Code to be used when the patient is eligibile

When HCP sends an eligibility request for an expired or canceled member’s policy on the eligibility service date.

When HCP sends an eligibility request mentioning a department that offers services out of patient policy coverage.

Facility is outside the member covered policy network.

Provider can be suspended for any reason (regulation, contractual, legal… etc.)

Insurance coverage can be suspended for any reason (regulation, financial, legal, etc.)

When HCP sends an eligibility request for insured member who is covered on patient reimbursement basis, so even the member has an active policy, but he will pay the medical fees out of his pocket and reimburse the claims. (e.g.: members covered under visit visa insurance policy)

When member consumed the annual or benefit limit, benefit limit can be indicated from the department in the eligibility request or from the provider type, e.g. request from received from optical shop for a member consumed the optical benefit.