Example 03: Termination

Reporting a termination of coverage for which the coverage had previously been sent as addition.

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 William Smith. He has a member ID of 920399398 and his Social Security Number (SSN) is 202443070. He is also the subscriber. William was born on September 14, 1970, is single, and is a white male. His employment class is Non-Union. He has no health related codes to report. William speaks English as his native language.

William lives at 1715 Southwind Ave, Anytown, PA 17111-000, but his mailing address is 2324 Northwind Ave., Anytown, PA 17111-0000. His employer is Member Employer Name. The responsible person for William is Person Responsible.

William previously had Employee Only HMO coverage sent. The termination is sent due to Non Payment. This transaction has a maintenance effective date of November 15, 2019, a benefit begins date of August 1, 2019 and a benefit end date of October 31, 2019. The premium was paid through October 31, 2019. This previously sent coverage had a deductible amount of $250 and a premium amount of $100. The group number is 888888.

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

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

William also previously had Employee Only Dental coverage sent. This transaction has a maintenance effective date of November 15, 2019, a benefit begins date of August 1, 2019 and a benefit end date of October 31, 2019. The premium was paid through October 31, 2019. This previously sent coverage had a deductible amount of $50 and a premium amount of $10. The group number is 333333.

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