HeW HIPAA Transaction Standard Companion Guide

Transcription

1 HeW COMPANION GUIDE HeW HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 Version /271 Version X279A1 276/277 Version X212 August 2016

2 Disclaimer Statement: This document may be redistributed in its entirety or in parts. The content of this document may not be altered by external entities and is copy written by Health-e-Web, Inc. (HeW). The information in this document is subject to change at any time. It is the responsibility of the reader to verify the correct version is referencing a downloaded copy. The most recent versions of HeW Companion Guides will be posted on the HeW web site:. 2

3 2015 HeW All rights reserved. Preface This Companion Guide to the v5010 ASC X12N Implementation Guides adopted under HIPAA clarifies and specifies the data content being requested when data is transmitted electronically to the HeW clearinghouse. Transmissions based on this companion document, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. 3

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5 Table of Contents 1 - Introduction Scope Overview References Additional Information GETTING STARTED Working with HeW Trading Partner Registration Certification and Testing Overview TESTING WITH HEW Testing and Training Test File Requirements CONNECTIVITY WITH THE SENDER/COMMUNICATIONS Process Flows Transmission Administrative Procedures... 9 System Availability... 9 File Naming Convention... 9 Special Characters Re-Transmission Procedures Communication Protocol Specifications Passwords CONTACT INFORMATION EDI Customer Service EDI Technical Assistance Provider Service Number Applicable Web Sites/ Addresses

6 6 - CONTROL SEGMENTS / ENVELOPES ISA IEA (270/271) GS GE (270/271) ST SE (270/271) ISA IEA (276/277) GS GE (276/277) ST SE (276/277) HEW SPECIFIC BUSINESS RULES AND LIMITATIONS ACKNOWLEDGEMENTS AND/OR REPORTS Report Inventory TRADING PARTNER AGREEMENTS Trading Partners TRANSACTION SPECIFIC INFORMATION Eligibility Enrollment Subscriber ID s for BCBSMT APPENDICES Appendix A Implementation Checklist Appendix B Business Scenarios Appendix C 270 Request Example Appendix D 271 Response Example Appendix F 277 Response Example Appendix G Frequently Asked Questions Appendix H Change Summary

7 1 - Introduction The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carry provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care senders and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard. 1.1 Scope The intended purpose of this HIPAA EDI Transaction Standard Companion Guide is to explain the procedures necessary for Trading Partners of HeW to transmit Electronic Data Interchange (EDI) transactions. These transactions include: o Health Care Eligibility Benefit Inquiry and Response 270/271 o Health Care Claim Status Request and Response 276/277 This Companion Guide is not intended to replace the v5010 ASC X12N Implementation Guides; rather it is intended to be used in conjunction with them. Additionally, the Companion Guide is intended to convey information that is within the framework and structure of the X12N Implementation Guides and not to contradict or exceed them. 1.2 Overview This document will replace any previous HeW 270/271 and 276/277 companion guide(s) and must be used in conjunction with the TR3 instructions. This document s intent is to assist trading partners of HeW in implementing the 270/271 and/or 276/277 transactions and meet the processing standards of HeW, by identifying necessary structural and/or data requirements and recommendations. 1.3 References For detailed information and standards for electronic submission of ANSI transactions, please reference the following documents: ANSI v5010 ASC X12N Implementation Guides, which can be purchased at Additional Information The intended audiences for this document are technical and operational staff responsible for generating, receiving, and reviewing electronic health care transactions. 2 - GETTING STARTED 2.1 Working with HeW 7

8 An entity that wants to send or receive transactions via the HeW Clearinghouse must contract with HeW. This is done by contacting the HeW Support Center (see Section 5.1) for coordination of all Trading Partner Agreements, Service Agreement Amendments (for existing clients), contracting and site setup, which includes assignment of a submitter ID and password. The HeW clearinghouse offers connectivity to multiple payers for 270/271 and 276/277 transactions. Payer availability is dependent on contract provisions with HeW. 2.2 Trading Partner Registration An EDI Trading Partner is defined by HeW as any clearinghouse, billing service, software vendor, payer etc. that transmits to, or receives electronic data from HeW. (See section 2.1 for information on contracting with HeW.) 2.3 Certification and Testing Overview Each Trading Partner must go through a testing phase to validate the format of the data being produced. The length of the testing phase and the final approval of the sender for production are governed by HeW. Once a sender is placed in production status, the ability to submit test data must be coordinated with HeW. Significant changes in the sender s system may require another test phase. 3 - TESTING WITH HEW 3.1 Testing and Training When the Trading Partner s setup is complete, testing and training staff will be assigned. This staff will assist the Trading Partner during the testing phase and arrange any necessary system training. 3.2 Test File Requirements Test files should consist of a variety of scenarios that represent the types or varieties of transactions the Trading Partner will be submitting once production status is achieved. Test transactions will not be processed in a production environment but will be validated against production tables, so they must contain valid procedure, diagnosis, eligibility/claim status payer IDs and sender information. HeW will provide test subscriber ID data that must be used in the test transactions to produce realistic responses. Payer IDs to be used in 270 / 276 files are located on the HeW web site Payer List page (/payer-list). 4 - CONNECTIVITY WITH THE SENDER/COMMUNICATIONS 4.1 Process Flows Trading Partner Registration Testing Phase Production Status 270 / 276 Transactions Submitted 271 / 277 Transactions Returned 8

9 4.2 Transmission Administrative Procedures System Availability The HeW servers are available for transaction submission 24 hours a day, 7 days a week, including Holidays where our Support Center is closed (see Section 5.1). HeW Systems maintenances are scheduled from 6:00 a.m. to 12:00 p.m. Mountain Time Zone on Saturday and notification is made available on the HeW web site home page () and via addresses we have on file. File Naming Convention All Trading Partners exchanging transactions via FTP will need to adhere to the following naming convention: File names must be unique beginning with the 4-character Submitter ID, as assigned by HeW, followed by a unique sequence number and the applicable file extension. The full file name, including the extension, is not to exceed 30 characters. Please note that file names must be unique for 366 days. File extensions have intelligence for identification of type of file Inbound:.270 = Eligibility Request.276 = Claim Status Request Special Characters Files should not contain trailing spaces. Significant characters as a tilde (~), colon (:), asterisk (*), parenthesis ( ), tick (`) or ( ) or quote ( ) cannot be used. Example: A telephone number (406) HeW recommends using no special characters if at all possible. 4.3 Re-Transmission Procedures Trading Partners can re-transmit a transaction at any time. Trading Partners exchanging transactions via FTP will need to adhere to the HeW file naming convention (see Section 7.1). 4.4 Communication Protocol Specifications HeW currently maintains the following communication protocols for batch and real-time transactions. The options are listed in order of preference for use: FTP File Transfer Protocol. HTTPS POST (single, real-time transactions) Web Service (single, real-time transactions) 9

10 Setup and support fees may be charged for any of the options listed. Charges will depend on the initial work efforts required to establish communications and the amount of continued support required to maintain the communications link. HeW will work with each client to determine which protocol will work best for them and identify any associated costs. Contact HeW for alternative communication methods (see Section 5.1). 4.5 Passwords HeW will assign a username and password to the Trading Partner during testing. 5 - CONTACT INFORMATION 5.1 EDI Customer Service The HeW Support Center is staffed between the hours of 6:00 AM and 6:00 PM Mountain Time, Monday through Friday, excluding Holidays. HeW recognizes the following Holidays each year: New Year s Day, Dr. Martin Luther King Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the day after Thanksgiving Day, Christmas Eve, and Christmas Day. Transactions can still be sent on Holidays even though our Support Center is closed. See Section 4.2 for HeW System maintenance schedules. Phone: HeWSupport@availity.com The Contact HeW Staff feature on the HeW website () under the Support link is available, 24 hours a day, 7 days a week. 5.2 EDI Technical Assistance See Section Provider Service Number See Section Applicable Web Sites/ Addresses HeW Web Site - HeW Companion Guides - HeW Support Center HeWSupport@availity.com HeW Enrollment Department HeWEnrollment@availity.com ASC X12 Guides Washington Publishing Company 10

11 6 - CONTROL SEGMENTS / ENVELOPES Page 6.1 ISA IEA (270/271) Loop ID C.4 ISA05 Ref Name Codes Length Notes Interchange ID Qualifier C.4 ISA06 Interchange Sender ID Sender Tax ID C.4 & C.5 ISA07 C.5 ISA08 C.5 ISA13 C.10 IEA GS GE (270/271) Interchange ID Qualifier Interchange Receiver ID Interchange Control Number Interchange Control Number ZZ Mutually Defined The sender is the entity that physically transmits a file. US Federal Tax Identification Number HeW s Tax ID, designated as the Receiver ID Must be identical to IEA02 Must be identical to ISA13 Page Loop ID Ref Name Codes Length Notes C.7 GS01 Functional Identifier Code HS / HB 2 HS=270 / HB=271 C.7 GS02 Application Sender Code Sender Tax ID Same as ISA06. C.7 GS03 Application Receiver Code Same as ISA08. C.8 GS06 Group Control Number Must be identical to GE C TRN02 Subscriber Trace Number D TRN02 Dependent Trace Number A NM101 Payer Name - Payer is currently the only value Information Source PR accepted by HeW Qualifier A NM108 Payer Identifier PI Payer ID is currently the only value A NM B NM108 Information Source Primary Identifier Identification Code Qualifier XX accepted by HeW Payer ID see HeW Eligibility Payer List Qualifier for NPI 11

12 Information Receiver HeW is only accepting the NPI B NM109 NPI Number ID Number number of the requestor. 521 GE02 Group Control Number Must be identical to the GS ST SE (270/271) HeW has no further information required outside of the normal IG requirements. 6.4 ISA IEA (276/277) Page Loop ID C.4 ISA05 Ref Name Codes Length Notes Interchange ID Qualifier C.4 ISA06 Interchange Sender ID Sender Tax ID C.5 ISA07 C.5 ISA08 C.5 ISA13 C.10 IEA GS GE (276/277) Interchange ID Qualifier Interchange Receiver ID Interchange Control Number Interchange Control Number ZZ Mutually Defined The sender is the entity that physically transmits a file. US Federal Tax Identification Number HeW s Tax ID, designated as the Receiver ID Must be identical to IEA02 Must be identical to ISA13 Page Loop ID Ref Name Codes Length Notes C.7 & Functional Identifier GS01 D.1 Code HR / HN 2 HR=276 / HN = 277 C.7 GS02 Application Sender s Code Sender Tax ID Same as ISA06. C.7 GS03 Application Receiver Code Same as ISA08. C.8 GS06 Group Control Number Must be identical to GE B NM108 Identification Code Qualifier B NM109 Information Receiver HeW Submitter ID Number ID D TRN02 Current Transaction Trace Number E TRN02 Current Transaction Trace Number 12

13 A NM A NM108 Payer Name Entity Identifier Qualifier Identification Code Qualifier A NM109 Payer Identifier C NM108 Identification Code Qualifier PR PI XX Payer is currently the only value accepted by HeW Payer ID see HeW Eligibility Payer List Qualifier for NPI C NM109 Provider Identifier HeW is only accepting the NPI number. C.9 GE02 Group Control Number Must be identical to GS ST SE (276/277) HeW has no further information required outside of the normal IG requirements. 7 - HEW SPECIFIC BUSINESS RULES AND LIMITATIONS None at this time. 8 - ACKNOWLEDGEMENTS AND/OR REPORTS 8.1 Report Inventory 999 reports 9 TRADING PARTNER AGREEMENTS 9.1 Trading Partners An EDI Trading Partner is defined as any HeW customer (provider, facility, billing service, software vendor, employer group, financial institution, etc.) that transmits to, or receives electronic data from HeW. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a later agreement, between each party to the agreement. For example a Trading Partner Agreement may specify among other things, the roles and responsibilities of each party to the agreement in conducting standard transmissions. 10 TRANSACTION SPECIFIC INFORMATION 10.1 Eligibility Enrollment 13

14 Please see our Payer List web page on our web site for any Eligibility and Claim Status payers that require enrollment Subscriber ID s for BCBSMT When submitting eligibility or claim status requests to BCBSMT the appropriate prefix must be used on the subscriber ID. Transactions submitted without the appropriate prefix may not receive accurate responses Place of Treatment for BCBSMT To receive eligibility response data that is specific to a Place of Treatment, it is recommended that an III segment be used. If the patient relationship to the insured is self (18), send the III segment in the 2110C Loop. If the patient relationship to the insured is not self (18), send the III segment in the 2110D Loop. These are the codes that are allowed to use for service type 30 (Sent in the EQ segment). III01 is ZZ III02 will either be 11, 21, 22 or 23. For other service types please contact HeW for assistance Service Types and Place of Treatment for HCSC EQ01 Service Type 1 - Medical Care 2 - Surgical 3 - Consultation 4 - Diagnostic X-Ray Place of Treatment 14

15 EQ01 Service Type 5 - Diagnostic Lab 6 - Radiation Therapy 7 - Anesthesia 8 - Surgical Assistance 10 - Blood Charges 12 - Durable Medical Equipment Purchase Place of Treatment 13 - Ambulatory Service Center Facility 18 - Durable Medical Equipment Rental 20 - Second Surgical Opinion 15

16 EQ01 Service Type 30 - Health Benefit Plan Coverage 33 - Chiropractic 40 - Oral Surgery 42 - Health Care 44 - Health Visits 45 - Hospice 47 - Hospital Place of Treatment 48 - Hospital Hospital - Room and Board 50 - Hospital Hospital - Emergency Accident 52 - Hospital - Emergency Medical 53 - Hospital - Ambulatory Surgical 57 - Air Transportation 59 - Licensed Ambulance 60 - General Benefits 16

17 EQ01 Service Type 61 - In-vitro Fertilization 62 - MRI/CAT Scan 64 - Acupuncture Place of Treatment 65 - Newborn Care 66 - Pathology 68 - Well Baby Care 69 - Maternity 71 - Audiology Exam 72 - Inhalation Therapy 73 - Diagnostic Medical 74 - Private Duty Nursing 75 - Prosthetic Device 17

18 EQ01 Service Type 76 - Dialysis 78 - Chemotherapy 79 - Allergy Testing 80 - Immunizations 81 - Routine Physical 82 - Family Planning 83 - Infertility 84 - Abortion 86 - Emergency Services 88 - Pharmacy 93 - Podiatry 97 - Anesthesiologist Place of Treatment Emergency room 98 - Professional (Physician) Visit - 18

19 EQ01 Service Type Place of Treatment 99 - Professional (Physician) Visit - A0 - Professional (Physician) Visit - A3 - Professional (Physician) Visit - A6 - Psychotherapy A7 - Psychiatric A8 - Psychiatric AD - Occupational Therapy AE - Physical Medicine AF - Speech Therapy AG - Skilled Nursing Care AH - Skilled Nursing Care - Room and Board AI - Substance Abuse AL - Vision (Optometry) AM - Frames AN - Routine Exam AO - Lenses BB - Partial Hospitalization (Psychiatric) Emergency room Emergency room 19

20 EQ01 Service Type BC - Day Care (Psychiatric) BG - Cardiac Rehabilitation BH - Pediatric BT - Gynecological BU - Obstetrical BV - Obstetrical/Gynecological BY - Physician Visit - : Sick BZ - Physician Visit - : Well CA - Private Duty Nursing CB - Private Duty Nursing CC Surgical Benefits Professional (Physician) CD Surgical Benefits Facility CE - MH Provider - CF - MH Provider - CG - MH Provider Facility - CH - MH Provider Facility - CI - Substance Abuse Facility - CJ - Substance Abuse Facility - CK - Screening X-ray Place of Treatment Emergency room 20

21 EQ01 Service Type CL - Screening Laboratory CM - Mammogram, HR Patient CN - Mammogram, LR Patient CO - Flu Vaccination DM - Durable Medical Equipment MH - Mental Health ON - Oncology PT - Physical Therapy UC - Urgent Care Place of Treatment APPENDICES Appendix A Implementation Checklist Obtain ASC X Implementation Guides on the Washington Publishing Company web site ( and the ASC X12 TR3 Implementation Guides at Signed HeW Service Agreement Pass testing for each line of business Complete Payer EDI Paperwork 21

22 Training (if applicable) Appendix B Business Scenarios No business scenarios at this time. Appendix C 270 Request Example ISA*00* *00* *ZZ* *30* *130221*0000*^*00501* *0*P*:~ GS*HS* *CMS* *1417*0*X*005010X279A1~ ST*270*0001*005010X279A1~ BHT*0022*13* * * ~ HL*1**20*1~ NM1*PR*2*MEDICARE*****PI*10001~ HL*2*1*21*1~ NM1*1P*1*JONES*JOE*J***XX* ~ N3*1234 MAIN STREET~ N4*PHOENIX*AZ*65000~ HL*3*2*22*0~ TRN*1* *WXYZCLEARH~ NM1*IL*1*SMITH*JANE****MI* A~ REF*SY* ~ DMG*D8* *F~ DTP*291*D8* ~ EQ*30~ SE*16*0001~ GE*1*0~ IEA*1* ~ Appendix D 271 Response Example ISA*00* *00* *ZZ* *ZZ* *130506*1429*^*00501* *0*P*:~ GS*HB* * * *1429* *X*005010X279A1~ ST*271* *005010X279A1~ BHT*0022*11* * *1429~ HL*1**20*1~ NM1*PR*2*SOMEONE INSURANCE*****PI*88888~ HL*2*1*21*1~ NM1*1P*2*WE CARE FOR YOU CLINIC*****XX* ~ HL*3*2*22*0~ TRN*2* *9PASSPORTH~ NM1*IL*1*DOE*JOHN****MI* ~ REF*6P* ~ 22

23 DMG*D8* ~ DTP*346*D8* ~ EB*1**1^30^59^86^50^98^UC^48^CG^33^CF^47^MH**EMPLOYER PLAN NAME~ EB*G*IND*30**EMPLOYER PLAN NAME*29*1500*****Y~ EB*G*FAM*30**EMPLOYER PLAN NAME*29* *****Y~ EB*G*IND*30**EMPLOYER PLAN NAME*29*3000*****Y~ EB*G*FAM*30**EMPLOYER PLAN NAME*29* *****Y~ EB*G*IND*30**EMPLOYER PLAN NAME*29*9100*****N~ EB*G*FAM*30**EMPLOYER PLAN NAME*29*19100*****N~ EB*C*IND*30**EMPLOYER PLAN NAME*29*300*****Y~ EB*C*FAM*30**EMPLOYER PLAN NAME*29*166.38*****Y~ EB*C*IND*30**EMPLOYER PLAN NAME*29*500*****Y~ EB*C*FAM*30**EMPLOYER PLAN NAME*29*366.38*****Y~ EB*C*IND*30**EMPLOYER PLAN NAME*29*0*****N~ EB*C*FAM*30**EMPLOYER PLAN NAME*29*0*****N~ EB*G*IND*30**EMPLOYER PLAN NAME*22*1500*****Y~ EB*G*FAM*30**EMPLOYER PLAN NAME*22*2500*****Y~ EB*G*IND*30**EMPLOYER PLAN NAME*22*3000*****Y~ EB*G*FAM*30**EMPLOYER PLAN NAME*22*5000*****Y~ EB*G*IND*30**EMPLOYER PLAN NAME*22*10000*****N~ EB*G*FAM*30**EMPLOYER PLAN NAME*22*20000*****N~ EB*C*IND*30**EMPLOYER PLAN NAME*22*300*****Y~ EB*C*FAM*30**EMPLOYER PLAN NAME*22*600*****Y~ EB*C*IND*30**EMPLOYER PLAN NAME*22*500*****Y~ EB*C*FAM*30**EMPLOYER PLAN NAME*22*1000*****Y~ EB*C*IND*30**EMPLOYER PLAN NAME*22*700*****N~ EB*C*FAM*30**EMPLOYER PLAN NAME*22*1400*****N~ EB*B**59***27*0.00*****Y~ EB*A**59*****0.3****Y~ 23

24 EB*B**59***27*0.00*****N~ EB*A**59*****0.3****N~ EB*B**86***27*150.00*****Y~ MSG*EMERGENCY~ EB*A**86*****0.0****Y~ MSG*EMERGENCY~ EB*B**86***27*150.00*****Y~ MSG*EMERGENCY~ EB*A**86*****0.0****Y~ MSG*EMERGENCY~ EB*B**86***27*150.00*****N~ MSG*EMERGENCY~ EB*A**86*****0.0****N~ MSG*EMERGENCY~ EB*B**50***27*0.00*****Y~ EB*C*IND*50****300.00*****Y~ EB*C*FAM*50****600.00*****Y~ EB*A**50*****0.1****Y~ EB*B**50***27*0.00*****N~ EB*C*IND*50****700.00*****N~ EB*C*FAM*50**** *****N~ EB*A**50*****0.5****N~ EB*B**98***27*20.00*****Y~ MSG*PRIMARY CARE~ EB*B**98***27*40.00*****Y~ MSG*SPECIALIST~ EB*A**98*****0.0****Y~ EB*B**98***27*20.00*****Y~ MSG*PRIMARY CARE~ EB*B**98***27*40.00*****Y~ MSG*SPECIALIST~ EB*A**98*****0.0****Y~ 24

25 EB*B**98***27*0.00*****N~ MSG*PRIMARY CARE~ EB*C*IND*98****700.00*****N~ EB*C*FAM*98**** *****N~ EB*A**98*****0.5****N~ EB*B**UC***27*40.00*****Y~ EB*A**UC*****0.0****Y~ EB*B**UC***27*40.00*****Y~ EB*A**UC*****0.0****Y~ EB*B**UC***27*0.00*****N~ EB*C*IND*UC****700.00*****N~ EB*C*FAM*UC**** *****N~ EB*A**UC*****0.5****N~ EB*B**48***27*150.00*****Y~ EB*C*IND*48***23*300.00*****Y~ EB*C*FAM*48***23*600.00*****Y~ EB*A**48*****0.1****Y~ EB*B**48***27*150.00*****Y~ EB*C*IND*48***23*300.00*****Y~ EB*C*FAM*48***23*600.00*****Y~ EB*A**48*****0.1****Y~ EB*B**48***27*300.00*****Y~ EB*C*IND*48***23*500.00*****Y~ EB*C*FAM*48***23* *****Y~ EB*A**48*****0.3****Y~ EB*B**48***27*600.00*****N~ EB*C*IND*48***23*700.00*****N~ EB*C*FAM*48***23* *****N~ EB*A**48*****0.5****N~ 25

26 26 EB*B**CG***27*150.00*****Y~ EB*C*IND*CG***23*300.00*****Y~ EB*C*FAM*CG***23*600.00*****Y~ EB*A**CG*****0.1****Y~ EB*B**CG***27*150.00*****Y~ EB*C*IND*CG***23*300.00*****Y~ EB*C*FAM*CG***23*600.00*****Y~ EB*A**CG*****0.1****Y~ EB*B**CG***27*300.00*****Y~ EB*C*IND*CG***23*500.00*****Y~ EB*C*FAM*CG***23* *****Y~ EB*A**CG*****0.3****Y~ EB*B**CG***27*600.00*****N~ EB*C*IND*CG***23*700.00*****N~ EB*C*FAM*CG***23* *****N~ EB*A**CG*****0.5****N~ EB*B**33***27*40.00*****Y~ EB*F**33***23***VS*20**Y~ EB*A**33*****0.0****Y~ EB*B**33***27*40.00*****Y~ EB*F**33***23***VS*20**Y~ EB*A**33*****0.0****Y~ EB*B**33***27*0.00*****N~ EB*F**33***23***VS*20**N~ EB*C*IND*33***23*700.00*****N~ EB*C*FAM*33***23* *****N~ EB*A**33*****0.5****N~ EB*B**CF***27*40.00*****Y~

27 27 EB*F**CF***23***VS*20**Y~ EB*A**CF*****0.0****Y~ EB*B**CF***27*0.00*****N~ EB*F**CF***23***VS*20**N~ EB*C*IND*CF***23*700.00*****N~ EB*C*FAM*CF***23* *****N~ EB*A**CF*****0.5****N~ EB*B**CF***27*40.00*****Y~ EB*F**CF***23***VS*20**Y~ EB*A**CF*****0.0****Y~ EB*B**50***27*0.00*****Y~ EB*C*IND*50****300.00*****Y~ EB*C*FAM*50****600.00*****Y~ EB*A**50*****0.3****Y~ EB*G*IND*30**EMPLOYER-RXD*24*0*****Y~ EB*G*FAM*30**EMPLOYER-RXD*24*0*****Y~ EB*G*IND*30**EMPLOYER-RXD*24*0*****Y~ EB*G*FAM*30**EMPLOYER-RXD*24*0*****Y~ EB*G*IND*30**EMPLOYER-RXD*24*0*****N~ EB*G*FAM*30**EMPLOYER-RXD*24*0*****N~ EB*C*IND*30**EMPLOYER-RXD*24*0*****Y~ EB*C*FAM*30**EMPLOYER-RXD*24*0*****Y~ EB*C*IND*30**EMPLOYER-RXD*24*0*****Y~ EB*C*FAM*30**EMPLOYER-RXD*24*0*****Y~ EB*C*IND*30**EMPLOYER-RXD*24*0*****N~ EB*C*FAM*30**EMPLOYER-RXD*24*0*****N~ SE*239* ~ GE*1* ~

28 IEA*1* ~ Appendix E 276 Request Example ISA*00* *00* *ZZ* *30* *130227*1050*^*00501* *0*P*>~ GS*HR* *BCBS* *1050*120001*X*005010X212~ ST*276*00023*005010X212~ BHT*0010*13*00023* *1050~ HL*1**20*1~ NM1*PR*2*BLUE CROSS BLUE SHIELD MT*****PI*BCBS~ HL*2*1*21*1~ NM1*41*2*WE CARE FOR YOU CLINIC*****46*HEW1~ HL*3*2*19*1~ NM1*1P*2*WE CARE FOR YOU CLINIC*****XX* ~ HL*4*3*22*0~ DMG*D8* *F~ NM1*IL*1*QUEUE*SUZIE*A***MI*XYZ ~ TRN*1*00023_C BB1~ REF*EJ*C BB1~ REF*BLT*131~ AMT*T3*71~ DTP*472*RD8* ~ SE*17*00023~ GE*1*120001~ IEA*1* ~ Appendix F 277 Response Example ISA*00* *00* *30* *ZZ*HEW1 *130104*1514*^*00501* *1*P*:~ GS*HN* *1234* *151455*1*X*005010X214~ ST*277*0001*005010X214~ BHT*0085*08*HEW102S9.EAP * *1514*TH~ HL*1**20*1~ NM1*PR*2*HEALTH E WEB*****46* ~ TRN*1* ~ DTP*050*D8* ~ DTP*009*D8* ~ HL*2*1*21*1~ NM1*41*2*WE CARE FOR YOU CLINIC*****46*HEW1~ TRN*2*HEW102S9.EAP ~ STC*A1:20* *WQ*134.00~ QTY*AA*1~ AMT*YY*134.00~ HL*3*2*19*1~ NM1*85*2*WE CARE FOR YOU CLINIC*****XX* ~ 28

29 TRN*1*0~ STC*A1:20**U*134.00~ QTY*QC*1~ AMT*YY*134.00~ HL*4*3*PT~ NM1*QC*1*QUEUE*SUZIE*R***MI* ~ TRN*2* ~ STC*A3:21* *U*134.00~ REF*D9* ~ DTP*472*RD8* ~ SE*26*0001~ GE*1*1~ IEA*1* ~ Appendix G Frequently Asked Questions Q: Do you accept batch transactional files? A: Yes, HeW can accept single transaction files through our Real Time server or batch transaction files through sftp. Appendix H Change Summary Version # Page Date Reason Author V 1.0 All 07/26/2012 Initial 5010 document HeW V 1.1 All 05/10/2013 Revised for CORE specifications Michelle Palermo V 1.2 Pages 9 & 10 08/22/2013 Updated sections to add Holiday information Michelle Palermo V 1.3 Page 9 11/27/2013 Updated Process Flows & Added III Information Michelle Palermo V 1.4 Pages /03/2014 Added Section 10.4 Michelle Palermo V 1.5 Page 10 08/13/2015 Updated Companion Guide web page Michelle Palermo V 1.6 Page 11, cover, footers 08/16/2016 link and HeW addresses Removed phone number extension. Adjusted Support . Michelle Palermo / DL 29