this transaction for eligibility.
Medicare Part A helps cover inpatient care in
hospitals, critical access hospitals, and skilled nursing facilities. It also covers hospice care and some home health care.
Medicare Part B helps cover these services when they are medically necessary: doctors’ services, outpatient hospital care, some of the services of physical and occupational therapists, and some home health care.
The Medicare HIPAA Eligibility Transaction System (HETS) will be loaded from the
common working files. HETS may be behind
the Medicare common working files by at least 24 hours. Claims to Medicare should be submitted using the HETS information returned with this transaction.
Railroad beneficiaries are accessible through this transaction.
This payer permits use of a National Provider Identifier (NPI) only as the provider identifier.
Service Types
CMS supports all Service Type codes.
HCCPS Codes
HCPCS Codes are accepted. Supported
codes are listed in the user interface.
Current versus Historical Data
The response returns only the spell data that has occurred within 60 days prior to the date of service. To receive historical spell
information, you must enter a date of service within 60 days of the spell date, or the date of service span must cover the spell date.
Hospital Days Remaining
If the inquiry is for the current date of service (the date on which the transaction was submitted), the number of hospital days remaining will be valid as of the current day. If your inquiry is for a prior date of service,
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 52
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Medicare Part A & B
Eligibility v2.8
(Continued)
Up to 12 months in the past, future dates up to four months, based upon the date the transaction was received. If no dates are entered, the dates of service will default to the current date.
Hospital Days Remaining
If the inquiry is for the current date of service (the date on which the transaction
was submitted), the number of hospital days remaining will be valid as of the current day. If your inquiry is for a prior date of service, or if the date span extends into the past, the number of hospital days remaining will be
valid as of the admission date shown in that segment.
HMO Enrollment
If the beneficiary has had HMO enrollment, the HMO information will appear in the response only if the beneficiary’s HMO enrollment period is active or if the
requested date span covers the HMO end date. For example, if a beneficiary was enrolled in an HMO from January 1, 2010
through December 31, 2012, the HMO information will appear on the response only if your beginning or ending dates of service
fall on or between January 1, 2010 and December 31, 2012.
Incarceration
If the patient is incarcerated during the date span submitted, then the person is ineligible.
PC-v5-Standard-Eligibility-Response.pdf
Medicare y Mucho Mas
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
Meridian Health Plan of Illinois
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Meritain Health
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of the National
Provider Identifier (NPI) only as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 53
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Meritus Health Partners
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
MetLife
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
Entry of the provider’s National Provider Identifier (NPI) is required.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
MetroPlus Health Plan
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
Entry of the provider’s National Provider Identifier (NPI) and tax ID is required.
MetLife highly recommends entry of the subscriber’s group number.
PC-v5-Standard-Eligibility-Response.pdf
Michigan Medicaid
Eligibility v3.0
A single date of service or a date of service range of up to three months.
Up to one year in the past, future dates up to the end of the current
month.
Enter the requesting provider’s National Provider Identifier (NPI) or provider ID.
This payer has card swipe capabilities.
PC-v5-Standard-Eligibility-Response.pdf
Michigan MIChild
Eligibility v2.5
Up to one year in the past, future dates up to the end of the current
month.
Enter the requesting provider’s National Provider Identifier (NPI), or for HIPAA-
exempt providers, their seven-digit Michigan provider ID.
This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
Minnesota Medicaid
Eligibility v4.1
Up to one year in the past, future
dates not allowed.
This payer permits use of a provider ID or a
tax ID as the provider identifier.
PC-v4-Standard-Eligibility-
Response.pdf
Mississippi Medicaid
Eligibility v4.3
Up to one year in the past, future dates not allowed.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 54
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Mississippi State Employees’ Health Plan (SEHP)
Eligibility v1.7
Up to one year in the past, future dates not allowed, date span of up to 31 days.
This payer has card swipe capabilities.
About License Numbers
Entry of the ordering provider’s MMIS provider ID or the License Number is optional. However, depending on the requesting provider’s classification with New
York Medicaid, it may be necessary for you to enter this information.
When using a License Number as a provider identifier for eMedNY Phase II, the New York State Department of Education (NYSDOH) additionally requires a three-digit Profession Code as a prefix. The codes are a subset of the two-digit Profession Codes assigned by NYSDOH and the Office of the Professions
when it issues professional licenses. A leading zero is added to the left to create the NYSDOH three-digit Profession Code, and, for
NYS licensed providers, two more zeros must follow between the Profession Code and the License Number.
An exception exists for services of a NYS licensed Privileged Nurse Practitioner or
Privileged Midwife. In these two cases, a value of 0F must be inserted between the Profession Code and License number instead of the two zeros. All out-of-state licenses must be formatted with the two-letter State,
District of Columbia, or US Territory Code as assigned by the United States Postal Service
in place of the 00 or 0F values.
When entering a license number in the
Ordering Prov ID field, omit the leading zero of the Profession Code. Emdeon will insert the leading zero before sending the request to New York Medicaid.
Mississippi-SEHP-Eligibility-PC.pdf
Missouri Medicaid
Eligibility v5.3
Up to one year in the past, future dates up to the end of the current
month, date span of up to 31 days.
The Case DCN is the dependent’s casehead ID number or Medicaid DCN number.
This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 55
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
MMSI
Subscriber Eligibility v1.3 Dependent Eligibility v1.3
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a provider ID or a tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
Molina Healthcare
Eligibility v2.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer supports multiple plans; see “Molina Healthcare Plans” on page 79.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Molina Healthcare of New Mexico
Eligibility v1.3
Up to one year in the past, future dates not allowed.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
Molina Healthcare of Virginia
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Montana Medicaid
Eligibility v2.3
Up to one year in the past, future
dates not allowed. This payer has card swipe capabilities. PC-v4-Standard-Eligibility-
Response.pdf
Molina of Puerto Rico
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Mountain State
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Up to two years in the past, up to six months in the future.
None. PC-v4-Standard-Eligibility-Response.pdf
Municipal Health Benefit Fund
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Mutual Health Services
Subscriber Eligibility v1.4 Dependent Eligibility v1.4
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Mutual of Omaha
Subscriber Eligibility v2.0 Dependent Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or provider ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 56
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
MVP Health Care (New York)
Eligibility v1.3
Any date on file. If no date is entered, the date of service will default to the current date.
None. PC-v4-Standard-Eligibility-Response.pdf
National Association of Letter Carriers (NALC)
Subscriber Eligibility v2.0 Dependent Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
National Claims Admin Services
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Nebraska Medicaid
Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), or a service provider ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Network Health Plan
Eligibility v1.1
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or a tax ID as
the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Nevada Medicaid
Eligibility v2.2
Up to one year in the past, up to five days in the future, date span of up to one calendar month.
This payer has card swipe capabilities. PC-v4-Standard-Eligibility-Response.pdf
New Era Life Insurance Company
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
This payer includes the following plans under the same payer ID:
• New Era Life Insurance Company of the Midwest
• Philadelphia American Life Insurance Company
PC-v5-Standard-Eligibility-Response.pdf
New Hampshire Medicaid
Eligibility v1.5
Up to one year in the past, future dates not allowed. Date span of up to one month.
This payer permits use of a National Provider Identifier (NPI) or provider ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 57
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
New Jersey Medicaid
Eligibility v5.3
Up to 24 months in the past, future dates up to the end of the current month, date span of up to three months.
Only hospital providers are allowed to use name/date of birth and Social Security number/name searches. An error is returned if a non-hospital provider attempts these search types.
This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
New Mexico Health Connections
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
If no date is entered, the date of service will default to the current
date.
This payer permits use of a National Provider Identifier (NPI) or Tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
New Mexico Medicaid
Eligibility v4.2
Up to one year in the past, future dates up to the end of the current
month.
This payer permits use of a National Provider Identifier (NPI) or provider ID as the provider
identifier.
This payer has card swipe capabilities.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 58
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
New York Medicaid
Eligibility v3.3
Up to two years in the past, future dates not allowed.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
This payer has card swipe capabilities.
About License Numbers
Entry of the ordering provider’s MMIS provider ID or the License Number is optional. However, depending on the
requesting provider’s classification with New York Medicaid, it may be necessary for you to enter this information.
When using a License Number as a provider identifier for eMedNY Phase II, the New York State Department of Education (NYSDOH) additionally requires a three-digit Profession Code as a prefix. The codes are a subset of the two-digit Profession Codes assigned by
NYSDOH and the Office of the Professions
when it issues professional licenses. A leading zero is added to the left to create the NYSDOH three-digit Profession Code, and, for NYS licensed providers, two more zeros must follow between the Profession Code and the
License Number.
An exception exists for services of a NYS licensed Privileged Nurse Practitioner or
Privileged Midwife. In these two cases, a value of 0F must be inserted between the
Profession Code and License number instead of the two zeros. All out-of-state licenses must be formatted with the two-letter State, District of Columbia, or US Territory Code as
assigned by the United States Postal Service in place of the 00 or 0F values.
When entering a license number in the
Ordering Prov ID field, omit the leading zero of the Profession Code. Emdeon will insert the leading zero before sending the request to New York Medicaid.
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 59
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Nippon Life Benefits
Subscriber Eligibility v2.0 Dependent Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
NMPSIA
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
NMRHCA
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
North Carolina Medicaid
Eligibility v3.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or provider ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
North Dakota Medicaid
Eligibility v4.4
Up to one year in the past, future dates not allowed.
This payer has card swipe capabilities. PC-v4-Standard-Eligibility-Response.pdf
Northwest Administrators, Inc.
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
NovaSys Health
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a provider ID or a tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
‘Ohana Health Plan (WellCare of Hawaii)
Eligibility v1.0
Up to two years in the past. This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Ohio Medicaid
Eligibility v3.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI), provider ID, or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 60
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Oklahoma Employees Group Insurance Division
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Oklahoma Medicaid
Eligibility v4.3
Up to 13 months in the past, future dates up to the end of the current month, date span must be within the
same month.
This payer has card swipe capabilities. PC-v4-Standard-Eligibility-Response.pdf
Operating Engineers Local No. 428 Health and
Welfare Trust Fund
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Optima Health
Eligibility v1.3
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a provider ID or a tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will
be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Orange County Fire Authority
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Oregon Medicaid
Eligibility v2.6
Up to one year in the past, future dates not allowed, date span of up to 90 days.
You must enter the patient’s first and last names exactly as they are on file with this payer.
PC-v4-Standard-Eligibility-Response.pdf
Oregon’s Health CO-OP
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Oxford Health Plans
Eligibility v1.5
Up to 18 months in the past, future dates up to the end of the current
month.
Emdeon sends the following service types to this payer regardless of the value entered in
the Service Types field: 30, 35, 47, 48, and 98. If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
See Appendix B: Service Types for code descriptions and abbreviations.
PC-v4-Standard-Eligibility-Response.pdf
Oxford Life Insurance Company
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 61
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
PacificSource Administrators
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
PacificSource Health Plans
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
PacificSource Community Solutions
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
PacificSource Medicare
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Pan-American Life
Insurance
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of a National Provider
Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Panamerican Life Puerto Rico (PALIC)
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
Partnership Health Plan of California
Eligibility v2.2
Up to one year in the past, future dates not allowed.
When searching by name/date of birth, you must enter the patient’s full last name. If the patient’s last name has more than 13 characters, you will not find a matching
record in the database. You must use a different search type instead.
PC-v4-Standard-Eligibility-Response.pdf
Passport Health Plan
Eligibility v1.4
Up to one year in the past, future dates not allowed.
None. PC-v4-Standard-Eligibility-Response.pdf
Pekin Life Insurance
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Payer supports a single date of service only. Any date on file can be submitted.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 62
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Penn Treaty Network America Insurance (REHAB) − Medicare Supplemental
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Pennsylvania Medical Assistance
Eligibility v2.4
Up to ten years in the past, future dates not allowed.
This payer has card swipe capabilities. PC-v4-Standard-Eligibility-Response.pdf
Peoples Health
Eligibility 2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
PerformCare
Eligibility v1.0
Date cannot be greater than current day & 1461 days in the past (4 years).
This payer permits use of a National Provider Identifier (NPI) or Service Provider ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Personal Insurance Administrators
Subscriber Eligibility v2.0 Dependent Eligibility v2.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
PHCS Savility Payers
Subscriber Eligibility v1.2 Dependent Eligibility v1.2
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Physicians Mutual
Subscriber Eligibility v1.3 Dependent Eligibility v1.3
Any date on file, future dates up to one month past the current contract date are allowed.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Piedmont Wellstar HealthPlans
Eligibility v1.0
Current date of service only. Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
Pittman and Associates
Subscriber Eligibility v1.2
Dependent Eligibility v1.2
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Plan de Salud Hospital Menonita
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
Entry of the provider’s National Provider Identifier (NPI) is required.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 63
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Planned Administrators, Inc.
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
Entry of the provider’s tax ID is required. PC-v5-Standard-Eligibility-Response.pdf
Plumbers and Pipefitters Local 525 Health & Welfare Trust
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Preferred Care Partners
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Preferred Health Systems
Subscriber Eligibility v1.4 Dependent Eligibility v1.4
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
PreferredOne
Eligibility v2.3
Any date on file. If no date is
entered, the date of service will default to the current date.
None. PC-v4-Standard-Eligibility-
Response.pdf
Premera Blue Cross
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
This payer includes the following plans under the same payer ID:
• Premera Blue Cross (PPO/PAR, Indemnity, Traditional)
• Premera Blue Cross Blue Shield of Alaska
(PPO/PAR, Indemnity, Traditional)
• Premera Dimensions – Foundation, Access, Global and Heritage
• LifeWise Health Plan of Washington
• LifeWise Health Plan of Oregon
• Federal Employee Program
PC-v5-Standard-Eligibility-Response.pdf
Prestige Health Choice
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 64
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Primary PhysicianCare, Inc.
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Principal Financial
Subscriber Eligibility v1.4 Dependent Eligibility v1.5
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer supports multiple plans; see “Principal Financial Plans” on page 79.
This payer permits use of a provider ID or a
tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Priority Health
Eligibility v1.1
Up to one year in the past, up to one year in the future.
This payer permits use of a provider ID or a tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
Prominence Health Plan
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Providence Health Plan
Subscriber Eligibility v2.1 Dependent Eligibility v2.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Provident American Life & Health Insurance Company ― Medicare Supplement
Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will
be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Puerto Rico Medicaid (ODSI)
Eligibility v3.2
If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) only as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Quartz ASO
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
QuikTrip Corporation
Subscriber Eligibility v2.0
Dependent Eligibility v2.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a provider ID or a tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 65
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
RightCare from Scott and White Health Plan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or a Tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Rocky Mountain Health Plan (HMO)
Eligibility v2.0
Payer supports a single date of service only. Any date on file can be submitted.
This payer permits use of a provider Identifier (NPI) or a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
SAMBA Health Benefit
Plan
Subscriber Eligibility v2.1 Dependent Eligibility v2.1
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of a provider
Identifier (NPI) or a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
San Joaquin Health Plan
Eligibility v2.3
Up to one year in the past, future dates not allowed.
When searching by name/date of birth, you must enter the patient’s full last name. If the patient’s last name has more than 13 characters, you will not find a matching record in the database. You must use a different search type.
PC-v4-Standard-Eligibility-Response.pdf
Santa Clara Family Health Plan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Schaller Anderson Health Plans
Eligibility v1.2
Any date on file. If no date is entered, the date of service will default to the current date.
This payer supports multiple plans; see “Schaller Anderson Health Plans” on page 80.
This payer permits use of a National Provider
Identifier (NPI), provider ID, or tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will
be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Schaller Anderson Mercy Maricopa
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or Tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Select Health of South Carolina
Eligibility v1.2
Any past date that is on file, future dates not allowed.
None. PC-v4-Standard-Eligibility-Response.pdf
Selman & Company
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 66
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Senior Care Action Network (SCAN) Health Maintenance Organization (HMO)
Eligibility v2.3
Up to one year in the past, future dates not allowed.
When searching by name/date of birth, you must enter the patient’s full last name. If the patient’s last name has more than 13 characters, you will not find a matching record in the database. You must use a different search type.
PC-v4-Standard-Eligibility-Response.pdf
Senior Health Services Center – Universal
American Family of Companies
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Senior Whole Health
Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Significa Benefit Services
Subscriber Eligibility v1.4
Dependent Eligibility v1.4
Any date on file. If no date is entered, the date of service will
default to the current date.
None. PC-v4-Standard-Eligibility-Response.pdf
Silver Summit Health Plan
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
If no date is entered, the date of service will default to the current date.0
This payer permits use of the provider ID or the tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-
Response.pdf
Simply Healthcare Plans
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
South Carolina Medicaid
Eligibility v3.4
Up to one year in the past, future dates not allowed.
Entry of the patient’s middle initial for name/date of birth searches is required if on
file in the payer’s database. If you do not enter the patient’s middle initial and it is on file, you will receive the error message RH0547 – Subscriber/Insured Not Found. You will also receive this error message if you enter a middle initial, and the patient does not have one on file.
This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
South Dakota Medicaid
Eligibility v1.3
Future dates not allowed. This payer has card swipe capabilities. PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 67
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
SPJST ― Medicare Supplement
Eligibility v2.0
If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Standard Life and Accident Insurance
Company
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
If no date is entered, the date of service will default to the current
date.
This payer permits use of the provider ID or the tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
Star HRG
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the federal tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
StayWell (WellCare of Florida)
Eligibility v1.0
Up to two years in the past. This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
StayWell Kids (WellCare of Florida)
Eligibility v1.0
Up to two years in the past. This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Stonebridge Life Insurance Company
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
If no date is entered, the date of service will default to the current
date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Summit America Insurance Service
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
If no date is entered, the date of service will default to the current
date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Sunflower State Health Plan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Sunshine State Health
Plan
Eligibility v1.2
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of a provider ID or a
tax ID as the provider identifier.
PC-v4-Standard-Eligibility-
Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 68
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Tennessee Medicaid (TennCare)
Eligibility v4.2
This payer allows providers to check eligibility for dates of service from 1994 to one calendar month in the future. Date span of up to 92 days.
The following information pertains to Emdeon MAX users who process transactions using a modem connection.
If the Auto MCO preference is selected and the TennCare response indicates the recipient has coverage by Better Health Plans of Tennessee, MAX will automatically query that payer to verify eligibility.
See your Emdeon MAX User’s Guide or online help for details on setting defaults.
Note: The Auto MCO feature will not work for users that process transactions via the Direct server connection.
This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
TexanPlus (North Texas Area)
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
None. PC-v4-Standard-Eligibility-Response.pdf
TexanPlus (Southeast Texas Area)
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
None. PC-v4-Standard-Eligibility-Response.pdf
Texas Childrens Health Plan
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Texas Medicaid
Eligibility v5.3
Up to three years in the past, up to one month in the future for CIDC
(Chronically Ill and Disabled Children program) patients only, date span of up to 90 days.
This payer has card swipe capabilities.
CIDC Medicaid numbers begin with 9.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will
be sent with your request.
To receive service-specific benefit limitations,
enter a service type code.
PC-v4-Standard-Eligibility-Response.pdf
The Ullico Family of Companies
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Three Rivers Health Plan
Eligibility v1.3
Up to one year in the past, future dates not allowed.
None. PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 69
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Today’s Options
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
None. PC-v4-Standard-Eligibility-Response.pdf
TransactRX Infusion and Specialty
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
None. PC-v5-Standard-Eligibility-Response.pdf
Transamerica Financial Life Insurance Company
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Transamerica Life Insurance Company
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Transamerica Premier
Life Insurance Company
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
If no date is entered, the date of
service will default to the current date.
This payer permits use of a National Provider
Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
TRICARE
Subscriber Eligibility v2.4 Dependent Eligibility v2.4
Any date on file. If no date is entered, the date of service will default to the current date.
Entry of the patient’s gender is optional but highly recommended.
PC-v4-Standard-Eligibility-Response.pdf
TRICARE East Region
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Tricare For Life
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Tricare Overseas
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 70
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Triple-S Salud (BCBS of Puerto Rico)
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the requesting provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Trillium Community Health Plan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the requesting provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
True Health New Mexico Inc
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the requesting provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Trustmark
Subscriber Eligibility v1.4
Dependent Eligibility v1.4
Up to one year in the past, future dates not allowed.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Tufts Health Plan
Eligibility v1.6
Any past date on file, future dates up to 90 days.
This payer has card swipe capabilities. PC-v4-Standard-Eligibility-Response.pdf
Ucare of Minnesota
Eligibility v1.0
Up to one year in the past, future dates not allowed.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Ultimate Health Plans
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
UMR Wausau
Subscriber Eligibility v2.0 Dependent Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the requesting provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
UMWA Health and
Retirement Funds
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of a National Provider
Identifier (NPI) or tax ID as the requesting provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
UniCare
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Up to 18 months in the past, future dates not allowed, date span up to 18 months.
None. PC-v4-Standard-Eligibility-Response.pdf
Union Pacific Railroad Employes Health Systems
Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the requesting provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 71
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
United American Insurance Company
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
United Healthcare Dental
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
If no date is present, default to current date.
Start date must be no greater than 18 months in the past.
End date must be no greater than the end of the current month.
This payer permits use of the National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
United Healthcare Nevada Market
Eligibility v1.0
Inquiries can be submitted for up to 18 months in the past, and up to 1 month in the future.
This payer permits use of the National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
UnitedHealthcare Shared Services
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or a tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will
be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
UnitedHealthcare StudentResources
Subscriber Eligibility v3.0 Dependent Eligibility v3.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
UnitedHealthcare (UHC)
Subscriber Eligibility v2.5 Dependent Eligibility v2.5
Up to one year in the past, future dates not allowed.
The group number is specific to the patient. If you enter a group number, it must match the group number on file for the patient. If it
does not match, you will receive the error
message RH547 – Subscriber/Insured Not Found.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
UnitedHealthcare Community Plan − Tennessee
Eligibility v3.0
Up to six months in the past; up to 30 days in the future.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 72
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
United Healthcare Securehorizons − Medicare Supplemental
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
United Teacher Associates Insurance
Company ― Medicare
Supplement
Eligibility v2.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Unity Health Insurance
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Universal Benefit Corp
Eligibility v1.0
If no date is entered, the date of service will default to the current
date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider
identifier.
PC-v5-Standard-Eligibility-Response.pdf
Universal Care of California
Eligibility v2.2
Up to one year in the past, future dates not allowed.
When searching by name/date of birth, you must enter the patient’s full last name. If the
patient’s last name has more than 13 characters, you will not find a matching record in the database. You must use a different search type.
PC-v4-Standard-Eligibility-Response.pdf
University Care Advantage (Arizona)
Subscriber Eligibility v2.1 Dependent Eligibility v2.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the provider’s National Provider Identifier (NPI) or a tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
University Family Care (Arizona)
Subscriber Eligibility v2.0 Dependent Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the provider’s National Provider Identifier (NPI) or a tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
University of Arizona
Health Plans − UHM
Eligibility v1.0
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of a National Provider
Identifier (NPI) or tax ID as the requesting provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 73
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
University Physicians Care Advantage
Eligibility v1.1
Up to one year in the past, future dates not allowed.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
UnitedHealthCare Life Insurance Company (UHCLIC)
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of the National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
UPMC Health Plan
Eligibility v1.0
Payer supports a single date of service only. Any date on file can be submitted.
This payer permits use of a provider Identifier (NPI) or a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
USAA – Medicare Supplemental
Subscriber Eligibility v1.2 Dependent Eligibility v1.2
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
USFHP – St. Vincent
Catholic Medical Centers of New York
Eligibility v1.0
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of a provider
Identifier (NPI) only as the provider identifier.
PC-v5-Standard-Eligibility-
Response.pdf
Vantage Health Plan
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a provider ID or a tax ID as the provider identifier.
If you do not enter a service type, service
type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v4-Standard-Eligibility-Response.pdf
Vermont Medicaid
Eligibility v1.4
Any past date on file, future dates up to the end of the current month.
The recipient ID can be either the 8-digit Vermont Medicaid ID or the recipient’s Social
Security number.
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 74
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Veterans Affairs Fee Basis Programs
Eligibility v1.3
If no date is entered, the date of service will default to the current date.
The Department of Veterans Affairs Fee Basis Programs are not health insurance plans. These programs are designed to assist veterans who cannot easily receive care at a VA medical center. Each individual veteran’s eligibility status and medical care needs are legally and medically reviewed for each episode of care. Each local Fee site
determines whether non-VA treatment can be approved. For these reasons, all Fee Basis Programs eligibility responses will return an Inactive status along with contact information for the local Fee office.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
Veterans Affairs Health Administration Center
Eligibility v1.3
Any date on file. If no date is entered, the date of service will default to the current date.
This transaction covers CHAMPVA, Spina Bifida, and Children of Women Vietnam Vets programs.
This payer permits use of a provider ID or a tax ID as the provider identifier.
This payer is not affiliated with TRICARE/CHAMPUS.
PC-v4-Standard-Eligibility-Response.pdf
Virginia Medicaid
Eligibility v2.4
Up to one year in the past, up to five days in the future, date span of up to one month.
If you enter both a procedure code and a service type code, the procedure code will be forwarded on to the payer.
This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
Viva Health Inc.
Subscriber Eligibility v1.0 Dependent Eligibility v1.0
Any date on file. If no date is
entered, the date of service will default to the current date.
This payer permits use of a National Provider
Identifier (NPI), provider ID, or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-
Response.pdf
VNS CHOICE Medicare
Eligibility v1.1
Any date on file. If no date is entered, the date of service will
default to the current date.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will
be sent with your request.
This payer permits use of a provider ID or a
tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 75
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Washington Medicaid
Eligibility v6.4
Up to four years in the past, future dates not allowed.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
WEB-TPA, Inc.
Subscriber Eligibility v1.1 Dependent Eligibility v1.1
If no date is entered, the date of service will default to the current date.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
This payer permits use of a provider ID or a tax ID as the provider identifier.
PC-v4-Standard-Eligibility-Response.pdf
WellCare Health Plans
Eligibility v2.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a provider ID or tax ID as the provider identifier.
If you do not enter a service type, service type 30 (Health Benefit Plan Coverage) will be sent with your request.
PC-v5-Standard-Eligibility-Response.pdf
Wells Fargo Third Party Administrators
Eligibility v1.4
Up to one year in the past, future dates not allowed.
If a child is enrolled in CHIPS Plans 1 through 12, enter the child’s member ID. If the child is enrolled in CHIPS Plan 13, enter his/her
guardian’s member ID.
If a child has siblings with the same date of birth (e.g., twins), you must enter the child’s
first name.
Wells-Fargo-TPA-Eligibility-PC.pdf
Wells-Fargo-TPA-Coverage-
Summary-Sheets.pdf
West Virginia Family Health Plan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will
default to the current date.
This payer permits use of a National Provider Identifier (NPI) as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
West Virginia Medicaid
Eligibility v3.3
Up to 12 months in the past, future dates up to the last day of the
current month, date span of up to one year in the past to the last day of the current month.
Once the provider has registered their NPI with this payer, the provider’s NPI must be
entered in the request.
PC-v4-Standard-Eligibility-Response.pdf
Western Health Advantage
Subscriber Eligibility v3.1 Dependent Eligibility v3.1
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Western Southern Financial Group
Subscriber Eligibility v1.0
Dependent Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 76
Payer Name / Version Date of Service Restrictions Special Considerations Response Guide
Windsor Health Plan
Eligibility v1.0
Any date on file. If no date is entered, the date of service will default to the current date.
This payer permits use of a National Provider Identifier (NPI) or tax ID as the provider identifier.
PC-v5-Standard-Eligibility-Response.pdf
Wisconsin Chronic Disease Program
Eligibility v1.2
Up to one year in the past, future dates not allowed, date span of up
to 365 days.
This payer has card swipe capabilities. PC-v4-Standard-Eligibility-Response.pdf
Wisconsin Medicaid
Eligibility v5.4
Up to one year in the past, future
dates not allowed, date span of up to 365 days.
This payer has card swipe capabilities. PC-v4-Standard-Eligibility-
Response.pdf
Wisconsin Well Woman Program
Eligibility v1.2
Up to one year in the past, future dates not allowed, date span of up to 365 days.
This payer has card swipe capabilities. PC-v4-Standard-Eligibility-Response.pdf
Wyoming Medicaid
Eligibility v2.5
Up to one year in the past, future dates not allowed.
For searches involving the name, enter the first five characters of the patient’s last name and the first two characters of the first name.
Once the provider has registered their NPI
with this payer, the provider’s NPI must be entered in the request. This payer has card swipe capabilities.
PC-v4-Standard-Eligibility-Response.pdf
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 77
Plan Network IDs
Ameritas Dental Group Plans
For details, see “Ameritas Dental Group” on page 12.
Plan Name Plan ID
Ameritas Life Insurance Company 00425
First Ameritas of New York 00426
First Reliance Standard Life Insurance
Company 00428
Reliance Standard Life Insurance Company 00427
Standard Insurance Company 00429
Standard Insurance Company of New York 00430
Cenpatico Plans
For details, see “Cenpatico” on page 27.
Plan Name Plan ID
Cenpatico Behavioral Health Arizona CBHAZ
Cenpatico Behavioral Health Florida CBHFL
Cenpatico Behavioral Health Illinois CBHIL
Cenpatico Behavioral Health Indiana CBHIN
Cenpatico Behavioral Health Kansas CBHKS
Cenpatico Behavioral Health Kentucky CBHKY
Cenpatico Behavioral Health Massachusetts CBHMA
Cenpatico Behavioral Health Ohio CBHOH
Cenpatico Behavioral Health South Carolina CBHSC
Cenpatico Behavioral Health Texas CBHTX
Cenpatico Behavioral Health Wisconsin CBRPR
Cenpatico – Managed Health Services (Indiana) CMHIN
Cenpatico – Managed Health Services (Wisconsin) CMHWI
Cenpatico – Superior Health Plan CHSPT
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 78
CoreSource Plans
For details, see “CoreSource” on page 30.
Plan Name Plan ID
CoreSource – FMH 00204
CoreSource – Little Rock 00205
CoreSource – Maryland, Pennsylvania, and Illinois
00236
CoreSource – Ohio 00239
Coventry Plans
For details, see “Coventry” on page 30.
Plan Name Plan ID
Health America of PA 00148
CHC Georgia 00154
CHC Virginia 00156
CHC Louisiana 00158
CHC West Virginia* 00160
CHC of Carolinas 00164
CHC Delaware 00166
CHC Iowa 00170
CHC Kansas / CHC Oklahoma 00172
CHC Nebraska 00176
CHC Illinois 00179
CoventryCares of West Virginia 00182
CHC of MO, MS, AK , TN 00184
CHC Healthcare USA* 00186
CoventryCares of Virginia* 00190
CvtyNatnlAccts/UofMO/CvtyOne 00250
Mail Handlers & FEHBP 00251
CHC Altius Health Plan/CHC Nevada 00364
CoventryCares of Michigan 00413
CHC Texas 00453
Vista 00508
CoventryCares of Pennsylvania 00510
CoventryCares of Nebraska* 00511
CHC Florida 00512
MHNET Behavioral Health 00514
Aetna Better Health of Kentucky 00515
*Medicaid Plans
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 79
Glassman Plans
For details, see “Glassman” on page Error! Bookmark not defined..
Plan Name Plan ID
AFTRA Health Fund 00258
Best Life and Health 00257
Molina Healthcare Plans
For details, see “Molina Healthcare” on page 55.
Plan Name Plan ID
Molina CA (California) 00222
Molina FL (Florida) 00506
Molina ID (Idaho) MLNID
Molina MI (Michigan) 00226
Molina NM (New Mexico) 00071
Molina OH (Ohio) 00445
Molina TX (Texas) 00451
Molina UT (Utah) 00227
Molina WA (Washington) 00228
Molina WI (Wisconsin) 00516
Principal Financial Plans
For details, see “Principal Financial” on page 64.
Plan Name Plan ID
Principal Financial Life Insurance Company of
America
00143
Nippon Life Insurance Company of America 00144
All Payers Eligibility Guide PC Payer-Specific Information
© 2018 Emdeon Business Services LLC. All rights reserved. Page 80
Schaller Anderson Health Plans
For details, see “Schaller Anderson Health Plans” on page 65.
Plan Name Plan ID
Schaller Anderson Aetna Better Health of New York ABHNY
Schaller Anderson Aetna Better Health of Ohio ABHOH
Schaller Anderson Aetna Better Health – PA Medicaid PENNS
Schaller Anderson Aetna IL Medicaid ILMSA
Schaller Anderson Aetna TX Medicaid & CHIP TMDSA
Schaller Anderson Delaware Physicians Care, Inc. DPCSA
Schaller Anderson MajestaCare VA MACVA
Schaller Anderson Maryland Physicians Care MPCSA
Schaller Anderson Mercy Care AEMED
Schaller Anderson Missouri Care MOSCA
Schaller Anderson Parkland Community Health Plan PRCHP
Schaller Anderson TX Christus TXCSA
All Payers Eligibility Guide PC Appendices
© 2018 Emdeon Business Services LLC. All rights reserved. Page 81
Appendices
Appendix A: Reference Guides
Guide Name Link to
Common Response Abbreviations Common-Response-Abbreviations.pdf
Country Codes Country-Codes.pdf
Emdeon MAX User’s Guide See your installation CD
Error Messages Dictionary Error Messages Dictionary.pdf
Insurance Types Insurance-Types.pdf
Payer Maintenance Schedule Payer_Maintenance_Windows.pdf
Appendix B: Service Types Payers’ eligibility requests often support entry of one or more service types.
Italicized rows represent service types which are available only for version 5 of the Emdeon standard request and response.
Code Full Description Service Types Input
Field Choice List
Service Types
Description in Response
1 Medical Care Medical Care Med Care
2 Surgical Surgical Surg
3 Consultation Consultation Consultation
4 Diagnostic X-Ray Dx X-Ray Dx X-Ray
5 Diagnostic Lab Dx Lab Dx Lab
6 Radiation Therapy Radiation Thrpy Radiation Thrpy
7 Anesthesia Anesthesia Anesth
8 Surgical Assistance Surgical Assistance Surg Asstnce
9 Other Medical Other Medical Other Medcl
10 Blood Charges Blood Charges Blood Charges
11 Used Durable Medical Equipment
Used DME Used DME
12 Durable Medical Equipment Purchase
DME Purchase DME Purchase
13 Ambulatory Service Center Facility
Amb Svc Ctr Facil Amb Svc Ctr Facility
14 Renal Supplies in the Home
Renal Supply-Home Renal Supplies in the Home
15 Alternate Method Dialysis
Alt Meth Dialysis Alternate Method Dial
16 Chronic Renal Disease (CRD) Equipment
CRD Equipment CRD Equipment
17 Pre-Admission Testing Pre-Admissn Testing Pre-Admin Testing
All Payers Eligibility Guide PC Appendices
© 2018 Emdeon Business Services LLC. All rights reserved. Page 82
Code Full Description Service Types Input
Field Choice List
Service Types
Description in Response
18 Durable Medical Equipment Rental
DME Rental DME Rent
19 Pneumonia Vaccine Pneumonia Vaccine Pneumonia Vaccine
20 Second Surgical Opinion
Second Surg Opinion Second Surg Opinion
21 Third Surgical Opinion Third Surg Opinion Third Surg Opinion
22 Social Work Social Work Social Work
23 Diagnostic Dental Dx Dntl Dx Dntl
24 Periodontics Periodontics Periodontics
25 Restorative Restorative Restorative
26 Endodontics Endodontics Endodontics
27 Maxillofacial Prosthetics
MFP MFP
28 Adjunctive Dental Services
Adjunc Dntl Svcs Adjunctive Dntl Svcs
30 Health Benefit Plan Coverage
Hlth Bene Plan Cvg Health Bene Plan Cvg
32 Plan Waiting Period Plan Waiting Period Plan Waiting Period
33 Chiropractic Chiropractic Chiropractic
34 Chiropractic Office Visits
Chiropractic Visits Chiropractic Office Visits
35 Dental Care Dntl Care Dntl Care
36 Dental Crowns Dntl Crowns Dntl Crowns
37 Dental Accident Dntl Accident Dntl Accident
38 Orthodontics Orthodontics Orthodontics
39 Prosthodontics Prosthodontics Prosthodontics
40 Oral Surgery Oral Surgery Oral Surg
41 Routine (Preventive) Dental
Routine Prev Dntl Routine (Preventive) Dntl
42 Home Health Care Home Health Care HHC
43 Home Health Prescriptions
Home Health Rxs HH Rxs
44 Home Health Visits Home Health Visits HH Visits
45 Hospice Hospice Hspc
46 Respite Care Respite Care Respite Care
47 Hospital Hospital Hosp
48 Hospital - Inpatient Hosp-IP Hosp - IP
49 Hospital - Room and Board
Hosp-Room Board Hosp - Room/Board
50 Hospital - Outpatient Hosp-OP Hosp - OP
51 Hospital - Emergency Accident
Hosp-Emerg Accident Hosp - Emergency Accident
All Payers Eligibility Guide PC Appendices
© 2018 Emdeon Business Services LLC. All rights reserved. Page 83
Code Full Description Service Types Input
Field Choice List
Service Types
Description in Response
52 Hospital - Emergency Medical
Hosp-Emerg Medical Hosp - Emergency Medical
53 Hospital - Ambulatory Surgical
Hosp-Amb Surgical Hosp - Ambulatory Surg
54 Long Term Care Long Term Care LTC
55 Major Medical Major Medical Major Medical
56 Medically Related Transportation
Med Related Trans Medical Related Transport
57 Air Transportation Air Transportation Air Transportation
58 Cabulance Cabulance Cabulance
59 Licensed Ambulance Licensed Ambulance Licensed Ambulance
60 General Benefits General Benefits General Benefits
61 In-vitro Fertilization IVF IVF
62 MRI/CAT Scan MRI/CAT Scan MRI/CAT Scan
63 Donor Procedures Donor Procedures Donor Procedures
64 Acupuncture Acupuncture Acupuncture
65 Newborn Care Newborn Care Newborn Care
66 Pathology Pathology Pa
67 Smoking Cessation Smoking Cessation Smoking Cessation
68 Well Baby Care Well Baby Care Well Baby Care
69 Maternity Maternity Maternity
70 Transplants Transplants Transplants
71 Audiology Exam Audiology Exam Audiology Exam
72 Inhalation Therapy Inhalation Therapy Inhalation Thrpy
73 Diagnostic Medical Dx Medical Dx Medical
74 Private Duty Nursing Private Duty Nurse Private Duty Nursing
75 Prosthetic Device Prosthetic Device Prosthetic Device
76 Dialysis Dialysis Dial
77 Otological Exam Otological Exam Otological Exam
78 Chemotherapy Chemotherapy CH
79 Allergy Testing Allergy Testing Allergy Testing
80 Immunizations Immunizations Immunizations
81 Routine Physical Routine Physical Routine Physical
82 Family Planning Family Planning FP
83 Infertility Infertility Infertility
84 Abortion Abortion Abortion
85 AIDS AIDS AIDS
86 Emergency Services Emergency Services Emergency Svcs
87 Cancer Cancer Cancer
All Payers Eligibility Guide PC Appendices
© 2018 Emdeon Business Services LLC. All rights reserved. Page 84
Code Full Description Service Types Input
Field Choice List
Service Types
Description in Response
88 Pharmacy Pharmacy Pharm
89 Free Standing Prescription Drug
Free Stand Rx Drug Free Standing Rx Drg
90 Mail Order Prescription Drug
Mail Order Rx Drug Mail Order Rx Drg
91 Brand Name Prescription Drug
Brand Name Rx Drug Brand Name Rx Drg
92 Generic Prescription Drug
Generic Rx Drug Generic Rx Drg
93 Podiatry Podiatry Podiatry
94 Podiatry - Office Visits Podiatry-Off Visits Podiatry - Office Visits
95 Podiatry - Nursing Home Visits
Podiatry-NH Visits Podiatry - Nursng Home Vsts
96 Professional (Physician)
Professional (PHY) Professional (PHY)
97 Anesthesiologist Anesthesiologist Anesthesiologist
98 Professional (Physician) Visit - Office
Prof PHY Vist-Offc Prof (PHY) Visit - Office
99 Professional (Physician) Visit - Inpatient
Prof PHY Vist-IP Prof (PHY) Visit - IP
A0 Professional (Physician) Visit - Outpatient
Prof PHY Vist-OP Prof (PHY) Visit - OP
A1 Professional (Physician) Visit - Nursing Home
Prof PHY Vist-NH Prof (PHY) Vst - Nursng Hme
A2 Professional (Physician) Visit - Skilled Nursing Facility
Prof PHY Vist-SNF Prof (PHY) Visit - SNF
A3 Professional (Physician) Visit -
Home
Prof PHY Vist-Home Prof (PHY) Visit - Home
A4 Psychiatric Psychiatric PC
A5 Psychiatric - Room and Board
Psych-Room Board PC - Room/Board
A6 Psychotherapy Psychotherapy Psychotherapy
A7 Psychiatric - Inpatient Psych-Inpatient PC - IP
A8 Psychiatric - Outpatient Psych-Outpatient PC - OP
A9 Rehabilitation Rehabilitation Rehab
AA Rehabilitation - Room and Board
Rehab-Room Board Rehab - Room/Board
AB Rehabilitation - Inpatient
Rehab-IP Rehab - IP
All Payers Eligibility Guide PC Appendices
© 2018 Emdeon Business Services LLC. All rights reserved. Page 85
Code Full Description Service Types Input
Field Choice List
Service Types
Description in Response
AC Rehabilitation - Outpatient
Rehab-OP Rehab - OP
AD Occupational Therapy Occupation Therapy OT
AE Physical Medicine Physical Medicine Physical Medicine
AF Speech Therapy Speech Therapy Spch Thrpy
AG Skilled Nursing Care Skilled Nurse Care Skilled Nursing Care
AH Skilled Nursing Care - Room and Board
SNC-Room Board Sklled Nrsng Cre - Rm & Brd
AI Substance Abuse Substance Abuse SA
AJ Alcoholism Alcoholism Alcoholism
AK Drug Addiction Drug Addiction Drg Addiction
AL Vision (Optometry) Vision (Optometry) Vision (Optometry)
AM Frames Frames Frames
AN Routine Exam Routine Exam Routine Exam
AO Lenses Lenses Lenses
AQ Nonmedically Necessary Physical
Nonmed Ncssry Phys Nonmedical Ncessry Physical
AR Experimental Drug
Therapy
Expermnt Drg Thrpy Experimental Drg Thrpy
B1 Burn Care Burn Care Burn care
B2 Brand Name Prescription Drug - Formulary
Brand Rx-Formly Brand Nm Rx-Formulary
B3 Brand Name Prescription Drug - Non-Formulary
Brand Rx-NoFormly Brand Nm Rx-NonFormulary
BA InDependent Medical Evaluation
Ind Medical Eval InDependent Medical Eval
BB Partial Hospitalization (Psychiatric)
Partial Hosp-Psych Prtl Hospitalization (PC)
BC Day Care (Psychiatric) Day Care-Psych Day Care (PC)
BD Cognitive Therapy Cognitive Therapy Cognitive Thrpy
BE Massage Therapy Massage Therapy Massage Thrpy
BF Pulmonary Rehabilitation
Pulmonary Rehab Pulmonary Rehab
BG Cardiac Rehabilitation Cardiac Rehab Cardiac Rehab
BH Pediatric Pediatric Peds
BI Nursery Nursery Nursery
BJ Skin Skin Skin
BK Orthopedic Orthopedic Orthopedic
BL Cardiac Cardiac Cardiac
BM Lymphatic Lymphatic Lymphatic
All Payers Eligibility Guide PC Appendices
© 2018 Emdeon Business Services LLC. All rights reserved. Page 86
Code Full Description Service Types Input
Field Choice List
Service Types
Description in Response
BN Gastrointestinal Gastrointestinal GI
BP Endocrine Endocrine Endocrine
BQ Neurology Neurology Neuro
BR Eye Eye Eye
BS Invasive Procedures Invasive Procedures Invasive Procs
BT Gynecological Gynecological Gynecological
BU Obstetrical Obstetrical Obstetrical
BV Obstetrical/
Gynecological Obstetrical/ Gynecological Obstetrical/ Gynecological
BW Mail Order Prescription Drug: Brand Name
Mail Order Rx-Brand Mail Order Rx-Brand Name
BX Mail Order Prescription Drug: Generic
Mail Order Rx-Gener Mail Order Rx-Generic
BY Physician Visit/Office: Sick
PHY Visit/Off-Sick PHY Visit/Office-Sick
BZ Physician Visit/Office: Well
PHY Visit/Off-Well PHY Visit/Office-Well
C1 Coronary Care Coronary Care Coronary Care
CA Private Duty Nursing - Inpatient
Private Nurse-IP Private Duty Nursing-IP
CB Private Duty Nursing - Home
Private Nurse-Home Private Duty Nursing-Home
CC Surgical Benefits - Professional (Physician)
Surgical Bene-PHY Surgical Benefits-PHY
CD Surgical Benefits - Facility
Surgical Bene-Facil Surgical Benefits-Facility
CE Mental Health Provider - Inpatient
Mental Hlth Prov-IP Mental Health Provider-IP
CF Mental Health Provider - Outpatient
Mental Hlth Prov-OP Mental Health Provider-OP
CG Mental Health Facility - Inpatient
Mental Hlth Fac-IP Mental Health Facility-IP
CH Mental Health Facility - Outpatient
Mental Hlth Fac-OP Mental Health Facility-OP
CI Substance Abuse Facility - Inpatient
SA Facility-IP SA Facility-IP
CJ Substance Abuse Facility - Outpatient
SA Facility-OP SA Facility-OP
CK Screening X-Ray Screening X-Ray Screening X-Ray
CL Screening Laboratory Screening Lab Screening Lab
CM Mammogram, high risk patient
Mammogram-high risk Mammogram-high risk patient
All Payers Eligibility Guide PC Appendices
© 2018 Emdeon Business Services LLC. All rights reserved. Page 87
Code Full Description Service Types Input
Field Choice List
Service Types
Description in Response
CN Mammogram, low risk patient
Mammogram-low risk Mammogram-low risk patient
CO Flu Vaccination Flu Vaccination Flu Vaccination
CP Eyewear and Eyewear Accessories
Eyewear/Accessories Eyewear/Accessories
CQ Case Management Case Management Case Management
DG Dermatology Dermatology Dermatology
DM Durable Medical Equipment
DME DME
DS Diabetic Supplies Diabetic Supplies Diabetic Supplies
GF Generic Prescription Drug - Formulary
Generic Rx-Formly Generic Rx-Formulary
GN Generic Prescription Drug - Non-Formulary
Generic Rx-NoFormly Generic Rx-NonFormulary
GY Allergy Allergy Allergy
IC Intensive Care IC IC
MH Mental Health Mental Health Mental Health
NI Neonatal Intensive Care
Neonatal IC Neonatal IC
ON Oncology Oncology Oncology
PT Physical Therapy PT PT
PU Pulmonary Pulmonary Pulmonary
RN Renal Renal Renal
RT Residential Psychiatric Treatment
Residential Psych Residential Psychiatric
TC Transitional Care Transitional Care Transitional Care
TN Transitional Nursery Care
Transition Nursery Transitional Nursery Care
UC Urgent Care Urgent Care Urgent Care
All Payers Eligibility Guide PC Index
© 2018 Emdeon Business Services LLC. All rights reserved. Page 88
Index
A
AARP, 6 About This Guide, 1 Absolute Total Care, 6 Add New Button, 5 Administrative Services, Inc., 6 Advantage by Bridgeway Health Solutions, 6 Advantage by Buckeye Community Health Plan, 6 Advantage by Managed Health Services, 6 Advantage by Superior HealthPlan, 6 Aetna, 7 Aetna Administrator − Medicare Supplemental, 7 Aetna Better Health - NJ, 7 Aetna Better Health of CA, 7 Aetna Better Health of FL, 7 Aetna Better Health of KY, 7 Aetna Better Health of LA, 7 Aetna Better Health of MD, 7 Aetna Better Health of MI, 7 Aetna Better Health of MO, 7 Aetna Better Health of NV, 8 Aetna Better Health of PA, 8 Aetna Better Health of VA, 8 Aetna Better Health of WV, 8 Aetna Long Term Care, 8 Affinity Essentials, 8 Affinity Health Plan, 8 Affinity Health Plan Medicare, 8 Aflac - Medicare Supplemental, 9 Aflac Dental Insurance, 8 AFTRA Health Fund, 79 AGIA Inc, 8 Alabama Medicaid, 9 All Savers Life Insurance Company, 9 Alliant Health Plans, 9 Allied Benefit Systems, Inc., 9 Alternative Insurance Resources, Inc, 9 AmeriBen, 9 American Behavioral Benefit Managers, 9 American Community Mutual, 10 American General Life and Accident), 10 American Health Medicare (Inmediata Health), 10
American Income Life Insurance Company, 10 American National Insurance Company, 10 American National Life Insurance Company of Texas, 10 American Network Insurance (REHAB) − Medicare
Supplemental, 11 American Postal Workers Union, 11 American Retirement Life Insurance Company – Medicare
Supplement, 11 Americhoice of New Jersey, 11 Amerigroup, 11 AmeriHealth Caritas Delaware, 11 AmeriHealth Caritas Iowa, 11 AmeriHealth Caritas Louisiana, 11 AmeriHealth Caritas Pennsylvania, 11 AmeriHealth Caritas VIP Care Plus, 12 AmeriHealth District of Columbia, 12 AmeriHealth VIP Care, 12 Ameritas Dental Group, 12 Ameritas Dental Group Plans, 77 Ameritas Life Insurance Company, 77 Anthem BlueCross of California, 12 Appendix A: Reference Guides, 81 Appendix B: Service Types, 81
APS, 12 Archbold Medical Center, 12 Arise Health Plan, 12 Arise Health Plan − Medicare Select Policy, 12 Arizona Medicaid (AHCCCS), 13 Arizona Physicians IPA, 13 Arkansas Medicaid, 13 Associacion de Maestros Puerto Rico, 13 AVMed, 13
B
Banner Health Plans, 13 Banner University Family Care, 13 Baptist Health Plan Advantage, 13 BC Complete of Michigan, 13 BC Idaho, 14 BC Medicare Advantage, 14 BCBS Alabama (Benefits), 14 BCBS Alabama (Eligibility), 14 BCBS Arizona, 15 BCBS Arkansas, 15 BCBS Colorado, 15 BCBS Connecticut, 15 BCBS Delaware (Highmark), 15 BCBS District of Columbia, 15 BCBS Florida, 16 BCBS Georgia, 16 BCBS Illinois, 16 BCBS Indiana, 16 BCBS Iowa, 16 BCBS Kansas, 16 BCBS Kansas City, 16 BCBS Kentucky, 17 BCBS LA Medicare Advantage, 17 BCBS Louisiana, 17 BCBS Maine, 17 BCBS Maryland, 17 BCBS Massachusetts, 17 BCBS Michigan, 18 BCBS Minnesota, 18 BCBS Mississippi, 19 BCBS Missouri, 19 BCBS Nebraska, 19
BCBS Nevada, 19 BCBS New Hampshire, 19 BCBS New Jersey (Horizon), 19 BCBS New Mexico, 19 BCBS New York Empire, 20 BCBS North Carolina, 20 BCBS North Dakota, 20 BCBS Ohio, 20 BCBS Oregon (Regence), 20 BCBS Pennsylvania (Highmark), 21 BCBS Rhode Island, 21 BCBS South Carolina, 21, 22 BCBS South Dakota, 22 BCBS Tennessee, 22 BCBS Texas, 23 BCBS Texas-Medicaid, 23 BCBS Vermont, 23 BCBS Virginia, 23 BCBS Wisconsin, 23 BCBS Wyoming, 23 Behavioral Health Systems, 23 Benefit Management Inc., 24
All Payers Eligibility Guide PC Index
© 2018 Emdeon Business Services LLC. All rights reserved. Page 89
Best Life and Health, 79 Better Health, 24 Better Health Plans of Tennessee, 24 BlueChoice HealthPlan of South Carolina Medicaid, 24 BlueCross BlueShield of Western New York Medicaid/CHP, 24 Bluegrass Family Health, 24 Boon Group, 24 Bridgeway Health Solutions (Arizona), 24 BS California, 24 BS Washington (Regence), 24 Buckeye Community Health, 25
C
California Medicaid (Medi-Cal), 25 Capital BlueCross, 25 Capital District Physician’s Health Plan, 25 Card Swipe, 5 Care Improvement Plus, 25 Care1st Health Plan Arizona, 25 CareFirst Administrators, 26 CarePlus Health Plan, 26 CarePoint Medicare Advantage Health Plan, 26 CareSource, 26 CareSource Health, 26 Carpenters Health and Welfare Trust Fund of St Louis, 26 CDS Group Health, 26 Celtic Insurance, 26 CeltiCare, 26 Cenpatico, 27 Central Reserve Life Insurance Company ― Medicare
Supplement, 27 Central States Funds, 27 Chesterfield Resources Inc, 27 Christian Brothers Services, 27 Christie Student Health Plans, 27 CHRISTUS Health Plan Medicaid, 27 CHRISTUS Health Plan New Mexico Health Insurance
Exchange, 27 CHRISTUS Health Plan NM MA, 28 Cigna, 28 CMFG Life Insurance, 28 Color Bars, 3 Colorado Access, 28 Colorado Medicaid, 29 Community Care of Oklahoma, 29 Community Health Plan of Washington, 29 Concentrix Insurance Solutions, 29 Connecticare Inc, 29 Connecticut Medicaid, 29
Consolidated Associates Railroad, 29 Consumer Mutal of Michigan, 29 Continental General Insurance Company ― Medicare
Supplement, 30 Cooperative Benefit Administrators, 30 CoreSource, 30 CoreSource - FMH, 78 CoreSource - Little Rock, 78 CoreSource - Maryland, Pennsylvania, and Illinois, 78 CoreSource - Ohio, 78 CoreSource Plans, 78 CountyCare, 30 Coventry, 30 Coventry Plans, 78 Coventry/Dentex Dental, 30 CREATE, 30 Crystal Run Health Plan, 30 CSA Fraternal Life ― Medicare Supplement, 31 Customer Support, 1
D
DAKOTACARE Administrative Services, 31 Data Input Area, 3
Date Entries, 4 Date of Service Restrictions, 5 Dean Health Plan, 31, 38 Dell Childrens Health Plan, 31 Dentaquest Government Payer WI, 31 Determine the Search Types, 2 Determine the Transaction Type, 2 District No. 9, I. A. of M. & A. W. Welfare Trust, 31 District of Columbia Medicaid, 31 Diversified Administration Corp, 31 Dollar Amounts, 5 Driscoll Health Plan, 31
E
EBMS, 31 Elderplan, 32 Emblem Health, 32 Emdeon Customer Support, 1 Enter the Search Data, 3 Epic Life Insurance, 32 Essence Healthcare, 32 Everence Financial, 32 Evergreen Health, 32 Excellus BlueCross BlueShield, 32
F
Fallon Community Health Plan, 32 Farm Bureau Health Plans, 32 Federated Insurance Company, 32 Fidelis Care New York, 33 First Ameritas of New York, 77 First Choice VIP Care Plus, 33 First Community Health Plan, 33 First Reliance Standard Life Insurance Company, 77 First United American Insurance Company, 33 Florida Medicaid, 34, 35 Food Employers & Bakery & Confectionery Workers Benefit
Fund of Southern California, 35 Fresenius Health Partners, 35
G
G.M.P. Employers Retiree Trust, 36 Georgia Medicaid, 36 Glassman Plans, 79 Globe Life & Accident Insurance Company, 36 Golden Rule, 36 Government Employees Hospital Association (GEHA), 36 Great American Life Assurance Company ― Medicare
Supplement, 36 Great American Life Insurance Company ― Medicare
Supplement, 36 Great-West Healthcare, 37 Group and Pension Administrators, 37 Group Dental Service, 37
H
Harmony Health Plan (WellCare of Florida), 37 Harvard Pilgrim Health Care, 37 Hawaii Medicaid, 37 Hawaii Medical Service Association, 38 Health Alliance Plan, 38
All Payers Eligibility Guide PC Index
© 2018 Emdeon Business Services LLC. All rights reserved. Page 90
Health Choice of Arizona, 6, 33, 38 Health First Health Plan, 38 Health First Insurance, 38 Health Partners MN, 38 Health Partners of Philadelphia, 38 Health Services for Children with Special Needs, 38 Health Sharer of Oregon, 38 HEALTHe Exchange, 39 HealthEase (WellCare of Florida), 39 HealthEase Kids (WellCare of Florida), 39 HealthEZ, 39 Healthfirst of New Jersey, 39 Healthfirst of New York, 39 HealthNet National, 39 HealthPlus of Michigan, 39 HealthSmart Benefit Solutions, 39 HealthSmart Benefit Solutions − WV, 39 HealthSpring, 40 Healthy Blue Louisiana, 40 Help Line, 3
Highmark BCBSD Health Options, 40 HMA (Hawaii Mainland Admin), 40 Horizon New Jersey Health, 40 HSBS Oklahoma City, 40 Humana, 40
I
IBEW Local 508 Health Plan, 40 Idaho Medicaid, 40 If you enter data for more than one type of search:, 2 IlliniCare Health Plan, 40 Illinois Medicaid, 41, 42 Independence Blue Cross, 42 Indiana Medicaid, 42 Inland Empire Health Plan, 42 Inter Valley Health Plan, 43 International Medical Card, 43 Iowa Medicaid, 43 Island Home Insurance, 43
J
Johns Hopkins HealthCare, 43 Johns Hopkins HealthCare LLC, 43 Johns Hopkins US Family Health Plan, 43
K
Kaiser Foundation Health Plan of Hawaii, 43 Kaiser Foundation Health Plan of Hawaii (DHMO/CHOICE, 44 Kaiser Foundation Health Plan of Northwest, 44 Kaiser Foundation Health Plans of Colorado, 43 Kaiser Foundation Mid-Atlantic, 44 Kaiser NW Dental, 44 Kaiser Permanente Insurance Company KPIC, 44 Kaiser Permanente of Georgia, 44 Kaiser Permanente of Northern California, 44 Kaiser Permanente of Southern California, 44 KanCare-UnitedHealthcare Community Plan Kansas, 44 Kansas Medicaid, 44 Kempton Company), 45 Kentucky Medicaid, 45 Kentucky Spirit Health Plan, 45 Key Benefit Administrators, 45
Key Benefit Administrators (Indianapolis, IN), 45 Keystone First, 45 Keystone VIP Choice, 45
L
L.A. Care, 45 Leon Medical Centers Health Plan, Inc., 45
Liberty National Life Insurance Company, 46 LifeCare Assurance Company, 46 Lincoln Financial, 46 Louisiana Healthcare Connections, 46 Louisiana Medicaid, 47 Loyal American Life ― Medicare Supplement, 47
M
MagnaCare, 48 Magnolia Health Plan, 47 Maine Community Health Options, 47 MaineCare (Maine Medicaid), 48 Managed Care of America, 48 Managed Health Network, 48 Managed Health Services - Indiana, 48 MAPFRE Life Puerto Rico, 48 MAPFRE Medicare Excel, 48 Maricopa Care Advantage, 48 Maricopa Health Plan (Arizona), 48 Maryland Medicaid, 48 Maryland Physicians Care, 49 Massachusetts Medicaid (MassHealth), 49 MDWISE Exchange, 49 MDWISE Medicaid Health Plans, 49 MedBen Newark OH, 49 Medica, 49 Medica Health Plans, 49 Medica2, 49 Medical Associates Health Plan/Health Choices, 49
Medical Card System), 50 Medical Mutual of Ohio (MMO), 50 Medicare Part A & B, 51, 52 Medicare y Mucho Mas, 52 Medi-Share, 49 Med-Pay, Inc., 49 Meridian Health Plan of Illinois, 52 Meritain Health, 52 Meritus Health Partners, 53 MetLife, 53 MetPlus Health Plan, 53 Michigan Medicaid, 53 Michigan MIChild, 53 Minnesota Medicaid, 53 Mississippi Medicaid, 53 Mississippi State Employees' Health Plan (SEHP), 54 Missouri Medicaid, 54 MMSI, 55 Molina CA (California), 79 Molina FL (Florida), 79 Molina Healthcare, 55 Molina Healthcare of New Mexico, 55 Molina Healthcare of Virginia, 55 Molina Healthcare Plans, 79 Molina ID (Idaho), 79 Molina MI (Michigan), 79 Molina NM (New Mexico), 79 Molina of Puerto Rico, 55 Molina OH (Ohio), 79 Molina TX (Texas), 79 Molina UT (Utah), 79 Molina WA (Washington), 79 Molina WI (Wisconsin), 79 Montana Medicaid, 55 Mountain State, 55
All Payers Eligibility Guide PC Index
© 2018 Emdeon Business Services LLC. All rights reserved. Page 91
Municipal Health Benefit Fund, 55 Mutual Health Services, 55 Mutual of Omaha, 55 MVP Health Care (New York), 56
N
National Association of Letter Carriers (NALC), 56 National Claims Admin Services, 56 Nebraska Medicaid, 56 Network Health Plan, 56 Nevada Medicaid, 56 New Era Life Insurance Company, 56 New Hampshire Medicaid, 56 New Jersey Medicaid, 57 New Mexico Health Connections, 57 New Mexico Medicaid, 57 New York Medicaid, 58 Nippon Life Benefits, 59 Nippon Life Insurance Company of America, 79 NMPSIA, 59 NMRHCA, 59 North Carolina Medicaid, 59 North Dakota Medicaid, 59 Northwest Administrators, Inc., 59 NovaSys Health, 59
'
'Ohana Health Plan (WellCare of Hawaii), 59
O
Ohio Medicaid, 59 Oklahoma Employees Group Insurance Division, 60 Oklahoma Medicaid, 60 Operating Engineers Local No. 428 Health and Welfare Trust
Fund, 60 Optima Health, 60 Orange County Fire Authority, 60 Oregon Medicaid, 60 Oregon’s Health CO-OP, 60 Oxford Health Plans, 60 Oxford Life Insurance Company, 60
P
PacificSource Administrators, 61 PacificSource Community Solutions, 61
PacificSource Health Plans, 61 PacificSource Medicare, 61 Panamerican Life Puerto Rico (PALIC), 61 Partnership Health Plan of California, 61 Passport Health Plan, 61 Payer Details, 6 Pekin Life Insurance, 61 Penn Treaty Network America Insurance (REHAB) − Medicare
Supplemental, 62 Pennsylvania Medical Assistance, 62 Peoples Health, 62 PerformCare, 62 Personal Insurance Administrators, 62 PHCS Savility Payers, 62 Physicians Mutual, 62 Piedmont Wellstar HealthPlans, 62 Pittman and Associates, 62 Plan de Salud Hospital Menonita, 62 Plan Network IDs, 77 Planned Administrators, Inc., 63
Plumbers and Pipefitters Local 525 Health & Welfare Trust, 63 Preferred Care Partners, 63 Preferred Health Systems, 63 PreferredOne, 63 Premera Blue Cross, 63 Prestige Health Choice, 63 Primary PhysicianCare, Inc., 64 Principal Financial, 64 Principal Financial Life Insurance Company of America, 79 Principal Financial Plans, 79 Priority Health, 64 Prominence Health Plan, 64 Providence Health Plan, 64 Provident American Life & Health Insurance Company ―
Medicare Supplement, 64 Provider IDs, 4 Puerto Rico Medicaid (ODSI), 64
Q
Quartz ASO, 64 QuikTrip Corporation, 64
R
Reliance Standard Life Insurance Company, 77 Requests, 2 Responses, 5 RightCare from Scott and White Health Plan, 65 Rocky Mountain Health Plan (HMO), 65
S
SAMBA Health Benefit Plan, 65 San Joaquin Health Plan, 65 Santa Clara Family Health Plan, 65 Schaller Anderson Health Plans, 65, 80 Schaller Anderson Mercy Maricopa, 65 Select Health of South Carolina, 65 Selman & Company, 65 Senior Care Action Network (SCAN) Health Maintenance
Organization (HMO), 66 Senior Health Services Center – Universal American Family of
Companies, 66 Senior Whole Health, 66 Significa Benefit Services, 66 Silver Summit Health Plan, 66 Simply Healthcare Plans, 66 South Carolina Medicaid, 66 South Dakota Medicaid, 66 Special Considerations, 4 SPJST ― Medicare Supplement, 67 Standard Insurance Company, 77 Standard Insurance Company of New York, 77 Standard Life and Accident Insurance Company, 67 Star HRG, 67 StayWell (WellCare of Florida), 67 StayWell Kids (WellCare of Florida), 67 Stonebridge Life Insurance Company, 67 Summit America Insurance Service, 67 Sunflower State Health Plan, 67 Sunshine State Health Plan, 67
T
Tennessee Medicaid (TennCare), 68 TexanPlus (North Texas Area), 68 TexanPlus (Southeast Texas Area), 68 Texas Childrens Health Plan, 68
All Payers Eligibility Guide PC Index
© 2018 Emdeon Business Services LLC. All rights reserved. Page 92
Texas Medicaid, 68 Text Color in Input Fields, 3 The Ullico Family of Companies, 68 Three Rivers Health Plan, 68 Today's Options, 69 TransactRX Infusion and Specialty, 69 Transamerica Financial Life Insurance Company, 69 Transamerica Life Insurance Company, 69 Transamerica Premier Life Insurance Company, 69 TRICARE, 69 TRICARE East Region, 69 Tricare For Life, 69 Tricare Overseas, 69 Trillium Community Health Plan, 70 Triple-S Salud (BCBS of Puerto Rico), 70 True Health New Mexico Inc), 70 Trustmark, 70 Tufts Health Plan, 70
U
Ucare of Minnesota, 70 Ultimate Health Plans, 70 UMR Wausau, 70 UMWA Health and Retirement Funds, 70 UniCare, 70 Union Pacific Railroad Employes Health Systems, 70 United American Insurance Company, 71 United Healthcare Dental, 71 United Healthcare Nevada Market, 71 United Healthcare Securehorizons − Medicare Supplemental,
72 United Teacher Associates Insurance Company ― Medicare
Supplement, 72 UnitedHealthcare (UHC), 71 UnitedHealthcare Community Plan − Tennessee, 71 UnitedHealthCare Life Insurance Company (UHCLIC), 73 UnitedHealthcare Shared Services, 71 UnitedHealthcare StudentResources, 71 Unity Health Insurance, 72 Universal Benefit Corp, 72 Universal Care of California, 72 University Care Advantage (Arizona), 72 University Family Care (Arizona), 72 University of Arizona Health Plans – UHM, 72 University Physicians Care Advantage, 73 UPMC Health Plan, 73 USAA − Medicare Supplemental, 73
V
Vantage Health Plan, 73 Vermont Medicaid, 73 Veterans Affairs Fee Basis Programs, 74 Veterans Affairs Health Administration Center, 74 Virginia Medicaid, 74 Viva Health Inc., 74 VNS CHOICE Medicare, 74
W
Washington Medicaid, 75 WEB-TPA, Inc., 75 WellCare Health Plans, 75 Wells Fargo Third Party Administrators, 75
West Virginia Family Heatlh Plan, 75 West Virginia Medicaid, 75 Western Health Advantage, 75 Western Southern Financial Group, 75
Windsor Health Plan, 76 Wisconsin Chronic Disease Program, 76 Wisconsin Medicaid, 76 Wisconsin Well Woman Program, 76 Wyoming Medicaid, 76
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