Eligibility Response for Medicare Patient
If you are submitting the request to Medicare, they would return additional information related to specific insuranceTypes, which allows you to determine if the benefits apply to Part A, Part B, or another insurance. Here is a sample response that contains this information:
},
"controlNumber": "123456789",
"reassociationKey": "123456789",
"tradingPartnerServiceId": "CMSMED",
"provider": {
"providerName": "HAPPY DOCTORS GROUP PRACTICE",
"entityIdentifier": "Provider",
"entityType": "Non-Person Entity",
"npi": "1234567893"
},
"subscriber": {
"memberId": "0000000000",
"firstName": "JOHNONE",
"lastName": "DOEONE",
"middleName": "M",
"gender": "F",
"entityIdentifier": "Insured or Subscriber",
"entityType": "Person",
"dateOfBirth": "18800102",
"relationToSubscriber": "Self",
"insuredIndicator": "Y",
"maintenanceTypeCode": "001",
"maintenanceReasonCode": "25",
"address": {
"address1": "123 address1",
"city": "SEATTLE",
"state": "WA",
"postalCode": "981010000"
}
},
"subscriberTraceNumbers": [
{
"traceTypeCode": "2",
"traceType": "Referenced Transaction Trace Numbers",
"referenceIdentification": "123456789",
"originatingCompanyIdentifier": "9877281234"
},
{
"traceTypeCode": "2",
"traceType": "Referenced Transaction Trace Numbers",
"referenceIdentification": "123456789",
"originatingCompanyIdentifier": "9877281234"
}
],
"payer": {
"entityIdentifier": "Payer",
"entityType": "Non-Person Entity",
"name": "CMS",
"payorIdentification": "CMSMED"
},
"planDateInformation": {
"eligibility": "20211020-20211020"
},
"planStatus": [
{
"statusCode": "1",
"status": "Active Coverage",
"serviceTypeCodes": [
"88",
"30",
"42",
"45",
"48",
"49",
"69",
"76",
"83",
"A5",
"A7",
"AG",
"BT",
"BU",
"BV",
"30",
"2",
"23",
"24",
"25",
"26",
"27",
"28",
"3",
"33",
"36",
"37",
"38",
"39",
"4",
"40",
"42",
"50",
"51",
"52",
"53",
"62",
"67",
"69",
"73",
"76",
"83",
"86",
"98",
"A4",
"A6",
"A8",
"AI",
"AJ",
"AK",
"AL",
"BT",
"BU",
"BV",
"DM",
"UC"
]
}
],
"benefitsInformation": [
{
"code": "I",
"name": "Non-Covered",
"serviceTypeCodes": [
"41",
"54"
],
"serviceTypes": [
"Routine (Preventive) Dental",
"Long Term Care"
]
},
{
"code": "1",
"name": "Active Coverage",
"serviceTypeCodes": [
"88"
],
"serviceTypes": [
"Pharmacy"
]
},
{
"code": "1",
"name": "Active Coverage",
"serviceTypeCodes": [
"30",
"42",
"45",
"48",
"49",
"69",
"76",
"83",
"A5",
"A7",
"AG",
"BT",
"BU",
"BV"
],
"serviceTypes": [
"Health Benefit Plan Coverage",
"Home Health Care",
"Hospice",
"Hospital - Inpatient",
"Hospital - Room and Board",
"Maternity",
"Dialysis",
"Infertility",
"Psychiatric - Room and Board",
"Psychiatric - Inpatient",
"Skilled Nursing Care",
"Gynecological",
"Obstetrical",
"Obstetrical/Gynecological"
],
"insuranceTypeCode": "MA",
"insuranceType": "Medicare Part A",
"benefitsDateInformation": {
"plan": "20041101"
},
"additionalInformation": [
{
"description": "0-Beneficiary insured due to age OASI"
}
]
},
{
"code": "C",
"name": "Deductible",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"insuranceTypeCode": "MA",
"insuranceType": "Medicare Part A",
"timeQualifierCode": "26",
"timeQualifier": "Episode",
"benefitAmount": "1484",
"benefitsDateInformation": {
"plan": "20210101-20211231"
}
},
{
"code": "C",
"name": "Deductible",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"insuranceTypeCode": "MA",
"insuranceType": "Medicare Part A",
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "1484",
"benefitsDateInformation": {
"plan": "20210101-20211231"
}
},
{
"code": "C",
"name": "Deductible",
"serviceTypeCodes": [
"42",
"45"
],
"serviceTypes": [
"Home Health Care",
"Hospice"
],
"insuranceTypeCode": "MA",
"insuranceType": "Medicare Part A",
"timeQualifierCode": "26",
"timeQualifier": "Episode",
"benefitAmount": "0",
"benefitsDateInformation": {
"benefit": "20210101-20211231"
}
},
{
"code": "1",
"name": "Active Coverage",
"serviceTypeCodes": [
"30",
"2",
"23",
"24",
"25",
"26",
"27",
"28",
"3",
"33",
"36",
"37",
"38",
"39",
"4",
"40",
"42",
"50",
"51",
"52",
"53",
"62",
"67",
"69",
"73",
"76",
"83",
"86",
"98",
"A4",
"A6",
"A8",
"AI",
"AJ",
"AK",
"AL",
"BT",
"BU",
"BV",
"DM",
"UC"
],
"serviceTypes": [
"Health Benefit Plan Coverage",
"Surgical",
"Diagnostic Dental",
"Periodontics",
"Restorative",
"Endodontics",
"Maxillofacial Prosthetics",
"Adjunctive Dental Services",
"Consultation",
"Chiropractic",
"Dental Crowns",
"Dental Accident",
"Orthodontics",
"Prosthodontics",
"Diagnostic X-Ray",
"Oral Surgery",
"Home Health Care",
"Hospital - Outpatient",
"Hospital - Emergency Accident",
"Hospital - Emergency Medical",
"Hospital - Ambulatory Surgical",
"MRI/CAT Scan",
"Smoking Cessation",
"Maternity",
"Diagnostic Medical",
"Dialysis",
"Infertility",
"Emergency Services",
"Professional (Physician) Visit - Office",
"Psychiatric",
"Psychotherapy",
"Psychiatric - Outpatient",
"Substance Abuse",
"Alcoholism",
"Drug Addiction",
"Vision (Optometry)",
"Gynecological",
"Obstetrical",
"Obstetrical/Gynecological",
"Durable Medical Equipment",
"Urgent Care"
],
"insuranceTypeCode": "MB",
"insuranceType": "Medicare Part B",
"benefitsDateInformation": {
"plan": "20041101"
},
"additionalInformation": [
{
"description": "0-Beneficiary insured due to age OASI"
}
]
},
{
"code": "C",
"name": "Deductible",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"insuranceTypeCode": "MB",
"insuranceType": "Medicare Part B",
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "203",
"benefitsDateInformation": {
"plan": "20210101-20211231"
}
},
{
"code": "C",
"name": "Deductible",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"insuranceTypeCode": "MB",
"insuranceType": "Medicare Part B",
"timeQualifierCode": "29",
"timeQualifier": "Remaining",
"benefitAmount": "0",
"benefitsDateInformation": {
"plan": "20210101-20211231"
}
},
{
"code": "A",
"name": "Co-Insurance",
"serviceTypeCodes": [
"30"
],
"serviceTypes": [
"Health Benefit Plan Coverage"
],
"insuranceTypeCode": "MB",
"insuranceType": "Medicare Part B",
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"benefitPercent": "0.2",
"benefitsDateInformation": {
"plan": "20210101-20211231"
}
},
{
"code": "C",
"name": "Deductible",
"serviceTypeCodes": [
"42",
"67",
"AJ"
],
"serviceTypes": [
"Home Health Care",
"Smoking Cessation",
"Alcoholism"
],
"insuranceTypeCode": "MB",
"insuranceType": "Medicare Part B",
"timeQualifierCode": "23",
"timeQualifier": "Calendar Year",
"benefitAmount": "0",
"benefitsDateInformation": {
"benefit": "20210101-20211231"
}
},
{
"code": "A",
"name": "Co-Insurance",
"serviceTypeCodes": [
"42",
"67",
"AJ"
],
"serviceTypes": [
"Home Health Care",
"Smoking Cessation",
"Alcoholism"
],
"insuranceTypeCode": "MB",
"insuranceType": "Medicare Part B",
"timeQualifierCode": "27",
"timeQualifier": "Visit",
"benefitPercent": "0",
"benefitsDateInformation": {
"benefit": "20210101-20211231"
}
},
{
"code": "R",
"name": "Other or Additional Payor",
"serviceTypeCodes": [
"88"
],
"serviceTypes": [
"Pharmacy"
],
"insuranceTypeCode": "OT",
"insuranceType": "Other",
"headerLoopIdentifierCode": "2120",
"trailerLoopIdentifierCode": "2120",
"benefitsAdditionalInformation": {
"planNumber": "S5601",
"planNetworkIdNumber": "203"
},
"benefitsDateInformation": {
"benefit": "20210101"
},
"benefitsRelatedEntity": {
"entityIdentifier": "Payer",
"entityType": "Non-Person Entity",
"entityName": "extra healthy insurance",
"address": {
"address1": "123 address1",
"city": "Nashville",
"state": "TN",
"postalCode": "37203"
},
"contactInformation": {
"contacts": [
{
"communicationMode": "Telephone",
"communicationNumber": "0000000000"
},
{
"communicationMode": "Uniform Resource Locator (URL)",
"communicationNumber": "www.testwebsite.com"
}
]
}
},
"benefitsRelatedEntities": [
{
"entityIdentifier": "Payer",
"entityType": "Non-Person Entity",
"entityName": "extra healthy insurance",
"address": {
"address1": "123 address1"
},
"contactInformation": {
"contacts": [
{
"communicationMode": "Telephone",
"communicationNumber": "0000000000"
},
{
"communicationMode": "Uniform Resource Locator (URL)",
"communicationNumber": "www.testwebsite.com"
}
]
}
}
]
}
],
"x12": "ISA*00* *01*SomePwd *ZZ*EMDEON *ZZ*TPG00000 *230808*1017*^*00501*123456789*0*T*:~GS*HB*MTEXE*LLX1210001*20131015*2219*123456789*X*005010X279A1~ST*271*0001*005010X279A1~BHT*0022*11*a3ccf869-a31b-ddf0-c3ed-876557226558*20230808*1017~HL*1**20*1~NM1*PR*2*CMS*****PI*CMSMED~HL*2*1*21*1~NM1*1P*2*HAPPY DOCTORS GROUP PRACTICE*****XX*1234567893~HL*3*2*22*0~TRN*2*123456789*9877281234~TRN*2*1266798199*9MCK-TSHRT~NM1*IL*1*DOEONE*JOHNONE*M***MI*0000000000~N3*123 address1~N4*SEATTLE*WA*981010000~DMG*D8*18800102*F~INS*Y*18*001*25~DTP*307*RD8*20211020-20211020~EB*I**41^54~EB*1**88~EB*1**30^42^45^48^49^69^76^83^A5^A7^AG^BT^BU^BV*MA~DTP*291*D8*20041101~MSG*0-Beneficiary insured due to age OASI~EB*C**30*MA**26*1484~DTP*291*RD8*20210101-20211231~EB*C**30*MA**29*1484~DTP*291*RD8*20210101-20211231~EB*C**42^45*MA**26*0~DTP*292*RD8*20210101-20211231~EB*1**30^2^23^24^25^26^27^28^3^33^36^37^38^39^4^40^42^50^51^52^53^62^67^69^73^76^83^86^98^A4^A6^A8^AI^AJ^AK^AL^BT^BU^BV^DM^UC*MB~DTP*291*D8*20041101~MSG*0-Beneficiary insured due to age OASI~EB*C**30*MB**23*203~DTP*291*RD8*20210101-20211231~EB*C**30*MB**29*0~DTP*291*RD8*20210101-20211231~EB*A**30*MB**27**0.2~DTP*291*RD8*20210101-20211231~EB*C**42^67^AJ*MB**23*0~DTP*292*RD8*20210101-20211231~EB*A**42^67^AJ*MB**27**0~DTP*292*RD8*20210101-20211231~EB*R**88*OT~REF*18*S5601~REF*N6*203*SilverScript SmartRx~DTP*292*D8*20210101~LS*2120~NM1*PR*2*extra healthy insurance~N3*123 address1~N4*Nashville*TN*37203~PER*IC**TE*0000000000*UR*www.testwebsite.com~LE*2120~SE*50*0001~GE*1*123456789~IEA*1*123456789~"
}
Updated 6 months ago