(Example only: Medicaid beneficiary enrolled in a Medicaid Health Plan with Other Insurance.)

					06/01/2004 1:07:04 PM
Status: CLOSED					Rec#: 1
Michigan
Eligibility v1.6
Medicaid: Y
Other Payer: Y
Medicare: N
Input Information		Response Information
MI Prov ID:	1111111
MI Prov Type:	10
Card #:
Recipient ID:	12345678	Recipient ID:			12345678
Begin DOS:	06/01/2004
End DOS:	06/30/2004
SSN:
Date Of Birth:		Date Of Birth:			12/04/2002
Last Name:		Last Name:			BENE
First Name:		First Name:			MI
Amount:
Account #:
Medicaid Information
MI:	S	Spenddown:		N
Gender:	F	Worker Load #:		00000999
Eligibility
Begin Date:	06/01/2004	Scope-Cvg:		1F
End Date:	06/30/2004	Medicaid-Enrolled in a Health Plan
Residence County Code:	63	PAMA Program:	L
Oakland		Healthy Kids Medicaid and Medicaid for
FIA County Code:	63	Pregnant Women.
Oakland		Case #:		X1111111A
FIA County Office Phone:	111-222-5555
Level Of Care
Begin Date:	06/01/2004	HMO.
End Date:	06/30/2004	Provider ID:			1234567
Level Of Care:	07	Provider Name:			HEALTHCARE HMO
Recipient is enrolled in an HMO.
Services must be authorized by the		Phone:			999-999-9999
Dental
Begin Date:	06/01/2004	Delta Premier Dental
End Date:	06/30/2004	Phone:			1-111-222-3333
Program Code:	11
Managed Care
Health Plan:	Healthcare HMO	PCP information provided by the Health
Current PCP:	DOE, JOHN	Plan.
PCP Phone:	999-999-9999
Third Party Liability
Begin Date:	05/01/2003	48226
End Date:	12/31/2099	Policy #:			99999999
Control #:	1111111111	Policyholder:			WALLACE
Carrier ID:	00029010	Contract #:			2222222222
Carrier Name:	BC BS PPO	Service Code:			111111111
000 LAFAYETTE		Other Ins:			89
DETROIT		Managed Care Plans/HMO's.