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April 2016 - 005010

HMSA

ASCX12N 270/271 (005010X279A1)

Health Care Eligibility Benefit Inquiry and

Response

CORE Standard Companion Guide v1.4

April 2016 - 005010

Disclosure Statement

The information in this document is subject to change. Any revisions will be posted on our Provider E-

library website (http://www.hmsa.com/portal/provider/zav_pel.aa.HIP.500.htm).

http://www.hmsa.com/portal/provider/zav_pel.aa.HIP.500.htm

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Preface

The Health Insurance Portability and Accountability Act (HIPAA) requires all covered entities to comply

with the HIPAA EDI standard transactions adopted under this Federal Regulation. The purpose of this

270/271 Companion Guide to the v5010 ASC X12N Technical Report Type 3 (TR3) is to clarify and specify

the data content when exchanging electronically with HMSA. This Companion Guide is intended to convey

information that is within the framework of the ASC X12N TR3s adopted for use under HIPAA. The

Companion Guide is not intended to convey information that in any way exceeds the requirements or

usages of data expressed in the TR3.

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Table of Contents 1 INTRODUCTION ................................................................................................................................ 5

2 GETTING STARTED ............................................................................................................................ 6

3 TESTING WITH THE PAYER ............................................................................................................... 7

4 CONNECTIVITY WITH THE PAYER/COMMUNICATIONS ................................................................... 7

5 CONTACT INFORMATION ............................................................................................................... 13

6 CONTROL SEGMENTS/ENVELOPES ................................................................................................ 14

7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS .................................................................... 18

8 ACKNOWLEDGMENTS .................................................................................................................... 21

9 TRADING PARTNER AGREEMENTS ................................................................................................. 21

10 TRANSACTION SPECIFIC INFORMATION ........................................................................................ 22

A. APPENDICES ....................................................................................................................................... 29

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1 INTRODUCTION

This application for real-time and batch 270/271 follows the CAQH CORE Phase II

guidelines.

1.1 SCOPE Covered entities (payers, health care providers, health plans and clearinghouses) must

comply with the ASC X12N 270/271 (005010X279A1) TR3 for submission of eligibility and

claim status inquiries to HMSA. Our companion guide defines CORE Business rules for

270/271 data content, response times, connectivity, and system availability. This

document should be used to supplement the X12 TR3.

1.2 OVERVIEW In January 2012, the U.S. Department of Health & Human Services finalized the first

regulation on operating rules for eligibility and claim status transactions. Effective January

1, 2013, the Affordable Care Act (ACA) mandates adoption of the rules for Health

Insurance Portability and Accountability Act (HIPAA) electronic data interchange (EDI)

transactions. This standard companion guide is part of the CAQH CORE Operating Rules

adopted under this Federal Regulation.

1.2.1 What is CAQH? The Council for Affordable and Quality Healthcare (CAQH) is a cross-section of

industry representatives from health plans, provider networks, and Health Insurance

Industry associations. This non-profit alliance came together to provide a variety of

solutions aimed at streamlining and simplifying health care administration.

1.2.2 What is CORE? The Committee on Operating Rules for Information Exchange (CORE) was created by

CAQH to author a set of Operating Rules that would help the industry meet

requirements not currently defined in the x12 TR3. These include data content rules

and infrastructure rules. CORE’s Phase II goal is to create, disseminate, and maintain

operating rules that enable health care providers to quickly and securely obtain reliable

health care eligibility and benefits information. These Rules decrease the amount of

time and resources providers spend checking patient eligibility, benefits and other

administrative information at the point of care.

1.2.3 What is CORE Certification?

Any entity that creates, transmits, or uses eligibility or claim status data is eligible to

become CORE-certified. CORE-certification indicates an entity has signed the CORE

Pledge and successfully completed certification testing, both of which are designed to

demonstrate an entity’s compliance with all the CORE Phase II rules. Any entity that

agrees to follow the CORE operating rules will be expected to exchange eligibility and

benefits information per the requirements of the CORE Phase II rules and policies.

Given the requirements of the CORE Phase II rules, use of these rules by the industry

will enhance the usability and content of the eligibility and claim status transaction as

well as decrease administrative costs and resources.

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1.3 REFERENCES

1.3.1 The ASC X12 5010 version of the HIPAA TR3s can be purchased at www.wpc-

edi.com

1.3.2 HMSA’s provider portal:


1.3.3 CAQH/CORE information can be found on their website:

http://www.caqh.org/ORMandate_Eligibility.php

1.3.4 WSDL: http://www.w3.org/TR/wsdl

1.3.5 SOAP: http://www.w3.org/TR/soap/

1.3.6: MIME Multipart: www.ietf.org/rfc/rfc2045.txt

1.3.7 CORE XML Schema: http://www.caqh.org/SOAP/WSDL/CORERule2.2.0.xsd

1.4 ADDITIONAL INFORMATION This Companion Guide is intended for professionals who are involved in implementing EDI

solutions for health care providers, such as vendors of practice management software,

and service providers such as claims clearinghouses who send EDI on their clients’ behalf.

As such, this Companion Guide assumes a working knowledge of ASC X12, its structure

and nomenclature, and implementing or supporting different methods of connectivity. It

also assumes a working knowledge of the 270 and 271 transactions as described in the

Technical Report Type 3 (TR3).

Submitters must have a secure internet connection (HTTPS) capability to submit a

CORE 270 request and receive 271 responses.

Both real-time and batch 270 inquiries are supported.

2. GETTING STARTED

2.1 WORKING WITH HMSA

Trading partners who wish to send electronic transactions to HMSA should contact

Electronic Transaction Services at (808) 948-6355 on Oahu or toll free at (800) 377-4672

or email [email protected].

2.2 TRADING PARTNER REGISTRATION If not already submitting electronic transactions to HMSA, a trading partner will need to

complete and send back HMSA’s Electronic Trading Partner Agreement before being set

up for electronic transactions. A copy of the agreement can be found at this URL:

http://www.hmsa.com/portal/provider/ps/Contracts/EDI_Trading_Partner_Agreement.pdf

http://www.wpc-edi.com/

http://www.wpc-edi.com/


http://www.caqh.org/ORMandate_Eligibility.php

http://www.w3.org/TR/wsdl

http://www.w3.org/TR/soap/

http://www.ietf.org/rfc/rfc2045.txt

http://www.caqh.org/SOAP/WSDL/CORERule2.2.0.xsd

mailto:[email protected]

http://www.hmsa.com/portal/provider/ps/Contracts/EDI_Trading_Partner_Agreement.pdf

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If the trading partner will be using a third-party to send electronic transactions to HMSA, it

must notify HMSA via Exhibit B on the agreement.

2.3 CERTIFICATION AND TESTING OVERVIEW There is no formal certification or testing for 270/271 & 276/277 HIPAA transactions.

3. TESTING WITH THE PAYER

Although there is no formal testing, HMSA recommends submitting at least one request transaction to ensure connectivity and data transfer is successful. Listed below are steps to follow:

Contact Electronic Transaction Services to register X.509 digital certificate and confirm submitter id is established for 270/276 real-time or batch submission

Create 270/276 request based on Companion Guide/TR3 and CAQH CORE specifications.

Submit initial request

Retrieve acknowledgement (TA1, 999) for batch submission

Retrieve response 271/277 and review content to determine production readiness

4. CONNECTIVITY WITH THE PAYER/COMMUNICATIONS

4.1 HMSA CORE System Availability Sunday 7 p.m. – Saturday 7 p.m.

(Normally processing will be 7 x 24, however maintenance may occur between Saturday 7

p.m. (HST) and Sunday 7 p.m. (HST). During this time, real-time BlueExchange

transactions (BlueCard and FEP) may not process between these hours.

All scheduled downtimes will be posted and emergency downtimes will be noted.

4.2 Process Flows 4.2.1 Real-time

1. The user application submits a real-time SOAP request to:

https://webservices.hmsa.com/CORE/realtime

2. The user application submits a real-time MIME request to:

https://webservices.hmsa.com/CORE/mime

3. HMSA’s system will authenticate client credentials. If unable to authenticate,

then an HTTP 403 Forbidden response is returned.

4. If the user is successfully authenticated, an HTTP 200 OK status response will

be returned to the user within 20 seconds along with the 271 response.

https://webservices.hmsa.com/CORE/realtime


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CORE Compatible Application

https://webservices.hmsa.com/CORE/realtime (SOAP)

https://webservices.hmsa.com/CORE/mime (MIME)

AuthenticationHTTP 403

HMSA CORE Processing

Send Request to

Invalid

Valid

HTTP 200 & 271

Valid SenderId, Envelope

Valid

HTTP 400Invalid

4.2.2 Batch Submission

1. The user application submits a batch submission SOAP request to:

https://webservices.hmsa.com/CORE/batch


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2. The user application submits a batch submission MIME request to:


3. HMSA’s system will authenticate client credentials. If unable to

authenticate, then an HTTP 403 Forbidden response is returned.

4. HMSA’s system will validate SenderId and other elements of CORE

envelope metadata. If validation fails, HTTP 400 status response is

returned.

5. If the user is successfully authorized and envelope validated, an HTTP 202

OK status response will be returned to the user indicating HMSA has

accepted the batch transaction for processing.


https://webservices.hmsa.com/CORE/batch (SOAP)


AuthenticationHTTP 403

HMSA CORE Processing

Send Request to

Invalid

Valid

HTTP 202 Valid SenderId, Envelope

ValidHTTP 400

Invalid

Valid

4.2.3 Batch Pickup 1. The user application submits a batch pickup SOAP request to:




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2. The user application submits a batch pikcup MIME request to:


3. HMSA’s system will authenticate client credentials. If unable to

authenticate, then an HTTP 403 Forbidden response is returned.

4. HMSA’s system will validate SenderId and other elements of CORE

envelope metadata. If validation fails, HTTP 400 status response is

returned.

5. If the user is successfully authorized and envelope validated, the message

is validated against the schema. If the validation is successful, one of the

following will be generated back to the user with HTTP 200 status:

999 Reject available within one hour, if there is a problem with the

segments occurring between the ISA and IEA.

999 Acceptance response will be available within one hour.

The 271 transaction(s) will be available within 8 hours during CORE

Availability Hours (see start of section 4 for availability)

Note: HMSA does not build TA1 acknowledgements.


https://webservices.hmsa.com/CORE/batch (SOAP)


Authentication HTTP 403

Send Request to

Invalid

Valid

HTTP 200 and 999 or

271

Valid Envelope and

Message ?Valid

HTTP 400Invalid

For 271 :

4.3 Transmission Administrative Procedures 4.3.1 Structure Requirements

Real-time 270 requests are limited to one inquiry, per patient, per transaction.

Batch 270 requests are limited to 99 inquires per file. Only one interchange

and one functional group allowed per file.

4.3.2 Response Times A response to the real time inquiry will be provided within 20 seconds.


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*Due to Blue Cross and Blue Shield Association requirements, transactions

that must be sent to another BCBS plan for processing (BlueCard or FEP), may

take longer than local requests.

A response to the batch inquiry will be provided 8 hours after submission from

Sunday 7pm HST to Saturday 7PM.

4.4 Re-Transmission Procedures If the HTTP post reply message is not received within the 60-second response

period, the user’s CORE compliant system should send a duplicate transaction

no sooner than 90 seconds after the initial attempt was sent.

If no response is received after the second attempt, the user’s CORE compliant

system should submit no more than one duplicate transaction within the next

30 minutes. If the additional attempt results in the same timeout termination,

the user’s CORE compliant system should notify the user to contact HMSA or

the information source directly to determine if system availability problems exist

or if there are known internet traffic constraints causing the delay.

4.5 Communication Protocols

4.5.1 HTTP MIME Multipart

HMSA supports standard HTTP MIME messages. The MIME format used must

be that of multipart/form-data. Responses to transactions sent in this manner

will also be returned as multipart/form-data.

4.5.2 SOAP + WSDL

HMSA also supports transactions formatted according to the Simple Object

Access Protocol (SOAP) conforming to standards set forth by the Web

Services Description Language (WSDL) for XML envelope formatting,

submission, and retrieval.

4.5.2.1 SOAP XML Schema

The XML schema definition set forth by CORE is located at:


4.5.2.2 WSDL Information

The WDSL definition set forth by CORE is located at:

http://www.caqh.org/SOAP/WSDL/CORERule2.2.0.wsdl

4.5.2.3 SOAP Version Requirements

HMSA requires that all SOAP transactions conform to SOAP Version 1.2.

4.5.3 Header Requirements

Field Accepted Values Comment


http://www.caqh.org/SOAP/WSDL/CORERule2.2.0.wsdl

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PayloadType X12_270_Request_005010X279A1 Real-time and Batch Submissions

X12_005010_Request_Batch_Results_271

Batch Results retrieval

X12_TA1_RetrievalRequest_005010X231A1

999 or TA1 pickup (Batch)

X12_999_RetrievalRequest_005010X231A1

999 or TA1 pickup (Batch)

ProcessingMode RealTime Batch

Batch used for either submission or pickup

PayloadID

Should conform to ISO UUID standards (described at ftp://ftp.rfceditor.org/in-notes/rfc4122.txt), with hexadecimal notation, generated using a combination of local timestamp (in milliseconds) as well as the hardware (MAC) address35, to ensure uniqueness.

Payload Length Length of the X12 document Required only if ProcessingMode is Batch

TimeStamp YYYY-MM-DDTHH:MM:SSZ

See http://www.w3.org/TR/xmlschema11-2/#dateTime

SenderID HMSA Assigned EDI Submitter ID Consistent with ISA06 of request

ReceiverID 990040115

CORERuleVersion 2.2.0

CheckSum Checksum of the X12 document

Using SHA-1; encoding is hex; required only if ProcessingMode is Batch

Payload This contains the X12 request

4.5.4 Error Reporting

HTTP Errors associated with connectivity, authorization, etc. will be reported at this level

HTTP 200 OK no errors

HTTP 202 Accepted batch submission accepted

HTTP 400 Bad Request error with HTTP header

HTTP 403 Authentication failed

HTTP 500 Internal Server error Unexpected error during processing

ftp://ftp.rfceditor.org/in-notes/rfc4122.txt









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Envelope

Errors regarding the structure or data included within the body of the MIME multipart message will be reported at this level in a response of type multipart/form-data.

Success no errors

PayloadTypeRequired Missing PayloadType

PayloadTypeIllegal Invalid or unsupported PayloadType

ProcessingModeRequired Missing ProcessingMode

ProcessingModeIllegal Invalid or ProcessingMode

PayloadIDRequired Missing PayloadID

PayloadIDIllegal Duplicate PayloadID sent by sender

Receiver Batch Response Not Available

SenderIDRequired Missing SenderID

SenderIDIllegal Invalid SenderID

ReceiverIDRequired Missing ReceiverID

ReceiverIDIllegal Invalid ReceiverID

ChecksumMismatched SHA-1 checksum invalid (batch only)

PayloadRequired Missing Payload

5. CONTACT INFORMATION

5.1 EDI CUSTOMER SERVICE AND TECHNICAL ASSISTANCE

Providers and their business associates can receive assistance by contacting Electronic

Transaction Services at (808) 948-6355 on Oahu or toll free at (800) 377-4672, between 6

a.m. and 6 p.m. HST. ETS can assist providers and vendors with EDI-related issues; that

is, issues that appear to be related directly to the EDI transmission process (including

front-end rejections, missing EDI files, etc.).

We ask that vendors or clearinghouses have the following information ready for the most

efficient service:

The name and/or NPI of the provider on whose behalf the transaction was

submitted.

A detailed description of the issue, including any error messages received.

If known, the loop and/or segment in which the issue is occurring.

The HMSA assigned submitter ID/user ID.

Any related reports that sent by HMSA.

If calling regarding claims, information on the claim(s) in question (name,

member ID, date of service, amount). If it involves a large number of claims, let

us know how many claims are affected and have one or two example claims for

the technician to check.

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If calling regarding remittances, information on the payment (payment date,

amount, check number, line of business, and the payee number.)

For eligibility, claim status, and other requests, the time when the request was

sent and the result.

A contact number or e-mail address should the EDI Support representative

need more information.

5.2 PROVIDER SERVICE NUMBER For issues not directly related to EDI (e.g. adjudication issues for claims), the provider can

contact Customer Relations at (808) 948-6330 or (800) 790-4672.

5.3 APPLICABLE WEBSITES/E-MAIL

More information on the EDI submission process can be found at the following web page:


6. CONTROL SEGMENTS/ENVELOPES

6.1 ISA-IEA

This section describes HMSA’s use of the interchange control segments. It includes a

description of expected sender and receiver codes, authorization information, and

delimiters. Files must contain a single ISA-IEA per transaction.

Incoming

ISA01 Authorization Information Qualifier “00”

ISA02 Authorization Information always spaces

ISA03 Security Information Qualifier “00”

ISA04 Security Information always spaces

ISA05 Interchange ID Qualifier (Sender) “ZZ”

ISA06 Interchange Sender ID HMSA assigned submitter ID

ISA07 Interchange ID Qualifier (Receiver) “30”

ISA08 Interchange Receiver ID “990040115”

ISA09 Interchange Date –provided by your software YYMMDD

ISA10 Interchange Time – time processed HHMM

ISA11 Interchange Repetition Separator “{“ Left Brace

ISA12 Interchange Control Version Number “00501”

ISA13 Interchange Control Number Unique number to identify the interchange. Usually assigned by original sender’s software

ISA14 Acknowledgment requested “0” on 999 acknowledgments

ISA15 Usage Indicator “P” for Production, “T” for Test

ISA16 Component Element Separator “:”


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IEA01 – Number of included functional groups

IEA02 – Interchange Control Number – must match the Interchange control number in

ISA13

Outgoing:

ISA01 Authorization Information Qualifier “00”

ISA02 Authorization Information always spaces

ISA03 Security Information Qualifier “00”

ISA04 Security Information always spaces

ISA05 Interchange ID Qualifier (Sender) “ZZ”

ISA06 Interchange Sender ID HMSA assigned submitter ID

ISA07 Interchange ID Qualifier (Receiver) “30”

ISA08 Interchange Receiver ID “990040115”

ISA09 Interchange Date– provided by your software YYMMDD

ISA10 Interchange Time – time processed HHMM

ISA11 Interchange Repetition Separator “{“ Left Brace

ISA12 Interchange Control Version Number “00501”

ISA13 Interchange Control Number Unique number to identify the interchange. Usually assigned by original sender’s software

ISA14 Acknowledgment requested “0” on 999 acknowledgments

ISA15 Usage Indicator “P” for Production, “T” for Test

ISA16 Component Element Separator “:”

IEA01 – Number of included functional groups

IEA02 – Interchange Control Number – must match the Interchange control number in

ISA13

6.2 GS-GE

This section describes HMSA’s use of the functional group control segments. It includes a

description of expected application sender and receiver codes. Also included in this

section is a description concerning how HMSA expects functional groups to be sent and

how HMSA will send functional groups. These discussions will describe how similar

transaction sets will be packaged and HMSA’s use of functional group control numbers.

Files must contain a single GS-GE per batch or real time transaction

Incoming:

GS01 Functional Identifier Code “HS” (for 270 transactions)

GS02 Application Sender’s Code

“BACC” = included transactions to be processed in batch mode or “RACC” if included transaction to be processed in real time mode.

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GS03 Application Receiver’s Code “BHAWA” if GS02 = “BACC” or “RHAWA” if GS02 = “RACC”

GS04 Date – provided by your software

CCYYMMDD

GS05 Time – provided by your software

HHMM

GS06 Group Control Number assigned by your software (usually sequential integer) 9 digit maximum with no leading zeros allowed

GS07 Responsible Agency Code

GS08 Version/Release/Industry Identifier Code

“005010X279A1”

Outgoing:

GS01 Functional Identifier Code “HB” (for 271 transactions)

GS02 Application Sender’s Code BHAWA if GS03 = “BACC” or “RHAWA” if GS03 = “RACC”

GS03 Application Receiver’s Code

“BACC” = Included transactions to be processed in batch mode. “RACC” = Included transaction to be processed in real time mode.

GS04 Date– date processed CCYYMMDD

GS05 Time –time processed HHMM

GS06 Group Control Number assigned by your software (usually sequential integer) 9 digit maximum with no leading zeros allowed

GS07 Responsible Agency Code

GS08 Version/Release/Industry Identifier Code

“005010X279A1”

GE01 – Number of transaction sets included

GE02 – Group Control Number – Matches group control number in GS06

6.3 ST-SE

Each 270 request within a batch transaction must be wrapped in its own ST-SE segment.

Real-time inquiries must contain only one ST-SE segment. Batch transactions are limited

to 99 or less ST-SE groupings per batch file.

Real-time

The X12 in the SOAP body should be submitted in a continuous data string without line

feeds and must not contain spaces between data tags.

270 (Inbound transactions to HMSA)

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Interchange ID Qualifier ISA05 “ZZ”

Interchange Sender ID ISA06 HMSA assigned submitter id

Interchange ID Qualifier ISA07 “30”

Interchange Receiver ID ISA08 “990040115”

Repetition Separator ISA11 “{“

Acknowledgment Requested

ISA14 “0”

Usage Indicator ISA15 “P”

2

271 (Outbound transactions from HMSA)

Interchange ID Qualifier ISA05 “30”

Interchange Sender ID ISA06 “990040115”

Interchange ID Qualifier ISA07 “ZZ”

Interchange Receiver ID ISA08 HMSA assigned submitter ID

Usage Indicator “P”

Delimiters

270/276 (Inbound transactions to HMSA)

Delimiter: Data Element Separator ( * ) Asterisk

Delimiter: Composite Element Separator

( : ) Colon

Delimiter: Segment Terminator ( ~ ) Tilde

271/277 (Outbound transactions from HMSA)

Delimiter: Data Element Separator ( * ) Asterisk

Delimiter: Composite Element Separator ( : ) Colon

Delimiter: Segment Terminator ( ~ ) Tilde

Application’s Sender Code

GS02 'RACC’

Application’s Receiver Code (GS03)

GS03 ‘RHAWA’

Application’s Sender Code (GS02)

GS02 “RHAWA”

Application’s Receiver Code

GS03 “RACC”

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For more information on CORE Connectivity Rule 270, please see the below link which

includes examples for both MIME & SOAP.

http://www.caqh.org/pdf/CLEAN5010/270-v5010.pdf

7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS

7.2 Supported Service Types

HMSA supports the following service types and will respond on the 271 with the following

service types in the list below. These may include Co-insurance, Deductible,

Co-pay, Benefit Limits, Accumulated Benefits and Place of Service.

Note: *** = Active/Inactive Only

270 Request 271 Response Description

1 1 2 42 45 69 76 83 AG BT BU DM

Medical Care*** Surgical Home Health Care Hospice Maternity Dialysis Infertility Skilled Nursing Care Gynecological Obstetrical Durable Medical Equipment***

2 2 7 8 20

Surgical Anesthesia Surgical Assistance Second Surgical Opinion

4 4 Diagnostic X-Ray

5 5 Diagnostic Lab

6 6 Radiation Therapy

7 7 Anesthesia

8 8 Surgical Assistance

12 12 Durable Medical Equipment Purchase

13 13 Ambulatory Service Center Facility

18 18 Durable Medical Equipment Rental

20 20 Second Surgical Opinion

30 1 33 35 47 51 52 86 88

Medical Care*** Chiropractic Dental Care*** Hospital Hospital – Emergency Accident Hospital – Emergency Medical Emergency Services Pharmacy***

http://www.caqh.org/pdf/CLEAN5010/270-v5010.pdf

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98 AL BY BZ MH UC

Professional Visit Office: Physician Vision/Optometry*** Professional Visit Office: Sick Professional Visit Office: Well Mental Health*** Urgent Care

33 33 Chiropractic

35 35 Dental Care***

40 40 Oral Surgery

42 42 A3

Home Health Care Professional (Physician) Visit – Home

45 45 Hospice

47 47 51 52 53

Hospital Hospital – Emergency Accident Hospital – Emergency Medical Hospital – Ambulatory Surgical

48 48 99

Hospital – Inpatient Professional (Physician) Visit - Inpatient

50 50 51 52 A0

Hospital Outpatient Hospital - Emergency Accident Hospital - Emergency Medical Professional (Physician) Visit - Inpatient

51 51 Hospital – Emergency Accident

52 52 Hospital – Emergency Medical

53 53 Hospital – Ambulatory Surgical

60 60 General Benefits***

61 61 In-vitro Fertilization

62 62 MRI/CAT Scan

65 65 Newborn Care

68 68 80 BH

Well Baby Care Immunizations Pediatric

69 69 Maternity

73 4 5 62 73

Diagnostic X-Ray Diagnostic Lab MRI/CAT Scan Diagnostic Medical

76 76 Dialysis

78 78 Chemotherapy

80 80 Immunizations

81 81 Routine Physical

82 82 Family Planning

83 83 61

Infertility In-vitro Fertilization

84 84 Abortion

86 51 52

Hospital - Emergency Accident Hospital - Emergency Medical

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86 98

Emergency Services Professional (Physician) Visit – Office

88 88 Pharmacy***

93 93 Podiatry

98 98 BZ

Professional (Physician) Visit – Office Physician Visit – Office: Well

99 99 Professional (Physician) Visit – Inpatient

A0 A0 Professional (Physician) Visit – Outpatient

A3 A3 Professional (Physician) Visit – Home

A6 A6 Psychotherapy

A7 A7 Psychiatric – Inpatient***

A8 A8 Psychiatric – Outpatient***

AD AD Occupational Therapy***

AE AE Physical Medicine

AF AF Speech Therapy

AG AG Skilled Nursing Care

AI AI Substance Abuse

AL AL Vision (Optometry)***

BG BG Cardiac Rehabilitation

BH BH Pediatric

BT BT Gynecological

BU BU Obstetrical

BV BV BT BU

Obstetrical/ Gynecological*** Gynecological Obstetrical

BY BY Physician Visit – Office: Sick

BZ BZ Physician Visit – Office: Well

CE CE MH Provider – Inpatient

CF CF MH Provider – Outpatient

CG CG MH Provider Facility Inpatient

CH CH MH Provider Facility Outpatient

CI CI Substance Abuse Facility- Inpatient

CJ CJ Substance Abuse Facility - Outpatient

CK CK Screening X-ray

CL CL Screening Laboratory

CM CM Mammogram, HR Patient

CN CN Mammogram, LR Patient

CO CO Flu Vaccination

DM DM 12 18

Durable Medical Equipment*** Durable Medical Equipment Purchase Durable Medical Equipment Rental

MH MH CE CF CG CH

Mental Health*** MH Provider- Inpatient MH Provider – Outpatient MH Provider Facility- Inpatient MH Provider Facility- Outpatient

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PT PT Physical Therapy

UC UC Urgent Care

7.2 HMSA responds with the following “AAA” codes for common errors regarding subscriber/patient demographic information:

AAA AAA Error Code Description

58 Invalid/Missing Date of Birth

64 Invalid/Missing Patient/Insured ID

65 Invalid/Missing Patient/Insured Name

68 Duplicate Patient ID Number

71 Patient DOB Does Not Match Patient on the DB

72 Invalid/Missing Subscriber/Insured ID

73 Invalid/Missing Subscriber/Insured Name

76 Duplicate Sub ID

8. ACKNOWLEDGMENTS 8.1 Real-time:

One of the following will be provided in response to a 270 inquiry:

TA1 Interchange Acknowledgment if the ISA-IEA envelope cannot be processed.

999 Implementation Acknowledgment if the 270 transaction contains HIPAA

compliancy errors within the ST-SE segments

271 Response Transaction indicating the requested member’s coverage or benefits

8.2 Batch: One of the following will be provided in response to a 270 inquiry:

TA1 Interchange Acknowledgment available within one hour if the ISA-IEA envelope

cannot be processed.

999 Implementation Acknowledgment (Reject) will be available within one hour if the

270 transaction contains HIPAA compliancy errors within the ST-SE segments

999 Acceptance response will be available within one hour. The 271 Response

Transaction(s) will be available the following day (no later than 7:00 a.m.) appended to

the original 999 acceptance response.

We will have a 999 for each functional group. It will have details down to the

transaction set level.

PLEASE NOTE – The acknowledgment file’s sole purpose is to state whether your

transmission was valid or erroneous.

9. TRADING PARTNER AGREEMENTS

9.2 TRADING PARTNERS

An EDI Trading Partner is defined as any HMSA customer (provider, billing service,

software vendor, employer group, financial institution, etc.) that transmits to, or receives

electronic data from HMSA.

April 2016 - 005010

Payers have EDI Trading Partner Agreements to ensure the integrity of the electronic

transaction process. The Trading Partner Agreement is related to the electronic exchange

of information, whether the agreement is an entity or a part of a larger agreement,

between each party to the agreement.

For example, a Trading Partner Agreement may specify among other things, the roles and

responsibilities of each party to the agreement in conducting standard transactions.

HMSA’s Trading Partner Agreement is located in our Provider E-library.

10. TRANSACTION SPECIFIC INFORMATION

This section describes how ASC X12N Technical Report Type 3 (TR3) adopted under

HIPAA will be detailed with the use of a table. The tables contain a row for each segment

that HMSA has something additional, over and above, the information in the TR3. That

information can:

1. Limit the repeat of loops, or segments

2. Limit the length of a simple data element

3. Specify a sub-set of the TR3 internal code listings

4. Clarify the use of loops, segments, composite or simple data elements

5. Any other information tied directly to a loop, segment, composite or simple data

element pertinent to trading electronically with HMSA

The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides.

Page Loop Reference Name Codes Length Notes/Comments

63 BHT Beginning of Hierarchical Transaction

64 BHT02 Transaction Set Purpose Code

01, 13 “13” = Request

69 2100A NM1

Information Source Name

70 NM103

Name Last or Organization Name

1, 2 “Hawaii Medical Service Association”

71 NM108 Information Source ID Qualifier

List “FI” = Federal Tax ID “PI” Payer ID

71 NM109 Information Source Primary Identifier

“990040115”

90 2000C TRN Subscriber Trace Number

90 2000C TRN02 Trace Number Assign a unique number that can be used to match the corresponding 271 response.

92 2100C NM1 Subscriber Name Eligibility Requests for QUEST patients should always be submitted at the Subscriber level.

93 NM103 Subscriber Last Name

Required when the subscriber is the patient and NM109 Subscriber ID is not submitted.

93 NM104 Subscriber First Name

Required when the subscriber is the patient and NM109 Subscriber ID is not submitted. Also required when the subscriber is the patient and

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is one of multiple births or has a spouse with the same birth date covered under the same contract.

95 NM109 Subscriber Primary Identifier

4-17 characters (if supplied).

Required for Private Business, Senior Plans and QUEST members when either NM103 and NM104 are not submitted. Required for BlueCard, FEP and Away From Home Care members. See Subscriber ID details in the Trading Partner Manual.

122 2100C DTP Subscriber Date

123 DTP03 Date Time Period Date of Service should be no less than 12 months or no greater than 1 month in the future.

125 2110C EQ Subscriber Eligibility or Benefit Inquiry Information

125 EQ01 Service Type Codes List When service type code is not supplied or unsupported (see Section 7), the default Service Type Code ”30" (Health Benefit Plan Coverage) is processed

149 2000D TRN Dependent Trace Number

This segment is recommended when the dependent is the patient.

150 TRN02 Trace Number Assign a unique number that can be used to match the corresponding 271 response.

151 2100D NM1

152 NM102 Dependent Last Name

Required when the dependent is the patient and NM109 Subscriber ID is not submitted in Loop 2100C.

152 NM103 Dependent First Name

Required when the dependent is the patient and NM109 Subscriber ID is not submitted in Loop 2100C. Also required when the dependent is the patient and is one of multiple births or has a spouse with the same birth date covered under the same contract.

179 2100D DTP Dependent Date

180 DTP03 Date Time Period Date of Service should be no less than 12 months or no greater than 1 month in the future.

181 2110D EQ Dependent Eligibility or Benefit Inquiry Information

182 EQ01 Service Type Code List When service type code is not supplied or unsupported (see Section 7), the default Service Type Code ”30" (Health Benefit Plan Coverage) is processed. HMSA supports single service type code. If more than one is supplied, we default to service type code “30.”

211 BHT Beginning of Hierarchical Transaction

271 Response

212 BHT03 Submitter Transaction Identifier

To be returned as submitted on the 270

215 AAA Request Validation

216 AAA03 Reject Reason Code

List “04” = Authorized Quantity Exceeded “42” = Unable to Respond at Current Time

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226 AAA Information Receiver Request Validation


List “43” = Invalid/Missing Provider Identification “51” = Provider Not on File

246 2000C TRN Subscriber Trace Number

248 TRN01 Trace Type Code “1” = HMSA-assigned trace number “2” = Submitter-assigned trace number

248 TRN02 Trace Number When the subscriber is the patient, all submitter-assigned trace numbers on the 270 will be returned on the 271 along with a HMSA-assigned trace number. Any of these trace numbers may be used to reference this transaction when contacting HMSA to inquire on this transaction.

249 2100C NM1 Subscriber Name

250 NM103 Subscriber Last Name

When the subscriber is the patient, NM103 may contain a different subscriber last name than submitted on the 270 based on HMSA’s records when INS03 = “001” (Change) and INS04 = “25” (Change in Identifying Data Elements).

250 NM104 Subscriber First Name

When the subscriber is the patient, NM104 may contain a different subscriber first name than submitted on the 270 based on HMSA’s records when INS03 = “001” (Change) and INS04 = “25” (Change in Identifying Data Elements).

252 NM109 Subscriber Primary Identifier

4-17 characters (if supplied).

See Subscriber ID details in the Trading Partner Manual

253 2100 REF Subscriber Additional Identification

254 REF01 Reference Identification Qualifier

6P = Group Number populated in the format Group Number + space + Sub Group Number + space Q4 = Prior Identifier Number is populated with corrected subscriber id if incorrect on 270 and match can be performed with other submitted data elements

255 REF03 Description Group Name

262 2100C AAA


“58” = Invalid/Missing Date of Birth “63” = Date of Service in Future (> 90 days) “72” = Invalid/Missing Subscriber/Insured ID “73” = Invalid/Missing Subscriber/Insured Name “75” = Subscriber/Insured Not Found

268 2100C DMG

269 DMG02 Subscriber Birth Date

When the subscriber is the patient, DMG02 may contain a different subscriber birth date than submitted on the 270 based on HMSA’s records when INS03 = “001” (Change) and INS04 = “25” (Change in Identifying Data Elements).

283 2100C DTP

283 DTP01 Date/Time Qualifier

When EB01 = “1” or “6”, DTP01 = “291” (Plan) When EB01 = “A” or “B” or “C”, DTP01 = “348” (Benefit Begin) When EB01 = “L”, DTP01 = “295” (Primary Care Provider) When EB01 = “R”, DTP01 = “193” (Primacy Period Start) and “194” (Primacy Period End)

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284 DTP03 Date Time Period Date based upon latest medical contract returned in 271 response

289 2110C EB Subscriber Eligibility or Benefit Information

291 EB01 Eligibility or Benefit Information

List “1” = Active Coverage “6” = Inactive “A” = Co-Insurance “B” = Co-Payment “C” = Deductible “F” = Limitation “G” = Stop Loss “I” = Non-Covered “L” = Primary Care Provider “P” = Disclaimer “R” = Other or Additional Payer

292 EB02 Coverage Level Code

List “FAM” = Family “IND” = Individual

293 EB03 Service Type Code List See Section 7

298 EB04 Insurance Type Code

List “HM” = Health Maintenance Organization (HMO) “PR” = Preferred Provider Organization (PPO) “MC” = Medicaid No Value

299 EB05 Plan Coverage Description

When EB01 = “1” or “6”, EB05 = HMSA Coverage Code or QUEST Benefit Code or QUEST “EPSDT” When EB01 = “L”, EB05 = Clinic or Network Name When EB01 = “R”, EB05 may contain QUEST Third Party Liability Description

299 EB06 Time Period Qualifier

List “7” = Day “22” = Service Year “23” = Calendar Year “25” = Contract “26” = Episode “27” = Visit “29” = Remaining Amount ( Annual Deductible, Co-Payment Maximum and certain Benefit Limits: Well-Woman Exam, Routine Physical, Home Health, Skilled Nursing Facility, Speech Therapy & Chrio) “32” = Lifetime

300 EB07 Benefit Amount When EB01 = “B”, EB07 = Co-Payment When EB01 = “C”, EB07 = Annual Deductible (if amount is ‘0’ or deductible is not applicable to service type in EB03) When EB01 = “F”, Monetary Limitation When EB01 = “G”, Copayment Maximum

301 EB08 Benefit Percent When EB01 = “A”, EB07 = Co-Insurance from member’s viewpoint

302 EB09 Quantity Qualifier List When EB01 = “F”, “DY” = Days “P6” = Number of Services or Procedures “57” = Age, High Value “58” = Age, Low Value “VS” = Visits

303 EB10 Benefit Quantity When EB01 = “F”, EB10 is quantity of units qualified in EB09

EB12 In Plan Network Indicator

List “N” = Out-of-Network “Y” = In-Network “W” = Not applicable (same regardless of in-network or out-of-network)

309 2110C HSD Health Care Services Delivery

Used to further quantify benefit limitations

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310 HSD01 Quantity Qualifier When EB01 = “F” and HSD01 = “VS”, used to define number of visits in HSD02

310 HSD02 Benefit Quantity When EB01 = “F” and HSD01 = “VS”, used to define number of visits with HSD01

310 HSD03 Unit or Basis for Measurement

When EB01 = “F” and HSD01 = “VS” and HSD03 = “YR”, used to define number of visits within a year

311 HSD05 Time Period Qualifier

When EB01 = “F” and HSD01 = “VS” and HSD05 = “21” and HSD06 = “2”, used to define number of visits every other year.

311 HSD06 Number of Periods

317 2110C DTP Subscriber Eligibility/Benefit Date


When EB01 = “A” or “B” or “C”, DTP01 = “348” (Benefit Begin) When EB01 = “L”, DTP01 = “295” (Primary Care Provider) When EB01 = “R”, DTP01 = “193” (Primacy Period Start) and “194” (Primacy Period End)

DTP03 Date Time Period When EB01 = “1” or “6”, DTP03 is the Current Policy Effective Date (most current product effective date for member based upon the 270 request date). When EB01 = “A” or “B” or “C”, DTP03 is the Benefit Effective Date based upon latest medical contract returned in 271 response.

2110C MSG Message Text

MSG01 Message Text May contain messages related to further quality benefit information in preceding EB segment.

2115C III Subscriber Eligibility or Benefit Additional Information

III02 Place of Service List When EB01 = “A” or “B” or “F”, “11” = Office “12” = Home “21” = Inpatient Hospital “22” = Outpatient Hospital “24” = Ambulatory Surgical Center “31” = Skilled Nursing Facility

329 2120C NM1 Subscriber Benefit Related Entity Name

330 NM101 Entity Identifier Code

When EB01 = “L”, NM101 = “P3” (Primary Care Provider) When EB01 = “R”, NM101 = “PRP” (Primary Payer), “SEP” (Secondary Payer) or “TTP” (Tertiary Payer)

331 NM103 Last Name or Organization

When NM101 = “P3”, NM103 = PCP Last Name When NM101 = “PRP”, “SEP” or “TTP”, NM103 = “Hawaii Medical Service Association” or Other Payer Name/Description

331 NM104 First Name When NM101 = “P3”, NM104 = PCP First Name

331 NM105 Middle Name When NM101 = “P3”, NM105 = PCP Middle Initial

351 2000D TRN Dependent Trace Number

This segment is always returned when the dependent is the patient.

353 TRN01 Trace Type Code “1” = HMSA-assigned trace number “2” = Submitter-assigned trace number

353 TRN02 Trace Number When the dependent is the patient, all submitter-assigned trace numbers on the 270 will be returned on the 271 along with a HMSA-

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assigned trace number. Any of these trace numbers may be used to reference this transaction when contacting HMSA to inquire on this transaction.

354 2100D NM1 Dependent Name

355 NM103 Dependent Last Name

When the dependent is the patient, NM103 may contain a different dependent last name than submitted on the 270 based on HMSA’s records when INS03 = “001” (Change) and INS04 = “25” (Change in Identifying Data Elements).

355 NM104 Dependent First Name

When the dependent is the patient, NM104 may contain a different dependent first name than submitted on the 270 based on HMSA’s records when INS03 = “001” (Change) and INS04 = “25” (Change in Identifying Data Elements).

357 2100D REF Dependent Additional Identification

358 REF01 Reference Identification Qualifier

6P = Group Number populated in the format Group Number + space + Sub Group Number + space

360 REF03 Description Group Name

366 2100D AAA Dependent Request Validation


List “58” = Invalid/Missing Date of Birth “63” = Date of Service in Future (> 90 days) “65” = Invalid/Missing Patient Name “67” = Patient Not Found “77” = Subscriber found, Patient Not Found

372 2100D DMG Dependent Demographic Information

373 DMG02 Dependent Birth Date

When the dependent is the patient, DMG02 may contain a different dependent birth date than submitted on the 270 based on HMSA’s records when INS03 = “001” (Change) and INS04 = “25” (Change in Identifying Data Elements).

387 2100D DTP Dependent Date


When EB01 = “1” or “6”, DTP01 = “291” (Plan) When EB01 = “A” or “B” or “C”, DTP01 = “348” (Benefit Begin) When EB01 = “L”, DTP01 = “295” (Primary Care Provider) When EB01 = “R”, DTP01 = “193” (Primacy Period Start) and “194” (Primacy Period End)

388 DTP03 Date Time Period When EB01 = “1” or “6”, DTP03 is the Current Policy Effective Date (most current product effective date for member based upon the 270 request date). When EB01 = “A” or “B” or “C”, DTP03 is the Benefit Effective Date based upon latest medical contract returned in 271 response.

393 2110D EB Dependent Eligibility or Benefit Information

395 EB01 Eligibility or Benefit Information

List “1” = Active Coverage “6” = Inactive “A” = Co-Insurance “B” = Co-Payment “C” = Deductible “F” = Limitation “G” = Stop Loss

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“I” = Non-Covered “L” = Primary Care Provider “P” = Disclaimer “R” = Other or Additional Payer

396 EB02 Coverage Level Code

List “FAM” = Family “IND” = Individual

397 EB03 Service Type Code List Service Type Code (see Section 7)

402 EB04 Insurance Type Codes

List “HM” = Health Maintenance Organization (HMO) “PR” = Preferred Provider Organization (PPO) “MC” = Medicaid No Value

403 EB05 Plan Coverage Description

When EB01 = “1” or “6”, EB05 = HMSA Coverage Code or QUEST Benefit Code or QUEST “EPSDT” When EB01 = “L”, EB05 = Clinic or Network Name When EB01 = “R”, EB05 may contain QUEST Third Party Liability Description

403 EB06 Time Period Qualifier

“7” = Day “22” = Service Year “23” = Calendar Year “25” = Contract “26” = Episode “27” = Visit “29” = Remaining Amount (Annual Deductible, Co-Payment Maximum and certain Benefit Limits: Well-Woman Exam, Routine Physical, Home Health, Skilled Nursing Facility, Speech Therapy and Chiro) “32” = Lifetime

404 EB07 Benefit Amount When EB01 = “B”, EB07 = Co-Payment When EB01 = “C”, EB07 = Annual Deductible (if amount is ‘0’, deductible is not applicable to service type in EB03). When EB01 = “F”, Monetary Limitation When EB01 = “G”, EB07 = Stop Loss

404 EB08 Benefit Percent When EB01 = “A”, EB07 = Co-Insurance from member’s viewpoint

404 EB09 Quantity Qualifier When EB01 = “F”, “DY” = Days “P6” = Number of Services or Procedures “S7” = Age, High Value “S8” = Age, Low Value “VS” = Visits

405 EB10 Benefit Quantity When EB01 = “F”, EB10 is quantity of units qualified in EB09

406 EB12 In Plan Network Indicator

List “N” = Out-of-Network “Y” = In-Network “W” = Not applicable (same regardless of in-network or out-of-network)

412 HSD Health Care Services Directory

Used to further qualify benefit limitations

413 HSD01 Quantity Qualifier When EB01 = “F” and HSD01 = “VS”, used to define number of visits with HSD02

413 HSD02 Benefit Quantity When EB01 = “F” and HSD01 = “VS”, used to define number of visits with HSD01

413 HSD03 Unit or Basis for Measurement

When EB01 = “F” and HSD01 = “VS” and HSD03 = “YR”, used to define number of visits within a year

414 HSD05 Time Period Qualifier

When EB01 = “F” and HSD01 = “VS” and HSD05 = “21” and HSD06 = “2”, used to define number of visits every other year.

414 HSD06 Number of Periods When EB01 = “F” and HSD01 = “VS” and HSD05 = “21” and HSD06 = “2”, used to define number

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of visits every other year.

420 2110D DTP Dependent Eligibility/Benefit Date


When EB01 = “A” or “B” or “C”, DTP01 = “348” (Benefit Begin) When EB01 = “L”, DTP01 = “295” (Primary Care Provider) When EB01 = “R”, DTP01 = “193” (Primacy Period Start) and “194” (Primacy Period End)

421 DTP03 Date Time Period When EB01 = “1” or “6”, DTP03 is the Current Policy Effective Date (most current product effective date for member based upon the 270 request date). When EB01 = “A” or “B”, DTP03 is the Benefit Effective Date based upon latest medical contract returned in 271 response.

425 MSG Message

426 MSG01 Message Text May contain messages related to COBRA eligibility, Medicare claim filing instructions or further qualify benefit information in preceding EB segment.

427 2115D III Dependent Eligibility or Benefit Additional Information

428 III02 Place of Service List When EB01 = “A” or “B” or “F”, “11” = Office “12” = Home “21” = Inpatient Hospital “22” = Outpatient Hospital “24” = Ambulatory Surgical Center “31” = Skilled Nursing Facility

432 NM1 Dependent Benefit Related Entity Name

433 NM101 Entity Identifier Code

When EB01 = “L”, NM101 = “P3” (Primary Care Provider) When EB01 = “R”, NM101 = “PRP” (Primary Payer), “SEP” (Secondary Payer) or “TTP” (Tertiary Payer)

434 NM103 Last Name or Organization Name

When NM101 = “P3”, NM103 = PCP Last Name When NM101 = “PRP”, “SEP” or “TTP”, NM103 = “Hawaii Medical Service Association” or Other Payer Name/Description

434 NM104 First Name When NM101 = “P3”, NM104 = PCP First Name

434 NM105 Middle Name When NM101 = “P3”, NM105 = PCP Middle Initial

A. APPENDICES

1. Frequently Asked Questions

This Frequently Asked Question list is written for healthcare information technology

professionals (software vendors, clearinghouses, etc.) and providers and billers with a sufficient

technical background. Most of the information below is also explained in more detail in the

Trading Partner Manual.

What information should I give EDI Support?

When calling EDI Support as a vendor or clearinghouse, have the following information

ready for the most efficient service:

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The name and/or NPI of the provider on whose behalf you are calling.

A detailed description of your issue. Include any error messages that you receive. If

you know in which loop and/or segment the issue is occurring, please provide that

information as well.

Your HMSA assigned submitter ID/user ID.

Any related reports that you may have received from HMSA.

If you are calling regarding claims, information on the claim(s) in question (name,

member ID, date of service, amount). If it involves a large number of claims, let us

know how many claims are affected and have one or two example claims for the

technician to check.

If you are calling regarding remittances, information on the payment (payment date,

amount, check number, line of business, and the payee number.)

A contact number or e-mail address that the EDI Support representative can reach you

at.

2. Change Summary

Chapter and Section Change Description Date of Change Version

Chapter 2, page 7 Removed Community Manager Testing 7/29/13 1.1

Chapter 4, page 10

Remove requirement for matching payload ID for acknowledgment or response transactions by combining 6 & 6. 7/29/13 1.1

Chapter 4, page 10 Modify Microsoft Visio Diagram 7/29/13 1.1

Chapter 4, page 13 Added new error for pay load type 7/29/13 1.1

Chapter 7, page 18-19

Removed 48 & 50 service type codes from 30 response 7/29/13 1.1

Chapter 6, page 16 Corrected spelling of “batch” on page 16 10/29/14 1.2

Chapter 10, page 23 Updated DTP03 Companion Guide notes 10/29/14 1.2

Chapter 6, page 16

Fix typo on page 16, “RHAWA” if GS02 = “RACC” 1/7/15 1.3

Chapter 10, page 25 & 28

Added “MC” = Medicaid to EB04

4/13/16 1.4

core standard companion guide v1.4 - 4/16€¦ · core standard companion guide v1.4 . april 2016 -...

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