Matching Pairs Coverage CodesOnline version Match the Coverage Code to the correct description. by Diane Martin 1 02 2 01 3 00 4 65 5 68 6 T3 7 U8 8 03 9 04 10 MU 11 T4 12 M8 Derived during adjudication when the Provider is identified as participating and the type of service derived requires an authorization and an authorization match is found or is not needed. Used when the member is over 65 and Medicare is prime. (Preferred benefit level) Derived during adjudication when the provider is identified as the member’s PCP (occurs on Referral optional and Referral required products)(Preferred PCP benefit level) Derived during adjudication when the provider is identified as participating and the type of service derived requires an authorization and an authorization match is found or is not needed. Used when the member is under 65 and Medicare is primary. (Preferred benefit level) Plan Sponsor Custom Network (IDS) claim. Authorization needed or one was needed and match found. Participating provider (Tier 1 Preferred benefit level) Plan Sponsor Custom Network (IDS) claim.Authorization not needed or needed and match was found. Participating provider.Member is under 65 and Medicare is primary (Tier 1 – Preferred benefit level). Passed down by the member API when the member is identified as being primary under Medicare and under the age of 65. provider is non-participating. (Non preferred benefit level) Plan Sponsor Custom Network (IDS) claim, PCP Claim. Consider as a preferred benefit, Participating provider. (Tier 1 – Preferred PCP benefit level) Derived during adjudication when the provider is identified as participating and the type of service derived requires an authorization and an authorization match is found or is not needed/waived. The base coverage code passed down by member API for all members who are not identified as an OSA member or Medicare prime.Provider on the claim is non participating/out of network for all single tier or multitier products. Derived during adjudication when the provider is identified as Participating and the type of service derived requires an authorization and an authorization match is not found. (Preferred – penalty benefit level) Passed down by member API when the member is identified as primary under Medicare. Provider is non participating. (Non preferred benefit level) Derived during adjudication when the provider is identified as non participating and the type of service generated requires a precert and a precert match is not found. (Non preferred penalty benefit level)
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