Example 02: Cancellation of Coverage

The Submitter (Submitter Name) with ETIN S12345 is submitting this transaction to the Receiver (Receiver Name) with ETIN R12345. The source of the information in this transaction is Infosrc Name with a ETIN of IS12345.

The member being sent in this transaction is Juanita Diaz. She has a member ID of 920395898 and her Social Security Number (SSN) is 202543189. She is also the subscriber. Juanita was born on March 24, 1974, is single, and is a Hispanic or latino white female. Her employment class is Salaried. She has no health related codes to report. Juanita speaks English as her native language, and can read Spanish and French.

Juanita lives at 1531 Southwind Ave, Anytown, PA 17111-000, but her mailing address is 2556 Northwind Ave., Anytown, PA 17111-0000. Her employer is Member Employer Name. The responsible person for Juanita is Person Responsible.

Juanita previously had Employee Only HMO coverage sent. This transaction has a maintenance effective date of October 1, 2019 and a benefit begins date of August 1, 2019. This previously sent coverage had a deductible amount of $250 and a premium amount of $100. The group number is 888888.

Juanita’s primary care physician is PCP Jones who has a NPI of 1700813623. PCP Jones is a General Practice physician.

Juanita had previously sent coverage under 2 different insurers. Her primary insurer was sent as Infosrcname, who is also the Information Source for this transaction. Her secondary insurer was sent as Secondary Ins Co.

Juanita also previously had Employee Only Dental coverage sent. This transaction has a maintenance effective date of October 1, 2019 and a benefit begins date of August 1, 2019.  This previously sent coverage had a deductible amount of $50 and a premium amount of $10. The group number is 333333. 

Juanita’s dentist is Dentist Jones who has a NPI of 1700814449. Dentist Jones is a General Practice dentist.