Assurant Health HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version 005010 270/271 Health Care Eligibility Benefit Inquiry and Response CORE v5010 Master Companion Guide December 2012 2012 Assurant, Inc. All rights reserved. 1
Disclosure Statement This document is subject to change. Changes will be posted to the Assurant Health website. See http://www.assuranthealth.com/corp/ah/providers/hipaatransactions.htm for updates. The 271 Response returned by Assurant Health should not be interpreted as a guarantee of payment. The payment of benefits remains subject to all health benefit terms, limits, conditions, exclusions and the member s eligibility at the time services are rendered. 2012 Assurant, Inc. All rights reserved. 2
Preface This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Assurant Health. 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. 2012 Assurant, Inc. All rights reserved. 3
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Table of Contents 1 INTRODUCTION...6 SCOPE...6 OVERVIEW...6 REFERENCES...6 ADDITIONAL INFORMATION...6 2 GETTING STARTED...6 WORKING WITH ASSURANT HEALTH...6 TRADING PARTNER REGISTRATION...7 3 TESTING WITH THE PAYER...7 4 CONNECTIVITY WITH PAYER/COMMUNICATIONS...7 PROCESS FLOWS...7 TRANSMISSION ADMINISTRATIVE PROCEDURES...8 RE-TRANSMISSION PROCEDURE...8 COMMUNICATION PROTOCOL SPECIFICATIONS...9 PASSWORDS...9 MAINTENANCE...9 5 CONTACT INFORMATION...10 EDI CUSTOMER SERVICE / TECHNICAL ASSISTANCE...10 PROVIDER SERVICE NUMBER...10 APPLICABLE WEBSITES/E-MAIL...10 6 CONTROL SEGMENTS/ENVELOPES...10 ISA-IEA...10 GS-GE...12 ST-SE...14 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS...14 Transaction Limitations...14 Supported Service Type s...14 Supported AAA s...16 8 ACKNOWLEDGEMENTS AND/OR REPORTS...16 9 TRADING PARTNER AGREEMENTS...16 10 TRANSACTION SPECIFIC INFORMATION...17 APPENDICES...22 IMPLEMENTATION CHECKLIST...22 BUSINESS SCENARIOS...22 TRANSMISSION EXAMPLES...22 FREQUENTLY ASKED QUESTIONS...25 CHANGE SUMMARY...25 2012 Assurant, Inc. All rights reserved. 5
1 INTRODUCTION Federal regulations of the Patent Protection and Affordable Care Act (PPACA) require expanded support of the HIPAA Eligibility Benefit Inquiry and Response transaction. SCOPE Providers, billing services and clearinghouses are advised to use the ASC X12N 270/271 (005010x279A1) Implementation Guide as a basis for their submission of Eligibility and Benefit Inquiries. This companion document should be used to clarify the CORE Business rules for 270/271 data content, transaction acknowledgment, connectivity, response time and system availability requirements. OVERVIEW The purpose of this document is to assist those responsible for testing and implementing electronic eligibility transactions. This document provides information about Assurant Health s implementation of the Eligibility and Benefit Inquiry transaction (270/271) and supplements requirements specified in the ASC X12N 270/271 (005010x279A1) Implementation Guide. REFERENCES ASC X12N 270/271 (Version 005010x279A1) Technical Report Type 3 guide for Health Care Eligibility Benefit Inquiry and Response: http://wpc-edi.com/ Assurant Health Companion Guide: http://www.assuranthealth.com/corp/ah/providers/hipaatransactions.htm CAQH/CORE Rules: http://www.caqh.org/benefits.php CORE XML Schema: http://www.caqh.org/soap/wsdl/corerule2.2.0.xsd WSDL: http://www.w3.org/tr/wsdl SOAP: http://www.w3.org/tr/soap/ MIME Multipart: http://www.w3.org/protocols/rfc1341/7_2_multipart.html ADDITIONAL INFORMATION Submitters must obtain a valid Assurant Health userid and password in order to submit an Eligibility and Benefit Inquiry (270) and receive an Eligibility and Benefit Inquiry Response (271). Assurant Health supports the Eligibility and Benefit Inquiry and Response in real time mode only. Real time 270s should have a single ST/SE loop, one information source, one information receiver, one subscriber loop, one dependent loop when needed, and a single EQ loop. If inquiring on multiple Service Type s, it is recommended that the submitter submit a Service Type of 30. 2 GETTING STARTED WORKING WITH ASSURANT HEALTH Providers, billing services and clearinghouses interested in submitting Eligibility and Benefit Inquiries (270) and receiving Eligibility and Benefit Inquiry Responses (271) should submit a completed EDI Enrollment form to Assurant Health via email at EnrollEDI@assurant.com. 2012 Assurant, Inc. All rights reserved. 6
TRADING PARTNER REGISTRATION 1. Complete the EDI Enrollment form and email to Assurant Health at EnrollEDI@assurant.com. The form is available at http://www.assuranthealth.com/corp/ah/providers/hipaatransactions.htm 2. Assurant Health will provide a user ID and password. 3. Provider / trading partner should configure their system following the connection instructions provided by Assurant Health. 4. Verify connectivity by submitting an Eligibility and Benefit Inquiry (270) and evaluating the Eligibility and Benefit Inquiry Response (271). 3 TESTING WITH THE PAYER Assurant Health does not support a test environment for testing the submission of Eligibility and Benefit Inquiries (270) and receiving Eligibility and Benefit Inquiry Responses (271). Once you have completed the Trading Partner registration process, you should submit a transaction to validate that connectivity has been successfully established and that you can process the returned response. If you encounter any errors during this process, please contact the EDI Services group for technical assistance. 4 CONNECTIVITY WITH PAYER/COMMUNICATIONS PROCESS FLOWS The user application submits a CORE compliant HTTPS request to https://biztalk.assurant.com/realtimeweb/processrequest.ashx or CORE compliant SOAP request to http://biztalk.assurant.com/providerrealtimesvc/coremanager.svc?wsdl The Assurant Health system authenticates the account. If the account is not authorized, an HTTP 401-Unauthorized response is returned. If the account is authorized, an HTTP 200-OK status response is returned to the user and one of the following will be returned: o TA1 (if a problem with the ISA/IEA segments exist) o 999 Reject (if a problem occurs within the 270 request) o 271 Eligibility and Benefit Response 2012 Assurant, Inc. All rights reserved. 7
Figure 1: Real Time Transaction Flow TRANSMISSION ADMINISTRATIVE PROCEDURES Real time Eligibility and Benefit Inquiry (270) transactions should have a single ST/SE loop, one information source, one information receiver, one subscriber loop, one dependent loop when needed, and a single EQ loop. If inquiring on multiple Service Type s, it is recommended that the submitter submit a Service Type of 30. RE-TRANSMISSION PROCEDURE A duplicate transaction may be sent by the user s CORE compliant system if the HTTP post reply message is not received within the 60 second response period. If no response is received after the second attempt, the user s CORE compliant system should submit no more than 5 duplicate transactions within the next 15 minutes. If the additional attempts result in the same timeout termination, the user should contact Assurant Health to determine if system availability problems exist. 2012 Assurant, Inc. All rights reserved. 8
COMMUNICATION PROTOCOL SPECIFICATIONS Assurant Health supports two options for submitting Eligibility and Benefit Inquiry (270) transactions directly to Assurant Health. Sending these transactions directly eliminates the need for an intermediary and is offered to providers at no cost per transaction. Our supported options are: PASSWORDS CAQH SOAP Assurant Health supports the use of HTTP SOAP + WSDL envelope standards as defined in the CAQH CORE Phase II Connectivity standards (see http://caqh.org/pdf/clean5010/270-v5010.pdf) The following is a list of technical standards and versions for the HTTP SOAP + WSDL envelope standards: o SOAP XML Schema: http://caqh.org/soap/wsdl/corerule2.2.0.xsd o WSDL Definition: http://caqh.org/soap/wsdl/corerule2.2.0.wsdl o HTTP Version 1.1 o SOAP Version 1.2 o SSL Version 3.0 o Health Care Eligibility and Benefit Inquiry and Response version 005010X279A1 The submitter of the Eligibility and Benefit Inquiry will need an Assurant Health issued userid and password to connect to Assurant Health. CAQH MIME Assurant Health supports the use of HTTP MIME Multipart existing envelope standards as defined in the CAQH CORE Phase II Connectivity standards (see http://caqh.org/pdf/clean5010/270-v5010.pdf) The following is a list of technical standards and versions for the HTTP MIME Multipart envelope and eligibility payload: o HTTP Version 1.1 o MIME Version 1.0 o SSL Version 3.0 o Health Care Eligibility and Benefit Inquiry and Response version 005010X279A1 The submitter of the Eligibility and Benefit Inquiry will need an Assurant Health issued userid and password to connect to Assurant Health. A userid and password must accompany each Eligibility and Benefit Inquiry (270) submitted to Assurant Health. The method in which it is passed to the system for authentication is dependent upon the transaction type used. MAINTENANCE Routine maintenance is performed on Sunday mornings between 6 9 a.m. Central time. Transactions submitted during this time may receive rejection messages indicating that Assurant Health is unable to process their transaction at that time. Please check the Assurant Health website for any additional planned outages. Notification of any non-routine or unscheduled downtime will be sent to the email address(es) provided in the enrollment process and posted on the Assurant Health website. 2012 Assurant, Inc. All rights reserved. 9
5 CONTACT INFORMATION PROVIDER SERVICE NUMBER / CUSTOMER SERVICE If you have questions regarding claim adjudication results, claim status, member eligibility or referral/authorization, contact the Assurant Health Customer Service department: Phone: 800.553.7654 EDI CUSTOMER SERVICE / TECHNICAL ASSISTANCE If the answers to questions you have are not found in this Companion Guide, please contact the Assurant Health EDI team: Phone: 888.647.9708 Assurant Help Desk ask to open a ticket with Assurant Health EDI Services group Email: ediserve@assurant.com APPLICABLE WEBSITES/E-MAIL Assurant Health Website: http://www.assuranthealth.com 6 CONTROL SEGMENTS/ENVELOPES Listed below are Assurant Health specific requirements for the exchange of a Health Care Eligibility and Benefit Inquiry and Response (270/271) transaction. ISA-IEA The ISA segment terminator, which immediately follows the component separator, must consist of only one character code. The same character code must be used as the segment terminator for each segment in the ISA-IEA segment set. Expected inbound values: Page # Reference Name s Expected Value C.3 ISA All positions within each of Interchange Control the data elements must be Header filled. C.4 ISA01 Authorization Information Qualifier 00 00 (zero zero) No Authorization Information Present (no meaningful information in ISA02) C.4 ISA02 Authorization Information Blank (fill with 10 spaces) C.4 ISA03 Security Information Qualifier 00 00 No Authorization Information Present (no meaningful information in ISA04) C.4 ISA04 Security Information Blank (fill with 10 spaces) C.4 ISA05 Interchange ID Qualifier ZZ ZZ (Mutually Defined) C.4 ISA06 Interchange Sender ID Electronic Transmitter Identification Number (ETIN) C.5 ISA07 Interchange ID Qualifier ZZ ZZ (Mutually Defined) 2012 Assurant, Inc. All rights reserved. 10
Page # Reference Name s Expected Value C.5 ISA08 Interchange Receiver ID 390658730 390658730 This field must be filled with 15 spaces and be left justified. C.5 ISA09 Interchange Date Interchange Creation Date in YYMMDD format C.5 ISA10 Interchange Time Interchange Creation Time in HHMM format C.5 ISA11 Interchange Repetition Separator C.5 ISA12 Interchange Control Version Number C.5 ISA13 Interchange Control Number ^ Assurant Health will utilize the carrot symbol ^ as the repetition separator. 00501 Indicates version number Assigned by your software (usually sequential integer), no leading zeros allowed 1 1 - Interchange Acknowledgment Requested C.6 ISA14 Acknowledgement Requested C.6 ISA15 Usage Indicator P P - Production data C.6 ISA16 Component Element : A : (colon) must be sent in Separator this field. C.10 IEA Interchange Control Trailer C.10 IEA01 Number of Included Functional Groups C.10 IEA02 Interchange Control Number Count of the number of functional groups included in an interchange. Control number assigned by the interchange sender that should be nine characters and be identical to the value in ISA13. Outbound values: Page # Reference Name s Expected Value C.3 ISA All positions within each of Interchange Control the data elements must be Header filled. C.4 ISA01 Authorization Information Qualifier 00 00 (zero zero) No Authorization Information Present (no meaningful information in ISA02) C.4 ISA02 Authorization Information Blank (fill with 10 spaces) C.4 ISA03 Security Information Qualifier 00 00 No Authorization Information Present (no meaningful information in ISA04) C.4 ISA04 Security Information Blank (fill with 10 spaces) C.4 ISA05 Interchange ID Qualifier ZZ ZZ (Mutually Defined) C.4 ISA06 Interchange Sender ID 390658730 390658730 This field must be filled with 15 spaces and 2012 Assurant, Inc. All rights reserved. 11
Page # Reference Name s Expected Value be left justified. C.5 ISA07 Interchange ID Qualifier ZZ ZZ (Mutually Defined) C.5 ISA08 Interchange Receiver ID Value submitted in ISA06 of the 270 Request C.5 ISA09 Interchange Date Interchange Creation Date in YYMMDD format C.5 ISA10 Interchange Time Interchange Creation Time in HHMM format C.5 ISA11 Interchange Repetition Separator C.5 ISA12 Interchange Control Version Number C.5 ISA13 Interchange Control Number C.6 ISA14 Acknowledgement Requested ^ Assurant Health will utilize the carrot symbol ^ as the repetition separator. 00501 Indicates version number Assigned by your software (usually sequential integer), no leading zeros allowed 0 0 No Acknowledgment Requested C.6 ISA15 Usage Indicator P P - Production data C.6 ISA16 Component Element : A : (colon) must be sent in Separator this field. C.10 IEA Interchange Control Trailer C.10 IEA01 Number of Included Functional Groups C.10 IEA02 Interchange Control Number Count of the number of functional groups included in an interchange. Control number assigned by the interchange sender that should be nine characters and be identical to the value in ISA13. GS-GE Files must contain a single GS-GE per real time transaction. Expected inbound values: Page # Reference Name s Expected Value C.7 GS Functional Group Header All positions within each of the data elements must be filled. C.7 GS01 Functional Identifier HS HS Eligibility, Coverage or Benefit Inquiry C.7 GS02 Application Sender Same value as ISA06. C.7 GS03 Application Receiver 390658730 Same value as ISA08. C.8 GS04 Date Functional Group Creation Date in CCYYMMDD format 2012 Assurant, Inc. All rights reserved. 12
Page # Reference Name s Expected Value C.8 GS05 Time Functional Group Creation Time in HHMM format C.8 GS06 Group Control Number Unique number within interchange. Will begin with 0001, and will be identical to GE02. C.8 GS07 Responsible Agency X X - Accredited Standards Committee X12 C.8 GS08 Version/Release/Industry Identifier 005010X279A1 Version and transaction number C.9 GE Functional Group Trailer C.9 GE01 Number of Transaction Sets Include C.9 GE02 Group Control Number 1 Total number of transaction sets included in the functional group. Unique number assigned by the sender that must be identical to GS06. Outbound values: Page # Reference Name s Expected Value C.7 GS Functional Group Header All positions within each of the data elements must be filled. C.7 GS01 Functional Identifier HB HB Eligibility, Coverage or Benefit Information C.7 GS02 Application Sender 390658730 Same value as ISA06. C.7 GS03 Application Receiver Same value as ISA08. C.8 GS04 Date Functional Group Creation Date in CCYYMMDD format C.8 GS05 Time Functional Group Creation Time in HHMM format C.8 GS06 Group Control Number Unique number within interchange. Will begin with 0001, and will be identical to GE02. C.8 GS07 Responsible Agency X X - Accredited Standards Committee X12 C.8 GS08 Version/Release/Industry Identifier 005010X279A1 Version and transaction number C.9 GE Functional Group Trailer 2012 Assurant, Inc. All rights reserved. 13
Page # Reference Name s Expected Value C.9 GE01 Total number of Number of Transaction 1 transaction sets included Sets Include in the functional group. Unique number assigned C.9 GE02 Group Control Number by the sender that must be identical to GS06. ST-SE Each real-time request should contain a single 270 Eligibility and Benefit Inquiry wrapped in a single ST-SE. Page # Reference Name s Expected Value 61 ST Transaction Set Header 61 ST01 Transaction Set Identifier 270 270 61 ST02 Transaction Set Control Number Nine-digit number starting with 1 and increasing sequentially. Must match 62 ST03 Implementation Convention Reference 005010X279A1 the number in SE02. This element contains the same value as GS08. 61 SE Transaction Set Trailer 61 SE01 Transaction Segment Count Total numbers of segments included in a transaction set (including the ST and SE segments). 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS Transaction Limitations Assurant Health supports the Eligibility and Benefit Inquiry and Response in real time mode only. Real time 270s should have a single ST/SE loop, one information source, one information receiver, one subscriber loop, one dependent loop when needed, and a single EQ loop. If inquiring on multiple Service Type s, it is recommended that the submitter submit a Service Type of 30. All data contained within the Eligibility and Benefit Inquiry should be submitted in UPPER CASE. Supported Service Type s Assurant Health supports the following Service Type s: 270 Request (EQ01) 1 - Medical Care 2 - Surgical 4 - Diagnostic X-ray 5 - Diagnostic Lab 2012 Assurant, Inc. All rights reserved. 14
270 Request (EQ01) 6 - Radiation Therapy 7 - Anesthesia 8 - Surgical Assistance 12 - Durable Medical Equipment Purchase 13 - Ambulatory Service Center Facility 18 - Durable Medical Equipment Rental 20 - Second Surgical Opinion 30 - General Request 33 - Chiropractic 35 - Dental Care 40 - Oral Surgery 42 - Home Health Care 45 - Hospice 47 - Hospital 48 - Hospital - Inpatient 49 - Hospital - Room and Board 50 - Hospital - Outpatient 51 - Hospital - Emergency Accident 52 - Hospital - Emergency Medical 53 - Hospital - Ambulatory Surgical 62 - MRI/CAT Scan 65 - Newborn Care 68 - Well Baby Care 73 - Diagnostic Medical 76 - Dialysis 78 - Chemotherapy 80 - Immunizations 81 - Routine Physical 82 - Family Planning 86 - Emergency Services 88 - Pharmacy 93 - Podiatry 98 - Professional (Physician) Visit - Office 99 - Professional (Physician) Visit - Inpatient A0 - Professional (Physician) Visit - Outpatient A3 - Professional (Physician) Visit - Home A6 - Psychotherapy A7 - Psychiatric - Inpatient A8 - Psychiatric - Outpatient AD - Occupational Therapy AE - Physical Medicine AF - Speech Therapy AG - Skilled Nursing Care AI - Substance Abuse AL - Vision (Optometry) MH - Mental Health UC - Urgent Care BG - Cardiac Rehabilitation BH- Pediatric 2012 Assurant, Inc. All rights reserved. 15
Supported AAA s Assurant Health supports the following AAA codes for error reporting: Loop Error Condition AAA03 Value 2100A Authorized quantity exceeded 04 Will occur when the number of patient requests submitted exceed 1. 2100C Required Application Data Missing 15 2100D 2100C Invalid/Missing Date(s) of Service 57 2100D 2100C Date of Service not within allowable inquiry 62 2100D period 2100D Invalid/Missing Patient ID 64 2100D Invalid/Missing Patient Name 65 2100D Patient Not Found 67 2100C Patient Birth Date does not batch Patient DOB 71 2100D in database 2100C Invalid/Missing Subscriber/Insured ID 72 2100D 2100C Invalid/Missing Subscriber/Insured Name 73 2100C Subscriber/Insured Not Found 75 2110C Invalid/Missing Date(s) of Service 57 2110D 2110C 2110D Date of Service not within allowable inquiry period 62 8 ACKNOWLEDGEMENTS AND/OR REPORTS For each 270 Eligibility and Benefit Inquiry submitted to Assurant Health, one of the following will be returned: TA1 Interchange Acknowledgement if the ISA/IEA envelope cannot be processed. 999 Implementation Acknowledgement if the 270 transaction contains HIPAA compliancy errors within the ST/SE segments. 271 Eligibility and Benefit Inquiry Response containing the requested member s coverage and benefits. 9 TRADING PARTNER AGREEMENTS A completed EDI Enrollment form is required for all providers, clearinghouses and software vendors wishing to connect directly with Assurant Health to exchange Eligibility and Benefit Inquiry and Response (270/271) transactions. 2012 Assurant, Inc. All rights reserved. 16
10 TRANSACTION SPECIFIC INFORMATION Listed below are specific requirements that Assurant Health requires for Eligibility and Benefit Inquiries where the patient is the subscriber: Page # Loop ID 69 2100A NM1 Reference Name s Length Expected Value Information Source Name 69 2100A NM101 Entity Identifier 70 2100A NM102 Entity Type Qualifier 71 2100A NM108 Identification Qualifier 71 2100A NM109 Identification 75 2100B NM1 Information Receiver Name 75 2100B NM101 Entity Identifier This is the source of information contained in the 271, i.e. Assurant Health 2B,36,GP, PR P5,PR 1,2 2 PI PI 390658730 9 390658730 1P, 2B, 36, 80, FA, GP, P5, PR 1P = Provider 2B = Third-Party Administrator 36 = Employer 80 = Hospital FA = Facility GP = Gateway Provider P5 = Plan Sponsor PR = Payer 75 2100B NM102 Entity Type Qualifier 1,2 1 = Person 2 = Nonperson entity 76 2100B NM103 Name Last or Organization Name Information receiver s last name or organization name. 76 2100B NM104 Name First Information receiver s first name. This is required when the value in NM102 is 1. 77 2100B NM108 Identification XX XX = National Provider ID Qualifier 78 2100B NM109 Identification Should contain the National Provider ID 90 2000C TRN Subscriber Trace Number Allows submitter tracking of the eligibility information 91 2000C TRN02 Reference Identification Include at least one TRN segment in either the subscriber or dependent loop 92 2100C NM1 Subscriber Name Subscriber identification information 92 2100C NM101 Entity Identifier IL IL 93 2100C NM102 Entity Type Qualifier 1,2 1 2012 Assurant, Inc. All rights reserved. 17
Page Loop Reference Name s Length Expected Value # ID 93 2100C NM103 Name Last or Subscriber last name Organization Name 93 2100C NM104 Name First Subscriber first name 95 2100C NM108 Identification MI MI = Member ID Qualifier 96 2100C NM109 Identification Subscriber ID number should contain the policy number and certificate number separated by a dash if a cert number is applicable or just policy number if cert number is not applicable. 107 2100C DMG Subscriber Demographic Information Example: #########-####### The policy number can be up to 10 characters in length. Leading zeroes are not required. The certificate number can be up to 7 characters in length. Leading zeroes are not required. Subscriber demographics 108 2100C DMG02 Date Time Period Subscriber DOB (not required if dependent is patient) 108 2100C DMG03 Gender Subscriber gender (not required if dependent is patient) 122 2100C DTP Subscriber Date 123 2100C DTP01 Date/Time Qualifier 123 2100C DTP02 Date Time Period Format Qualifier 291 291 = Plan Date D8 D8 = Date expressed in CCYYMMDD If RD8 is submitted, the response will be based on the From date submitted in DTP03 123 2100C DTP03 Date Time Period Date expressed in CCYYMMDD If a date range is submitted, the response will be based on the from date. 2012 Assurant, Inc. All rights reserved. 18
Page Loop Reference Name s Length Expected Value # ID 124 2110C EQ Subscriber Defines type of information Eligibility or requested Benefit Information 125 2110C EQ01 Service Type If unsupported service types and/or multiple service type codes are submitted, the system will respond with the default service type = 30 Listed below are specific requirements that Assurant Health requires for Eligibility and Benefit Inquiries where the patient is a dependent: Page # Loop ID 69 2100A NM1 Reference Name s Length Expected Value Information Source Name 69 2100A NM101 Entity Identifier 70 2100A NM102 Entity Type Qualifier 71 2100A NM108 Identification Qualifier 71 2100A NM109 Identification 75 2100B NM1 Information Receiver Name 75 2100B NM101 Entity Identifier This is the source of information contained in the 271, i.e. Assurant Health 2B,36,GP, PR P5,PR 1,2 2 PI PI 390658730 9 390658730 1P, 2B, 36, 80, FA, GP, P5, PR 1P = Provider 2B = Third-Party Administrator 36 = Employer 80 = Hospital FA = Facility GP = Gateway Provider P5 = Plan Sponsor PR = Payer 75 2100B NM102 Entity Type Qualifier 1,2 1 = Person 2 = Nonperson entity 76 2100B NM103 Name Last or Organization Name Information receiver s last name or organization name. 76 2100B NM104 Name First Information receiver s first name. This is required when the value in NM102 is 1. 77 2100B NM108 Identification Qualifier 78 2100B NM109 Identification XX XX = National Provider ID Should contain the National Provider ID 2012 Assurant, Inc. All rights reserved. 19
Page Loop Reference Name s Length Expected Value # ID 90 2000C TRN Subscriber Trace Allows submitter tracking of Number the eligibility information 91 2000C TRN02 Reference Include at least one TRN Identification segment in either the subscriber or dependent loop 92 2100C NM1 Subscriber Name Subscriber identification information 92 2100C NM101 Entity Identifier IL IL 93 2100C NM102 Entity Type 1,2 1 Qualifier 93 2100C NM103 Name Last or Subscriber s last name Organization Name 95 2100C NM108 Identification MI Submitters must use value Qualifier 96 2100C NM109 Identification MI Subscriber ID number should contain the policy number and certificate number separated by a dash if a cert number is applicable or just policy number if cert number is not applicable. Example: #########-####### The policy number can be up to 10 characters in length. Leading zeroes are not required. The certificate number can be up to 7 characters in length. Leading zeroes are not required. 151 2100D NM1 Dependent Name Dependent identification information 151 2100D NM101 Entity Identifier 03 03 = Dependent 152 2100D NM102 Entity Type 1,2 1 Qualifier 152 2100D NM103 Name Last or Organization Name Dependent last name (not required if subscriber is patient) 152 2100D NM104 Name First Dependent first name (not required if subscriber is patient) 2012 Assurant, Inc. All rights reserved. 20
Page Loop Reference Name s Length Expected Value # ID 164 2100D DMG Dependent Dependent demographics Demographic Information 165 2100D DMG02 Date Time Period Dependent DOB (not required if subscriber is patient) 166 2100D DMG03 Gender Dependent gender (not required if subscriber is patient) 167 2100D INS Dependent DO NOT SEND Indicates Relationship dependent relationship to Subscriber; Alternate Search Option is not in use therefore this segment 181 2110D EQ Dependent Eligibility or Benefit Information should not be sent Defines type of information requested 182 183 2110D EQ01 Service Type If unsupported service types and/or multiple service type codes are submitted, the system will respond with the default service type = 30 2012 Assurant, Inc. All rights reserved. 21
APPENDICES IMPLEMENTATION CHECKLIST Complete the EDI Enrollment form and email to Assurant Health at EnrollEDI@assurant.com. The form is available at http://www.assuranthealth.com/corp/ah/providers/hipaatransactions.htm Assurant Health will provide a user ID and password. Provider / trading partner should configure their system following the connection instructions provided by Assurant Health. Verify connectivity by submitting an Eligibility and Benefit Inquiry (270) and evaluating the Eligibility and Benefit Inquiry Response (271). BUSINESS SCENARIOS Example 1 Generic request for a patient s (subscriber) eligibility Example 2 Specific Service Type Category request for a patient s (subscriber) eligibility TRANSMISSION EXAMPLES Example 1 Generic request for a patient s (subscriber) eligibility ISA*00* *00* *ZZ*TESTHARNESS *ZZ*390658730 *121213*0748*^*00501*111111111*0*T*:~ GS*HS*TESTHARNESS*390658730*20121213*0748*123456789*X*005010X279A1~ ST*270*1234*005010X279A1~ BHT*0022*13*TRANSA*20121213*0748~ HL*1**20*1~ NM1*PR*2*TIME*****PI*390658730~ HL*2*1*21*1~ NM1*1P*1*TTEE*TTEE****XX*1000001010~ HL*3*2*22*0~ NM1*IL*1*DOE*JOHN****MI*0001093418~ DMG*D8*19680206~ DTP*291*RD8*20121213-20121213~ EQ*30~ SE*12*1234~ GE*1*123456789~ IEA*1*111111111~ Example 1 Response to a generic request for a patient s (subscriber) eligibility ISA*00* *00* *ZZ*390658730 *ZZ*533052274 *121213*0748*^*00501*000001586*0*T*:~ GS*HB*390658730*533052274*20121213*0748*1586*X*005010X279A1~ ST*271*1586*005010X279A1~ BHT*0022*11*TRANSA*20121213*0748~ HL*1**20*1~ NM1*PR*2*TIME INSURANCE COMPANY*****PI*390658730~ PER*IC*CUSTOMER SERVICE*TE*8003284316~ HL*2*1*21*1~ NM1*1P*1*TTEE*TTEE****XX*1000001010~ HL*3*2*22*1~ NM1*IL*1*DOE*JOHN****MI*0001093418-0000002~ N3*HITACHI STREET21*LANE 58~ N4*ALBERT*KS*67511~ DMG*D8*19650206*F~ 2012 Assurant, Inc. All rights reserved. 22
INS*Y*18*001*25~ DTP*346*D8*20110925~ HL*4*3*23*0~ NM1*03*1*DOE*JOHN~ N3*HITACHI STREET21*LANE 58~ N4*ALBERT*KS*67511~ DMG*D8*19680206*M~ DTP*346*D8*20110925~ EB*1**30*GP*CLEAR CHOICE~ EB*C*IND*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^ A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*23*1*****U~ EB*1**1^88~ EB*6**A6^A7^A8^AI^MH~ EB*A*IND*11^12^13^18^2^20^33^4^42^45^47^48^49^5^50^51^52^53^6^62^65^68^7^73^ 76^78^8^86^93^98^99^A0^A3^A9^AD^AE^AF^AG^BG^BH^UC*GP*CLEAR CHOICE*23**0.2****Y~ EB*A*IND*11^12^13^18^2^20^33^4^42^45^47^48^49^5^50^51^52^53^6^62^65^68^7^73^ 76^78^8^86^93^98^99^A0^A3^A9^AD^AE^AF^AG^BG^BH^UC*GP*CLEAR CHOICE*23**0.5****N~ EB*B*IND*98*GP*CLEAR CHOICE*23*0*****Y~ DTP*348*D8*20050101~ EB*B*IND*98*GP*CLEAR CHOICE*23*0*****Y~ EB*C*FAM*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^ A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*23*4800*****Y~ EB*C*FAM*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^ A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*29*4800*****Y~ EB*U**65^68^80~ MSG*Benefits may be limited based on the age of the claimant.~ EB*C*IND*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^ A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*23*2400*****N~ EB*C*IND*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^ A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*23*2400*****Y~ EB*C*IND*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^ A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*29*1*****U~ EB*C*IND*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^ A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*29*2400*****N~ EB*C*IND*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^ A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*29*2400*****Y~ EB*F*IND*AG*GP*CLEAR CHOICE*23***DY*30**U~ DTP*348*D8*20050101~ EB*F*IND*42*GP*CLEAR CHOICE*23***HS*160**U~ DTP*348*D8*20050101~ EB*F*IND*33^AD^AE*GP*CLEAR CHOICE*23***VS*20**U~ DTP*348*D8*20050101~ EB*G*FAM*11^12^13^18^2^20^33^4^42^45^47^48^49^5^50^51^52^53^6^62^65^68^7^73^ 76^78^8^86^93^98^99^A0^A3^A9^AD^AE^AF^AG^BG^BH^UC*GP*CLEAR CHOICE*23*3000*****U~ EB*I**40^AL~ EB*G*IND*11^12^13^18^2^20^33^4^42^45^47^48^49^5^50^51^52^53^6^62^65^68^7^73^ 76^78^8^86^93^98^99^A0^A3^A9^AD^AE^AF^AG^BG^BH^UC*GP*CLEAR CHOICE*23*1500*****U~ EB*U**80^81^82~ SE*49*1586~ GE*1*1586~ IEA*1*000001586~ 2012 Assurant, Inc. All rights reserved. 23
Example 2 Specific Service Type Category request for a patient s (subscriber) eligibility ISA*00* *00* *ZZ*TESTHARNESS *ZZ*390658730 *121213*0750*^*00501*111111111*0*T*:~ GS*HS*TESTHARNESS*390658730*20121213*0750*123456789*X*005010X279A1~ ST*270*1234*005010X279A1~ BHT*0022*13*TRANSA*20121213*0750~ HL*1**20*1~ NM1*PR*2*TIME*****PI*390658730~ HL*2*1*21*1~ NM1*1P*1*TTEE*TTEE****XX*1000001010~ HL*3*2*22*0~ NM1*IL*1*DOE*JOHN****MI*0001093418~ DMG*D8*19680206~ DTP*291*RD8*20121213-20121213~ EQ*7~ SE*12*1234~ GE*1*123456789~ IEA*1*111111111~ Example 2 Response to a specific Service Type Category request for a patient s eligibility ISA*00* *00* *ZZ*390658730 *ZZ*533052274 *121213*0750*^*00501*000001591*0*T*:~ GS*HB*390658730*533052274*20121213*0750*1591*X*005010X279A1~ ST*271*1591*005010X279A1~ BHT*0022*11*TRANSA*20121213*0750~ HL*1**20*1~ NM1*PR*2*TIME INSURANCE COMPANY*****PI*390658730~ PER*IC*CUSTOMER SERVICE*TE*8003284316~ HL*2*1*21*1~ NM1*1P*1*TTEE*TTEE****XX*1000001010~ HL*3*2*22*1~ NM1*IL*1*DOE*JOHN****MI*0001093418-0000002~ N3*HITACHI STREET21*LANE 58~ N4*ALBERT*KS*67511~ DMG*D8*19650206*F~ INS*Y*18*001*25~ DTP*346*D8*20110925~ HL*4*3*23*0~ NM1*03*1*DOE*JOHN~ N3*HITACHI STREET21*LANE 58~ N4*ALBERT*KS*67511~ DMG*D8*19680206*M~ DTP*346*D8*20110925~ EB*1**30*GP*CLEAR CHOICE~ EB*C*IND*7*GP*CLEAR CHOICE*23*1*****U~ EB*A*IND*7*GP*CLEAR CHOICE*23**0.5****N~ EB*C*FAM*7*GP*CLEAR CHOICE*23*4800*****Y~ EB*C*FAM*7*GP*CLEAR CHOICE*29*4800*****Y~ EB*A*IND*7*GP*CLEAR CHOICE*23**0.2****Y~ EB*C*IND*7*GP*CLEAR CHOICE*23*2400*****N~ EB*C*IND*7*GP*CLEAR CHOICE*23*2400*****Y~ EB*C*IND*7*GP*CLEAR CHOICE*29*1*****U~ EB*C*IND*7*GP*CLEAR CHOICE*29*2400*****N~ EB*G*FAM*7*GP*CLEAR CHOICE*23*3000*****U~ EB*C*IND*7*GP*CLEAR CHOICE*29*2400*****Y~ EB*G*IND*7*GP*CLEAR CHOICE*23*1500*****U~ SE*34*1591~ GE*1*1591~ IEA*1*000001591~ 2012 Assurant, Inc. All rights reserved. 24
FREQUENTLY ASKED QUESTIONS Q. Is there a charge for a provider to submit 270 requests and receive 271 responses back from Assurant Health? A. This is a free service offered by Assurant Health to providers, clearinghouses and billing services and there are no fees associated with the use of this service. Q. Once a request is submitted when will a response be received back from Assurant Health? A. A single real-time request will receive a response back within 20 seconds. Q. Who do I call for support if a problem arises? A. If the answers to questions you have are not found in this Companion Guide, please contact the Assurant Health EDI team: Phone: 888.647.9708 Assurant Help Desk ask to open a ticket with Assurant Health EDI Services group CHANGE SUMMARY Version 0.1 10/3/2012 Initial draft Version 1.0 12/14/2012 First published version 2012 Assurant, Inc. All rights reserved. 25