Payer Sheet for Part A / B

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This section includes the following programmer details:

E1 Specifications

• Request
• Response: Accepted
• Response: Rejected

Standardize Messaging on Medicare Part D Eligibility Response

• Message Definition
• Message Example

E1 Specifications for Part A / B

Request for Part A / B

Patient Segment: Required for Proper Matching
Field	Field Name	Value	Comments
111-AM	SEGMENT IDENTIFICATION	“01”	M – PATIENT SEGMENT
3Ø4-C4	DATE OF BIRTH	19400615	R – Born June 16, 1940
3Ø5-C5	PATIENT GENDER CODE	1	R – Male
31Ø-CA	PATIENT FIRST NAME	JOHN	R
311-CB	PATIENT LAST NAME	DOE	R
322-CM	PATIENT STREET ADDRESS	123 MAIN STREET	O
322-CN	PATIENT CITY ADDRESS	MY TOWN	O
324-CO	PATIENT STATE/PROVINCE ADDRESS	CO	O
325-CP	PATIENT ZIP/POSTAL ZONE	34567	R – Zip Code (5 digit zip)
326-CQ	PATIENT PHONE NUMBER	2015551234	O
Note: Other optional fields not shown in these segments are not used.

Insurance Segment: Mandatory Segment
Field	Field Name	Value	Comments
111-AM	SEGMENT IDENTIFICATION	“Ø4”	M – INSURANCE SEGMENT
3Ø2-C2	CARDHOLDER ID	998877665	M – Must include one of the following: – ID from Medicare Part A card – ID from Medicare Part B card – Last 4 digits of the SSN

Response: Accepted for Part A / B

The Facilitator sends this response when the data provided in the E1 Request enables the Facilitator to find one unique patient.

Response: Rejected for Part A / B

This is the response when a single match is NOT found.

Standard Messaging on Medicare Part D Eligibility Response

Messaging should be returned in field 504-F4 (Message field) AFTER processor message of MEDICARE A/B CHECK: Field 504-F4 (Message field) is a 200-byte field. If additional bytes are needed the Additional Message field (526-FQ) should be used.

Message Definition

Field 504-F4 will contain a string in the following format.

Field Identifier: Field Value;

The Field Identifier describes what the Field Value means. For example, the Field Identifier could be "ID," which means that the Field Value represents the beneficiaries ID.

The Field Value contains the actual value for the beneficiary. For example, the Field Value could be "123456," which means that the beneficiary's ID is 123456.

Field Identifiers are followed by a colon.

Field Values are followed by a semicolon.

The Field Identifiers are, in order:

Message Example

MEDICARE A/B CHECK;
ID:123456789;DOB:19190101;LN:JONES;FN:JOHN;ZIP:12345;AB:A