BCBSLA Companion Guide. Blue Cross and Blue Shield of Louisiana Eligibility Benefit and response Companion Guide

Transcription

1 Blue Cross and Blue Shield of Louisiana Eligibility Benefit and response Companion Guide 1

2 Table of Contents REVISION HISTORY... 4 Introduction... 5 Scope...5 Overview...5 Blue Card and Federal Employee (FEP) Inquiries... 5 Eligibility Inquiry Processing... 6 Acknowledgements...6 Batch Data Retention...6 Error Reporting...6 Security Validation Edits...8 Validation of Dates...9 Legacy Contracts...9 Date Ranges...9 Subscriber or Dependent Identification...9 BCBSLA SPECIFIC BUSINESS RULES AND LIMITATIONS GENERAL STRUCTURAL NOTES /271 Transaction Set Business Use and Description Control Segments/Envelope Specifications 270 Inbound Control Segments/Envelope Specifications 270 Inbound, Continued Control Segments/Envelope Specifications 271 Outbound Control Segments/Envelope Specifications 271 Outbound, Continued Transaction Specifications 270 Inbound Transaction Specifications 271 Outbound /271-ASC X12N-Health Care Eligibility Benefit Inquiry and Response /271-ASC X12N-Health Care Eligibility Benefit Inquiry and Response, Continued /271-ASC X12N-Health Care Eligibility Benefit Inquiry and Response Service Type Code List and Responses (STC) Service Type Code List and Responses (STC), continued Service Type Code List and Responses (STC), continued Service Type Code List and Responses (STC), continued Service Type Code List and Responses (STC), continued

3 Service Type Code List and Responses (STC), continued Service Type Code List and Responses (STC), continued Service Type Code List and Responses (STC), continued /271-ASC X12N-Health Care Eligibility Benefit Inquiry and Response /271-ASC X12N-Health Care Eligibility Benefit Inquiry and Response, Continued /271-ASC X12N-Health Care Eligibility Benefit Inquiry and Response, Continued ACKNOWLEDGEMENTS, ERROR CODES AND/OR REPORTS Response Transaction Testing Acronyms APPENDIX A- Member Search APPENDIX B SAMPLE REAL TIME ELIGIBILITY REQUEST TRANSACTION APPENDIX C SAMPLE REAL TIME ELIGIBILITY RESPONSE TRANSACTION APPENDIX D SAMPLE BATCH ELIGIBILITY REQUEST TRANSACTION APPENDIX E SAMPLE BATCH ELIGIBILITY RESPONSE TRANSACTION

4 REVISION HISTORY Documented revisions are maintained in this document through the use of the Revision History Table shown below. All revisions made to this companion guide after the creation Date are noted along with the date, page affected and reason for the change. S. Date Page Description Change Summary No 1 10/01/2010 Initial Document 2 02/10/2010 Format Changes to the Document 4

5 Introduction This guide was developed by Blue Cross and Blue Shield of Louisiana (BCBSLA) to be used in conjunction with 5010 ASC X12N 270/271 Eligibility Benefit and Response (005010X279A1) TR3. If the transactions do not meet the specifications outlined in this guide, then BCBSLA may not be able to process those transactions. Scope This companion guide is intended for BCBSLA Trading Partners interested in exchanging HIPAA compliant X12 eligibility information (270/271 transactions) with BCBSLA. It is intended to be used in conjunction with not as a replacement for, the ASC X12N 5010 version of the HIPAA Transaction Technical Report Type 3 (TR3) and are not intended to contradict or exceed X12 standards. It contains information about specific BCBSLA requirements for processing the 270/271 X12 transactions. Overview This Companion Guide is issued in an effort to provide the trading partners of BCBSLA with the most upto-date information related to standard transactions. Any and all information in this guide is subject to change at any time without notice. This is applicable to all lines of business within BCBSLA. This document is designed to assist both technical and business areas of trading partners who wish to exchange HIPAA standard 270/271 transactions with BCBSLA. It contains specifications for the transactions, contact information, and other information that is helpful. All instructions in this document are written using information known at the time of publication and will change as necessary to provide the most up-to-date information. The most up-to-date version of the Companion Guide is available on the BCBSLA Web site ( Please be sure to use the most current version of the Companion Guide available at the BCBSLA Web site. BCBSLA is not responsible for the performance of software outside of its installations. Important Notice: Unless otherwise required by state law, a 271 Response is not a guarantee of payment. Benefits are subject to all contract limitations and the member s eligibility status on the date of service. Blue Card and Federal Employee (FEP) Inquiries In order to manage inquiries for Out of Area Blue Card holders and Federal employees, BCBSLA accesses Blue Exchange, a data management system shared with Blue Cross and Blue Shield plans around the country. This system facilitates the routing of 270 Inquiries to the appropriate Blue Cross and Blue Shield Associate and the return of the 271 Response to the original Trading Partner. Important Notices: For Batch Submitters: Submitters of batch x12 files will receive a TA1 and/or 999 Acknowledgement from BCBSLA. Responses for out- of-area subscribers or FEP members may take longer to be returned than those in state. Batches received by BCBSLA prior to 9:00 p.m. will have a response returned no later than 7:00 a.m. the next morning. 5

6 If Blue Exchange (for OOA and FEP members) is unable to respond within 24 hours, submitters will receive the 271 Response after Blue Exchange sends response to BCBSLA. For Real-time Submitters: Responses are received from Blue Exchange usually less than 2-3 minute from submission during normal business hours (CST). No positive TA1 or 999 are returned for Real-time 270 submitters, as a 271 is returned. Eligibility Inquiry Processing Inquiries are handled in both batch and real-time mode. Batch transmissions can be bundled with more than one request per batch. Real-time 270s should be submitted in batches of one one request per ST/SE transmission. Acknowledgements Both negative and positive TA1 Interchange Acknowledgements and the 999 Functional Group Acknowledgement are returned upon the receipt of batch 270 Inquiries. Receipt of a positive TA1 and 999 indicates that no TR3 errors are contained within the transmission. If TR3 errors are found within the transmission, a negative TA1 or 999 (999 along with the Validation Report) is returned, identifying the error and the batch is rejected. For every 270 transaction received, a 271 response is returned. However, submitters may receive multiple 271 Responses to one 270 Inquiry if the 270 batch includes inquiries for patients with out-of- Area coverage. See the Error Reporting section of this chapter for more information about the 271 Response for error reporting. For Real-time transactions, only a negative TA1 or 999 is returned. Batch Data Retention Data from inquiries that are rejected with a TA1 or 999 Transaction is not retained. Data from inquiries that are accepted are retained for 90 days from the date of receipt. Error Reporting The following table indicates the various error responses one may receive to a 270 Transaction. Transmission Structure Level of Error ISA/IEA Interchange Control GS/GE (Functional Group) ST/SE (Transaction Set) Detail Segments Type of Error HIPAA TR3 Violations Invalid Message Invalid Batch ID Inactive Message Improper Batch Structure HIPAA TR3 Violations Transaction Returned TA1 (Negative) 999 (Negative) Validation Report 6

7 Detail Segments Error Reporting for Eligibility Inquiries BCBSLA Business Edits (see Data Element Table for details) Security Validation Messages 271 Transaction (See AAA segments) The TA1 and 999 Transactions are used to indicate Technical Report (TR3) errors. If a transaction is rejected at the Interchange Control (ISA/IEA) level or Functional Group (GS/GE), the batch returns a TA1 Interchange Acknowledgement transaction that identifies the TR3 error contained in the transmission. If a transmission is rejected at the Transaction Set (ST/SE) level, a 999 Functional Acknowledgement (and a validation Report) that identifies the TR3 errors is returned. Important Notices: For Technical Report (TR3) violations, BCBSLA returns the TA1 or 999(with Validation Report) Acknowledgement Transactions ONLY. Trading partners who are unable to accept a 999 or TA1 transaction are not provided with alternative Technical Report (Type 3) error reporting mechanisms. See AAA Responses, below, for information about messages returned for security validation or local business edits. AAA Responses The 271 AAA Segments are used to identify security validation requirement issues and to indicate BCBSLA business edits. Submitters that provide insufficient or invalid information within the 270 Inquiries are sent a 271 Response with AAA segments identifying the error. The following table displays the values, and their descriptions, typically sent in the 271 AAA Response. AAA AAA Error Code Description 58 Invalid/Missing Date-of-Birth 64 Invalid/Missing Patient ID 65 Invalid/Missing Patient Name 67 Patient Not Found 71 Patient Birth Date Does Not Match That for the Patient on the Database 72 Invalid/Missing Subscriber/Insured ID 73 Invalid/Missing Subscriber/Insured Name 75 Subscriber/Insured Not Found The following table displays the AAA response codes returned for an unsuccessful inquiry. Multiple codes may be returned, depending on what search criteria was sent: SID (Subscriber ID), DOB (Date of Birth), LN (Last Name), or FN (First Name). Input Pre Query - AAA Stp SID DOB LN FN Sub Dep 1 X 73,58 65,58 2 X X 73,58 65,58 3 X X 73,58 65,58 7

8 Stp Input No Match - AAA Multiple Match - AAA SID DOB LN FN Sub Dep Sub Dep 1 X X X X 72/73/71 64/65/ X X 72/71 64/ X X X 72/73/71 64/65/ X X X 72/73/71 64/65/ X X X 72/73 64/ Security Validation Edits BCBSLA has a variety of edits to ensure the security of data transmission within the Transaction Set or ST/SE portion of a transmission. These security checks or edits are in addition to the verification of identifiers within the Interchange Control envelope and Functional Group. The edits involve validating information that has been exchanged between BCBSLA and its business partners via the Electronic Connectivity Request form, as well as the approval letter returned by BCBSLA to verify security information. These edits stop the processing of a transaction prior to any business edits performed on the detailed segments of a transaction. The table below identifies the Security Validation edits performed on the 270 Eligibility Inquiry and the possible modifications needed to correct the edit. Security Validation failures result in the rejection of all Eligibility Inquiries within the loop attached to the Provider Identifier in question, essentially the entire transaction set (ST/SE). The modifications suggested do not identify an error; submitters are advised to contact the EDI Customer Operations at EDI (4334) for more specific information. Security Validation Error and Data Element Validated Provider ID not authorized. 2100B, NM109 for NPI Provider ID not authorized. 2100B, NM109 for SV 271 Response Message 271, 2100B, AAA03 51 (Provider Not on File) 271, 2100B, AAA03 51 (Provider Not on File) Modification Required Enter the NPI Number given to BCBSLA when enrolling Enter the BCBSLA Provider Number Real time transaction submitted with more than one member BCBSLA not able to respond in time allotted for real time transaction A AAA03 04 (Authorized Quantity Exceeded) A AAA03 42 Unable to Respond at Current Time Submit a single Request when submitted in a Real time Mode. Submit the same Request again Security Validation for 270 Eligibility Requests 8

9 Validation of Dates If a future or blank date is submitted for a Date of Service (DTP03) on the 270 Inquiry, BCBSLA edits the data and enters the current date. BCBSLA cannot project future coverage or liability for members. If a Prior Date is submitted for a Date of Service (DTP03) on the 270 Inquiry (for the date which member is not even active), BCBSLA rejects the requests and sends the 271 Response with 62 (Date of Service Not within Allowable Inquiry Period) in 2100C/D AAA03. Legacy Contracts BCSBSLA will not respond to Contract Numbers who are in Legacy and not moved to Facets for /271 Transactions. So when a 270 is submitted with Legacy Number, BCBSLA responds with a 271 Response containing AAA01 = Y, the AAA03 = 42 (unable to respond at current time) and the AAA04 = N (resubmission not allowed) at 2100A loop. Date Ranges BCBSLA returns the date range of the member s eligibility, regardless of the date sent in the inquiry. Important Notices: Date Range inquiries are supported. Only the first date of a date range submitted is utilized to determine eligibility. If the first date of a date range submitted falls outside of the member s coverage dates, the 271 Response returns a value of 6 (Inactive) on the 2110C/D, EB01. Subscriber or Dependent Identification BCBSLA uses only the following HIPAA Search Option (HSO) data elements within the 270 Transaction to validate the patient s eligibility: Data Element for Patient Matching First Name Last Name Date of Birth Identification Code (Subscriber ID) TR3 Location (270 Request) (Subscriber or Dependent Loop) 2100C NM104 or 2100D NM C NM103 or 2100D NM C DMG02 or 2100D DMG C NM109 (see Important Notices below) If trading partners elect to use the Subscriber s ID for the search criterion, they must submit the entire alphanumeric or numeric member identification code, as it appears on the subscriber s card, for patient identification. Nearly all BCBSLA members have a three (3) character alpha prefix, followed by either a nine (9) or an eleven (11) digit number. Some exceptions are Federal employees, who have only one (1) alpha prefix(r) and eight (8) numeric characters to their member number. The alpha prefix must be included when providing the subscriber identifier in the transaction, using upper case for the letters. Important Notices: The BCBSLA member s identification number (ID) for the patient ( Identification Code ) is a unique ID and may be submitted at the subscriber level, regardless of whether the patient is a dependent. Federal Employee Plan (FEP) members share identification numbers with their dependents. For inquiries on dependents of FEP members, use the dependent (2100D) loop. 9

10 BCBSLA SPECIFIC BUSINESS RULES AND LIMITATIONS This section describes the business rules and limitations of the 270/271 application. All references to the ASC X12N 270/271 TR3 assume the version referenced in Introduction of this companion guide. GENERAL STRUCTURAL NOTES Trading Partners should follow the ST/SE guidelines outlined in the 270 section of the TR3. Trading Partners should follow the ISA/IEA, GS/GE, TA1, and 999 guidelines for HIPAA in Table 5 and section of the Front Matter of the TR3. Trading Partners must follow the character set guidelines as defined in section B of the TR3. BCBSLA strongly recommends that Trading Partners use the preferred 270 request transaction delimiters in Table 1. Table 1 Preferred 270 Request Transaction Delimiters Character Name Delimiter * Asterisk Data Element Separator : Pipe Component Element Separator ~ Tilde Segment Terminator { curly brackets Repetition Separator For Batch Transactions, Each ST-SE may contain more one Patient Request. Each 270 request must have only one ISA/IEA, one GS/GE, one or more ST/SE, and a single/more than single 2100C Subscriber Loop. The 270/271 application will return additional eligibility information along with the basic set of eligibility data for certain service type codes. Refer to Service Type Code List and Responses (STC) of this companion guide, for a list of data elements included within the basic set and the additional eligibility data elements returned on the 271 response for each supported STC. Only the basic set of eligibility data will be returned for valid STCs that are not referenced in this companion guide. The 271 response is based upon information obtained from the BCBSLA database at the time of inquiry and is not considered a guarantee of payment. The 270/271 application will construct 271 responses with the preferred delimiters as noted in Table 1 of this companion guide. 10

11 270/271 Transaction Set Business Use and Description Health Care Eligibility Benefit Inquiry and Response Transaction Set ASC X12N 270 Transaction DASC X12N 271 D Transaction e s c r i p t i o n Business Use To inquire about the eligibility, coverage, or benefits associated with a benefit plan employer plan sponsor subscriber or a dependent under the subscriber s policy To communicate information about or changes to eligibility coverage benefits from information sources, insurers, sponsors, and health plans to information receivers, i.e., the following: healthcare providers clearinghouses third-party administrators healthcare adjudication processors Provides a method for the following sources to inquire about eligibility, coverage, and benefits associated with a subscriber s policy: o physicians o hospitals o third-party administrators o government agencies BCBSLA doesn t support any Procedure/Diagnosis code level 270/271 request response Does not provide a history of benefit use 11

12 Control Segments/Envelope Specifications 270 Inbound ISA Interchange Control Header Segment Data Element ID ISA01 ISA02 ISA03 ISA04 ISA05 ISA06 ISA07 ISA08 Technical Report Type WPC Version 5 Release 1 Data Element Size Value Notes/Comments Authorization Information Qualifier Authorization Information Security Information Qualifier Security Information Interchange ID Qualifier Interchange Sender ID/Trading Partner ID Interchange ID Qualifier Interchange Receiver ID/BCBSLA 2/ /10 2/ /10 2/2 ZZ 15/15 (ISA06 must be identical to GS02) TP number assigned by BCBSLA. Field is fixed length requiring 15 positions and must be left justified 2/2 ZZ 15/15 BCBSLA001 Field is fixed length requiring 15 positions and must be left justified ISA09 Interchange Date 6/6 Interchange Date in YYMMDD format ISA10 Interchange Time 4/4 Interchange Time in HHMM format ISA11 Repetition separator 1/1 { BCBSLA accepts only { at this time ISA12 Interchange Control Version Number 5/ ISA13 Interchange Control Number 9/9 TP determines the Control number; must match IEA02 1/1 0,1 0 = No 1 = Yes (TA1) ISA14 Acknowledgment Request ISA15 Usage Indicator 1/1 P,T P=Production, T=Test ISA16 Component Element 1/1 : Separator IEA01 Number of Included 1/5 Count of GS-GE Functional Groups Functional Group IEA02 Interchange Control 9/9 Number Must be same as ISA13 12

13 Control Segments/Envelope Specifications 270 Inbound, Continued Technical Report Type WPC Version 5 Release 1 Data Element ID Data Element Size Value Notes/Comments GS01 Functional Identifier Code 2/2 HS GS Functional Group Header Segment GS02 GS03 Application Sender s Code Application Receiver s Code 2/15 (GS02 must be identical to ISA06) TP number assigned by BCBSLA 2/15 BCBSLA001 GS04 Date 8/8 Functional Group Creation Date in CCYYMMDD Format GS05 Time 4/8 Functional Group Creation Time in HHMM Format GS06 GS07 GS08 Group Control Number Responsible Agency Code Version/Release/In dustry Identifier Code 1/9 Assigned by the Trading Partner. (GS06 must be identical to GE02) 1/2 X 1/ X279A1 GS08 must be identical to ST03 GE01 GE02 Number of Transaction Sets Included Group Control Number 1/6 Count of ST-SE in the Transaction 1/9 Assigned by the Trading Partner (GS06 must be identical to GE02) 13

14 Control Segments/Envelope Specifications 271 Outbound Technical Report Type WPC Version 5 Release 1 ISA Interchange Control Header Segment Dat a Element ID ISA01 ISA02 ISA03 ISA04 ISA05 ISA06 ISA07 ISA08 Data Element Size Value Notes/Comments Authorization Information Qualifier Authorization Information Security Information Qualifier Security Information Interchange ID Qualifier Interchange Sender ID Interchange ID Qualifier Interchange Receiver 2/ /10 Space filled 2/ /10 Space filled 2/2 ZZ 15/15 BCBSLA001 Field is fixed length requiring 15 positions and must be left justified 2/2 ZZ 15/15 TP ID (ISA08 must be identical to GS03) Trading Partner number assigned by BCBSLA. Field is fixed length requiring 15 positions and must be left ISA09 Interchange Date 6/6 Interchange Date in YYMMDD format ISA10 Interchange Time 4/4 Interchange Time in HHMM format ISA11 Repetition Separator 1/1 { ISA12 Interchange Control Version Number 5/ ISA13 ISA14 Interchange Control/ Last Control Number 9/9 Assigned by the Trading Partner. (ISA13 must be identical to IEA02) 1/1 0 Acknowledgment Request ISA15 Usage Indicator 1/1 T T (Test Data) P (Production Data) ISA16 IEA01 IEA02 Component Element Separator Number of Included Functional Groups Interchange Control Number 1/1 : 1/5 Count of GS-GE Functional Group 9/9 Must be same as ISA13 14

15 Control Segments/Envelope Specifications 271 Outbound, Continued Technical Report Type WPC Version 5 Release 1 Data Element ID Data Element Size Value Notes/Comments GS01 GS02 Functional Identifier Code Application Sender s Code 2/2 HB 2/15 BCBSLA001 GS Functional Group Header Segment GS03 Application Receiver s Code 2/15 TP ID (GS03 must be identical to ISA08) Trading Partner number assigned by BCBSLA GS04 Date 8/8 Functional Group Creation Date in CCYYMMDD Format GS05 Time 4/8 Functional Group Creation Time in HHMM Format GS06 GS07 GS08 Group Control Number Responsible Agency Code Version/Release/In dustry Identifier Code 1/9 Assigned by the Trading Partner. (GS06 must be identical to GE02) 1/2 X 1/ X279A1 GS08 must be identical to ST03 GE01 GE02 Number of Transaction Sets Included Group Control Number 1/6 Count of ST-SE in the Transaction 1/9 Assigned by the Trading Partner (GS06 must be identical to GE02) 15

16 Transaction Specifications 270 Inbound Technical Report Type WPC Version 5 Release 1 ST Transaction Header Segment Data Element ID ST01 ST02 ST03 SE01 SE02 Data Element Size Value Notes/Comments Transaction Set Identifier Code Transaction Set Control Number Implementation Convention Reference Number of Included Segments Transaction Set Control Number 3/ /9 Assigned by the Sender (Use the corresponding value in SE02 for this transaction set). 1/ X279A1 GS08 must be identical to ST03 1/10 Segment count between ST-SE 4/9 Assigned by the Sender (Use the corresponding value in SE02 for this transaction set). Transaction Specifications 271 Outbound Technical Report Type WPC Version 5 Release 1 ST Transaction Trailer Segment Data Element ID ST01 ST02 ST03 SE01 SE02 Data Element Size Value Notes/Comments Transaction Set Identifier Code Transaction Set Control Number Implementation Convention Reference Number of Included Segments Transaction Set Control Number 16 3/ /9 Assigned by the TP (Use the corresponding value in SE02 for this transaction set). 1/ X279A1 GS08 must be identical to ST03 1/10 Segment count between ST-SE 4/9 Assigned by the Trading Partner (Use the corresponding value in SE02 for this transaction set).

17 270/271-ASC X12N-Health Care Eligibility Benefit Inquiry and Response TR3 Loop Element Name Codes Length Comments Page ID # A NM101 Entity Identifier PR 2/3 Use PR - Payer Code 270/271 Data Elements 71 NM108 Identification Code Qualifier 71 NM109 Identification Code B NM103 Name Last/ Organization Name PI 1/2 Use PI - Payer Identification code /80 Enter BCBSLA NAIC Number 1/60 This field is always Required 76 NM104 Name First 1/35 This field is Required & must be entered only when NM102=1(Individual) 77 NM108 Identification Code Qualifier 78 NM109 Information Source Identifier C NM103 Subscriber Last Name SV or XX 1/2 2/80 When NM108=SV, Enter the submitter s 8-position numeric code assigned by BCBSLA which identifies your organization. And When NM108=XX, Enter the Provider NPI Number 1/60 This field is optional. BUT In order for BCBSLA to correctly match subscriber records, follow Appendix A 93 NM104 Name First 1/35 This field is optional. BUT In order for BCBSLA to correctly match subscriber records, follow Appendix A 95 NM108 Identification Code Qualifier 95 NM109 Identification Code MI 1/2 Use MI -- Member Identification Number 2/80 To ensure correct matching of data, the 3- byte alpha prefix must be included with the member ID number (BCBS contract #number) 17

18 270/271-ASC X12N-Health Care Eligibility Benefit Inquiry and Response, Continued 270/271 Data Elements, Continued TR3 Page # Loop ID C DMG02 Subscriber Birth Date DMG03 Subscriber Gender Code 123 DTP01 Date Time Qualifier Element Name Codes Length Comments DTP02 DTP03 Date Time Period Format Qualifier Date Time Period D NM103 Name Last/ Organization Name 1/35 This field is optional. BUT In order for BCBSLA to correctly match subscriber records, follow Appendix A F, M 1/ /3 Currently BCBSLA will be accepting only 291 = Plan D8, RD8 2/3 D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD 1/35 1/60 This field is optional. BUT In order for BCBSLA to correctly match member records, follow Appendix A NM104 Name First 1/35 This field is optional. BUT In order for BCBSLA to correctly match member records, follow Appendix A 165 DMG02 Dependent Date of Birth 166 DMG03 Gender Code 179 DTP01 Date Time Qualifier C/D EQ01 Service Type Code F, M 1/35 This field is optional. BUT In order for BCBSLA to correctly match member records, follow Appendix A 1/1 Use F - Female, M - Male 291 3/3 Currently BCBSLA will be accepting 291= Plan EQ01 must be present and may contain one or more Service Type Code(s). Refer to the TR3 for the specific set of supported Service Type codes. Use Repetition Separator in this element same as used in ISA11 18

19 270/271-ASC X12N-Health Care Eligibility Benefit Inquiry and Response Service Type Code List and Responses (STC)-- 270/271 Service Type Guidelines Service Type HIPAA Description Included Service Types on 271 Responses 1 # Medical Care 1,2,42,45,69,73,76,83,AG, BT,BU,DM 2 Surgical 2,7,8,20 3 Consultation 48, 50, 52, BY, BZ 4 Diagnostic X-Ray 4 5 Diagnostic Lab 5 6 Radiation Therapy 6 7 Anesthesia 7 8 Surgical Assistance 8 9 Other Medical 10 Blood Charges 11 Used Durable Medical Equipment 12 Durable Medical Equipment Purchase 13 Ambulatory Service Center Facility 14 Renal Supplies in the Home 15 Alternate Method Dialysis 16 Chronic Renal Disease (CRD) Equipment Pre-Admission Testing 18 Durable Medical 18 Equipment Rental 19 Pneumonia Vaccine 20 Second Surgical Opinion Third Surgical Opinion 22 Social Work 23 Diagnostic Dental 24 Periodontics 19

20 Service Type Code List and Responses (STC), continued-- Service HIPAA Description Type 270/271 Service Type Guidelines Included Service Types on 271 Responses 25 Restorative 26 Endodontic 27 Maxillofacial Prosthetics 28 Adjunctive Dental Services 30 # Health Benefit Plan Coverage 32 Plan Waiting Period 33 Chiropractic 4,33 34 Chiropractic Office Visits 35 Dental Care Dental Crowns 37 Dental Accident 38 Orthodontics 39 Prosthodontics 40 Oral Surgery 40 Routine 41 (Preventive) Dental 42 Home Health Care 42,A3 Home Health 43 Prescriptions 44 Home Health Visits 45 Hospice Respite Care 47 # Hospital 47,48,50,51,52,53 48 Hospital - Inpatient 48,99 49 Hospital - Room and Board 50 # Hospital Outpatient Hospital - Emergency Accident Hospital - Emergency Medical Hospital - Ambulatory Surgical 50,51,52,A

21 Service Type Code List and Responses (STC), continued-- Service HIPAA Description Type 270/271 Service Type Guidelines 54 Long Term Care 55 Major Medical 56 Medically Related Transportation 57 Air Transportation Included Service Types on 271 Responses 58 Cabulance 59 Licensed Ambulance 60 General Benefits Fertilization In-vitro MRI/CAT Scan Donor Procedures 64 Acupuncture 65 Newborn Care Pathology 67 Smoking Cessation 68 Well Baby Care 68,80,BH 69 Maternity Transplants 71 Audiology Exam 72 Inhalation Therapy 73 Diagnostic Medical 4,5,62,73 Private Duty 74 Nursing 75 Prosthetic Device 76 Dialysis Ontological Exam 78 Chemotherapy Allergy Testing 80 Immunizations Routine Physical 81 21

22 Service Type Code List and Responses (STC), continued-- Service HIPAA Description Type 270/271 Service Type Guidelines Included Service Types on 271 Responses 82 Family Planning Infertility 83,61 84 Abortion AIDS 86 Emergency Services 87 Cancer 51,52,86,98 88 Pharmacy 88 Free Standing 89 Prescription Drug Mail Order 90 Prescription Drug Brand Name 91 Prescription Drug Generic 92 Prescription Drug 93 # Podiatry Podiatry - Office 94 Visits 95 Podiatry - Nursing Home Visits 96 Professional (Physician) 97 Anesthesiologist 98 # Professional 98,BY,BZ (Physician) Visit - Office 99 Professional (Physician) Visit - Inpatient A0 A1 A2 A3 Professional (Physician) Visit - Outpatient Professional (Physician) Visit - Nursing Home Professional (Physician) Visit - Skilled Nursing Facility Professional (Physician) Visit - Home 99 A0 A4 Psychiatric 22

23 Service Type Code List and Responses (STC), continued-- Service HIPAA Description Type 270/271 Service Type Guidelines Included Service Types on 271 Responses A5 Psychiatric - Room and Board A6 # Psychotherapy A7 # Psychiatric - Inpatient A8 # Psychiatric - Outpatient A9 Rehabilitation AA Rehabilitation - Room and Board AB Rehabilitation - Inpatient AC Rehabilitation - Outpatient AD Occupational AD Therapy AE # Physical Medicine AF Speech Therapy AF AG AH Skilled Nursing Care Skilled Nursing Care - Room and Board AG AI Substance Abuse AI AJ Alcoholism AK Drug Addiction AL Vision (Optometry) AL AM Frames AN Routine Exam AO Lenses Non medically AQ Necessary Physical AR BA Experimental Drug Therapy Independent Medical Evaluation 23

24 Service Type Code List and Responses (STC), continued-- Service HIPAA Description Type 270/271 Service Type Guidelines BB Partial Hospitalization (Psychiatric) Day Care (Psychiatric) Included Service Types on 271 Responses BC BD Cognitive Therapy BE Massage Therapy Pulmonary BF Rehabilitation Cardiac BG BG Rehabilitation BH Pediatric BH BI Nursery BJ Skin BK Orthopedic 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, BL Cardiac 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, BM Lymphatic 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, BN Gastrointestinal 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, BP Endocrine 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, BQ Neurology 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, BR Eye 48, 50, 52, BY, BZ BS Invasive 48, 50, 52, Procedures BY, BZ B1 * Burn Care 48, 50, 52, BY, BZ Prescription Drug 48, 50, 52, B2 * Formulary BY, BZ Prescription Drug 48, 50, 52, B3 * Non Formulary BY, BZ BT * Gynecological BT BU * Obstetrical BU BV * Obstetrical/ BT, BU, BV Gynecological 24

25 Service Type Code List and Responses (STC), continued-- Service HIPAA Description Type 270/271 Service Type Guidelines BW * BX * Mail Order Prescription Drug: Brand Name Mail Order Prescription Drug: Generic BY * Physician Visit Office Sick * Physician Visit BZ Office Well C1 * Coronary Care CA * CB * CC * CD * CE * CF * CG * CH * CI * CJ * Private Duty Nursing Inpatient Private Duty Nursing Home Surgical Benefits Professional Surgical Benefits Facility MH Professional- Inpatient MH Professional Outpatient MH Facility- Inpatient MH Facility Outpatient Substance Abuse Facility Inpatient Substance Abuse Facility Outpatient Included Service Types on 271 Responses 48, 50, 52, BY, BZ 48, 50, 52, BY, BZ BY BZ 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, * CK Screening X-Ray CK CL * Screening Laboratory CL Screening CM * Mammogram HR CM Patient Screening CN * Mammogram LR CN Patient * Flu Vaccination CO CO CP * Eye Wear & Eye Wear Associates CE CF CG CH CI CJ 48, 50, 52, BY, BZ 25

26 Service Type Code List and Responses (STC), continued Service HIPAA Description Type 270/271 Service Type Guidelines Included Service Types on 271 Responses Case Management 1, 86, 98, 47, MH, AL, 35, 88, UC, CQ * 33, DG * Dermatology 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, DM * DME 12, 18, DM DS * Diabetic Supply 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, GF * GN * Prescription Drug Generic Formulary Prescription Drug Generic Non Formulary 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, 1, 86, 98, 47, MH, AL, 35, 88, UC, 33, Allergy 1, 86, 98, 47, MH, AL, 35, 88, UC, GY * 33, Intensive Care 1, 86, 98, 47, MH, AL, 35, 88, UC, IC * 33, Mental Health MH, CE, CF, CG, MH * CH NI * Intensive Care Neonatal 48, 50, 52, BY, BZ Oncology 1, 86, 98, 47, MH, AL, 35, 88, UC, ON * 33, Physical Therapy PT PT * Pulmonary 1, 86, 98, 47, MH, AL, 35, 88, UC, PU * 33, Renal 1, 86, 98, 47, MH, AL, 35, 88, UC, RN * 33, Residential 1, 86, 98, 47, MH, AL, 35, 88, UC, RT * Psychiatric TX 33, Transitional Care 1, 86, 98, 47, MH, AL, 35, 88, UC, TC * 33, TN * Transitional Nursery Care 48, 50, 52, BY, BZ UC * Urgent Care UC *-- New Service Type Codes for 5010 #-- Benefits changed for 5010 from 4010 for the existing service codes. 26

27 270/271-ASC X12N-Health Care Eligibility Benefit Inquiry and Response TR3 Loop Element Name Codes Length Comments Page # ID 271 Data Element Segments 272/ C/D INS03 272/ C/D INS04 302/ C/D EB / C/D DTP01 Maintenance Type Code Maintenance Reason Code Yes/No Cond Resp Code Date/Time Qualifier 001 3/3 25 2/3 Y,N,U 1/1 348,292 3/3 This element is Required only when the Group number sent on 270 is invalid. 001 Indicates a correction in Group Number This element is Required only when the Group number sent on 270 is invalid. 25 Indicates a correction in Group Number Refer Pre Auth Section(In Below tables) for complete segment information when EB11 = Y or U If a Service Type have only a Start Date, 271 Response shows with 348 Date. If a Service Type Start Date and End Date, 271 Response shows with 292 Date 318/ C/D DTP02 318/ C/D DTP03 Date Time Period Format Qualifier Date Time Period D8, RD8 2/3 1/35 D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD- CCYYMMDD This element is Required only when DTP01 and DTP02 are present 27

28 270/271-ASC X12N-Health Care Eligibility Benefit Inquiry and Response, Continued TR3 Page Loop Referen Code Name Length ID ce s # 270/271 Other Payer Data Elements / C/D EB01 315/ C/D REF / C/D DTP03 328/ C/D LS01 331/ C/D NM103 Eligibility or Benefit Information Code Reference Identification Qualifier Date/Time Qualifier Loop Identifier Code Name Last or Organization Name 28 R 1/2 2/3 1/ /4 1/60 331/ C/D NM104 Name First 1/35 331/ C/D NM105 Name Middle 1/ / C/D NM / C/D NM / C/D NM101 Identification Code Qualifier Identification Code Entity Identifier Code MI 1/2 PR,PR P,SEP, TTP 2/80 2/3 331/ C/D NM103 Name Last or Organization Name 1/60 335/ C/D N301 Address Information 1/55 335/ C/D N302 Address Information 1/55 336/ C/D N401 City Name 2/30 Comments If Other Payer info is present, EB01 must be R If group number is present, this segment has to be present. This is Required along with DTP01=290 (Coordination of Benefits) and DTP02=D8 Last name of the Insured Subscriber. This is Required when NM101=IL First name of the Insured Subscriber. This is Required when NM101=IL Middle name of the Insured Subscriber. This is Required when NM108 is present. NM101=PR (Payer); or PRP (Primary Payer), SEP (Secondary Payer), or TTP (Tertiary Payer) if know order of payment This is Required if NM101= PR or PRP or SEP or TTP

29 270/271-ASC X12N-Health Care Eligibility Benefit Inquiry and Response, Continued TR3 Page Loop ID # 270/271 Other Payer Data Elements, Continued 337/ C/D N / C/D N / C/D LE01 Reference Name Codes Length Comments State or Province Code Postal Code OR ZIP Loop Identifier Code 2/2 3/ /4 ACKNOWLEDGEMENTS, ERROR CODES AND/OR REPORTS The BCBSLA Clearinghouse provides a series of reports to assist in the tracking and monitoring of transactions. Clearinghouse reports are a critical part of the electronic submission process. Trading Partners that use Https URL can see the TA1/999/271 Responses automatically on the screen after few seconds once Request is submitted, whereas trading partners who use secure FTP must download them unless the FTP software is configured to pull them automatically. The Trading Partner is responsible for monitoring all reports to ensure that all transactions were received and accepted for processing by BCBSLA. In addition, the Trading Partner is required to take corrective action when necessary. All questions regarding reports should be directed to EDI Customer Operations at EDI (4334). We recommend that you maintain a copy of these reports for at least 60 days. Summary of Reports Eligibility Benefit and Response Transactions: 1. Communication Report: File Acknowledgement(TA1) 2. Functional Acknowledgement Report: ANSI 999 Communication Reports Communication Reports are an immediate acknowledgement of successful communication and receipt of transmitted files. They are the first step in the reconciliation process. They are not an indication that the transmitted files were accepted for processing. The Trading Partner is responsible for monitoring the reports and ensuring that all transactions submitted were received by the BCBSLA Clearinghouse. If you do not receive a communication report, we did not receive the transmission and the transmission will need to be resent. TA1 The TA1 Interchange Acknowledgement is used by the 270/271 application to communicate the 29

30 rejection of a 270 request transaction based on errors encountered with X12 compliance, formatting, or BCBSLA specific requirements of the ISA/IEA or GS/GE Interchange segments. The TA1 interchange acknowledgement will be used to verify the syntactical accuracy of the envelope of the X12 interchange. The TA1 interchange will indicate that the file was successfully received; as well as indicate what errors existed within the envelope segments of the received X12 file. A TA1 response message will always contain the ISA and IEA segments. However, if the error occurs in the functional group header or trailer (GS/GE) segments of the received X12 file, then the TA1 response will also contain these elements. The following sample File Acknowledgement Reports (TA1) is presented on subsequent pages: Accepted File Acknowledgement Rejected File Acknowledgement Examples of File Acknowledgements (TA1) Accepted Acknowledgement TA1* *101203*0828*A*000~ TA1-- Interchange Acknowledgment Interchange Control Number Interchange Date Interchange Time A -- Interchange Acknowledgment Code( A or E) Interchange Note Code KEY: Items That Vary (See the TR3 to view a list of available codes/options.) ~ Segment Terminator * Element Separator Rejected Acknowledgement TA1* *101203*0828*R*001~ TA1-- Interchange Acknowledgment Interchange Control Number Interchange Date Interchange Time R -- Interchange Acknowledgment Code ( A or E) Interchange Note Code KEY: Items That Vary (See the TR3 to view a list of available codes/options.) ~ Segment Terminator * Element Separator File Acknowledgement Report 30

31 This report indicates that the BCBSLA Clearinghouse has received a transaction. File Acknowledgement Reports are returned for all transactions. This report is titled Comm.rpt and indicates the size of the file that the BCBSLA clearinghouse received from the Trading Partner and the time we received it. The File Acknowledgement Report is presented on the next page. Example of File Acknowledgement Report Filename: Comm.rpt NOTE: PLEASE CHECK BACK FOR FUTURE UPDATES TO THIS PAGE ANSI 999 The Functional Acknowledgement Report is titled X12Ntrans.out and indicates the validity of a standard X12N transaction. Trading Partners will be able to pull this report the next time they connect to the BCBSLA Clearinghouse. All Trading Partners will receive this report. All Trading Partners will be responsible for reviewing this report to ensure that the files are accepted. If rejected, the Trading Partner must correct the errors and retransmit the file. The following sample Functional Acknowledgement Reports (999) are presented on subsequent pages: Accepted Functional Acknowledgement Rejected Functional Acknowledgement Validation Report Examples of Functional Acknowledgements (999) Filename: X12Ntrans.out Accepted Acknowledgement ST*999*0001*005010X231A1~AK1*HS*1*005010X279~AK2*270*0001*005010X279A1~IK5*A~AK9*A*1* 1*1~ SE*6*0001~ ST Transaction Set Header 999 Transaction Set Identifier 0001 Transaction Set Control Number X231A Version / Release / Industry Identifier Code AK1 Functional Group Response Header HS Eligibility, Coverage or Benefit Inquiry (270) 1 Group Control Number X279A Version / Release / Industry Identifier Code 31

32 AK2 Transaction Set Response Header 270 Transaction Set Identifier Code 0001 Transaction Set Control Number X279A Version / Release / Industry Identifier Code IK5 Transaction Set Response Trailer A Transaction Set Acknowledgement Code (Accepted Codes include A and E) AK9 Functional Group Response Trailer A Functional Group Acknowledgement Code 1 Number of Transaction Sets Included 1 Number of Received Transaction Sets 1 Number of Accepted Transaction Sets SE Transaction Set Trailer 6 Number of Included Segments 0001 Transaction Set Control Number KEY: Items That Vary (See the TR3 to view a list of available codes/options.) ~ Segment Terminator * Element Separator Rejected Acknowledgement ST*999*0001*005010X231A1~AK1*HS*2*005010X279~AK2*270*0002*005010X279A1~IK3*BHT*2**8~ IK4*2*353*1~IK5*R*5~AK9*R*1*1*0~SE*8*0001~ ST Transaction Set Header 999 Transaction Set Identifier 0001 Transaction Set Control Number X231A Version / Release / Industry Identifier Code AK1 Functional Group Response Header HS Functional Identifier Code (HS = Eligibility, Coverage or Benefit Information) 2 Group Control Number X279A Version / Release / Industry Identifier Code AK2 Transaction Set Response Header 270 Transaction Set Identifier Code 0002 Transaction Set Control Number X279A Version / Release / Industry Identifier Code IK3 Data Segment Note BHT Segment ID Code 2 Segment Position in Transaction Set 32

33 2100C Loop Identifier Code 8 Segment Syntax Error Code IK4 Data Element Note 2 Position in Segment 353 Data Element Reference Number 1 Data Element Syntax Error Code IK5 Transaction Set Response Trailer R Transaction Set Acknowledgement Code (Rejected codes include M, R, W and X) AK9 Functional Group Response Trailer R Functional Group Acknowledgement Code 1 Number of Transaction Sets Included 1 Number of Received Transaction Sets 1 Number of Accepted Transaction Sets SE Transaction Set Trailer 8 Number of Included Segments 0001 Transaction Set Control Number Partial Acknowledgement ST*999*0001*005010X231A1~AK1*HS*1*005010X279A1~AK2*270*0001*005010X279A1~IK5*A~AK2*27 0*0002*005010X279A1~IK3*DTP*11*2100*8~CTX*TRN02:9994defectRON203~IK4*2*1250*7*12~IK5*R* I5~AK9*P*2*2*1~SE*11*0001~GE*1*2~IEA*1* ~ In the example above, the original 270 file contained 2 ST/SE with a single business item in each ST/SE. The First ST/SE Business item was accepted. The Second ST/SE and Business Item was Rejected. In this situation the AK9 will show partial because the file contained ST/SE with single business items so when one of the business items rejected, it shows the entire ST/SE as rejected. AK9 Functional Group Response Trailer P Partially Accepted, At Least One Transaction Set Was Rejected 2 Number of Transaction Sets Included 2 Number of Received Transaction Sets 1 Number of Accepted Transaction Sets KEY: Items That Vary (See the TR3 to view a list of available codes/options.) ~ Segment Terminator * Element Separator Validation Reports 33

34 Trading Partners will be able to pull this report the next time they connect to the BCBSLA Clearinghouse. All Trading Partners will receive this report when the Request fails at ST/SE level. They will receive this Report in addition to the 999 Transaction. 34

35 271 Response When the 270 request complies with the X12 standard syntax requirements and all additional formatting rules as specified by this companion guide, then a 271 response transaction is returned to the Trading Partner. If no error exists, the Beneficiary eligibility data will be returned within the 271 response. The AAA error segment is utilized within the 271 response to communicate error conditions based on BCBSLA business rules. The 270/271 application will return the invalid or non-matching data element(s) that cause the error in the 271 response. The AAA error codes are specified in AAA Responses Section. Transaction Testing BCBSLA will require testing with trading partners before accepting production transmissions. The Trading Partner will receive all of the outputs that will be available in a production environment. For example, if a 35

36 trading partner submits a valid test file, they could receive one or all of the following, a Communication Report, a Functional Acknowledgement Report, and a 271 response. Testing will ensure that the data is accurate and formatted properly for processing. Retesting is required if you are upgrading your software, or changing software vendors. BCBSLA reserves the right to revoke production status when Trading Partners transactions repeatedly cause production errors. Testing Steps 1. BCBSLA distributes a test submitter ID, secure password, and dial-up phone number and/or FTP. 2. Trading Partner creates test file representative of all types that will be submitted in production. It is important that valid subscriber/member data is used within the test file; otherwise, the test may fail. 3. Trading Partner reviews the reports and response file BCBSLA provides: Communication Report verifies BCBSLA received the file Functional Acknowledgement Report (999) Accepted or Rejected 278 eligibility response 4. Trading Partner must correct all errors and resubmit the test files until these errors are corrected. For assistance on these errors contact Trading Partner must contact when the majority of transmissions are accepted. An EDI representative will distribute a production submitter ID number and password. NOTE: Test Transactions are NOT Processed for Payment. Acronyms Shortcut used in this entire Document TR3 TP OOA CST Actual Meaning Technical Report Type 3(Also called as Implementation Guide) Trading Partner(Also Called as Submitter) Out Of Area Central Standard Time APPENDICES APPENDIX A- Member Search Search Search Combinations # 36 Searches Performed 1 Subscriber ID, First Name, Last Name and Date of Birth 1,2,3,4,5 2 Subscriber ID, Last Name, and Date of Birth 2,5 3 Subscriber ID, First name, and Last Name 3,5 4 Subscriber ID, First Name, and Date of Birth 4,5

37 5 Subscriber ID and Date of Birth 5 APPENDIX B SAMPLE REAL TIME ELIGIBILITY REQUEST TRANSACTION ISA*00* *00* *ZZ*TPID *ZZ*BCBSLA001 *101203*0828*{*00501* *1*T*:~ GS*HS*TPID*BCBSLA001* *1339*1*X*005010X279~ ST*270*0001*005010X279~ BHT*0022*13* * *133949~ HL*1**20*1~ NM1*PR*2*BCBSLA*****PI*53120~ HL*2*1*21*1~ NM1*1P*2*TESTPROVIDER*****XX* ~ HL*3*2*22*0~ TRN*1* A A31* ~ NM1*IL*1*AAAAAA*BBBBBBBB****MI*XUP ~ DMG*D8* ~ DTP*291*D8* ~ EQ*1{BT~ SE*13*0001~ GE*1*1~ IEA*1* ~ APPENDIX C SAMPLE REAL TIME ELIGIBILITY RESPONSE TRANSACTION ISA*00* *00* *ZZ*BCBSLA001 *ZZ*TPID *101105*1458*{*00501* *1*T*:~ GS*HB*BCBSLA001*TPID* *1458*2*X*005010X279~ ST*271*0001*005010X279~ BHT*0022*11* * * ~ HL*1**20*1~ NM1*PR*2*BCBSLA*****PI*53120~ PER*IC*CUSTOMER SERVICE CENTER EDI SUPPORT*TE* ~ HL*2*1*21*1~ NM1*1P*2*Provider Name*****XX* ~ HL*3*2*22*0~ TRN*1* A A31* ~ NM1*IL*1*AAAAAAAA*BBBBBBBBB****MI*XUH ~ REF*SY* ~ REF*6P*12345ABC0000~ DMG*D8* *M~ INS*Y*18*001*25~ DTP*291*RD8* ~ DTP*382*D8* ~ DTP*539*D8* ~ DTP*540*D8* ~ 37

38 EB*1*EMP*30*HM*HMOLA HMO~ EB*I**AL{MH{35~ EB*1**1{47{86{88{98{UC~ DTP*292*RD8* ~ EB*A**30*****.10****Y~ DTP*292*RD8* ~ EB*A**30*****.30****N~ DTP*292*RD8* ~ EB*B**98***27*25*****Y~ MSG*SPECIALIST~ EB*B**48***27*300*****Y~ III*ZZ*21~ EB*B**48***36*900*****Y~ III*ZZ*21~ EB*B**50***27*300*****Y~ III*ZZ*22~ EB*B**52***27*100*****Y~ III*ZZ*23~ EB*A**30*****.1****Y~ EB*C*IND*30***23*0*****W~ EB*C*FAM*30***23*0*****W~ EB*C*IND*30***29*0*****W~ EB*G*IND*30***23*3000*****Y~ EB*G*IND*30***29* *****Y~ EB*G*IND*30***23*0*****N~ EB*G*IND*30***29*0*****N~ EB*C*IND*BY{UC{33{88***23*0*****Y~ EB*B**BY{UC***27*25*****Y~ DTP*292*RD8* ~ EB*A**BY{UC*****.00****Y~ DTP*292*RD8* ~ EB*C*IND*BY{UC{98***23*0*****Y~ MSG*SPECIALIST~ EB*B**BY{UC{98***27*40*****Y~ DTP*292*RD8* ~ MSG*SPECIALIST~ EB*A**BY{UC{98*****.00****Y~ DTP*292*RD8* ~ EB*R~ REF*1L*GROUP1234~ DTP*290*D8* ~ LS*2120~ NM1*SEP*2*PAYER NAME******48~ N3*201 PARK AVENUE*SUITE 300~ 38