Maryland Health Insurance Exchange (MHBE) Standard Companion Guide Transaction Information

Transcription

1 A service of the Maryland Health Benefit Exchange Maryland Health Insurance Exchange (MHBE) Standard Companion Guide Transaction Information 999 Implementation Acknowledgments for Health Care Insurance Version-1.0 Companion Guide Version: 1.0 July 24, 2013

2 Maryland Health Benefit Exchange PREFACE This Companion Guide to the v5010 Accredited Standards Committee (ASC) X12N Implementation Guides and associated errata adopted under Health Insurance Portability and Accountability Act (HIPAA) clarifies and specifies the data content when exchanging electronically. Transmissions based on this companion guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC 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. This Companion Guide is based on, and must be used in conjunction with, the ASC X12 X12N/005010X231A1. See Error! Reference source not found. for ASC X12 TR3 Implementation uides. The Companion Guide clarifies and specifies specific transmission requirements for exchanging data. The instructions in this companion guide conform to the requirements of the TR3, ASC X12 syntax and semantic rules and the ASC X12 Fair Use Requirements. In case of any conflict between this Companion Guide and the instructions in the Type 3 Technical Report (TR3), the TR3 takes precedence. 999 Companion Guide Version 1.0 i

3 Maryland Health Benefit Exchange Disclaimer Companion Guides (CG) are documents created to supplement ASC X12 TR3. TR3s, commonly known as Implementation Guides (IG), define the data content and format for specific business purposes. This CG was created for distribution to health care issuers, clearinghouses, and software vendors. The instructions in this CG are not intended to be stand-alone requirements, the CG must be used in conjunction with the ASC X12/005010X231A1 Healthcare Insurance Exchange Related Payments (820) TR3 and any associated Addenda. ASC X12 TR3s are copyrighted documents and may be purchased at the ASCX12 website. See Error! Reference source not found. for ASCX12 website link. 999 Companion Guide Version 1.0 ii

4 Maryland Health Benefit Exchange TABLE OF CONTENTS Change Summary Getting Started TRADING PARTNER PROFILE Testing TESTING OVERVIEW TESTING PROCESS Connectivity TRANSMISSION SPECIFICS Delimiters: Control Numbers: Processing Capabilities: File Rejection Reasons: Contact Information Acknowledgement (999) Acknowledgements MHC Specific Business Rules and Limitations GENERAL BUSINESS RULES BUSINESS RULES FOR THE 999 IN RESPONSE TO ENROLLMENT FILES BUSINESS RULES FOR THE 999 IN RESPONSE TO PREMIUM FILES Acronyms/Glossary Table of Tables Table 1: Document History... 4 Table 2: Exchange Enrollment Other Resources... Error! Bookmark not defined. Table 3: X231A1 Implementation Acknowledgement Table 4: Acronyms/Glossary Table of Figures No table of figures entries found. 999 Companion Guide Version 1.0 iii

5 Change Summary Table 1: Document History Date Version Document Revision Description Document Author 7/24/ Initial Release Noridian 999 Companion Guide Version 1.0 4

6 1. Getting Started In order to send and/or receive transactions, Trading Partners (clearinghouses, qualified health plan (QHP) issuers, and Third Party Administrator (TPA)s must complete a trading partner agreement, exchange profile information and establish connectivity. In this companion guide; Chapter 2 Testing, Chapter 3 Connectivity, and Chapter 4 Contact Information, document the integration setup. 1.1 Trading Partner Profile To establish a Trading Partner Profile the trading partner completes and signs a Trading Partner Agreement form and submits it to MHC for processing. Electronic Data Interchange (EDI) interface will be set up and tested with the trading partner. The first step that MHC will take is to establish Trading Partner Profile(s). The MHC team will configure a test profile for one or more EDI interfaces with the Trading Partner. A Trading Partner with multiple data centers must acquire multiple Trading Partner Profiles. Once the EDI interface(s) have been successfully tested, the MHC team will notify MHC to open the Trading Partner s QHP for enrollment and will switch the Trading Partner Profile to a production status. 999 Companion Guide Version 1.0 5

7 2. Testing Syntax Integrity and Syntax Requirement specifications must be met in order for 999 transactions to be processed in a production mode. The MHC team will work with Trading Partners (clearinghouses, QHP Issuers and SBEs) throughout the testing process. 2.1 Testing Overview Testing is conducted to ensure compliance with Health Insurance Portability and Accountability Act (HIPAA) guidelines as related to: Syntactical integrity: EDI files must pass verification checks related to valid segment use, segment order, element attributes, proper transmission of numeric values, validation of ASC X12 syntax, and compliance with ASC X12 rules. Syntactical requirements: EDI files must be validated for compliance with HIPAA Implementation Guide-specific syntax requirements, such as limits on repeat counts and the use of qualifiers, codes, elements and segments. Testing will also verify intra-segment situational data elements, non-medical code sets and that values and codes are used according to the Implementation Guide instructions. Testing is conducted to ensure compliance with MHC guidelines, as related to following: Syntactical integrity: EDI files must pass verification checks related to valid segment use, segment order, element attributes, proper transmission of numeric values, validation of ASC X12 syntax, and compliance with ASC X12 rules. Syntactical requirements: EDI files must be validated for compliance with HIPAA Implementation Guidespecific syntax requirements, such as limits on repeat counts and the use of qualifiers, codes, elements and segments. Testing will also verify intra-segment situational data elements, non-medical code sets and that values and codes are used according to the Implementation Guide instructions. Additional testing may be required when the system is upgraded, when business requirements change, or when new versions of the ASC X implementation guide are implemented. 2.2 Testing Process The Trading Partners have the ability to call MHC via the Contact Information Section. The standard testing process is outlined in steps 1 through 7: 1. The Trading Partner downloads the 999 Companion Guides and Trading Partner Enrollment package 2. The Trading Partner completes and signs the Trading Partner Agreement and submits the signed agreement to MHC. 3. The MHC QA team coordinates the linkage between the Trading Partner Submitter Identifier and passwords. The MHC QA team then notifies the Trading Partner of this linkage. 4. The MHC QA team provides a limited number of initial test files to the Trading Partner for processing. The Trading Partner downloads the files via Secure File Transfer Protocol (SFTP). 5. The Trading Partner provides 999 test files to MHC for validation. 6. If the both MHC and the Trading Partner s 999 are successfully validated, the test is considered successful and the trading partner is approved to begin processing 999 files in the production environment. 7. If issues or errors are identified in steps 4 or 5, the test is not considered successful. The MHC team and the Trading Partner(s) will work together until the issues are resolved and a successful test is completed without errors or issues. 999 Companion Guide Version 1.0 6

8 3. Connectivity Trading Partners will connect to [the Exchange s] SFTP server for all EDI transactions (enrollment, acknowledgement, payment, etc.) via the [File Transfer (EFT) system] which is a batch system. Each Trading Partner is assigned a Submitter Identifier in the EFT system, which allows access to an Inbox and an Outbox. The Trading Partner and MHBE will use these folders to pick up and drop off data files. 3.1 Transmission Specifics Delimiters: MHC is not establishing a requirement or preference for delimiters on inbound transactions Control Numbers: MHC is not establishing specific requirements for the ISA, GS and ST control numbers, other than a rule that at least one of the control numbers must increment from one day to the next. However, since the ASC X12C005010X231 Implementation Acknowledgement for Health Care Insurance (999) transaction does not reflect the ISA control number, it is necessary for one or both of the GS and ST control numbers to increment from day to day Processing Capabilities: MHC has the ability to accept multiple processing capabilities: Submissions in one day. ISA-IEA envelopes within a single physical file. GS-GE envelopes within a single ISA-IEA interchange. ST-SE envelopes within a single GS-GE functional group File Rejection Reasons: The entire submission will be rejected in the following situations: Submission of data that is not valid based on the TR3. Submission of a segment or data element specified in the TR3 as Not Used. Submission of non-unique values in the ST02 or GS06 Control Number elements. 999 Companion Guide Version 1.0 7

9 4. Contact Information Trading Partners that need to interact with customer support shall be able to contact MHC customer support at the following telephone number and address: Telephone: TBD TBD 999 Companion Guide Version 1.0 8

10 5. Acknowledgement (999) Table 2 Notes: Observe the HIX Information columns of Table. The columns labeled Min/Max, Usage and Acceptable Values = all define what MHC Information will be using for processing. There may be a difference in the usage of the item documented and the same item in the HIPAA X231A1.Iin such case, the HIX Information prevails. Any data element who s Usage is Not Considered for Processing (NCFP). The meaning of NCFP is that the sender may send the data, but the will not use or save the data. 999 Companion Guide Version 1.0 9

11 Segments and Data s ISA - INTERCHANGE CONTROL HEADER ISA INTERCHANG E CONTROL HEADER HDR 1 R N/A ISA01 Authorization Information ID 2-2 R 00 = No authorization required Qualifier ISA02 Authorization Information AN R Spaces ISA03 ISA04 ISA05 ISA06 ISA07 ISA08 ISA09 ISA10 ISA11 ISA12 Security Information Qualifier Security Information Interchange ID Qualifier Interchange Sender ID Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time Repetition Separator Interchange Control Version ID 2-2 R 00 = No Authorization Present AN R Spaces ID 2-2 R ZZ = Mutually Defined AN R M Must be fixed length, padded with spaces. Document in Trading Partner Agreement ID R ZZ = Mutually Defined AN R Must be 15 in length and padded with spaces. Document in Trading Partner Agreement DT 6-6 R YYMMDD TM 4-4 R HHMM R ^ ID 5-5 R = Standards Approved for publication 999 Companion Guide Version

12 Segments and Data s ISA13 ISA14 Number Interchange Control Number Acknowledgem ent Requested by ASC X12 procedures Review Board through October 2003 NO 9-9 R Unique 9-digit number with leading zeroes. Started at and incremented by 1 for each successive Interchange from Sender to Receiver. Do not reset to a starting value of within each Transmission or each day. ID 1-1 R 0 = Interchange Acknowledgement Requested (TA1) ISA15 Usage Indicator ID 1-1 R P = Production Data T = Test Data ISA16 Component Separator AN 1-1 R GS Functional Group Header GS GS01 GS02 GS03 Functional Group Header Functional Identifier Code Application Sender's Code Application Receiver's Code - HDR 1 R This concerns a 999 that is not expecting or requesting TA1 responses. ID 2-2 R FA = Functional or Implementation Acknowledgement s (997,999) AN 2-15 R MHC will send the same value as ISA06. AN 2-15 R MHC will send the same value as ISA08. GS04 Date DT 8-8 R CCYYMMDD CURRENT-DATE 999 Companion Guide Version

13 Segments and Data s GS05 Time TM 4-8 R HHMM CURRENT-TIME GS06 GS07 Group Control Number Responsible Agency Code NO 1-9 R DDDnnnnnn MHC will send only one GS per file. This number shall be unique for a given year. This number will be the Julian day plus a sequence number to allow for multiple files per day. ID 1-2 R X = Accredited Standards Committee X12 GS08 Header ST ST01 ST02 ST03 AK1 AK101 Version Identifier Code TRANSACTIO N SET HEADER Identifier Code Control Number Implementation Convention Reference FUNCTIONAL GROUP RESPONSE HEADER Functional Identifier Code AN 1-12 R X231A1 HDR 1 R ID 3-3 R 999 = Implementation Acknowledgement Implementation Acknowledgement. AN 4-9 R nnnn The value starts at 0001 and increments for each successive ST-SE loop. AN 1-35 R X231A1 HDR R ID 2-2 R BE = Benefit Enrollment and Maintenance RA = Payment Order/ Send a code for the file in which a response is required. For 834 send BE. For 820 send RA. 999 Companion Guide Version

14 Segments and Data s AK102 AK103 Group Control Number Version Release/Industr y Identifier Code Remittance Advice (820) N0 1-9 R Send the GS06 value from the file that is being responded to. AN 1-12 S Send the GS08 Identifier from the file that is being responded to AK2 TRANSACTION SET RESPONSE HEADER Repeat: >1 AK2 AK201 AK202 AK203 TRANSACTIO N SET RESPONSE HEADER Identifier Code Control Number Implementation Convention Reference 2000 S Will not be sent if no errors are present. ID 3-3 R 834 = Benefit Enrollment and Maintenance 820 = Healthcare Insurance Exchange Related Payments Needs to code for the transaction set that was sent. For 834 transactions - Send 834. For 820 transactions - Send 820. AN 4-9 R Send the ST02 of the transaction being responded to. AN R Send the ST03 value from the transaction set being responded to AK2/IK3 ERROR IDENTIFICATION Repeat: >1 IK3 IK301 IK302 Error Identification Segment Identifier Segment Position in 2100 S ID 2-3 R Send the segment identifier that has the error (DTP, INS, etc). N R This is the segment count from the ST segment. The count includes the ST 999 Companion Guide Version

15 Segments and Data s segment. IK303 IK304 Identifier Code Implementation Segment Syntax Error Code AN 1-4 S Send when the error is in LS-LE loop and the LS01 value is known. ID 1-3 R 1 = Unrecognized segment ID 2 = Unexpected segment 3 = Required segment missing 4 = over maximum times 5 = Segment exceeds maximum use 6 = Segment not in defined transaction set 7 = Segment not in proper sequence 8 = segment has data element errors I4 = Implementation Not Used segment present I6 = Implementation dependent segment missing I7 = Implementation loop occurs under minimum times I8 = Implementation segment below minimum use I9 = Implementation dependent Not Used segment present 999 Companion Guide Version

16 Segments and Data s CTX Segment Context 2100 S CTX01 Composite - R CTX01-1 Context Name AN 1-35 R SITUATIONAL TRIGGER CTX01-2 Context Reference AN 0 N/U CTX03 CTX04 CTX05 CTX05-1 CTX05-2 CTX05-3 CTX06 CTX06-1 Segment Position in Identifier Code Position in Segment Position in Segment Component Data Position in Composite Repeating Data Position Reference in Segment Data Reference Number N R This is the numerical count position of the data segment from the start of the transaction set. The transaction set header is count position 1. AN 1-4 S The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE. S Composite element Only create an element if there is information to report. N0 1-2 R N0 1-2 S N0 1-4 S S N0 1-4 R Composite element 999 Companion Guide Version

17 Segments and Data s CTX Business Unit Identifier S CTX01 Context R Composite element Identification CTX01-1 Context Name AN 1-35 R SUBSCRIBER NUMBER REF02 Or ENT01 CTX01-2 Context Reference AK2/IK3/IK4 Implementation Data Note (loop repeat >1) For 834, send Subscriber number. For 820, send ENT01. AN 1-35 R Send value from original file. IK4 IK401 IK401-1 IK401-2 IK401-3 IK402 IK403 Implementation Data Note Position in segment Position in Segment Component Data Position In Composite Repeating Data Position Data Reference Number Implementation Data Syntax Error Code S R N0 1-2 R N0 1-2 S N0 1-4 S N0 1-4 S Composite ID 1-3 R 1 = Required Data Missing 2 = Conditional Required Data Missing 999 Companion Guide Version

18 Segments and Data s 3 = Too Many Data s 4 = Data Too Short 5 = Data Too Long 6 = Invalid Character In Data 7 = Invalid Code Value 8 = Invalid Date 9 = Invalid Time 10 = Exclusion Condition Violated 12 = Too Many Repetitions 13 = Too Many Components I10 = Implementation Not Used Data Present I11 = Implementation Too Few Repetitions I12 = Implementation Pattern Match Failure I13 = Implementation Dependent Not Used Data Present I6 = Code Value Not Used in Implementation I9 = Implementation Dependent Data Missing 999 Companion Guide Version

19 Segments and Data s IK404 CTX CTX01 Copy of Bad Data Context Composite AN 1-99 S Send bad data element. Limit 99 characters. Do Not Send Invalid Characters S CTX01-1 Context Name AN 1-35 R SITUATIONAL TRIGGER CTX01-2 Context Reference AN 0 N/U CTX03 CTX04 CTX05 CTX05-1 CTX05-2 CTX05-3 CTX06 Segment Position in Identifier Code Position in Segment Position in Segment Component Data Position in Composite Repeating Data Position Reference in Segment R N R The numerical count position of this data segment from the start of the Transaction Set. The transaction set header is count position 1. AN 1-4 S The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE. S Composite element Only create an element if there is information to report. N0 1-2 R N0 1-2 S N0 1-4 S S Composite element 999 Companion Guide Version

20 Segments and Data s CTX06-1 IK5 IK501 IK502 Data Reference Number Response Trailer Acknowledgme nt Code Implementation Syntax Error Code N0 1-4 R R ID 1-1 R A = Accepted E = Accepted But Errors Were Noted 80 = The transaction set indicated in this AK2 loop contained errors, but was forwarded for further processing. M = Rejected, Message Authentication Code (MAC) Failed R = Rejected 81 = The transaction set indicated in this AK2 loop contained errors, and was NOT forwarded for further processing. It will need to be corrected and resubmitted. W = Rejected, Assurance Failed Validity Tests X = Rejected, Content After Decryption Could Not Be Analyzed ID 1-3 S 1 = Not Supported 2 = Trailer Missing 999 Companion Guide Version

21 Segments and Data s 3 = Control Number in Header and Trailer Do Not Match 4 = Number of Included Segments Does Not Match Actual Count 5 = One or More Segments in Error 6 = Missing or Invalid Identifier 7 = Missing or Invalid Control Number 8 = Authentication Key Name Unknown 9 = Encryption Key Name Unknown 10 = Requested Service (Authentication or Encrypted) Not Available 11 = Unknown Security Recipient 12 = Incorrect Message Length (Encryption Only) 13 = Message Authentication Code Failed 15 = Unknown Security Originator 16 = Syntax Error in Decrypted Text 17 = Security Not Supported 18 = not 999 Companion Guide Version

22 Segments and Data s IK503 IK504 IK505 Implementation Syntax Error Code Implementation Syntax Error Code Implementation in Functional Group 19 = Invalid Transaction Set Implementation Convention Reference 23 = Control Number Not Unique within the Functional Group 24 = S3E Security End Segment Missing for S3S Security Start Segment 25 = S3S Security Start Segment Missing for S3E Security End Segment 26 = S4E Security End Segment Missing for S4S Security Start Segment 27 = S4S Security Start Segment Missing for S4E Security End Segment I5 = Implementation One or More Segments in Error I6 = Implementation Convention Not Supported ID 1-3 S Additional error codes. ID 1-3 S ID 1-3 S 999 Companion Guide Version

23 Segments and Data s IK506 AK9 AK901 Syntax Error Code Implementation Syntax Error Code Functional Group Response Trailer Functional group Acknowledge Code ID 1-3 S - Traile r 1 R ID 1-1 R A = Accepted This code value can only be used if there are no AK2 loops or all IK501 values = A. E = Accepted, But Errors Were Noted. The functional group indicated in this 999 contained errors, but was forwarded for further processing. M = Rejected, Message Authentication Code (MAC) Failed P = Partially Accepted, At Least One Was Rejected R = Rejected The functional group indicated in this 999 contained errors, and was NOT forwarded for further processing. It will need to be corrected and resubmitted. 999 Companion Guide Version

24 Segments and Data s AK902 AK903 AK904 AK905 Number of Transaction Sets Included Number of Received Transaction Sets Number of Accepted Transaction Sets Functional Group Syntax Error Code N0 1-6 R N0 1-6 R N0 1-6 R W = Rejected, Assurance Failed Validity Tests X = Rejected, Content After Decryption Could Not Be Analyzed. ID 1-3 S 1 = Functional Group Not Supported 2 = Functional Group Version Not Supported 3 = Functional Group Trailer Missing 4 = Group Control Number in the Functional Group Header and Trailer Do Not Agree 5 = Number of Included s Does Not Match Actual Count 6 = Group Control Number Violates Syntax 10 = Authentication Key Name Unknown 11 = Encryption Key Name 999 Companion Guide Version

25 Segments and Data s AK906 Functional Group Syntax ID 1-3 S Unknown 12 = Requested Service (Authentication or Encryption) Not Available 13 = Unknown Security Recipient 14 = Unknown Security Originator 15 = Syntax Error in Decrypted Text 16 = Security Not Supported 17 = Incorrect Message Length (Encryption Only) 18 = Message Authentication Code Failed 19 = Functional Group Control Number not Unique within Interchange 23 = S3E Security End Segment Missing for S3S Security Start Segment 24 = S3S Security Start Segment Missing for S3E End Segment 25 = S4E Security End Segment Missing for S4S Security Start Segment 26 = S4S Security Start Segment Missing for S4E Security End Segment 999 Companion Guide Version

26 Segments and Data s Error Code AK907 AK908 AK909 SE SE01 SE02 GE GE01 GE02 IEA IEA01 Functional Group Syntax Error Code Functional Group Syntax Error Code Functional Group Syntax Error Code Trailer Number of Included Segments Control Number Functional Group Trailer Number of Transaction Sets Included Group Control Number Interchange Control Header Number of Included Functional Groups ID 1-3 S ID 1-3 S ID 1-3 S - HDR 1 R N R Send the number of included segments including ST-SE. AN 4-9 R NNNN The value starts at 0001 and increments for each successive ST-SE loop. - HDR 1 R N0 1-6 R Send the number of s included in the file. N0 1-9 R Send value from GS06. - HDR 1 R N0 1-5 R Send number of functional groups. 999 Companion Guide Version

27 Segments and Data s IEA02 Interchange Control Number N0 9-9 R Send same value as ISA Companion Guide Version

28 6. Acknowledgements MHC does not expect acknowledgments on 999 files. 999 Companion Guide Version

29 7. MHC Specific Business Rules and Limitations This section contains design rules and other helpful information used as transaction requirements were developed. 7.1 General Business Rules 7.2 Business rules for the 999 in response to Enrollment files [TBD] 7.3 Business Rules for the 999 in response to premium files [TBD] 999 Companion Guide Version

30 Acronym/Term ASC CG EDI Acronyms/Glossary Accredited Standards Committee Companion Guide Electronic Data Interchange Table 2: Acronyms/Glossary Description GS-GE GS and GE identify the header and trailer for the Functional Group portion of an ISA/IEA envelope within an EDI transmission. The Functional Group identifies the type of transaction sent, such as an 837 Claim or a 270 Eligibility Inquiry. HIPAA Health Insurance Portability and Accountability Act of 1996 IG Implementation Guide ISA-IEA ISA and IEA identify the header and trailer for the Interchange Control envelope, which define the parameters of an Interchange Control envelope of a EDI transmission. NCFP QHP MHC SFTP TR3 Not Considered for Processing Qualified Health Plan Maryland Health Connection Secure File Transfer Protocol Type 3 Technical Report 999 Companion Guide Version