Required Eligibility File Format

One eligibility record per member is preferable unless there is a lapse in coverage. Only Medical Coverage should be selected. Microsoft Excel File Format is preferred, .CSV, or Tab Delimited Text File.

• Last Name
• First Name
• Middle Name
• Address Line 1
• Address Line 2
• City
• State
• Zip
• Patient's Phone (Not Required)
• Sex
• Date of Birth
• Unique Member ID #
• DSN (If used)
• Relation to insured
• Insured SSN
• Group # or Employer Code
• Employer Group Name
• Earliest Effective Date
• Term Date

Disclaimer: This information is for informational purposes only and is not intended to constitute professional advice as circumstances may vary. CHA is not liable for information contained on this site. Fee schedule information applies only to M.D.s and D.O.s, not to any other Allied or Behavioral Health providers. CPT code allowables are global and do not represent modifiers. Information contained on this website is subject to change.