Molina Medicaid Solutions

Transcription

1 olina edicaid Solutions Louisiana edicaid anagement Information Systems (LA IS) Vendor Specifications Document for the edicaid Eligibility Verification System (EVS) 05 ctober, 2011 Version 1.13 EDI-VSD-LA-EVS Prepared by: olina edicaid Solutions 477 Viking Drive, Suite 310 Virginia Beach, Virginia 23452

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3 olina edicaid Solutions EDI Solutions Group 10/05/2011 Table of Contents 1.0 INTRDUCTIN ELIGIBILITY VERIFICATIN VERVIEW EVS VENDR QUALIFICATIN REQUIREENTS EVS PERATINS SERVICES D PRCEDURES Registration Form Information Telecommunications Vendor Contract EVS VENDR CUNICATINS SPECIFICATINS Requirements for Network Connections Physical Connection TCP Connections Transaction Processing Claim/Request/Response Formatting Default Response Formats Coordination with olina edicaid Solutions EVS SI ELIGIBILITY TRSACTIN SPECIFICATINS APPING DATA ELEENTS CRSSWALK EVS Input Data Structure (270 Transaction) EVS utput Data Structure (271 Transaction) EVS EDIT (REJECT) CDES CRSSWALK EVS Edit (Reject) s Crosswalk DISPLAY F EVS INFRATIN Personal computer (pc) software screens EVS ain enu Screen Recipient Eligibility Information Request Recipient Eligibility Information Response Recipient Eligibility Information Response (continued) Recipient Eligibility Information Response TPL ptional Display Recipient Eligibility Information Response TPL ptional Display (continued) Recipient Eligibility Information Response Lock-In ptional Display EDI-VSD-LA-EVS Vendor Specifications Document 1-1 of 108

4 olina edicaid Solutions EDI Solutions Group 10/05/ Recipient Eligibility Information Response H ptional Display Recipient Eligibility Information Response Community Care ptional Display Recipient Eligibility Information Response Service Limit ptional Display PS DEVICE SCREENS EVS VENDR TESTING REQUIREENTS Testing bjectives Confidentiality During Application Testing ARKETING Provider Information Available To Vendors Vendor arketing aterial Approval PRBLE RESLUTIN EVS Availability Problem Escalation Procedures GLSSARY CNTACT INFRATIN EDI-VSD-LA-EVS Vendor Specifications Document 1-2 of 108

5 olina edicaid Solutions EDI Solutions Group 10/05/2011 REVISIN HISTRY CNTRLLED CPIES ISSUED BY: EDI Solutions Group Revision Revision Description Approval Date 1.0 Initial Release N. Alford 04/11/ Updates made for work associated with PR Updates made for work associated with PRs 2915 and 2916 N. Alford 08/06/2004 N. Alford 08/31/ Updates made for work associated with CRs 2957 and 2958 N. Alford 03/29/ Updates made for NPI (CR2974) N. Alford 04/17/ Updates related to DHH Core Team Comments for NPI. C. Daniel 05/08/ Deleted references to version Updated Sections 1.0, 11.2 and 13.0 per DHH Core Team request. N. Alford, K. lson 05/18/2007 C. Daniel 5/28/ Updates to program messages (kao) N. Alford, C. Daniel 11/18/ Updates to edicare messages (kao) N. Alford 01/28/ Updates made for work associated with CRs 3053 and 3057 Information Receiver (kao) N. Alford 04/06/ Add RW message, olina Branding (kao) N. Alford 08/24/ Add Co-Care Network messages (kao) N. Alford 09/23/ Replace code specific olina branding references; remove Co-Care references CR0118 (kao) N. Alford 12/14/ Add GNCHC messages CR121 (kao) N. Alford 12/14/ Add LACHIP Dental CR142 (kao). Luettel 07/08/ Add AAS-CCW/ADHC/EDA waiver messages CR143 (kao). Luettel 07/28/ Back out LACHIP Dental CR142 (kao). Luettel 10/05/2011 EDI-VSD-LA-EVS Vendor Specifications Document 1-3 of 108

6 olina edicaid Solutions EDI Solutions Group 10/05/ INTRDUCTIN The olina edicaid Solutions/ Louisiana edicaid anagement Information System (LIS) provides access to edicaid recipient eligibility information via software and equipment provided by commercial network vendors for edicaid service providers to verify eligibility information in a real time environment. The edicaid Eligibility Verification System (EVS) is available in conjunction with plastic edicaid eligibility cards. The plastic edicaid eligibility cards do not contain a readily visible expiration date thus making it necessary to verify eligibility at the time of service. The edicaid recipient through periods of ineligibility will retain the plastic edicaid eligibility cards. It is expected that should the edicaid recipient again become eligible for edicaid services the same edicaid eligibility card will be used to verify eligibility. The Department of Health and Hospitals (DHH) will replace the card only in the event that it is lost, stolen, or damaged beyond reasonable usefulness. Network vendors are provided specifications for the communications interface protocol and transaction formats. Network vendor software will allow a provider to make an eligibility inquiry and receive an eligibility response using the SI ASC X.12 EDI Health Care Eligibility/Benefit Inquiry transaction set 270 for eligibility inquiries and set 271 for the responses to the eligibility inquiries. Network vendors are expected to provide a variety of interface devices from which the edicaid provider can chose. These interfaces are expected to include PC based software access, PS devices, magnetic card reader devices and terminals. The EVS system will support eligibility information including basic eligibility, service limits, provider lock-in information and Third Party Liability (TPL) information. TPL information will include carrier name, policy and group numbers and scopes of coverage. The EVS system augments an automated voice response system and a web based system to provide rapid, up-to-date eligibility information to the edicaid provider thereby enabling the provider to file claims accurately and quickly. EDI-VSD-LA-EVS Vendor Specifications Document 1-4 of 108

7 olina edicaid Solutions EDI Solutions Group 10/05/ ELIGIBILITY VERIFICATIN VERVIEW The EVS system is designed to be a multi-faceted product that provides: convenient retrieval of eligibility information, a more complete medical perspective of the recipient and payor information that will allow more effective billing. The verification process expedites reimbursement, reduces claim denials and restricts the occurrence of fraud. A significant advantage to providers is the availability of EVS: 24 hours a day, six days a week, with the seventh day available 20 hours (except the time needed each day for file updates and system maintenance). In order to assist the provider community with eligibility verification responsibility, a principle objective of EVS is to provide a system that is quick, easy to understand and use and one that can be easily integrated into a variety of office environments. A joint effort between olina edicaid Solutions and commercial network vendors is required to accomplish this goal. olina edicaid Solutions provides technical, operational and professional services to establish the environment required to process eligibility verification inquires from vendors who market their services to individual providers. Network vendors are provided with interface protocol and transaction format specifications supported by EVS. Vendor software must allow a provider to submit inquiry transactions and receive transaction response information through a personal computer, Web application or special point-of-service (PS) devices. The information may be presented as a formatted screen (PC or web) or a paper printout (similar to an adding machine tape) on point-of-service devices. Commercial network vendors must obtain authorization from olina edicaid Solutions and DHH allowing them to provide EVS services to the provider community. It is the responsibility of the provider to choose and establish an agreement with an authorized commercial network vendor for EVS services. olina edicaid Solutions provides a list of authorized vendors to the provider community. The edicaid Eligibility Verification System, through an interface to IS managed care, third -party liability, service limitations, recipient and provider components, provides a more complete medical perspective of the recipient and payor information that will allow more effective billing. The following outline summarizes the eligibility verification information available. Recipient Eligibility Verification Recipient Demographic Information Provider Authorization Information Recipient Program Coverage Illegal Aliens utpatient Tuberculosis Etc. Restricted Services Information Waiver Participation Service limits EDI-VSD-LA-EVS Vendor Specifications Document 2-1 of 108

8 olina edicaid Solutions EDI Solutions Group 10/05/2011 Lock-In information (physician and pharmacy) Hospice anaged Care information H (Health aintenance rganization information) CC (Community Care information) Payor Information edicaid TPL (Third Party Liability information) edicare Eligible Spenddown. EDI-VSD-LA-EVS Vendor Specifications Document 2-2 of 108

9 olina edicaid Solutions EDI Solutions Group 10/05/ EVS VENDR QUALIFICATIN REQUIREENTS Each telecommunications network vendor must meet the following specifications and criteria prior to being granted authorization to provide Eligibility Verification services: 1. Prospective vendor must obtain a Vendor from olina edicaid Solutions. 2. Prospective vendor must sign a telecommunications contract with olina edicaid Solutions. 3. Vendor must comply with communications specifications (section 5). EDI-VSD-LA-EVS Vendor Specifications Document 3-1 of 108

10 olina edicaid Solutions EDI Solutions Group 10/05/ EVS PERATINS SERVICES D PRCEDURES The process for becoming a Louisiana EVS vendor is depicted in the following graphic: LINA Decision to be a EVS Telecommunications Vendor for Louisiana Contact olina and receive the Louisiana EVS Vendor anual and Registration Form Sign contractual agreement Procure and Establish a connection with the Western WesterConsolidated Regional Services Center in accordance with doumented specifications Develop a software product to meet the documented specification Test software connectivity and processing Schedule implementation into the production system Ready to be an official Louisiana EVS vendor EDI-VSD-LA-EVS Vendor Specifications Document 4-1 of 108

11 olina edicaid Solutions EDI Solutions Group 10/05/ Registration Form Information The vendor registration form notifies olina edicaid Solutions that a vendor wants to become an authorized Louisiana EVS vendor and offer EVS services to the provider community. A business contact is requested for contract negotiations, etc. A project contact is requested for the dissemination of information regarding new options, changing requirements, scheduled downtime, vendor conferences, etc. A technical contact may also be listed. The Technical Specifications Information section requests the following information to enable appropriate scheduling: Whether a new or existing telecommunications line to olina edicaid Solutions Western Regional Service Center is to be used for the Louisiana project Whether an existing telecommunications line upgrade is planned. It should be noted that submittal of the vendor registration form is not a guarantee that the submitting vendor shall be accepted by the state authority and/or olina edicaid Solutions. This is not a commitment to contract with the vendor for the requested services. Submittal of the vendor registration form in no way obligates the state or olina edicaid Solutions regarding the submittal of transactions through the DHH EVS program. Please mail the Vendor Registration form to: olina edicaid Solutions United Plaza Blvd Ste 300 Baton Rouge, LA United States Attn: Gloria Gardner EDI-VSD-LA-EVS Vendor Specifications Document 4-2 of 108

12 olina edicaid Solutions EDI Solutions Group 10/05/2011 Vendor Registration Form Name of Vendor ailing Address of Vendor VENDR REGISTRATIN FR Vendor Proc. City State Zip Phone Number FAX Number Name (Business Contact) LIST F CNTACTS Phone/FAX Address City/State/ZIP Name (Project anager) Phone/FAX Address City/State/ZIP Name (Technical Contact) Phone/FAX Address City/State/ZIP TECHNICAL SPECIFICATINS INFRATIN arketing & Research Provider Information Requested: Yes: No: Signature (Project anager) EDI-VSD-LA-EVS Vendor Specifications Document 4-3 of 108

13 olina edicaid Solutions EDI Solutions Group 10/05/ Telecommunications Vendor Contract The Louisiana telecommunications contract is being revised to ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA). Direct questions concerning Vendor Contract status to: olina edicaid Solutions Kermit Patty: Phone: (225) Fax Number: (225) E-ail Address: EDI-VSD-LA-EVS Vendor Specifications Document 4-4 of 108

14 olina edicaid Solutions EDI Solutions Group 10/05/ EVS VENDR CUNICATINS SPECIFICATINS The following paragraphs describe the Vendor Communications Specifications. 5.1 Requirements for Network Connections This section describes the requirements for network switches to be able to send (Pharmacy) PS, Claim Status Inquiries (CSI) and edicaid Eligibility Verification System (EVS) transactions to olina edicaid Solutions. olina edicaid Solutions supports connections via TCP/IP only. The first section addresses the physical connection into the olina edicaid Solutions systems. The second section addresses the network parameters that must be established to enable communications. A preferred set of parameters is described along with the possible variations that can be accommodated. The third section addresses the establishment of a connection to olina edicaid Solutions and the transmission of transactions. The fourth section addresses the formatting requirements for the transactions and responses. 5.2 Physical Connection The network vendor must provide the data line into the olina edicaid Solutions facility in Salt Lake City, UT along with the terminating CSU/DSU and Ethernet Router as appropriate to the line service. In addition, a transceiver and/or cable from the Router to the patch panel are required. The cable must terminate in an RJ45 (CAT 5 UTP recommended). The length of the cable will need to be coordinated with olina edicaid Solutions prior to installation. CSU/DSUs and Router must include rack-mounting hardware for a standard 19 electronics rack. Note, the telco DEARC is located in a separate room approximately 600 feet from the rack housing the CSU/DSU. The connection between the DEARC and the rack will be provided by olina edicaid Solutions. Standard phone wiring will be used unless special arrangements are established prior to installation. 5.3 TCP Connections The Vendor/provider is responsible for all IP addressing space up to, but not including the Ethernet interface on the olina edicaid Solutions side of the Router. olina edicaid Solutions will provide the specific Ethernet IP address at olina edicaid Solutions unless otherwise negotiated; and the Vendor s interface will be connected to a non-secure Ethernet DZ. Routing protocols such as RIP will not be enabled, static routes will be used. Testing with a temporary IP address may be accommodated. EDI-VSD-LA-EVS Vendor Specifications Document 5-1 of 108

15 olina edicaid Solutions EDI Solutions Group 10/05/2011 Generally, four virtual connections can be established via TCP. olina edicaid Solutions will assign the specific port number. No other TCP port or IP protocol should be used. 5.4 Transaction Processing The number of connections to olina edicaid Solutions is limited to ensure that all networks are provided equitable service. Normally, networks are limited to eight connections to each olina edicaid Solutions machine. Since machines can process multiple states, this does not equate to eight connections per state. Each connection can process transactions for all PS/EVS/CSI systems on the machine. We do not designate connections for any specific application. PS, CSI and EVS transactions and responses are handled by each connection. nce the connection is established, it is normally left connected and transactions are processed when sent. The connection should only be disconnected under error conditions. Each connection can handle multiple simultaneous transactions. The responses will be returned when processing is completed. nce transmission of a transaction has been initiated, all packets for that transaction must be transmitted before sending packets from any other transaction. Likewise, olina edicaid Solutions will send all packets for a response together. Packets from different responses will not be intermingled. All olina edicaid Solutions processing is performed in stream mode. Packets are constructed for convenience in transmission only. The envelope described in the following section provides an ET flag to identify the end of each transaction and response. Because of the nature of streams processing, responses will not always be contained in separate packets. The size of the response packets is such that the start of the following response may be in the same packet as the termination of the preceding response. The ET flag must be scanned to properly locate the end of the responses. olina edicaid Solutions supports two types of connections: single-threaded and multithreaded. In a single-threaded connection, once a transaction is received, we will not accept any additional transactions on that connection until the response has been returned. All transactions in the single-threaded connections have a timeout response. If, for some reason, olina edicaid Solutions is unable to process a transaction within the timeout period, a timeout response is returned at the end of the timeout period. Timeouts for PS claims are normally 15 seconds for each prescription. For example, a claim with three (3) prescriptions will have a timeout response sent after 45 seconds. Timeouts for EVS requests are 12 seconds. Under some situations, the timeout response for transactions may be 60 seconds. The timeout numbers vary slightly between states. For a multi-threaded connection, transactions can be submitted at any time. You do not need to wait until the previous response is returned. However, the order of responses may be different than the order the transactions were received. The returned envelope can be used to associate the EDI-VSD-LA-EVS Vendor Specifications Document 5-2 of 108

16 olina edicaid Solutions EDI Solutions Group 10/05/2011 response with the transaction. Timeouts for processing are similar to those for single-threaded except that not all timeouts will result in system unavailable responses. There are conditions where no response will be provided. If a vendor/provider choose to timeout the line earlier than our timeout response and reestablish the connection, you may encounter a situation where we will not startup another connection until the first connection has completely dropped. This will not occur until after the timeout period has completed and the connection itself has timed out. As a result, there may be periods where you will not be able to immediately reestablish the connection. We recommend that you wait until the timeout message has been received, or set your timeouts to beyond 48 seconds for PS claims and 12 seconds for EVS requests. Also note, that when a multi-thread connection is dropped, any transactions that have been received, but not responded to will be effectively lost since there are no longer any way to return the response. The transactions will be processed. 5.5 Claim/Request/Response Formatting All PS and EVS transactions and responses must be placed in envelopes. The data in the envelope, transaction and response will be sent using the ASCII character set. Transactions submitted by the network switches to olina edicaid Solutions must be in the following envelope: 1. A 16-byte header must be prefixed to each NCPDP/EVS/CSI transaction. 2. The first three (3) bytes of the header must be a network switch identifier. The value of the identifier will be assigned by olina edicaid Solutions. 3. The next six (6) bytes should contain a transaction identifier containing any combination of the characters 0-9, A-Z and a-z, or they must contain all zeros. The network switch to match the response with the corresponding request uses this transaction identifier. This is necessary since multiple claims are processed in parallel and the responses are not necessarily returned in the same order the requests were received. If a network switch does not use this transaction identifier, the network switch will have to wait for the response to a transaction before sending the next transaction. 4. The next seven (7) bytes must be spaces, as denoted from the arch 10 issue of the Federal Register contains a correction notice for the odifications to Transactions and Sets regulation published on February 20. The notice fixes some significant errors in the February 20 publication. 5. An End f Transmission (ET) flag consisting of a single byte with the binary value must terminate each NCPDP/EVS/CSI transaction, which are decimal 04. The response to a transaction will be returned in the same envelope. The response will be prefixed with the header that was received with the transaction. If a network switch requires variations in the response header, they must be negotiated with olina edicaid Solutions prior to installation. EDI-VSD-LA-EVS Vendor Specifications Document 5-3 of 108

17 olina edicaid Solutions EDI Solutions Group 10/05/ Default Response Formats There are situations where olina edicaid Solutions will not be able to process the transaction. In those situations, a default response will be returned in the received envelope. The format of this response is as follows: ERRRISnnnneeeeeee 9 Where nnnn is a four-digit message identifier that identifies the reason the claim was not processed; eeeeeee is a seven-digit sequence number that identifies the transaction within the olina edicaid Solutions systems. There are nine spaces after the sequence number. The message identifiers currently in use are: EVS - An error occurred while processing a EVS transaction Application is not currently active Application is not currently active Application is not currently active Network in envelope is not correct Unable to respond within required time limits Application is not authorized Cannot determine the appropriate application Default response not defined for this application. 5.7 Coordination with olina edicaid Solutions The contact point for coordination of the line parameters and connections is Kermit Patty. olina edicaid Solutions Kermit Patty: Phone: (225) Fax Number: (225) E-ail Address: Kermit.Patty@olinahealthcare.com The contact point for line installation is Scott Totman, (801) EDI-VSD-LA-EVS Vendor Specifications Document 5-4 of 108

18 olina edicaid Solutions EDI Solutions Group 10/05/ EVS SI ELIGIBILITY TRSACTIN SPECIFICATINS APPING The primary input to the LIS EVS application is the SI 270 transaction in X12 version 4010 (with addenda) format, for Eligibility request. A description of the format is provided below in Table 6-1.1, Eligibility Inquiry (270) Data Elements. HIPAA 270 Data Element INTERCHGE CNTRL HEADER Table Eligibility Inquiry (270) Data Elements / IN- AX D/ PT. NTES Author Info Qualifier ISA01 DED I01 Author Information ISA02 DED I02 Security Info Qualifier ISA03 DED I03 Security Information ISA04 DED I04 Interchange Qualifier ISA05 DED I05 Interchange Sender ISA06 DED I06 Interchange Qualifier ISA07 DED I05 2/2 10/10 2/2 10/10 2/2 15/15 2/2 Constant of 00 Not meaningful, spaces or zeroes Constant of 00 To identify the security information about the interchange sender or the data in the interchange Not meaningful, spaces or zeroes Constant of ZZ Variable Vendor Constant of ZZ EDI-VSD-LA-EVS Vendor Specifications Document 6-1 of 108

19 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 270 Data Element Interchange Receiver ISA08 DED I07 Interchange Date ISA09 DED I08 Interchange Time ISA10 DED I09 Interchange Control Standards Identifier ISA11 DED I10 Interchange Control Version Number ISA12 DED I11 Interchange Control Number ISA13 DED I12 Acknowledgment Requested ISA14 DED I13 Usage Indicator ISA15 DED I14 Component Element Separator ISA16 DED I15 FUNCTINAL GRUP HEADER / IN- AX 15/15 6/6 DT 4/4 T 1/1 5/5 9/9 N0 1/1 1/1 1/1 D/ PT (BIN Number) YYDD format HH format Constant of U Constant of ust match IEA02 NTES 0 No Acknowledgment Requested 1 Interchange Acknowledgment Requested P - Production Data T Test Data This field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator. Value is ASCII character <us>. EDI-VSD-LA-EVS Vendor Specifications Document 6-2 of 108

20 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 270 Data Element Functional Identifier code GS01 DED 479 Application Sender s GS02 DED 142 Application Receiver s GS03 DED 124 Date GS04 DED 373 Time GS05 DED 337 Group Control Number GS06 DED 28 Responsible Agency GS07 DED 455 Version/Release/Indus try Identifier GS08 DED 480 TRSACTIN SET HEADER / IN- AX 2/2 2/15 2/15 8/8 DT 4/8 T 1/9 N0 1/2 1/12 D/ PT. Constant of HS NTES identifying party sending transmission Vendor, minimum first three characters of current transaction submissions identifying party receiving transmission CCYYDD format HH format ust match GE02. Assigned number originated and maintained by the sender Constant of X Accredited Standards Committee X12 Constant of X092A1 ************************************** Transaction Set Identifier ST01 DED 143 3/3 Constant of Eligibility, Coverage or Benefit inquiry EDI-VSD-LA-EVS Vendor Specifications Document 6-3 of 108

21 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 270 Data Element Transaction Set Control Number ST02 DED 329 / IN- AX 4/9 D/ PT. NTES Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set. ust match SE02. BEGINNING F HIERARCHICAL TRSACTIN ************************************** Hierarchical Structure BHT01 DED 1005 Transaction Set Purpose BHT02 DED 353 Reference Identification BHT03 DED 127 Date BHT04 DED 373 Time BHT05 DED 337 4/4 2/2 1/30 8/8 DT 4/8 T Constant of 0022 Information Source, Information Receiver, Subscriber, Dependent Constant of 13 - Request Number assigned by the originator to identify the transaction within the originator s business application system Transaction Set Creation Date in format CCYYDD Transaction Set Creation Time in format HH INFRATIN SURCE LEVEL ************************************** Hierarchical Level Loop 2000A HL01 DED 628 Hierarchical Level HL03 DED 735 1/12 1/2 Constant of 1 - Hierarchical Number Constant 20 Information Source EDI-VSD-LA-EVS Vendor Specifications Document 6-4 of 108

22 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 270 Data Element Hierarchical Child HL04 DED 736 / IN- AX 1/1 D/ PT. NTES Constant 1 Additional Subordinate HL Data Segment in this Hierarchical structure INFRATIN SURCE NAE ************************************** Entity Identifier Loop 2100A N101 DED 98 Entity Type Qualifier Loop 2100A N102 DED 1065 Name Last or rganization Name Loop 2100A N103 DED 1035 Identification Qualifier Loop 2100A N108 DED 66 Identification Loop 2100A N109 DED 67 2/3 1/1 1/35 1/2 2/80 Constant of PR Payor Constant of 2 Non-Person Entity Constant of LINA LAIS Constant of PI Payor identification Constant of (BIN number) INFRATIN RECEIVER LEVEL ************************************** Hierarchical Number Loop 2000B HL01 1/12 Constant of 2 - Hierarchical Number EDI-VSD-LA-EVS Vendor Specifications Document 6-5 of 108

23 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 270 Data Element Hierarchical Parent Number HL02 Hierarchical Level HL03 Hierarchical Child HL04 / IN- AX 1/12 1/2 1/1 D/ PT. NTES Identifies the hierarchical number of the HL segment to which the current HL segment is subordinate. Constant 1. Constant 21 Information Receiver Constant 1 Additional Subordinate HL Data Segment in this Hierarchical structure INFRATIN RECEIVER NAE (PRVER) ************************************** Entity Identifier Loop 2100B N101 DED 98 Entity Type Qualifier Loop 2100B N102 DED 1065 Name Last or rganization Name Loop 2100B N103 DED 1035 Name First Loop 2100B N104 DED 1036 Name iddle Loop 2100B N105 DED 1037 Name Suffix Loop 2100B N107 DED /3 1/1 1/35 1/25 1/25 1/10 Constant of 1P Provider 1 Person 2 Non-person entity Last name, if person rganization name if non-person entity (Not used) First name, if N102 is 1 (not used) iddle name, if N102 is 1 (not used) Use only if N102 is 1 ; example SR, JR or III (not used) EDI-VSD-LA-EVS Vendor Specifications Document 6-6 of 108

24 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 270 Data Element Identification Qualifier Loop 2100B N108 DED 66 / IN- AX 1/2 D/ PT. NTES XX National Provider (NPI) SV Service Provider Number (for atypical providers, starting with 1 or 2.) PI Payor Identification (for ther Health Plans - batch or eevs only) Identification Loop 2100B N109 DED 67 2/80 Identification - NPI or Provider Number INFRATIN RECEIVER ADDITINAL INFRATIN (PRVER) ************************************** Reference Identification Qualifier Loop 2100B REF01 DED 128 Reference Identification Loop 2100B REF02 DED 127 2/3 1/30 1D edicaid Provider Number Seven character edicaid (to be used when NPI + Taxonomy or NPI + Zip do not point to a unique edicaid ) INFRATIN RECEIVER CITY/STATE/ZIP CDE (PRVER) ************************************** City Name Loop 2100B N401 DED 19 2/30 City Name EDI-VSD-LA-EVS Vendor Specifications Document 6-7 of 108

25 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 270 Data Element State or Province Loop 2100B N402 DED 156 Postal Loop 2100B N403 DED 116 / IN- AX 2/2 3/15 D/ PT. NTES Two character State Nine digit Zip to be used if registered with NPI plus zip code INFRATIN RECEIVER CNTACT INFRATIN (PRVER) ************************************** Provider Loop 2100B PRV01 DED 1221 Reference Identification Qualifier Loop 2100B PRV02 DED 128 Reference Identification Loop 2100B PRV03 DED 127 1/3 2/3 1/30 SB Submitting ZZ Health Care Provider Taxonomy Provider Taxonomy to be used if registered with NPI plus taxonomy code SUBSCRIBER LEVEL ************************************** Hierarchical Number Loop 2000C HL01 1/12 Constant of 3 - Hierarchical Number EDI-VSD-LA-EVS Vendor Specifications Document 6-8 of 108

26 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 270 Data Element Hierarchical Parent Number Loop 2000C HL02 Hierarchical Level Loop 2000C HL03 Hierarchical Child Loop 2000C HL04 / IN- AX 1/12 1/2 1/1 D/ PT. NTES Identifies the Hierarchical number of the HL segment to which the current HL segment is subordinate. Constant of 2 Constant 22 Subscriber 0 No Subordinate HL Segment in this Hierarchical structure SUBSCRIBER TRACE NUBER ************************************** Trace Type Loop 2000C TRN01 DED 481 Reference Identification Loop 2000C TRN02 DED 127 riginating Company Identifier Loop 2000C TRN03 DED 509 1/2 1/30 10/10 Constant 1 Current Transaction Trace Numbers Vendor trace number is currently submitted in the transaction envelope. If it is present in the 270, it must be returned in the 271. The current format is a three-character vendor followed by a 6 digit tracking number. Identifies an organization. User assigned number must begin with 9. SUBSCRIBER NAE ************************************** Entity Identifier Loop 2100C N101 DED 98 2/3 Constant IL Insured or Subscriber EDI-VSD-LA-EVS Vendor Specifications Document 6-9 of 108

27 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 270 Data Element Entity Type Qualifier Loop 2100C N Name Last or rganization Name Loop 2100C N103 DED 1035 Name First Loop 2100C N104 DED 1036 Name iddle Loop 2100C N105 DED 1037 Name Suffix Loop 2100C N107 DED 1039 Identification Qualifier Loop 2100C N108 DED 66 Identification Loop 2100C N109 DED 67 SUBSCRIBER ADDITINAL ENTIFICATIN SSN / IN- AX 1/1 1/35 1/25 1/25 1/10 1/2 2/80 D/ PT. Constant 1 Person NTES Last name required if access method includes recipient name First name required if access method includes recipient name iddle name, if N102 is 1 Use only if N102 is 1 ; example SR, JR or III When access method includes recipient Constant I ember Identification Number Recipient ************************************** EDI-VSD-LA-EVS Vendor Specifications Document 6-10 of 108

28 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 270 Data Element Reference Identification Qualifier Loop 2100C REF01 DED 128 Reference Identification Loop 2100C REF02 DED 127 / IN- AX 2/3 1/30 D/ PT. NTES When access method includes SSN Constant SY Social Security Number Recipient SSN = Reference Identification SUBSCRIBER ADDITINAL ENTIFICATIN Card Control Number ************************************** Reference Identification Qualifier Loop 2100C REF01 DED 128 Reference Identification Loop 2100C REF02 DED 127 2/3 1/30 When access method includes Card Control Number Constant HJ Identity Card Number Card Control Number = reference identification SUBSCRIBER DEGRAPHIC INFRATIN - DB ************************************** Date Time Period Format Qualifier Loop 2100C DG01 DED /3 When access method includes Date of Birth Constant D8 date format CCYYDD EDI-VSD-LA-EVS Vendor Specifications Document 6-11 of 108

29 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 270 Data Element Date Time Period Loop 2100C DG02 DED 1251 SUBSCRIBER DATE - DS Date/Time Qualifier Loop 2100C DTP01 DED 374 Date Time Period Format Qualifier Loop 2100C DTP02 DED 1250 Date Time Period Loop 2100C DTP03 DED 1251 SUBSCRIBER ELIGIBILITY INFRATIN / IN- AX D/ PT. NTES 1/35 Recipient Date of Birth = date time period CCYYDD format 3/3 2/3 ************************************** The current date of the processing system will be used as the subscriber DS if this segment is not received. Switch vendors may choose to default to the current date and send this segment if the information is not received from the provider. Date of Service is specified for all access methods (eligibility inquiries). Constant 472 Service Constant D8 1/35 Date of Service expressed in format CCYYDD ************************************** Service type code EQ01 DED /2 Service Type = 30 - Generic Eligibility request TRSACTIN SET TRAILER ************************************** EDI-VSD-LA-EVS Vendor Specifications Document 6-12 of 108

30 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 270 Data Element Number of Included Segments SE01 DED 96 Transaction Set Control Number SE02 DED 329 / IN- AX 1/10 N0 4/9 D/ PT. NTES Total number of segments included in a transaction set including the ST and SE segments ust match ST02 FUNCTINAL GRUP TRAILER ************************************** Number of Transaction Sets Included GE01 1/6 N0 Total number of transaction sets in the functional group or interchange group terminated by the trailer containing this data element Group Control Number GE02 1/9 N0 Assigned number originated and maintained by the sender. ust match GS06. INTERCHGE CNTRL TRAILER Number of Included Functional Groups IEA01 DED I16 Interchange Control Number IEA02 DED I12 1/5 N0 9/9 N0 ************************************** Constant of 1 A control number assigned by the interchange sender EDI-VSD-LA-EVS Vendor Specifications Document 6-13 of 108

31 olina edicaid Solutions EDI Solutions Group 10/05/ APPING The primary output of the LIS EVS application is an SI X12 version 4010 (with addenda) 271 transaction. A description of the format is provided below in Table 6.2-1, Eligibility utput (271) Data Elements. Table Eligibility utput (271) Data Elements HIPAA 271 DATA ELEENT IN/ AX D /PT. NTES INTERCHGE CNTRL HEADER ************************************* Author Info Qualifier ISA01 DED I01 Author Information ISA02 DED I02 Security Info Qualifier ISA03 DED I03 Security Information ISA04 DED I04 Interchange Qualifier ISA05 DED I05 Interchange Sender ISA06 DED I06 Interchange Qualifier ISA07 DED I05 Interchange Receiver ISA08 DED I07 Interchange Date ISA09 DED I08 2/2 10/10 2/2 10/10 2/2 15/15 2/2 15/15 6/6 DT Constant of 00 Not meaningful, zeroes or spaces Constant of 00 To identify the security information about the interchange sender or the data in the interchange Not meaningful, zeroes or spaces Constant of ZZ BIN Number Constant of ZZ Variable - Vendor YYDD format Interchange Time 4/4 HH format EDI-VSD-LA-EVS Vendor Specifications Document 6-14 of 108

32 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 271 DATA ELEENT ISA10 DED I09 Interchange Control Standards Identifier ISA11 DED I10 Interchange Control Version Number ISA12 DED I11 Interchange Control Number ISA13 DED I12 Acknowledgment Requested ISA14 DED I13 Usage Indicator ISA15 DED I14 Component Element Separator ISA16 DED I15 FUNCTINAL GRUP HEADER Functional Identifier code GS01 DED 479 Application Sender s GS02 DED 142 Application Receiver s IN/ AX T 1/1 5/5 9/9 N0 1/1 1/1 1/1 2/2 2/15 2/15 D /PT. Constant of U Constant of ust match IEA02 NTES 0 No Acknowledgment Requested 1 Interchange Acknowledgment Requested P - Production Data T Test Data ASCII character <us> ************************************* Constant of HB 271 identifying party sending transmission BIN Number identifying party receiving transmission Vendor EDI-VSD-LA-EVS Vendor Specifications Document 6-15 of 108

33 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 271 DATA ELEENT GS03 IN/ AX D /PT. NTES DED 124 Date 8/8 CCYYDD format GS04 DT DED 373 Time 4/8 HH format GS05 T DED 337 Group Control Number GS06 1/9 N0 ust match GE02. Assigned number originated and maintained by the sender DED 28 Responsible Agency GS07 1/2 Constant of X Accredited Standards Committee X12 DED 455 Version/Release/ 1/12 Constant of X092A1 Industry Identifier GS08 DED 480 TRSACTIN SET HEADER ************************************* Transaction Set Identifier ST01 3/3 Constant of 271 Eligibility, Coverage or Benefit information DED 143 Transaction Set Control Number ST02 DED 329 4/9 Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set. ust match SE02. EDI-VSD-LA-EVS Vendor Specifications Document 6-16 of 108

34 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 271 DATA ELEENT IN/ AX D /PT. NTES BEGINNING F HIERARCHICAL TRSACTIN ************************************* Hierarchical Structure BHT01 4/4 Constant of 0022 Information Source, Information Receiver, Subscriber, Dependent DED 1005 Transaction Set Purpose BHT02 2/2 Constant of 11 Response DED 353 Reference Identification BHT03 DED 127 1/30 Number assigned by the originator to identify the transaction within the originator s business application system. ust match BHT03 in the 270. Date BHT04 8/8 DT Transaction Set Creation Date, in CCYYDD format DED 373 Time BHT05 4/8 T Transaction Set Creation Time, in HH format DED 337 INFRATIN SURCE LEVEL HIERARCHICAL LEVEL ************************************* Hierarchical Identification Number Loop 2000A 1/12 Constant of 1 - Hierarchical Number EDI-VSD-LA-EVS Vendor Specifications Document 6-17 of 108

35 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 271 DATA ELEENT HL01 IN/ AX D /PT. NTES DED 628 Hierarchical Level 1/2 Constant 20 Information Source HL03 Loop 2000A DED 735 Hierarchical Child HL04 1/1 Constant 1 Additional Subordinate HL Data Segment in this Hierarchical structure Loop 2000A DED 736 REQUEST VALATIN ************************************* Yes/No Condition or Response Loop 2000A 1/1 This segment will be returned when the system or application is not able to process the transaction. AAA01 DED 1073 Constant N Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03. Reject Reason Loop 2000A AAA03 DED 901 2/2 Constant Y Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA Unable to Respond at Current Time Follow-up Action 1/1 Use this code to instruct the recipient of the EDI-VSD-LA-EVS Vendor Specifications Document 6-18 of 108

36 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 271 DATA ELEENT Loop 2000A AAA04 DED 889 IN/ AX D /PT. NTES 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable). N - Resubmission Not Allowed C Please Correct and Resubmit Yes/No Condition or Response Loop 2000A 1/1 P Please Resubmit riginal Transaction This segment will be returned when the system or application is not able to process the transaction. AAA01 DED 1073 Constant N Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03. Constant Y Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA03. INFRATIN SURCE NAE ************************************* Entity Identifier 2/3 Constant PR Payor Loop 2100A N101 DED 98 Entity Type Qualifier 1/1 Constant 2 Non-Person Entity Loop 2100A N102 DED 1065 Name Last or rganization Name 1/35 Constant LINA LAIS EDI-VSD-LA-EVS Vendor Specifications Document 6-19 of 108

37 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 271 DATA ELEENT Loop 2100A IN/ AX D /PT. NTES N103 DED 1035 Identification Qualifier Loop 2100A 1/2 Constant PI Payor Identification N108 DED 66 Identification 2/80 Constant of BIN number Loop 2100A N109 DED 67 REQUEST VALATIN Use this segment to indicate problems in processing the transaction specifically related to the information source data contained in the original 270 transaction s information source name loop (Loop 2100A) or to indicate that the information source itself is experiencing system problems. Yes/No Condition or Response Loop 2100A AAA01 DED 1073 Reject Reason Loop 2100A AAA03 DED 901 1/1 2/2 Information will be sent in this section when a transaction is received from an unauthorized vendor. Constant Y - Yes Constant 79 Invalid Participant Identification: Error in GS02 Follow-up Action 1/1 N - Resubmission Not Allowed C Please correct and resubmit EDI-VSD-LA-EVS Vendor Specifications Document 6-20 of 108

38 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 271 DATA ELEENT Loop 2100A IN/ AX D /PT. NTES AAA04 DED 889 INQUIRING PRVER INFRATIN INFRATIN RECEIVER LEVEL ************************************* Hierarchical Level Loop 2000B HL01 DED 628 Hierarchical Level Loop 2000B HL02 DED 734 1/12 1/12 Constant of 2 - Hierarchical Number Constant 1 INFRATIN RECEIVER NAE ************************************* Entity Identifier 2/3 Constant 1P Provider Loop 2100B N101 DED 98 Type Qualifier 1/1 1 Person Loop 2100B 2 Non-Person Entity N102 EDI-VSD-LA-EVS Vendor Specifications Document 6-21 of 108

39 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 271 DATA ELEENT DED 1065 Name Last or rganization Name N103 DED 1035 Name First N104 DED 1036 Name iddle N105 DED 1037 Name Suffix N107 DED 1039 Identification Qualifier Loop 2100B N108 DED 66 Identification Loop 2100B N109 DED 67 IN/ AX 1/35 1/25 1/25 1/10 1/2 2/80 D /PT. NTES Provider s Last Name or rganization Name Use if N102 is 1 Use if N102 is 1 Use if N102 is 1 XX NPI SV - Service Provider Number (for atypical providers) PI Payor Identification. LIS Provider = NPI or Provider Number INFRATIN RECEIVER ADDITINAL ENTIFICATIN PRVER PHNE NUBER ************************************* *********** EDI-VSD-LA-EVS Vendor Specifications Document 6-22 of 108

40 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 271 DATA ELEENT Reference Identification Qualifier Loop 2100B IN/ AX 2/3 D /PT. NTES Used to return the provider phone number Constant E Submitter Identification Number REF01 DED 128 Reference Identification 1/30 Provider Phone Number Loop 2100B REF02 DED 127 INFRATIN RECEIVER ADDITINAL ENTIFICATIN PRVER TAXNY CDE ************************************* *********** Reference Identification Qualifier Loop 2100B 2/3 JD User Identification REF01 DED 128 Reference Identification 1/30 Taxonomy or Zip Loop 2100B REF02 DED 127 INFRATIN RECEIVER ADDITINAL ENTIFICATIN PRVER ************************************* *********** EDI-VSD-LA-EVS Vendor Specifications Document 6-23 of 108

41 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 271 DATA ELEENT EDICA IN/ AX D /PT. NTES Reference Identification Qualifier Loop 2100B 2/3 1D edicaid Provider Number REF01 DED 128 Reference Identification 1/30 edicaid Provider Loop 2100B REF02 DED 127 EDI-VSD-LA-EVS Vendor Specifications Document 6-24 of 108

42 olina edicaid Solutions EDI Solutions Group 10/05/2011 PRVER VALATIN HIPAA 271 DATA ELEENT INFRATIN RECEIVER REQUEST VALATIN IN/ AX D /PT. NTES ************************************* Yes/No Condition or Response Loop 2100B AAA01 DED /1 Values of N No r Y yes Reject Reason Loop 2100B AAA03 DED 901 2/2 43 Invalid/missing Provider 50 Provider Ineligible for Inquiries 51 provider Not on File Follow-up Action Loop 2100B AAA04 DED 889 1/1 Constant C Please Correct and Resubmit SUBSCRIBER LEVEL ************************************* Hierarchical Number Loop 2000C HL01 DED 628 Hierarchical Parent HL02 DED 734 Hierarchical Level HL03 DED 735 Hierarchical Child HL04 1/12 1/12 1/2 1/1 Constant 3 Constant 2 Constant 22 0 No subordinate HL segment in this hierarchical structure 1 Additional subordinate HL segment in EDI-VSD-LA-EVS Vendor Specifications Document 6-25 of 108

43 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 271 DATA ELEENT DED 736 IN/ AX D /PT. NTES this Hierarchical Structure SUBSCRIBER TRACE NUBER ************************************* Trace Type Loop 2000C TRN01 DED 481 Reference Identification Loop 2000C TRN02 DED 127 riginating Company Identifier Loop 2000C TRN03 DED 509 SUBSCRIBER TRACE NUBER TRACKING NBR 1/2 1/30 10/10 Any trace numbers received in the 270 request must be returned in the 271 response with a value of 2 Referenced Transaction Trace Numbers. aximum of two. Trace number from 270 transaction. (LA EVS envelope Trace Number) The value received in the original 270 transaction. ************************************* Trace Type Loop 2000C TRN01 DED 481 1/2 Payor assigned trace numbers are designated with a value of 1 Current Transaction Trace Numbers Reference Identification Loop 2000C TRN02 DED 127 1/30 Tracking Number riginating Company Identifier Loop 2000C TRN03 10/10 Use this information to identify the organization that assigned this trace number. The 10 digit-number will begin with a 9" indicating a user assigned identifier is used. EDI-VSD-LA-EVS Vendor Specifications Document 6-26 of 108

44 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA 271 DATA ELEENT DED 509 IN/ AX D /PT. NTES RECIPIENT DEGRAPHIC INFRATIN HIPAA DATA ELEENT IN/ AX D /PT RECIPIENT DEGRAPHIC INFRATIN SUBSCRIBER NAE NTES ************************************* **** Entity Identifier 2/3 Constant "IL Insured or Subscriber Loop 2100C N101 DED 98 Entity Type Qualifier 1/1 Constant 1 Person Loop 2100C N102 DED 1065 Name Last or rganization Name Loop 2100C 1/35 Required unless a rejection response is generated and this element was not valued in the request. N103 DED 1035 Name First Loop 2100C N104 1/25 Required unless a rejection response is generated and this element was not valued in the request. DED 1036 Name iddle Loop 2100C 1/25 Recipient s iddle Initial, if available, unless a rejection response is generated and this element was not valued in the request EDI-VSD-LA-EVS Vendor Specifications Document 6-27 of 108

45 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA DATA ELEENT N105 DED 1036 Name Suffix Loop 2100C N107 DED 1036 Identification Qualifier Loop 2100C N108 DED 66 Identification Loop 2100C N109 DED 67 SUBSCRIBER ADDITINAL ENTIFICATIN SSN/Card Control Number/riginal Recipient IN/ AX 1/10 1/2 2/80 D /PT NTES Constant I ember Identification Number Current Recipient = Identification Corrected or new Identification Number is returned in N109. ************************************* Reference Identification Qualifier Loop 2100C REF01 DED 128 2/3 This data element allows an additional Recipient to be returned. For example, both the current and original s will be returned if they are not the same. Q4 Indicates that the originally submitted Identification Number is to be returned in REF02, if the submitted Identification Number was not the current Recipient. SY Social Security Number, if entered in the 270 EDI-VSD-LA-EVS Vendor Specifications Document 6-28 of 108

46 olina edicaid Solutions EDI Solutions Group 10/05/2011 HIPAA DATA ELEENT IN/ AX D /PT NTES Reference Identification 1/30 HJ Identity Card Number for Card Control Number, if entered in the 270 Subscriber Supplemental Identifier Loop 2100C REF02 DED 127 SSN, Card Control Number, or originally submitted Identification Number, if the submitted was not the current RESPNSE RETURN CDES HIPAA 271 DATA ELEENT IN/ AX SUBSCRIBER REQUEST VALATIN D /PT. NTES **** RESPNSE RETURN CDES ***** Yes/No Condition or Response Loop 2100C 1/1 Valid values are N or Y AAA01 DED 1073 EDI-VSD-LA-EVS Vendor Specifications Document 6-29 of 108