Health Care Claims: Status Request and Response (Version 1.12 January 2007)

Transcription

1 PacifiCare Electronic Data Interchange 276/277 Transaction Companion Guide Health Care Claims: Status Request and Response (Version 1.12 January 2007) 276/277 ANSI ASC X12 276/277 (004010X093) ANSI ASC X12 276/277 (004010X093A1)

2 Table of Contents TABLE OF CONTENTS...2 INTRODUCTION...4 ASSUMPTIONS...5 PREFERENCES AND CONVENTIONS...5 General File Submission Requirements...5 Causes for Rejection of File Submission...7 COMMUNICATION METHODS SUPPORTED...7 Clearinghouse...7 Direct Submission...7 PRIVACY AND SECURITY PROTECTION...8 ENCRYPTION REQUIREMENTS...8 INTENT AND SCOPE OF THE CLAIMS STATUS REQUEST AND RESPONSE TRANSACTION...8 INTERACTIVE TRANSACTION PROCESSING...9 Interactive Transaction...9 CLAIMS PROCESSING SYSTEM ENVIRONMENT...9 GENERAL USAGE...11 SPECIFIC USAGE...13 ERROR HANDLING...13 APPENDIX A SAMPLE INQUIRIES...15 Sample 276 Request Scenario # Sample 277 Response Scenario # Sample 276 Request Scenario # Sample 277 Response Scenario # APPENDIX B TESTING REQUIREMENTS TRANSACTION SET...28 //HIPAA/DSR/Comp Guides/276/ /25/2007

3 277 TRANSACTION SET...42 ADDENDA 276 TRANSACTION SET...63 ADDENDA 277 TRANSACTION SET...77 //HIPAA/DSR/Comp Guides/276/ /25/2007

4 Introduction PacifiCare is publishing this Transaction Companion Guide to accompany the ASC X12N Implementation Guide for the ASC X12N Health Care Claims Status Request and Response (276/277) (004010X093) transaction set and the Addenda version of the ASC X12N Health Care Claims Status Request and Response (276/277) (004010X093A1) transaction set. The primary purpose of this 276 Transaction Companion Guide (Companion Guide) is to minimize the variability in the transaction set that is exchanged within all of the regions of PacifiCare. The Companion Guide will document assumptions, conventions, and preferences that PacifiCare expects health plans, providers, and information system vendors to comply with. Additionally, the Companion Guide will help to walk organizations through the implementation process so that the resulting transaction will meet the following business objectives: 1. Convey all required business information: The transaction will convey the comprehensive set of information that is required for health plans to conduct their business. 2. Interpret information in the same way: The definition of the transaction will be specific so that Trading Partners can correctly interpret the information that is received from each other from a business perspective. 3. Simplify the communication: The transaction will be standard to simplify communication between Trading Partners as well as comply with Health Insurance Portability and Accountability Act (HIPAA) regulations. The underlying premise of the PacifiCare Companion Guide is that it defines the superset of business functionality for the Health Care Claims Status Request and Response (276/277) Transaction Set. The ASC X12N Implementation Guide provides general information about EDI transmission, such as delimiters, enveloping, and related topics. PacifiCare s document will not duplicate these efforts. In order to establish a simplified implementation environment, the Companion Guide describes a set of assumptions and conventions that will be followed by Trading Partners as they implement the 276/277 transaction and interpret the information that is contained within it. These conventions provide additional clarity about data structures and data elements (i.e., what they mean), and describe how these data elements relate to information contained in the information systems belonging to each Trading Partner (i.e., how they will be used). It should be noted that the Companion Guide does not add, delete, or change the name of any data element or segment nor change the meaning or intent of any implementation specification that is specified in the ASC X12N Implementation Guide. HIPAA Implementation Guides are available through Washington Publishing, Inc. at: //HIPAA/DSR/Comp Guides/276/ /25/2007

5 Assumptions The following assumptions are being made for purposes of this guide: The Interchange Transmission refers to an ISA/IEA. The Functional Group refers to the GS/GE. The Transaction Set refers to the ST/SE (can come in multiple functional groups). Providers or clearinghouses submitting the 276/277 Health Care Claims Status Request and Response transaction directly to PacifiCare must first be registered. Registration includes the exchange of important information necessary for successful e-commerce, including submitter and receiver information, connectivity specifications, etc. For most questions relating to information in this guide, contact the PacifiCare Enterprise EDI Services (EES) department at: Fax: Telephone: Attn: EDI Support Health Care Claims Status Request transactions submitted to PacifiCare, either directly or through a clearinghouse, must be compliant with HIPAA. According to HIPAA legislation, a penalty of not more than $100 for each violation, and up to $25,000 may be imposed by the U.S. Department of Health and Human Services for transactions that are not compliant. For more information, please refer to the U.S. Department of Health and Human Services website at: Health Care Claims Status Request transactions submitted to PacifiCare are assumed to be production-ready. The provider, clearinghouse, and system vendor(s) will have completed testing prior to submission to ensure HIPAA compliance. Preferences and Conventions The items listed below outline specific preferences and conventions to be used when transmitting data to PacifiCare. General File Submission Requirements 1. Trading Partner Agreements specify the terms and conditions by which transactions are exchanged electronically with PacifiCare. This Companion Guide may be an addendum to a new or existing Trading Partner Agreement or other Business Agreement. 2. Every Trading Partner submitting the 276 Health Care Claims Status Request transaction directly to PacifiCare, must have signed a Trading Partner Agreement. For technical assistance on new or existing electronic transmissions. For all other questions, contact the appropriate PacifiCare representative. //HIPAA/DSR/Comp Guides/276/ /25/2007

6 3. PacifiCare will request that providers obtain certification from an approved Third-Party Certification System and Service (TPCSS), stipulating that its transactions are HIPAA compliant. For more information about certification and certification vendors, speak to the appropriate EES Project Manager. 4. While PacifiCare supports all of the characters in the extended character set, it is recommended that incoming 276 data use the basic character set as defined in Appendix A of the ANSI 276/277 Implementation Guide. 5. The subscriber hierarchical level (HL segment) must be in order from one, in increments of one (+1), and must be numeric. 6. Some of the segments and data elements labeled as Not Used in this Companion Guide, but labeled as Situational in the Implementation Guide, may still be accepted and validated to ensure HIPAA compliance. However, PacifiCare will not actually process these segments and data elements. 7. Data submitted to PacifiCare in ANSI HIPAA standard format will be translated into a proprietary format for purposes of internal processing. 8. Only multiple data loops or segments should be populated with the first occurrence, and each loop or segment populated consecutively thereafter. There should be no loops or segments without data. 9. PacifiCare suggests retrieval of the ANSI 997 functional acknowledgment files on or before the first business day after the file is submitted, but no later than five business days after the file submission. Beginning with the fifth business day after submission, it will no longer be available. 10. Encryption and compression of files using PGP v2.6 or later is supported for transmissions between the submitter and PacifiCare. 11. PacifiCare prefers to receive only one transaction type (records group) per interchange (transmission). A submitter should only submit one GS-GE (Functional Group) within an ISA-IEA (Interchange). 12. Trading Partners cannot send test and production information within the same transaction file, regardless of the transaction. Test data and production data must be submitted in separate files. Notify your EES Project Manager if you intend to send test data. 13. As of the release of this document (June 2003), PacifiCare accepts the following versions of the Implementation Guide, and any future versions as specified by the regulation: ANSI ASC X12N 276/277 (004010X093) ANSI ASC X12N 276/277 (004010X093A1) //HIPAA/DSR/Comp Guides/276/ /25/2007

7 Causes for Rejection of File Submission 1. Delimiters must be consistently applied throughout the transmissions. Any delimiter can be used as long as the same one is used throughout the transaction. Printable characters are preferred. A carriage return/linefeed will cause an interchange/transmission to be rejected. 2. Only loops, segments, and data elements valid for the Implementation Guide will be translated. Submission of data that is not valid based on the Implementation Guide will cause files to be rejected. 3. If a segment or data element within a segment is specified in the Implementation Guide as Not Used, yet is present in the transaction, it will be rejected as an error. 4. PacifiCare will reject an interchange transmission that is submitted with a submitter identification number in either ISA06 (Sender ID) or GS02 (Application Sender s Code) that is not registered for electronic claims submission. 5. PacifiCare will reject a functional group or interchange transmission that is submitted with an invalid value in either ISA08 (Receiver ID) and/or GS03 (Application Receiver s Code), based on the Trading Partner agreement. 6. PacifiCare will reject an interchange transmission that is not submitted with unique values in the ST02 (Transaction Set Control Number) or GS06 (Group Control Number) elements within the interchange transmission. 7. After March 2007, PacifiCare will allow inbound claim status requests to include either a Health Care Financing Administration(HCFA) National Provider ID (NPI) or Federal Tax Identification Number (TIN) since only one identifier can be submitted on the 276 and returned on the 277. The only instance where a 276 transaction will be rejected is when we do not have enough information to process the request. This includes the following scenarios: The transaction does not include an NPI or TIN. The transaction includes an NPI or TIN. but it is invalid. Communication Methods Supported PacifiCare supports the following communication methods: Clearinghouse For clearinghouse EDI claims status requests, it is necessary to contact the clearinghouse directly. They will provide all of the necessary testing and submission information required. Direct Submission For direct submission of claims status requests to PacifiCare or for details regarding communication protocols, contact the PacifiCare EES department at: Fax: EDISupport@phs.com Attn: EDI Support //HIPAA/DSR/Comp Guides/276/ /25/2007

8 Telephone: Privacy and Security Protection PacifiCare will comply with the privacy and confidentiality requirements as outlined in the HIPAA Privacy and Security regulations regarding the need to protect health information. All Trading Partners are also expected to comply with these regulations. Encryption Requirements PacifiCare will comply with the data encryption policy as outlined in the HIPAA Privacy and Security regulations regarding the need to encrypt health information and other confidential data. All data within a transaction that is included in the HIPAA definition of Electronic Protected Health Information (ephi) will be subject to the HIPAA Privacy and Security regulations and encryption rules will be adhered to. All Trading Partners are also expected to comply with these regulations and encryption policies. Intent and Scope of the Claims Status Request and Response Transaction The Claims Status Request (276) and Response (277) transaction set will be used to convey information about claims status between health plans and provider organizations. The intent of this transaction is to answer questions from providers such as: Did you receive my claim? Where is my claim in your system? What is the current status of my claim in your system? Is my claim on hold waiting for additional information? The information provided in the transaction will reflect the status of the claim at the point in time the request is made. The status of the claims may change. This transaction WILL NOT automatically notify a provider about a change in claims status. Status information will only be provided upon request. The intent of this transaction IS NOT to provide information explaining how the claim was adjudicated or why certain amounts were or were not paid. Answers to those types of questions will be contained in the Remittance Advice (835) transaction. Finding the right claim upon receipt of the initial 276 will eliminate the need for follow-up electronic interactions and/or telephone calls. The likelihood of PacifiCare identifying the right claim the first time around will be increased to the extent that the conventions outlined in this document are followed in preparing a 276 request. For technical assistance on new or existing electronic transmissions. For all other questions, contact the appropriate PacifiCare representative. //HIPAA/DSR/Comp Guides/276/ /25/2007

9 Interactive Transaction Processing This Companion Guide reflects conventions for interactive implementation of the ANSI X12N 276/277 Health Care Claims Status Request and Response transaction. PacifiCare will only accept interactive claim status/response transactions from its Trading Partners. Providers wishing to perform batch transactions must use a clearinghouse to perform batch transactions. Interactive Transaction An interactive transaction contains a request for status information on one single claim. If PacifiCare s processing system finds more than one claim that matches the criteria submitted, it will return up to five claims (HL 22 or 23 segment) that were previously submitted to PacifiCare by the provider organization. There will be a single request in a single envelope. As such, there will be only one of each of the following segments: ISA, GS, ST, SE, GE, IEA. The Information Receiver or their electronic intermediary will send the 276 transaction to PacifiCare through some means of telecommunications (as defined in the Trading Partner agreement) and will remain connected while the transaction is being processed and returns a 277. The speed of processing a real time transaction will depend upon how long it takes to match a claim in the claims processing system using information that is contained in the 276. The more specific the information contained in the 276 is, the quicker the processing time. The Provider or its electronic intermediary will send the 276 batch transaction to its clearinghouse. The clearinghouse will submit each 276 transaction from the batch to PacifiCare one at a time. PacifiCare prefers to only receive one 276 transaction per transmission. Once PacifiCare provides each 277 transaction to the clearinghouse, the clearinghouse will send the transaction back to the provider in its original batch form. PacifiCare intends to respond with a negative TA1 or 997 acknowledgement as appropriate to every 276 transaction that is received. A positive TA1 or 997 will only be sent upon the request of the provider or their intermediary. Claims Processing System Environment 1. PacifiCare s claims processing system will look to match a 276 inquiry with a previously submitted claim. For a match to be made, either: a) Must have a combination of the three data elements (1) (2) (3) PacifiCare Claim Member Identification Number Number NPI or Service Provider Tax Identification Number or Member Date of Birth //HIPAA/DSR/Comp Guides/276/ /25/2007

10 b) Must have a combination of the four data elements (1) (2) (3) (4) Member s Member s Date Identification of Birth NPI or Service Provider Tax Identification Number Date of Service or Member s Social Security Number or Member s HIC Number or Member s Last and First Name Note: In the case of a newborn (if the date of service is within 3 days after the date of birth), use the subscriber information instead of member information in the above scenarios. 2. PacifiCare will maintain, and have the ability to provide claims status information for an entire claim as well as for individual line item(s). 3. PacifiCare may receive claims that cannot be processed for any number of reasons, including the patient is not one of their covered members. In the case of a patient not being a member of PacifiCare, you may receive a response such as, A4 (Acknowledgement/Not Found The claim/encounter cannot be found in the adjudication system). 4. PacifiCare will be able to provide claim status for HMO claims for PacifiCare Health Systems. 5. PacifiCare s claims are archived after 6 years. Electronic claim status requests for claims archived after 6 years will not be accessible. 6. When submitting a claim status request by a date of service range, the date range cannot exceed a 3-month period. 7. When submitting an interactive request by date of service range, if the claim processing system finds more than five results, you will receive a response requesting that you narrow your search. You will need to make a change to your desired date of service range to comply with the request. 8. A claim status response received in interactive mode does not constitute a remittance advice; refer to your Explanation of Payment (EOP)/Remittance Advice for complete payment information. 9. Adjustments made at the claim level may not be reflected in the payment amount at the service line level; refer to your EOP/Remittance Advice for complete payment information. //HIPAA/DSR/Comp Guides/276/ /25/2007

11 10. If ISA 14 is set to 0 (zero), then a TA1 will not be returned. Neither a (negative) or +. (positive) TA1 will be returned. 11. If ISA 14 is set to 1 (one), then a (negative) TA1 will be returned if an error is found in the ISA segment. General Usage 1. The Information Source is a Health Plan. The Information Receiver could be a Provider Organization or an electronic intermediary acting on behalf of a Provider Organization. Either of those two situations will be handled in the 276 requests as follows: If the Information Receiver is an electronic intermediary acting on behalf of one or more provider organizations the ISA segment, the GS segment, and the 2000B Loop (Information Receiver Level) will identify the intermediary. Each Provider Organization would be identified in one occurrence of the 2000C Loop (Service Provider Level). Each individual provider rendering the service will be identified in a second occurrence of the Loop (Service Provider Level). If the Information Receiver is the provider organization the ISA segment, the GS segment, and the 2000B Loop (Information Receiver Level) will identify the Provider Organization. The individual provider rendering the service will be identified in the 2000C Loop (Service Provider Level). 2. PacifiCare will process Claim Status Requests (276) that contain the following minimum set of information. Case 1 When Subscriber is the patient Provider ID, Provider Name Subscriber Date of birth, Gender Subscriber Last Name, First Name, Member ID Number Claim submitter trace number Generated by the submitter to enable them to reconcile the request with the response Total (submitted) charges Dates of service or Payer s claim number Case 2 When Subscriber is NOT the patient Provider ID, Provider Name Subscriber Date of birth, Gender Subscriber last name, First name, Member ID Number of the subscriber Patient Date of birth, Gender Patient Last name, First Name, Member ID Number of the patient //HIPAA/DSR/Comp Guides/276/ /25/2007

12 Claim submitter trace number Generated by the submitter to enable them to reconcile the request with the response Total submitted charges Dates of service or Payer s claim number. The Provider Name, Gender (member), and Total submitted charges will not be used to match the claim. However, since they are required data segments/elements, they need to be supplied. There are two possible scenarios depending on the information contained in the 276. Scenario 1: The provider could ask for status on a particular claim number. Scenario 2: The provider could ask for status of claims for a range of dates. The following is the logic used when matching a 276 inquiry to claims in the PacifiCare processing system: The patient and the service provider on the 276 inquiry must match a patient and service provider in our claim processing system. When matching for a patient, PacifiCare will check for that patient within their claims system. Refer to Claim System Processing Environment for search elements utilized. When matching for service provider, the system will determine if the service provider identification number (NPI or TIN) in the 276 matches a service provider on a claim for that patient in the PacifiCare claims processing system. If a single date of service was included in the 276 inquiry, it must match the first and last date of service exactly on a submitted claim in PacifiCare s claim processing system for that patient-provider combination, in order for a 277 response to be created. If a date range was entered in the 276 inquiry, a 277 response will be created for all claims with a date of service that falls within the range entered in the 276 for that patient-provider combination in PacifiCare s processing system; see Claims System Processing Environment for additional details. 3. In situations where the processing of a 276 inquiry results in multiple claims (e.g., multiple claims for the specified month, etc.) PacifiCare will return up to 5 claims that were previously submitted. If the 276 request results in more than 5 claims being matched, the search criteria must be narrowed to reduce the number of claims being matched. 4. There are various reasons why a 276 request would not be processed by PacifiCare. These reasons include, but are not limited to, the provider is not known to PacifiCare or the patient is not covered by PacifiCare. In those cases, when a 276 request cannot be processed, a 277 response will be returned with STC segment(s) that indicate(s) the reason. //HIPAA/DSR/Comp Guides/276/ /25/2007

13 Specific Usage 1. The following will be the expected sequence of transaction exchange for interactive transactions. Upon receipt of a Claim Status Request (276) received in interactive mode: If the ISA segment does not comply with the Implementation Guide, PacifiCare will respond with an appropriate TA1 Interchange Acknowledgement and the request will not be processed. If the sender or receiver ID in the ISA segment is unidentifiable, the file will be considered to be invalid and PacifiCare will respond with the following message, Malformed X12. If the ISA segment is unreadable, the file will be considered to be invalid and will not be processed. A TA1 will not be returned if the ISA segment is unreadable. If an error is found within the transaction set, PacifiCare will respond with a 997 functional acknowledgement. In all other cases, PacifiCare will process the 276 and respond with a Claims Status Response (277). 2. The 276/277 transactions will use the following HL structure: Information Source/Information Receiver/Provider/Subscriber/Dependent. 3. Contact information for the Information Source (i.e., PacifiCare) will be populated within the PER segment. This contact telephone number is for technical EDI assistance. If there are questions regarding the claim status response, please contact PacifiCare s Customer Service Department. 4. The provider identified in the Service Provider Level (Loop 2100C) of the 276 request must be the billing provider from the original submitted claim. 5. Until a National Provider Identifier (using the qualifier XX Health Care Financing Administration National Provider ID) is assigned, PacifiCare will utilize FI Federal Taxpayer s Identification Number as the Identification Code Qualifier (NM108 of the Service Provider Level Loop 2100C). 6. Outbound HIPAA transactions from PacifiCare will include NPI information that was submitted on the inbound transaction. We will pass back the same NPI that was received. Clearinghouses and trading partners who send transactions with incorrect/invalid NPI to PacifiCare must accept outbound transactions from PacifiCare with the original NPI information transmitted. If no NPI was included in the inbound transaction, we will not return an NPI on the outbound transaction. Error Handling The following are a few examples of possible errors and how they will be handled: //HIPAA/DSR/Comp Guides/276/ /25/2007

14 1. SITUATION: There is a difference between information contained in the 276 and information PacifiCare has on file. ACTION: The 277 response will always reflect the information that PacifiCare has on file. EXAMPLE: Subscriber Name is identified in the 276 as a Fred Flintstone, but PacifiCare s system has the Subscriber Name as Frederick Flintsone. The health plan will return a 277 response with the name Frederick Flintstone. If the differences prevent PacifiCare s system from matching the claim, a claim not found will be returned. 2. SITUATION: PacifiCare cannot reply to a 276 with a complete 277 because one or more of their systems are not operational. ACTION: PacifiCare will reply with a 277 that contains an STC segment in the 2200D Loop. The STC01-1 field will contain an E1 (Response not possible System Status) and STC01-2 field will contain a 484 (Business Application Currently Not Available). 3. SITUATION: PacifiCare cannot uniquely match a claim identified in the 276 to a claim in their database because all of the required inquiry fields have not been completed. ACTION: PacifiCare will reply with a 277 that contains an STC segment in the 2200D Loop. The STC01-1 field will contain an E0 (Error in Submitted Request Data) and the STC01-03 field will contain a 123 (additional information requested from entity). 4. SITUATION: PacifiCare cannot uniquely match a claim identified in the 276 to a claim in their database even if/when all of the required inquiry fields are completed. ACTION: PacifiCare will reply with a 277 that contains an STC segment in the 2200D Loop. The STC01-01 field will contain an A4 (Acknowledgement/Not Found The claim/encounter cannot be found in the adjudication system) and the STC01-02 field will contain a 35 (claim/encounter not found). //HIPAA/DSR/Comp Guides/276/ /25/2007

15 Information Source: PacifiCare Information Receiver: Clearing House USA Subscriber: Mary Poppins DOB: 06/25/1965 SSN: Member ID: Acct.: Date of Service: 02/28/2002 Provider: Dr Cure All Provider ID: (NPI) Organization: Emerg Phys USA Claim Amount: $ Appendix A Sample Inquiries Sample 276 Request Scenario #1 (Subscriber is Patient) ISA*00* *00* *ZZ*Trading Partner*01* *020807*1352*U*00401* *0*T*:! GS*HR*Trading Partner* * *1615*1*X*004010X093! ST*276*0001! BHT*0010*13** ! HL*1**20*1! NM1*PR*2*PACIFICARE/SECURE HORIZONS*****21* ! HL*2*1*21*1! NM1*41*2*Clearing House USA*****46*X67E! HL*3*2*19*1! NM1*1P*2*Cure All*****XX* ! HL*4*3*22*0! DMG*D8* *F! NM1*QC*1*POPPINS*MARY****MI* ! TRN*1* ! AMT*T3*550.00! DTP*232*RD8* ! SE*15*0001! GE*1*1! IEA*1* ! //HIPAA/DSR/Comp Guides/276/ /25/2007

16 Sample 277 Response Scenario #1 Condition A Claim in Process (2J = ER Report received, returns HIPAA code 20 = Accepted for processing) ISA*00* *00* *01* *ZZ*Trading Partner*020808*0931*U*00401* *0*T*:! GS*HN* *Trading Partner* *0931*2*X*004010X093! ST*277*0002! BHT*0010*08* * **DG! HL*1**20*1! NM1*PR*2*PACIFICARE/SECURE HORIZONS*****PI* ! PER*IC**TE* ! HL*2*1*21*1! NM1*41*2*Clearing House USA*****46*X67E! HL*3*2*19*1! NM1*1P*2*CURE ALL*****XX* ! HL*4*3*22*0! DMG*D8* *F! NM1*QC*1*POPPINS*MARY****MI* ! TRN*2* ! STC*P1:20* **550.00*550.00! REF*1K* ! REF*BLT*111! REF*EA* ! DTP*232*RD8* ! SVC*HC:99291*550.00*550.00! STC*P1:20* **550.00*550.00! REF*FJ*1! DTP*472*RD8* ! SE*23*0002! GE*1*2! IEA*1* ! //HIPAA/DSR/Comp Guides/276/ /25/2007

17 Condition B Claim in Process Possible Third-Party Claim (2G = COB Claim, return HIPAA codes 41 = Special handling required at payer site and 52 = Investigating existence of other insurance coverage) ISA*00* *00* *01* *ZZ*Trading Partner*020808*0931*U*00401* *0*T*:! GS*HN* *Trading Partner* *0931*2*X*004010X093! ST*277*0002! BHT*0010*08* * **DG! HL*1**20*1! NM1*PR*2*PACIFICARE/SECURE HORIZONS*****PI* ! PER*IC**TE* ! HL*2*1*21*1! NM1*41*2*Clearing House USA*****46*X67E! HL*3*2*19*1! NM1*1P*2*CURE ALL*****XX* ! HL*4*3*22*0! DMG*D8* *F! NM1*QC*1*POPPINS*MARY****MI* ! TRN*2* ! STC*P1:41* **550.00*550.00*****P1:52! REF*1K* ! REF*BLT*111! REF*EA* ! DTP*232*RD8* ! SVC*HC:99291*550.00*550.00! STC*P1:41* **550.00*550.00! REF*FJ*1! DTP*472*RD8* ! SE*23*0002! GE*1*2! IEA*1* ! //HIPAA/DSR/Comp Guides/276/ /25/2007

18 Condition C Claim is not in the system, eligible POS member. Claim may or may not be in POS out of network processing system. (returns HIPAA code 0 = Cannot provide further status electronically) ISA*00* *00* *01* *ZZ*Trading Partner*020808*0931*U*00401* *0*T*:! GS*HN* *Trading Partner* *0931*2*X*004010X093! ST*277*0002! BHT*0010*08* * **DG! HL*1**20*1! NM1*PR*2*PACIFICARE/SECURE HORIZONS*****PI* ! PER*IC**TE* ! HL*2*1*21*1! NM1*41*2*Clearing House USA*****46*X67E! HL*3*2*19*1! NM1*1P*2*CURE ALL*****XX* ! HL*4*3*22*0! DMG*D8* *F! NM1*QC*1*POPPINS*MARY****MI* ! TRN*2* ! STC*A4:0* **550.00*550.00! DTP*232*RD8* ! SE*16*0002! GE*1*2! IEA*1* ! //HIPAA/DSR/Comp Guides/276/ /25/2007

19 Condition D Member not found (returns HIPAA code 33 Subscriber and subscriber id not found) ISA*00* *00* *01* *ZZ*Trading Partner*020808*0931*U*00401* *0*T*:! GS*HN* *Trading Partner* *0931*2*X*004010X093! ST*277*0002! BHT*0010*08* * **DG! HL*1**20*1! NM1*PR*2*PACIFICARE/SECURE HORIZONS*****PI* ! PER*IC**TE* ! HL*2*1*21*1! NM1*41*2*Clearing House USA*****46*X67E! HL*3*2*19*1! NM1*1P*2*CURE ALL*****XX* ! HL*4*3*22*0! DMG*D8* *F! NM1*QC*1*POPPINS*MARY****MI* ! TRN*2* ! STC*E0:33* **550.00*550.00*****E0:34! DTP*232*RD8* ! SE*16*0002! GE*1*2! IEA*1* ! //HIPAA/DSR/Comp Guides/276/ /25/2007

20 Condition E Group Returns GRP, returns HIPAA code 16 = Claim encounter has been forwarded to entity and Entity = QD Responsible Party, 106 = This amount is not entities responsibility and Entity = 1E HMO ISA*00* *00* *01* *ZZ*Trading Partner*020808*0931*U*00401* *0*T*:! GS*HN* *Trading Partner* *0931*2*X*004010X093! ST*277*0002! BHT*0010*08* * **DG! HL*1**20*1! NM1*PR*2*PACIFICARE/SECURE HORIZONS*****PI* ! PER*IC**TE* ! HL*2*1*21*1! NM1*41*2*Clearing House USA*****46*X67E! HL*3*2*19*1! NM1*1P*2*CURE ALL*****XX* ! HL*4*3*22*0! DMG*D8* *F! NM1*QC*1*POPPINS*MARY****MI* ! TRN*2* ! STC*A0:16:QD* **550.00*550.00*****A0:106:1E! DTP*232*RD8* ! SE*16*0002! GE*1*2! IEA*1* ! //HIPAA/DSR/Comp Guides/276/ /25/2007

21 Condition F Encounters (ENC, returns HIPAA code 107 = Processed according to contract provisions) ISA*00* *00* *01* *ZZ*Trading Partner*020808*0931*U*00401* *0*T*:! GS*HN* *Trading Partner* *0931*2*X*004010X093! ST*277*0002! BHT*0010*08* * **DG! HL*1**20*1! NM1*PR*2*PACIFICARE/SECURE HORIZONS*****PI* ! PER*IC**TE* ! HL*2*1*21*1! NM1*41*2*Clearing House USA*****46*X67E! HL*3*2*19*1! NM1*1P*2*CURE ALL*****XX* ! HL*4*3*22*0! DMG*D8* *F! NM1*QC*1*POPPINS*MARY****MI* ! TRN*2* ! STC*F4:107* **550.00*550.00! DTP*232*RD8* ! SE*16*0002! GE*1*2! IEA*1* ! //HIPAA/DSR/Comp Guides/276/ /25/2007

22 Condition G Minimally compliant 277 for RIMS (returns HIPAA code 0 = Cannot provide further status electronically) ISA*00* *00* *01* *ZZ*Trading Partner*020808*0931*U*00401* *0*T*:! GS*HN* *Trading Partner* *0931*2*X*004010X093! ST*277*0002! BHT*0010*08* * **DG! HL*1**20*1! NM1*PR*2*PACIFICARE/SECURE HORIZONS*****PI* ! PER*IC**TE* ! HL*2*1*21*1! NM1*41*2*Clearing House USA*****46*X67E! HL*3*2*19*1! NM1*1P*2*CURE ALL*****XX* ! HL*4*3*22*0! DMG*D8* *F! NM1*QC*1*POPPINS*MARY****MI* ! TRN*2* ! STC*A4:0* **550.00*550.00! DTP*232*RD8* ! SE*16*0002! GE*1*2! IEA*1* ! //HIPAA/DSR/Comp Guides/276/ /25/2007

23 Condition H Deleted DEL, Returns HIPAA code 0 = Cannot provide further status electronically ISA*00* *00* *01* *ZZ*Trading Partner*020808*0931*U*00401* *0*T*:! GS*HN* *Trading Partner* *0931*2*X*004010X093! ST*277*0002! BHT*0010*08* * **DG! HL*1**20*1! NM1*PR*2*PACIFICARE/SECURE HORIZONS*****PI* ! PER*IC**TE* ! HL*2*1*21*1! NM1*41*2*Clearing House USA*****46*X67E! HL*3*2*19*1! NM1*1P*2*CURE ALL*****XX* ! HL*4*3*22*0! DMG*D8* *F! NM1*QC*1*POPPINS*MARY****MI* ! TRN*2* ! STC*A3:0* **550.00*550.00! DTP*232*RD8* ! SE*16*0002! GE*1*2! IEA*1* ! //HIPAA/DSR/Comp Guides/276/ /25/2007

24 Information Source: PacifiCare Information Receiver: Clearing House USA Subscriber: Mary Poppins DOB: 06/25/1965 SSN: Member ID: Acct.: Dependent: Dick Poppins DOB 07/14/1964 Date of Service: 02/01/2002 to 4/02/2002 Provider: Dr Cure All Provider ID: 1122 Organization: Emerg Phys USA Claim Amount: $ Sample 276 Request Scenario #2 (Dependent is Patient) ISA*00* *00* *ZZ*Trading Partner*01* *020807*1352*U*00401* *0*T*:! GS*HR*Trading Partner* * *1615*1*X*004010X093! ST*276*0001! BHT*0010*13** ! HL*1**20*1! NM1*PR*2*PACIFICARE/SECURE HORIZONS*****21* ! HL*2*1*21*1! NM1*41*2*Clearing House USA*****46*X67E! HL*3*2*19*1! NM1*1P*2*Cure All*****XX* ! HL*4*3*22*1! NM1*IL*1*POPPINS*MARY****MI* ! TRN*1* ! HL*5*4*23! DMG*D8* *M! NM1*QC*1*POPPINS*DICK****MI* ! TRN*1* ! AMT*T3*780.00! DTP*232*RD8* ! SE*18*0001! GE*1*1! IEA*1* ! //HIPAA/DSR/Comp Guides/276/ /25/2007

25 Sample 277 Response Scenario #2 Condition A 2 claims are pulled one is (1) Paid the other is (2) Processing 1. 5A = Paid by A/P with adj. code 01, return HIPAA code 65 = Claim/line has been paid, 1 = for more detailed information, see remittance advice.) 2. 2E = Discount Contract STD, return HIPAA code 20 = Accepted for processing.) ISA*00* *00* *01* *ZZ*Trading Partner*020808*0931*U*00401* *0*T*:! GS*HN* *Trading Partner* *0931*2*X*004010X093! ST*277*0002! BHT*0010*08* * **DG! HL*1**20*1! NM1*PR*2*PACIFICARE/SECURE HORIZONS*****PI* ! PER*IC**TE* ! HL*2*1*21*1! NM1*41*2*Clearing House USA*****46*X67E! HL*3*2*19*1! NM1*1P*2*CURE ALL*****XX* ! HL*4*3*22*1! DMG*D8* *F! NM1*IL*1*POPPINS*MARY****MI* ! TRN*2* ! STC*F1:65* **780.00*780.00*****F1:1! HL*5*4*23! DMG*D8* *M! NM1*QC*1*POPPINS*DICK****MI* ! TRN*2* ! STC*F1:65* **780.00*780.00*****F1:1! REF*1K* ! REF*BLT*111! REF*EA* ! SVC*HC:99291*780.00*780.00! STC*F1:65* **780.00*780.00! REF*FJ*1! DTP*472*RD8* ! TRN*2* ! STC*P1:20* **500.00*500.00! REF*1K* ! SVC*NU:320*200.00*200.00! STC*P1:20* **200.00*200.00! REF*FJ*1! DTP*472*RD8* ! SVC*HC:99203*300.00*300.00*250! STC*P1:20* **300.00*300.00! REF*FJ*2! DTP*472*RD8* ! SE*38*0002! GE*1*2! IEA*1* ! //HIPAA/DSR/Comp Guides/276/ /25/2007

26 Condition B Member was not eligible until 03/01/2001, 2 claims are pulled one is (1) Paid the other is (2) Denied 1. 5C = Paid Reopened Twice with adj. code 01, return HIPAA code 65 = Claim/line has been paid, 1 = for more detailed information, see remittance advice.) 2. 3A = Not Eligible, returns HIPAA code 9 = no payment will be made for this claim and 88 = Entity not eligible for benefits for submitted dates of service (Entity, QC = Patient) ISA*00* *00* *01* *ZZ*Trading Partner*020808*0931*U*00401* *0*T*:! GS*HN* *Trading Partner* *0931*2*X*004010X093! ST*277*0002! BHT*0010*08* * **DG! HL*1**20*1! NM1*PR*2*PACIFICARE/SECURE HORIZONS*****PI* ! PER*IC**TE* ! HL*2*1*21*1! NM1*41*2*Clearing House USA*****46*X67E! HL*3*2*19*1! NM1*1P*2*CURE ALL*****XX* ! HL*4*3*22*1! DMG*D8* *F! NM1*IL*1*POPPINS*MARY****MI* ! TRN*2* ! STC*F1:65* **780.00*780.00*****F1:1! HL*5*4*23! DMG*D8* *M! NM1*QC*1*POPPINS*DICK****MI* ! TRN*2* ! STC*F1:65* **780.00*780.00*****F1:1! REF*1K* ! REF*BLT*111! REF*EA* ! SVC*HC:99291*780.00*780.00! STC*F1:65* **780.00*780.00! REF*FJ*1! DTP*472*RD8* ! TRN*2* ! STC*F2:9* **500.00*500.00*****F2:88:QC! REF*1K* ! SVC*NU:320*200.00*200.00! STC*F2:9* **200.00*200.00! REF*FJ*1! DTP*472*RD8* ! SVC*HC:99203*300.00*300.00*250! STC*F2:9* **300.00*300.00! REF*FJ*2! DTP*472*RD8* ! SE*38*0002! GE*1*2! IEA*1* ! //HIPAA/DSR/Comp Guides/276/ /25/2007

27 Appendix B Testing Requirements Testing Requirements EDI Trading Partner Testing PacifiCare has adopted the Workgroup for Electronic Data Interchange (WEDI) Strategic National Implementation Process (SNIP) Testing Sub-Workgroups recommendations on the types of testing that need to occur in order to remain in line with the health care industry s testing recommendations. Initially, the types of testing that PacifiCare strongly recommends for the 276/277 Transaction Sets include: Type 1: EDI syntax integrity testing Testing of the EDI file for valid segments, segment order, element attributes, testing for numeric values in numeric data elements, validation of X12 or NCPDP syntax, and compliance with X12 and NCPDP rules. This will validate the basic syntactical integrity of the EDI submission. Type 2: HIPAA syntactical requirement testing Testing for HIPAA Implementation Guidespecific syntax requirements, such as limits on repeat counts, used and not used qualifiers, codes, elements and segments. Also included in this type is testing for HIPAA required or intra-segment situational data elements, testing for non-medical code sets as laid out in the Implementation Guide, and values and codes noted in the Implementation Guide via an X12 code list or table. Third-Party Certification Systems and Services (TPCSS) TPCSS vendors provide test data and testing services for anyone in need of testing compliance of their HIPAA transactions. PacifiCare requests that Trading Partners test with a TPCSS and provide evidence of such testing. EDI submitters that have tested their 276/277 Transaction Sets with a certification system may provide a certificate of compliance. The certificate should specify the different types of testing passed, or provide us with a certification website that indicates you have successfully passed certain types of certification testing. PacifiCare will collect evidence of the Third-Party Certification during the Trading Partner Setup process. //HI PAA/DSR/Comp Guides/276/ /25/2007

28 276 Transaction Set 276 Transaction Set Segment Element Use Page Possible Values Description/Preferred Usage ISA - Interchange Control Header R B.3 Authorization Information Qualifier ISA01 R 00 - No Authorization Information Present Advised unless security requirements mandate use of additional identification information Additional Data Identification Authorization Information ISA02 R Security Information Qualifier ISA03 R B No security information present. Advised unless security requirements mandate use of password data Password Security Information ISA04 R Interchange ID Qualifier ISA05 R See the 276 Transaction Set Implementation Guide This ID qualifies the Sender in ISA06 for a list of values. Interchange Sender ID ISA06 R Interchange ID Qualifier ISA07 R See the 276 Transaction Set Implementation Guide This ID qualifies the Receiver in ISA08 for a list of values. Interchange Receiver ID ISA08 R B.5 Interchange Date ISA09 R YYMMDD Interchange Time ISA10 R HHMM Interchange Control Standards Identifier ISA11 R U - U.S. EDI Community of ASC x12, TCDD, and UCS Interchange Control Version Number ISA12 R Draft Standards for Trial Use Approved for Publication by ASCx12 Procedures Review Board through October 1997 Interchange Control Number ISA13 R The interchange Control Number, ISA13, must be identical to the associated Interchange Trailer IEA02. Acknowledgment Requested ISA14 R B No acknowledgment requested 1 - Interchange acknowledgment requested Usage Indicator ISA15 R P - Production Data T - Test Data Component Element Separator ISA16 R This is the delimiter used to separate component data elements within a composite data structure. GS - Functional Group Header R B.8 Functional Identifier Code GS01 R HN - Health Care Claim Status Notification (277) HR - Health Care Claim Status Request (276) Application Sender s Code GS02 R Use this code to identify the unit sending the information. Application Receiver s Code GS03 R Use this code to identify the unit receiving the information. Preferred Values: //HIPAA/DSR/Comp Guides/276/ /25/2007

29 276 Transaction Set Segment Element Use Page Possible Values Description/Preferred Usage PacifiCare of Arizona = PacifiCare of California = PacifiCare of Colorado = PacifiCare of Nevada = PacifiCare of Oklahoma = PacifiCare of Oregon = PacifiCare of Texas = PacifiCare of Washington = Date GS04 R Use this date for the functional group creation date. Time GS05 R Time - HHMM Creation Time Group Control Number GS06 R B.9 Must be identical to GE02 Responsible Agency Code GS07 R X - Accredited Standards Committee X12 Version/Release/Industry Identifier Code GS08 R X093 - Draft Standards Approved for Publication by ASCx12 Procedures Review Board through October 1997, as published in the implementation guide. ST - Transaction Set Header R 49 Transaction Set Identifier Code ST01 R Eligibility, Coverage or Benefit Inquiry. Use this code to identify the transaction set ID for the transaction set that will follow the ST segment. Each X12 standard has a transaction set identifier code that is unique to that transaction set. Transaction Set Control # ST02 R 49 Assigned by requester. Must be identical to SE02. BHT - Beginning of Hierarchical Transaction R 50 Hierarchical Structure Code BHT01 R Information Source, Information Receiver, Provider of Service, Subscriber, Dependent Transaction Set Purpose Code BHT02 R Cancellation 13 - Request 36 - Authority to Deduct (Reply) Preferred Value: 13 - Request Reference Identification BHT03 Not Used 50 Not Used Date BHT04 R 50 CCYYMMDD - Transaction Set Creation Date. Transaction Set Creation Date (CCYYMMDD; established by the submitter) Time BHT05 Not Used 51 Not Used Transaction Type Code BHT06 Not Used 51 Not Used Loop 2000A - Information Source Level R 52 HL - Hierarchical Level R 52 //HIPAA/DSR/Comp Guides/276/ /25/2007

30 276 Transaction Set Segment Element Use Page Possible Values Description/Preferred Usage Hierarchical ID Number HL01 R 52 Use this sequentially assigned positive number to Unique sequentially assigned positive number for each identify each specific occurrence of an HL segment specific occurrence of the HL segment within a within a transaction set. It should begin with the number one and be incremented by one for each successive occurrence of the HL segment within transaction set. It should begin with 1 and be incremented by 1 for each subsequent HL segment within the transaction set. that specific transaction set (ST through SE). Hierarchical Parent ID Number HL02 Not Used 52 Not Used Hierarchical Level Code HL03 R Information Source Hierarchical Child Code HL04 R Additional Subordinate HL Data Segment in this Hierarchical Structure Loop 2100A - Payer Name R 54 NM1 - Individual or Organizational Name R 54 Entity Identifier Code NM101 R 54 2B - Third-Party Administrator 36 - Employer GP - Gateway Provider P5 - Plan Sponsor PR - Payer Entity Type Qualifier NM102 R Non-Person Entity Name Last or Organization Name NM103 R 55 Information Source Last or Organization Name. Use this name for the organization's name if the entity type qualifier is a non-person entity. Otherwise, use this name for the individual's last name. Use if name information is needed to identify the source of eligibility or benefit information. Preferred Value: PR - Payer Name First NM104 Not Used 55 Not Used Name Middle NM105 Not Used 55 Not Used Name Prefix NM106 Not Used 55 Not Used Name Suffix NM107 Not Used 55 Not Used Preferred Values: PacifiCare of Arizona PacifiCare of California PacifiCare of Colorado PacifiCare of Nevada PacifiCare of Oklahoma PacifiCare of Oregon PacifiCare of Texas PacifiCare of Washington Identification Code Qualifier NM108 R 55 Refer to the 276 Transaction Set Implementation Guide for a list of values. Preferred Value: PI - Payer ID Identification Code NM109 R 56 Information Source Primary Identifier. Preferred Values: PacifiCare of Arizona = PacifiCare of California = PacifiCare of Colorado = PacifiCare of Nevada = PacifiCare of Oklahoma = PacifiCare of Oregon = PacifiCare of Texas = PacifiCare of Washington = //HIPAA/DSR/Comp Guides/276/ /25/2007

31 276 Transaction Set Segment Element Use Page Possible Values Description/Preferred Usage Entity Relationship Code NM110 Not Used 56 Not Used Entity Identifier Code NM111 Not Used 56 Not Used PER - Payer Contact Information Not Used 57 Not Used Loop 2000B - Information Receiver Level R 60 HL - Hierarchical Level R 60 Hierarchical ID Number HL01 R 60 Unique sequentially assigned positive number for each specific occurrence of the HL segment within a transaction set. It should begin with 1 and be incremented by 1 for each subsequent HL segment within the transaction set. Hierarchical Parent ID Number HL02 R 60 Used to identify the specific hierarchical level to which this level is subordinate Hierarchical Level Code HL03 R Information Receiver Hierarchical Child Code HL04 R Additional Subordinate HL Data Segment in this Hierarchical Structure Loop ID 2100B - Information Receiver Name R 62 NM1 - Individual or Organizational Name R 62 Entity Identifier Code NM101 R Submitter Entity Type Qualifier NM102 R Person 2 - Non-Person Entity Name Last or Organization Name NM103 R 63 Information Receiver Last Name or Organization Name. To be defined by Trading Partner Set Up Form. Name First NM104 S 63 Information Receiver First Name. Required when NM102 = "1". Name Middle NM105 S 63 Information Receiver Middle Name. Required if additional name information is needed to identify the information receiver. Name Prefix NM106 Not Used 63 Not Used Name Suffix NM107 S 63 Information Receiver Name Suffix. Required if additional name information is needed to identify the information receiver. Identification Code Qualifier NM108 R Electronic Transmitter Identification Number (ETIN) FI - Federal Taxpayer's Identification Number Preferred Value: XX Health Care Financing Administration National Provider ID (NPI) XX - Health Care Financing Administration National Provider Identifier (when mandated for use) FI - Federal Tax ID Number Identification Code NM109 R 63 Information Receiver Identification Number. Provider's NPI, IF nm108 =- XX Federal Tax ID Number, IF nm108 = FI Entity Relationship Code NM110 Not Used 64 Not Used //HIPAA/DSR/Comp Guides/276/ /25/2007

32 276 Transaction Set Segment Element Use Page Possible Values Description/Preferred Usage Entity Identifier Code NM111 Not Used 64 Not Used Loop 2000C - Service Provider Level R 65 HL - Hierarchical Level R 65 Hierarchical ID Number HL01 R 65 Unique sequentially assigned positive number for each specific occurrence of the HL segment within a transaction set. It should begin with 1 and be incremented by 1 for each subsequent HL segment within the transaction set. Hierarchical Parent ID Number HL02 R 65 Used to identify the specific hierarchical level to which this level is subordinate. Hierarchical Level Code HL03 R Provider of Service Hierarchical Child Code HL04 R Additional Subordinate HL Data Segment in this Hierarchical Structure. Loop 2100C - Provider Name R 67 NM1 - Individual or Organizational Name R 67 Entity Identifier Code NM101 R 67 1P - Provider Entity Type Qualifier NM102 R Person 2 - Non-Person Entity Name Last or Organization Name NM103 R 68 Provider Last or Organization Name Name First NM104 S 68 Provider First Name. Required when NM102 = "1" Name Middle NM105 S 68 Provider Middle Name. Required when NM102 = "1" Name Prefix NM106 S 68 Provider Name Prefix. Required if additional name information is needed to identify the provider of service. Name Suffix NM107 S 68 Provider Name Suffix. Required if additional name information is needed to identify the provider of service. Identification Code Qualifier NM108 R 68 MII - Member Identification Number ZZ - Mutually Defined Preferred Value: MI - Member Identification Number Identification Code NM109 R 69 Provider Identifier. Note: PacifiCare will use the Federal Tax Identification Number until the National Provider Identification Number is mandated for use. Entity Relationship Code NM110 Not Used 69 Not Used //HIPAA/DSR/Comp Guides/276/ /25/2007