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Version 4.1 i

WPS Health Solutions | 27X Transactions Companion Guide

HIPAA Transaction Standard Companion Guide

Complements the Implementation Guides for ASC X12N 005010X279A1 & 005010X212

Companion Guide Version 4.1

July 2020


Version 4.1 Modified: 7/10/2020 ii

Preface This Companion Guide (the Guide) to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with WPS Health Solutions (WPS). Transmissions based on the Guide, used in tandem with the v5010 ASX X12N Implementation Guides, are compliant with both the ASC X12 syntax and those guides. The Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides.

The Guide is based on, and must be used in conjunction with, the ASC X12N 005010X279A1 and 005010X212 Type 3 Technical Report (TR3). In case of any conflict between the Guide and the TR3, the TR3 takes precedence.

Contract Codes Throughout the Guide, WPS is defined as WPS Health Solutions and encompasses the following wholly owned subsidiaries and government contracts:

Line of Business Contract Code*

WPS Health Insurance Plan WPS Aspirus Arise Health Plan WPS Arise Health Plan ARISE TRICARE For Life TDFIC TRICARE Overseas FOREN TRICARE East TREST

Veterans’ Administration (VA) Patient-Centered Community Care (PC3) Regions

• VAPC3 Region 1 VAPCCC3



• VAPC3 Region 4 VAPCCC4**

• VAPC3 Region 5A VAPCCC5A**

• VAPC3 Region 5B VAPCCC5B**

• VAPC3 Region 6

Medicare Administrative Contracts (MACs)

VAPCCC6**

• MAC J5A o Iowa o

Kansas o

Missouri o

Nebraska o

National

05101 05201 05301 05401 05901

• MAC J5B o

Iowa o

Kansas o

Missouri o

Nebraska

05102 05202 05302 05402

• MAC J8A o

Indiana o

Michigan

08101 08201

• MAC J8B o

Indiana o

Michigan

08102 08202


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* The Contract Code is used as the Interchange Receiver ID of the Interchange Control Header (ISA) and the ReceiverID of the SOAP envelope (real-time mode only) for transactions sent to WPS; the Contract Code is used as the Interchange Sender ID of the ISA and the SenderID of the SOAP envelope (real-time mode only) for transactions sent from WPS.

Page

** The Contract Codes for VA PC3 Regions 4-6 have been sunset by WPS. Trading Partners may continue to utilize those codes if they have in the past, but all new VA registrations (PC3 and CCN) will use the VAPCCC3 code.


Version 4.1 Modified: 7/10/2020 iv

Table of Contents Preface ...................................................................................................................................................................................... ii

Contract Codes......................................................................................................................................................................... ii

1 Introduction ..................................................................................................................................................................... 1

1.1 Overview ....................................................................................................................................................................... 1

1.2 Scope......................................................................................................................................................................... 1

1.3 References ................................................................................................................................................................ 1

1.4 Additional Information ........................................................................................................................................... 1

2 Getting Started ................................................................................................................................................................ 2

2.1 Working with WPS Health Solutions .................................................................................................................... 2

2.2 Trading Partner Registration ................................................................................................................................. 2

2.3 Certification ............................................................................................................................................................ 2

3 Testing with WPS ............................................................................................................................................................ 2

4 Connectivity/Communications ...................................................................................................................................... 2

4.1 Process Flows .......................................................................................................................................................... 2

4.1.1 27X Transaction Real-Time Processing ........................................................................................................ 3

4.1.2 27X Transaction Batch Processing ................................................................................................................ 3

4.2 Transmission Administrative Procedures ............................................................................................................. 3

4.3 Re-Transmission Procedure ................................................................................................................................... 3

4.4 Communication Protocol Specifications ............................................................................................................... 3

4.4.1 Real-Time Specifications ............................................................................................................................... 3

4.4.2 Batch Specifications ....................................................................................................................................... 4

4.5 Password Requirements ......................................................................................................................................... 4

5 Contact Information ........................................................................................................................................................ 4

5.1 EDI Help Desk ........................................................................................................................................................ 4


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5.1.1 Non-Medicare (WPS Health Insurance, Arise, Aspirus-Arise, TRICARE, VA) .......................................... 4

5.1.2 Medicare J5 (IA, KS, MO, NE, & National) .................................................................................................. 4

5.1.3 Medicare J8 (IN & MI) ....................................................................................................................................5

5.2 Provider Customer Service ......................................................................................................................................5

6 Control Segments ..............................................................................................................................................................5

6.1 Interchange Control (ISA/IEA) ..............................................................................................................................5

6.1.1 Delimiters – Inbound Transactions ...............................................................................................................5

6.1.2 Delimiters – Outbound Transactions .............................................................................................................5

6.1.3 ISA Data Element Detail and Explanation ................................................................................................... 6

6.2 Functional Group Control (GS/GE) ...................................................................................................................... 6

6.2.1 GS Data Element Detail and Explanation ..................................................................................................... 6

6.2.2 GE Data Element Detail and Explanation ..................................................................................................... 7

6.3 Transaction Set (ST/SE) ......................................................................................................................................... 8

6.3.1 ST Data Element Detail and Explanation ..................................................................................................... 8

6.3.2 SE Data Element Detail and Explanation ..................................................................................................... 8

7 Payer Specific Business Rules ......................................................................................................................................... 8

8 Transaction Specific Information ................................................................................................................................... 9

8.1 270/271 Eligibility Requirements

.......................................................................................................................... 9

8.2 276/277...................................................................................................................................................................

. 9

9 Acknowledgements and Reports ..................................................................................................................................... 8

9.1 Report Inventory ....................................................................................................................................................

8

10 Trading Partner Agreements ...................................................................................................................................... 9


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10.1 Trading Partners

..................................................................................................................................................... 9

11 Change Summary

............................................................................................................................................................. 9

Version 4.1


1 Introduction This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that WPS has something additional, over and above, the information in the IGs. 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 IGs internal code listings

4. Clarify the use of loops, segments, composite and single data elements

5. Any other information tied directly to a loop, segment, composite or simple data element pertinent to trading electronically with WPS

In addition to the row for each segment, one or more additional rows are used to describe WPS’s usage for composite and simple data elements and for any other information. Notes and comments are placed at the deepest level of detail. For example, a note about a code value is placed on a row specifically for that code value, not in a general note about the segment.

1.1 Overview The Guide includes the information needed to successfully exchange 270/271 & 276/277 (collectively referred to as 27X) transactions with WPS. The Guide is written to assist trading partners in designing and implementing transaction standards to meet WPS’s processing requirements.

1.2 Scope The Guide details the format and data contents for the interconnect control structures for use within an Electronic Data Interchange (EDI) environment. The Guide defines the control segments used to start and end EDI data to be exchanged between two interconnecting entities.

The purpose of the Guide is to provide an audit mechanism to facilitate the exchange and receipt acknowledgement of EDI data between interconnecting entities. The original send and the final receiver of the transactions have no responsibility for creating, managing, or removing the interconnect segments. The Guide is solely for use between directly interconnected entities.

Delivery of data from the original send to the final receiver may require several interconnect links. It is recognized that other point-to-point data tracking mechanisms exist. The interconnect control structures are designed to stand alone in addressing a given interconnect link.

1.3 References The following websites provide information and documentation for EDI transactions and code sets:

Resource Website

ASC X12N TR3s The official ASC X12 website.

Washington Publishing Company Health Care Code Sets The official Washington Publishing Company

website.

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


Version 4.1 Modified: 7/10/2020 Page 2

1.4 Additional Information The exchange of EDI transactions provides trading partners an efficient tool for the transmission of business data from one software application to another. Data can be exchanged by otherwise incompatible systems. Using EDI message standards, data is communicated quickly, efficiently, and accurately irrespective of the hardware and/or software in use.

The successful implementation of EDI provides benefits for all involved parties:

• Cost Efficiency – Reduce the volume paper handled • Increased Speed – Communicate large volumes of data in minutes and receive acknowledgement of the

data

• Improved Accuracy – Eliminate errors resulting from manual data entry

2 Getting Started

2.1 Working with WPS Health Solutions WPS provides a single point of contact for EDI support to ensure timely and accurate communication. WPS is committed to supplying the Trading Partner community with a variety of support channels.

The EDI Help Desk provides front-line support regarding basic EDI information and troubleshooting. The EDI Help Desk can support most EDI questions and can triage more complex issues for advanced research. The EDI Help Desk can be reach via phone, e-mail, fax, and standard mail. Specific information about these options can be found in Section 5.

2.2 Trading Partner Registration All entities desiring to exchange EDI transactions with WPS must register as a Trading Partner via the EDI Express Enrollment (E3) website here: https://edi.wpsic.com/edir/home

Instructions for E3 can be found here: https://www.wpshealth.com/resources/files/edi-express-enrollment-e3external-user-guide.pdf

2.3 Certification Trading Partners that desire to exchange 27X transactions in real-time mode are required to provide a digital certificate to secure the connection with WPS. The digital certificate is uploaded via WPS Community Manager

A digital certificate is not required to exchange 27X transactions in batch mode.

3 Testing with WPS

WPS does not require testing for the 27X transactions, batch or real-time mode.

4 Connectivity/Communications

4.1 Process Flows

WPS supports the exchange of 27X transactions in both batch and real-time mode with three exceptions:

• The 270/271 Health Care Eligibility Benefit Inquiry and Response transaction is not supported for Veterans Affairs (VA) healthcare patients because prior authorization is required for VA healthcare services.

https://edi.wpsic.com/edir/home


https://www.wpshealth.com/resources/files/edi-express-enrollment-e3-external-user-guide.pdf
















• The 270/271 Health Care Eligibility Benefit Inquiry and Response transaction is not supported for Medicare beneficiaries because the Centers for Medicare & Medicaid Services (CMS) requires the use of the HIPAA Eligibility Transaction System (HETS) for real-time Medicare eligibility queries.

• The 276/277 Health Care Claim Status Request and Response transaction is not supported in real-time mode for Medicare claims.

4.1.1 27X Transaction Real-Time Processing

Figure 1

1. Trading Partner Registration – Complete the Trading Partner Registration process on the E3 website (https://edi.wpsic.com/edir/home). User will set up their Trading Partner ID and password through this process.

2. Upload Digital Certificate – Upload the digital certificate for the webserver that will be sending the 270 transaction. This can also be done during Step 1.

3. Account Configuration – WPS completes configuration of the Trading Partner account to facilitate the exchange of real-time transactions

4. Submit Requesting Transaction – User submits an eligibility (270) or claim status (276) payload, packaged in a SOAP envelope.

5. Return Response Transaction – WPS returns a corresponding eligibility response (271) or claim status response (277) payload, packaged in a SOAP envelope.

4.1.2 27X Transaction Batch Processing

Figure 2

1. Trading Partner Registration – Complete the Trading Partner Registration process on the E3 website (https://edi.wpsic.com/edir/home). User will set up their Trading Partner ID and password through this process.

2. Submit Requesting File – User submits an eligibility (270) or claim status (276) file

3. Return Response File – WPS returns a corresponding eligibility response (271) or claim status response (277) file

4.2 Transmission Administrative Procedures WPS follows the X12N TR3 requirements and supports the Primary Search option as well as the required Alternate Search options. WPS does not support search options outside of these two categories, such as eligibility inquiries lacking a member ID; the member ID is required in all requests.

WPS processes 27X transactions in compliance with the CAQH CORE Phase 1 Operating Rules

4.3 Re-Transmission Procedure If inquiries within a file are rejected for any reason, the user can either correct and resend the file, or create a new file with the corrected requests. The same transmission method can be used to resend the file.

User Registers for a Trading Partner ID

User Provides Their Digital Certificate

WPS Completes User Account

Configuration for Real - Time Processing

User Submits an Inquiry

WPS Returns a Response

User Registers for a Trading Partner ID

User Submits an Inquiry

WPS Returns a Response









4.4 Communication Protocol Specifications

4.4.1 Real-Time Specifications

• Per the TR3, WPS only supports a single inquiry per real-time transmission • The connection URL is https://communitymanager.wpsic.com:16705

• The Trading Partner must provide WPS a digital certificate prior to submitting real-time transactions

• After the Trading Partner submits the transaction, the connection remains open until the response is received.

4.4.2 Batch Specifications

There are two methods to exchange batch 27x transactions with WPS:

• Over HTTPS using WPS Gateway Express (https://edi.wpsic.com/GatewayExpress/px/login.html)

• Over SFTP using https://communitymanager.wpsic.com:22

4.5 Password Requirements A password is required only for batch exchange of transactions; a password is not required for real-time exchange of transactions.

To meet WPS corporate requirements and federal security mandates, the following password policies are in place:

• Passwords expire after 60 days

• All passwords must be at least fifteen (15) characters in length • All passwords must contain at least one (1) UPPERCASE letter

• All passwords must contain at least one (1) lowercase letter

• All passwords must contain at least one (1) number • All passwords must contain at least one (1) special character (e.g. #, $, @, &, etc.)

• Passwords cannot be modified more than once within a 24-hour period

• New passwords must be different that the previous 24 passwords used • A user account is locked after three (3) unsuccessful login attempts within a 60-minute period; the account

remains locked for 180 minutes

Trading Partners who conduct business with WPS are subject to WPS security policies.

Users should take appropriate measures to prevent unauthorized disclosure or modification of assigned user IDs and passwords. Violation of this policy will result in the revocation of access to all WPS systems including, but not limited to, the EDI systems.

Trading Partners are not permitted to share their personal EDI user ID and password with any billing agent or clearinghouse/network service vendor. Providers must not share their personal EDI access number with anyone on their staff who does not need access to the data. Non-staff individuals or entities are not permitted to use a provider’s EDI number and password to access WPS systems.

5 Contact Information

5.1 EDI Help Desk

5.1.1 Non-Medicare (WPS Health Insurance, Arise, Aspirus-Arise, TRICARE, VA)

Phone 1-800-782-2680 (Option 1) 8:00 AM-4:30 PM (Central) Monday-Friday

E-Mail [email protected]

5.1.2 Medicare J5 (IA, KS, MO, NE, & National)

Phone 1-866-518-3285 (Say ‘EDI’) 7:00 AM-5:00 PM (Central) Monday-Friday

https://edi.wpsic.com/GatewayExpress/px/login.html

https://edi.wpsic.com/GatewayExpress/px/login.html



E-Mail [email protected] (Part A) [email protected] (Part B)

5.1.3 Medicare J8 (IN & MI)

Phone 1-866-234-7331 (Say ‘EDI’) 8:00 AM-5:00 PM (Eastern) Monday-Friday

E-Mail [email protected] (Part A) [email protected] (Part B)

5.2 Provider Customer Service For any non-EDI related inquiries, please contact the appropriate WPS Customer Service contact center:

WPS Health Insurance 1-800-765-4977

Arise Health Plan 1-877-711-1444

Aspirus-Arise Health Plan 1-800-332-3297

TRICARE For Life 1-866-773-0404

TRICARE Overseas 1-877-451-8659

TRICARE East 1-800-444-5445

Veterans Affairs 1-855-722-2838

Medicare J5 1-866-518-3285

Medicare J8 1-866-234-7331

6 Control Segments Interchange Control (ISA/IEA), Functional Group (GS/GE), and Transaction (ST/SE) envelopes must be used as described in the X12N implementation guides. WPS’s expectations for inbound ISAs and a description of data on outbound ISAs are detailed in this section.

NOTE: WPS does not accept functional groups based on more than one TR3 per Interchange Control envelope (ISA/IEA). If transactions based on more than one TR3 are submitted, each must be contained within its own Interchange Control envelope.

6.1 Interchange Control (ISA/IEA)

6.1.1 Delimiters – Inbound Transactions

As detailed in the HIPAA adopted implementation guides, delimiters are determined by the characters sent in specific, set positions of the ISA header. For transmission to WPS (inbound transmissions), these characters are determined by the submitter and can be any characters which are not included in any data element within the Interchange Control Envelope.

6.1.2 Delimiters – Outbound Transactions

WPS will use the following delimiters in all outbound transactions.

Delimiter Character Dec Value Hex Value

Data Element Separator * 42 2A

Repetition Separator ^ 94 5E

Component Element Separator : 58 3A



Segment Terminator ~ 126 7E

6.1.3 ISA Data Element Detail and Explanation

All data elements within the Interchange Control envelope (ISA/IEA) must follow X12 syntax rules as defined within the adopted implementation guide.

Data Element Name Codes Comments

ISA01 Authorization Information Qualifier

WPS does not utilize the Authorization Information data elements and will ignore content sent in ISA01 & ISA02 ISA02 Authorization Information

ISA03 Security Information

Qualifier

WPS does not utilize the Security

Information data elements and will ignore content sent in ISA03 & ISA04

ISA04 Security Information

ISA05 Interchange ID Qualifier ZZ

ISA06 Interchange Sender ID WPS assigned Trading Partner ID

ISA07 Interchange ID Qualifier ZZ

ISA08 Interchange Receiver ID Enter the appropriate Contract Code

6.1.4 IEA Data Element Detail and Explanation


IEA01 Number of Included Functional Groups

For real-time transactions, this value must be 1.

IEA02 Interchange Control Number

Must be identical to the associated ISA13 data element

6.2 Functional Group Control (GS/GE)

6.2.1 GS Data Element Detail and Explanation


GS01 Functional Identifier Code • HS - Eligibility,

Coverage, or Benefit Inquiry (270)




• HR - Health Care Claim

Status Request (276))

GS02 Application Sender’s Code Code agreed to by trading partners

For batch transmissions, this is the WPS assigned Trading Partner ID

(e.g. ‘12345’)

For real-time transmissions, this is the WPS assigned Trading Partner ID with an ‘R’ appended (e.g. ‘12345R’)

GS03 Application Receiver’s

Code

Enter the appropriate

Contract Code

GS04 Date Date expressed as CCYYMMDD where CC represents the first two

digits of the calendar year

GS05 Time Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (0059), S = integer seconds (00-59)

and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths

(00-99)

GS06 Group Control Number Number assigned and maintained by the sender

GS06 must be unique within a single transmission (ISA/IEA envelope)

GS07 Responsible Agency Code X

GS08 Version / Release / Industry Identifier Code

• 005010X279A1 (270)

• 005010X212 (276)

6.2.2 GE Data Element Detail and Explanation


GE01 Number of Transaction Sets Included

For real-time transactions, this value must be 1.

GE02 Group Control Number Number assigned and maintained by the sender

Must be identical to the associated GS06 data element

6.3 Transaction Set (ST/SE)

6.3.1 ST Data Element Detail and Explanation


ST01 Transaction Set Identifier Code

• 270 (Eligibility)

• 276 (Claim Status)



ST02 Transaction Set Control Number

Number assigned and maintained by the sender

ST02 must be unique within the functional group (GS/GE envelope)

ST03 Implementation Convention Reference

• 005010X279A1 (270)

• 005010X212 (276)

6.3.2 SE Data Element Detail and Explanation


SE01 Transaction Segment Count

Total number of segments included in the transaction set inclusive of the ST and SE segments

SE02 Transaction Set Control Number

Number assigned and maintained by the sender

Must be identical to the associated ST02 data element

7 Payer Specific Business Rules • WPS will convert all lowercase characters submitted on an inbound transaction to uppercase when sending

data to the WPS processing system

• Only loops, segments, and data elements valid for the HIPAA Implementation Guides will be translated; invalid data will not be sent for processing and may cause files to be rejected

• WPS may reject an interchange that is not submitted with unique values in the ST02 data elements • Only valid qualifiers for WPS (defined below) should be submitted on inbound transactions; transactions with

invalid qualifiers may be rejected

• The WPS EDI Maintenance Window is from 6 PM Saturday to 12 PM Sunday (Central)

8 Acknowledgements and Reports WPS utilizes the 999 Implementation Acknowledgement, 271 Health Care Eligibility Benefit Response, and 277 Health Care Claim Status Response.

8.1 Report Inventory The 999 Implementation Acknowledgement will report any implementation errors against a functional group based on the implementation guides. The 999 will also confirm receipt of fully compliant functional groups received in the batch mode.

The Response File (271 or 277) will contain the corresponding eligibility benefit or claim status information in accordance with the implementation guides.

9 Trading Partner Agreements WPS does not require a trading partner agreement to exchange 27X transactions.

9.1 Trading Partners An EDI Trading Partner is defined as any entity (provider, clearinghouse, billing service, software vendor, employer group, financial institution, etc.) that exchanges electronic data from WPS.



10 Transaction Specific Information

10.1 270/271 Eligibility Requirements

Loop Segment Element Business Requirement

2100C NM1 08 Must = MI

2100C NM1 09 • TRICARE must be: o 9-digit Sponsor SSN, OR o

10-digit DoD Identifier, OR o 11-digit

DBN

• WPS Health Insurance must be: o 9 or 10

numeric digits; no spaces or hyphens

• Arise and Aspirus-Arise Health Plans must be: o

9-11 numeric digits; no spaces or hyphens

• Medicare: N/A

• VA: N/A

10.2 276/277

Loop Segment Element Business Requirement

2100C NM1 08 For WPS Health Insurance, Arise Health Plan, Aspirus-Arise

Health Plan, and VA this segment must contain information

about the rendering provider.

2100D NM1 08 Must = MI

2100D NM1 09 • TRICARE must be: o 10-digit DoD Identifier,

OR o 11-digit DBN

• WPS Health Insurance must be: o 9 or 10

numeric digits; no spaces or hyphens

• Arise and Aspirus-Arise Health Plans must be: o

9-11 numeric digits; no spaces or

hyphens • Medicare: 11-digit MBI

11 Change Summary Version Date Sections Changed Change Summary

1.0 01/24/2014 N/A Guide Created

1.1 01/31/2014 5.1 Updated for new Medicare EDI Single Point of Contact Numbers

1.2 04/30/2014 4.1, 4.4 and 5.1 Updated Connectivity and Customer Service SPOC numbers

1.3 06/16/2014 4.1,4.4 Updated Real –Time Transaction

capability.



1.4 07/08/2014 4.4 Updated WPS’ URL for Real-Time Connectivity

1.5 08/14/2014 4.4, 10 Updated Real-Time Connectivity. Updated Transaction Specific Information.

1.6 09/03/2014 10 Updated 276/277 Business Requirements.

1.7 09/10/2014 7 Real – time Planned outage

1.8 10/24/2014 4.4 Updated WPS’ URL Real – Time Connectivity information.

1.9 11/04/2014 4.4 Updated the IP address for Real – time Connectivity information.

2.0 11/10/2014 Throughout the guide. The mention of EPIC taken out Throughout the guide.

3.0 11/21/14 4.5 Added clarification of password use.

3.0 11/21/14 4.1 Added that 270/271 is not available for VAPC3.

3.0 11/21/2014 Throughout Guide WPS Health Insurance (WPS) defined

3.1 10/12/2015 7 Payer Specific Business Rules and

Limitations: Changed planned outage time.

3.2 2/25/16 4.1, 6.1, 6.2 Added clarification that WPS does not offer 270/271 for VAPC3.

3.3 9/29/2016 Throughout for WPS Health Insurance

to WPS Health Solutions And sections 4.2 & 4.3 for the transmissions received by WPS

Anywhere the company was referenced as WPS Health Insurance to WPS Health Solutions. Added **Notice: Date editing on all inbound transactions will be done based on WPS Health Solutions local time, e.g. CST in sections 4.2 & 4.3

3.4 09/07/2017 All 4.3

Added Aspirus Arise Health Plan in addition to Arise Health Plan throughout Added pre and post bc information

3.5 09/27/2017 All Preface

Added TRICARE East Region info throughout Expanded the LOB Contract Code list to include all Medicare codes

4.0 3/26/2020 All Rewrote and reformatted the entire document

4.1 7/10/2020 1.3 References to WPC & X12 URL

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