Full Eligibility Data (All Fields)

Data

Check Eligibility

Eligibility

Eligibility Info

Trn Id

***MASKED***

Member

Member Id

***MASKED***

First Name

***MASKED***

Last Name

***MASKED***

Middle Name

***MASKED***

Suffix

Null

Date Of Birth

***MASKED***

Gender

***MASKED***

Relationship Code

***MASKED***

Dependent Sequence Number

***MASKED***

Individual Relationship

Code	*MASKED*
Description	Subscriber

Relationship Type

Code	*MASKED*
Description	*MASKED*

Contact

Addresses

Type
Street1	*MASKED*
Street2
City	*MASKED*
State	*MASKED*
Country	Null
Zip	*MASKED*
Zip4

Insurance Info

Policy Number

***MASKED***

Eligibility Start Date

***MASKED***

Eligibility End Date

***MASKED***

Plan Start Date

***MASKED***

Plan End Date

***MASKED***

Policy Status

Active Policy

Plan Type Description

***MASKED***

Group Name

Null

Address

Type	Claim
Street1	*MASKED*
Street2
City	*MASKED*
State	*MASKED*
Country	Null
Zip	*MASKED*
Zip4	Null

State Of Issue Code

Product Type

***MASKED***

Product Id

***MASKED***

Product Code

***MASKED***

Payer Id

87726

Line Of Business Code

E&I

Government Program Code

Coverage Type

Medical

Insurance Type Code

***MASKED***

Insurance Type

Commercial

Associated Ids

Alternate Id	*MASKED*
Medicaid Recipient Id
Exchange Member Id
Alternate Subscriber Id
Hic Number	*MASKED*
Mbi Number	*MASKED*
Subscriber Member Facing Identifier
Surviving Spouse Id	Null
Subscriber Id	*MASKED*
Member Replacement Id	Null
Legacy Member Id	Null
Health Insurance Exchange Id

Plan Levels

Level

deductibleInfo

Family

Network Status	inNetwork
Plan Amount	*MASKED*
Plan Amount Frequency
Remaining Amount	0.0

Network Status	outOfNetwork
Plan Amount	*MASKED*
Plan Amount Frequency
Remaining Amount	0.0

Individual

Network Status	inNetwork
Plan Amount	*MASKED*
Plan Amount Frequency
Remaining Amount	0.0

Network Status	outOfNetwork
Plan Amount	*MASKED*
Plan Amount Frequency
Remaining Amount	0.0

Level

outOfPocketInfo

Family

Network Status	inNetwork
Plan Amount	*MASKED*
Plan Amount Frequency	(Calendar Year)
Remaining Amount	6975.43

Network Status	outOfNetwork
Plan Amount	*MASKED*
Plan Amount Frequency	(Calendar Year)
Remaining Amount	0.0

Individual

Network Status	inNetwork
Plan Amount	*MASKED*
Plan Amount Frequency	(Calendar Year)
Remaining Amount	1975.43

Network Status	outOfNetwork
Plan Amount	0.0
Plan Amount Frequency	(Calendar Year)
Remaining Amount	0.0

Level

copayMaxInfo

Family

Individual

Level

outOfPocketMaxInfo

Family

Individual

Delegated Info

Entity

Null

Payer Id

Contact

Phone	Null
Fax	Null
Email	Null

Addresses

Null

Primary Care Physician

Last Name

***MASKED***

First Name

***MASKED***

Middle Name

***MASKED***

Phone Number

***MASKED***

Address

Type	Null
Street1	*MASKED*
Street2	Null
City	*MASKED*
State	*MASKED*
Country	Null
Zip	*MASKED*
Zip4	Null

Affiliate Hospital Name

Null

Provider Group Name

Null

Pcp Speciality

***MASKED***

Pcp Start Date

***MASKED***

Pcp End Date

Provider NPI

***MASKED***

Provider TIN

***MASKED***

Aco Network Description

Aco Network Id

Coordination Of Benefits

Coordination Of Benefit Details

Member

Id	Null
Name	Null

Policy

Policy Number	Null
Group Number	Null
Coverage Type	*MASKED*
Insurance Type Code	Null
Medicare Entitlement Type	A
Medicare Entitlement Reason	Null
Effective Date	*MASKED*
Termination Date	*MASKED*
Verification Date	Null

Payer

Name

Null

Phone Number

Null

Address

Type	Null
Street1	Null
Street2	Null
City	Null
State	Null
Country	Null
Zip	Null
Zip4	Null

Cob Primacy

Indicator	*MASKED*
Description	Primary
Message	Null

Member

Id	*MASKED*
Name	*MASKED*

Policy

Policy Number	*MASKED*
Group Number	*MASKED*
Coverage Type	*MASKED*
Insurance Type Code	Null
Medicare Entitlement Type	Null
Medicare Entitlement Reason	Null
Effective Date	*MASKED*
Termination Date	*MASKED*
Verification Date	Null

Payer

Name

UHC

Phone Number

Null

Address

Type	Null
Street1	Null
Street2	Null
City	Null
State	Null
Country	Null
Zip	Null
Zip4	Null

Cob Primacy

Indicator	*MASKED*
Description	Secondary
Message	Null

Primacy Status

Uhc Policy Number

***MASKED***

Policy Effective Date

***MASKED***

Policy Termination Date

***MASKED***

Primacy

Indicator	*MASKED*
Description	Secondary
Message	Null

Cob Update Information

Cob Update Message	Null
Cob Last Verified Date	Null

Disclaimer

Null

Id Card Images

Side	Front
Content	*MASKED*
Content Type	image/png

Side	Back
Content	*MASKED*
Content Type	image/png

Provider Network

Status	Out-of-Network
Tier	Null
Speciality	Null

Service Levels

Family

Individual

Network Status

In-Network

Services

Service

chiropractic

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

#1	$0 / Visit

Sub Messages

Service

chiropractic

Status

Active

Copay

Frequency

***MASKED***

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Yes

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

#1	*MASKED*

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Yes

Messages

#1	Visits-0, $500 / Calendar Year ADDITIONAL VISITS AVAILABLE BASED ON MEDICAL NECESSITY REVIEW
#2	$0 / Visit
#3	$0 / Visit Allow $0 over covered amount

Sub Messages

Limitation Info

Lmt Period	Calendar Year
Lmt Type	Visits
Lmt Occur Per Period	0
Lmt Dollar Per Period	500
Message	Null

Lmt Period	Visit
Lmt Type	Null
Lmt Occur Per Period	Null
Lmt Dollar Per Period	0
Message	Null

Lmt Period	Visit
Lmt Type	Null
Lmt Occur Per Period	Null
Lmt Dollar Per Period	0
Message	Null

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Service

emergencyServices

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Yes

Messages

#1	$325 / Visit
#2	$325 / Visit NON-EMERGENCY SERVICES

Sub Messages

Service

***MASKED***

Status

Active

Copay

$325

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Yes

Exact Copay

Covered Status	Null
Copay Details	Null

Service

***MASKED***

Status

Active

Copay

$325

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Yes

Messages

#1	0% / Visit
#2	0% / Visit NON-EMERGENCY SERVICES

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Place Of Service

Outpatient Hospital (on-campus)

Copay

$325 / Visit

Service

***MASKED***

Start Date

***MASKED***

End Date

***MASKED***

Messages

Place Of Service

Outpatient Hospital (on-campus)

Copay

$325 / Visit

Service

emergencyServices

Start Date

***MASKED***

End Date

***MASKED***

Messages

#1	*MASKED*

Co Insurance List

Place Of Service

Outpatient Hospital (on-campus)

Coinsurance Percent

0% / Visit

Service

***MASKED***

Messages

Start Date

Null

End Date

Null

Place Of Service

Outpatient Hospital (on-campus)

Coinsurance Percent

0% / Visit

Service

***MASKED***

Messages

#1	*MASKED*

Start Date

Null

End Date

Null

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

#1	$250 / Visit

Sub Messages

Service

***MASKED***

Status

Active

Copay

$250

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Yes

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

#1	0% / Visit

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

#1	0 Visits / Calendar Year for Period(s) LIMITATION IS COMBINED FOR BOTH IN AND OUT OF NETWORK

Sub Messages

Limitation Info

Lmt Period	Calendar Year
Lmt Type	Visits
Lmt Occur Per Period	0
Lmt Dollar Per Period	Null
Message	Null

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Yes

Messages

#1	$300 / Visit
#2	$150 / Visit FREESTANDING FACILITY

Sub Messages

Service

***MASKED***

Status

Active

Copay

$150

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Exact Copay

Covered Status	Null
Copay Details	Null

Service

hospitalOutPatient

Status

Active

Copay

$300

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Yes

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Yes

Messages

#1	0% / Visit
#2	0% / Visit FREESTANDING FACILITY

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Place Of Service

***MASKED***

Copay

***MASKED***

Service

***MASKED***

Start Date

***MASKED***

End Date

***MASKED***

Messages

#1	*MASKED*

Place Of Service

***MASKED***

Copay

$300 / Visit

Service

***MASKED***

Start Date

***MASKED***

End Date

***MASKED***

Messages

Co Insurance List

Place Of Service

***MASKED***

Coinsurance Percent

0% / Visit

Service

***MASKED***

Messages

Start Date

Null

End Date

Null

Place Of Service

***MASKED***

Coinsurance Percent

0% / Visit

Service

***MASKED***

Messages

#1	*MASKED*

Start Date

Null

End Date

Null

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

#1	$25 / Visit

Sub Messages

Service

***MASKED***

Status

Active

Copay

$25

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Yes

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

#1	0% / Visit

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

#1	$40 / Visit SPECIALIST

Sub Messages

Service

***MASKED***

Status

Active

Copay

***MASKED***

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

#1	0% / Visit SPECIALIST

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

#1	*MASKED*

Sub Messages

Service

***MASKED***

Status

Active

Copay

***MASKED***

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Yes

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

#1	0% / Visit

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Network Status

***MASKED***

Services

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

#1	$0 / Visit

Sub Messages

Service

***MASKED***

Status

Active

Copay

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Yes

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

#1	0% / Visit

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

#1	Visits-0, $500 / Calendar Year ADDITIONAL VISITS AVAILABLE BASED ON MEDICAL NECESSITY REVIEW

Sub Messages

Limitation Info

Lmt Period	Calendar Year
Lmt Type	Visits
Lmt Occur Per Period	*MASKED*
Lmt Dollar Per Period	*MASKED*
Message	Null

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Yes

Messages

#1	*MASKED*

Sub Messages

Service

***MASKED***

Status

Active

Copay

***MASKED***

Frequency

***MASKED***

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Yes

Exact Copay

Covered Status	Null
Copay Details	Null

Service

***MASKED***

Status

Active

Copay

***MASKED***

Frequency

***MASKED***

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Yes

Messages

#1	*MASKED*

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Place Of Service

***MASKED***

Copay

***MASKED***

Service

***MASKED***

Start Date

***MASKED***

End Date

***MASKED***

Messages

Place Of Service

***MASKED***

Copay

***MASKED***

Service

***MASKED***

Start Date

***MASKED***

End Date

***MASKED***

Messages

#1	*MASKED*

Co Insurance List

Place Of Service

***MASKED***

Coinsurance Percent

0% / Visit

Service

***MASKED***

Messages

Start Date

Null

End Date

Null

Place Of Service

***MASKED***

Coinsurance Percent

0% / Visit

Service

***MASKED***

Messages

#1	NON-EMERGENCY SERVICES

Start Date

Null

End Date

Null

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

#1	$0 / Visit

Sub Messages

Service

***MASKED***

Status

Active

Copay

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Yes

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

#1	0% / Visit

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

#1	0 Visits / Calendar Year for Period(s) LIMITATION IS COMBINED FOR BOTH IN AND OUT OF NETWORK

Sub Messages

Limitation Info

Lmt Period	Calendar Year
Lmt Type	Visits
Lmt Occur Per Period	*MASKED*
Lmt Dollar Per Period	Null
Message	Null

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Yes

Messages

#1	$0 / Visit
#2	$0 / Visit FREESTANDING FACILITY

Sub Messages

Service

***MASKED***

Status

Active

Copay

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Exact Copay

Covered Status	Null
Copay Details	Null

Service

***MASKED***

Status

Active

Copay

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Yes

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Yes

Messages

#1	0% / Visit
#2	0% / Visit FREESTANDING FACILITY

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Place Of Service

***MASKED***

Copay

***MASKED***

Service

hospitalOutPatient

Start Date

***MASKED***

End Date

***MASKED***

Messages

#1	FREESTANDING FACILITY

Place Of Service

***MASKED***

Copay

$0 / Visit

Service

***MASKED***

Start Date

***MASKED***

End Date

***MASKED***

Messages

Co Insurance List

Place Of Service

***MASKED***

Coinsurance Percent

0% / Visit

Service

***MASKED***

Messages

Start Date

Null

End Date

Null

Place Of Service

***MASKED***

Coinsurance Percent

0% / Visit

Service

***MASKED***

Messages

#1	FREESTANDING FACILITY

Start Date

Null

End Date

Null

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

#1	$0 / Visit

Sub Messages

Service

***MASKED***

Status

Active

Copay

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Yes

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

#1	0% / Visit

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

#1	$0 / Visit SPECIALIST

Sub Messages

Service

***MASKED***

Status

Active

Copay

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

#1	0% / Visit SPECIALIST

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Active

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

#1	$0 / Visit

Sub Messages

Service

***MASKED***

Status

Active

Copay

Frequency

/ visit

Msg

Start Date

***MASKED***

End Date

***MASKED***

Min Copay

Null

Min Copay Msg

Null

Max Copay

Null

Max Copay Msg

Null

Is Primary Indicator

Yes

Exact Copay

Covered Status	Null
Copay Details	Null

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

#1	0% / Visit

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Service

***MASKED***

Service Code

***MASKED***

Service Date

Null

Status

Plan Amount

Null

Remaining Amount

Null

Met Year To Date Amount

Null

Message

Co Pay

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Insurance

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Deductible

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Allowed

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Benefits Remaining

Is Single Message Detail

Is View Detail

Messages

Sub Messages

Limitation Info

Is Multiple Copays Found

Is Multiple Coinsurance Found

Co Pay List

Co Insurance List

Other Beneficiaries

Additional Info

Funding Type	Fully Insured-Large Group
Business Segment	Null
Size Definition Description	Null
Revenue Arrangement Description	Null
Hsa	*MASKED*
Cdhp	*MASKED*
Cms HId
Cms Package Benefit Plan Code
Cms Segment Id
Cms Contract Id
Benefit Plan Id
Virtual Visit	*MASKED*
Designated Virtual Clinic Network	Null
Medicaid Variable Code
Hra Balance
Hra Message
Hra Unavailable Message
Grace Message By State	By law, exchange members who receive a subsidy have a three-month grace period to pay their premiums. We will process claims during the first month. During the second and third month of the grace period, we will pend claims if the premium hasn't been paid. If we receive the premium payment within the grace period, we will process this claim.
Grace Paid Through	Null
Grace Period Month	Null
Medicare Guidelines	Null
Medicare Entitlement Reason	Null
Medicaid Entitlement	Null