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 2 months ago