HIPAA 276/277 Companion Guide Cardinal Innovations Prepared for Health Care Providers

Cardinal Innovations Prepared for Health Care Providers, February 2017

Table of Contents Preface... 4 1. Transaction Instruction (TI) Introduction... 5 1.1 Scope... 5 1.2 Overview... 5 1.3 References... 5 2. Getting Started... 5 2.1 Working with Cardinal Innovations... 5 2.2 Trading partner Registration... 6 3. Testing with the Payer and Contact Information... 6 3.1 Batch Transaction... 7 3.1.1 PROCESS FLOWS... 8 4. Control Segments/Envelopes... 9 4.1 ISA-IEA... 9 4.2 GS-GE... 9 4.3 ST-SE... 9 5. Acknowledgements... 9 6. Trading Partner Agreements... 9 7. Transaction Specific Information... 10 7.1 276 Transaction Map... 10 7.2 277 Transaction Map... 20 7.3. Category code and status code... 35 8. Sample Files... 36 8.1 276 Transaction... 36 8.2 277 Response transaction... 39

Summary... 42

Preface This Companion Guide (CG) to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Cardinal Innovations. 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. The Communications/Connectivity component is included in the Companion Guide when the publishing entity wants to convey the information needed to commence and maintain communication exchange. The Transaction Instruction component is included in the Companion Guide when the publishing entity wants to clarify the Implementation Guide instructions for submission of specific electronic transactions. The Transaction Instruction component content is limited by ASCX12 s copyrights and Fair Use statement. Page 4

1. Transaction Instruction (TI) Introduction 1.1 Scope This Companion Guide provides specific requirements for sending Claim status request to Cardinal Innovations. This document provides information about the Claim status Response.It supplements the ASC X12N 276/277 (005010X212) Health Care Implementation Guide and should only be used for the purpose of clarification. 1.2 Overview The Claim Status Inquiry/Response Companion Guide has been written to assist you in designing and implementing Batch mode Claim status transactions to meet Cardinal Innovations processing standards. This Companion Guide must be used in conjunction with the Claim status Inquiry/Response (276/277) instructions as set forth by the ASC X12 Standards for Electronic Data Interchange (Version 005010X212). 1.3 References ASC X12 Version 5010 Implementation Guides: http://www.wpc-edi.com Washington Publishing Company: www.wpc-edi.com ASC X12 Organization : http://www.x12.org/ Workgroup for Electronic Data Interchange (WEDI): www.wedi.org 2. Getting Started 2.1 Working with Cardinal Innovations The table below identifies the X12N Implementation Guides for all of the transactions supported by Cardinal Innovations. Companion guides are available for each of the transactions. Section 7 of this document provides information specific to the 276/277 Health Care Claim Status Request and Response transaction set, as defined in the ASC/X12N 005010X212 Health Care Claim Status Request and Response Technical Report 3 (TR3) dated August 2006, and updated by: Page 5

Errata 005010X212E1 Health Care Claim Status Request and Response dated April 2008 Errata 005010X212E2 Health Care Claim Status Request and Response dated January 2009 Unique ID Name 005010X222 005010X223 005010X228 Health Care Claim: Professional (837P) Health Care Claim: Institutional (837I) Health Care Claim Pending Status Information (277P) 005010X279 Health Care Eligibility Benefit Inquiry and Response (270/271) 005010X221 Health Care Claim Payment/ Advice (835) 005010X212 Health Care Claim Status Request and Response (276/277) 005010X220 Benefit Enrollment and Maintenance (834) 005010X218 Payroll Deducted and Other Group Premium Payment for Insurance Products (820) 005010X231 Implementation Acknowledgment for Health Care Insurance (999) 2.2 Trading partner Registration For the purposes of this interface with Cardinal Innovations an Electronic Data Interchange (EDI) Trading Partner is either a provider or a clearinghouse that transmits electronic data to or receives electronic data from another entity. Trading partner registration, which includes electronic signature of the Trading Partner Agreement (TPA), generation of Transaction Supplier Number (TSN) is an on-line process. Clearing houses and Providers that intend to exchange electronic transactions with Cardinal Innovations must sign the TPA or Cardinal must have a TPA on file for this entity. 3. Testing with the Payer and Contact Information Cardinal Innovations require testing prior to approving a trading partner to submit claims in production. Once trading partner claims are in production, Cardinal Innovation reserves the right to require re-testing if it is determined that the trading partner is receiving/generating an unacceptable volume of errors. You can request claim status through Batch Real time through web API Page 6

3.1 Batch Transaction In order to submit 276 files through Batch please follow the below instruction - Contact the EDI Technical Support Team to set up testing pdsupport@cardinalinnovations.org Send a zipped, password protected 276 Test Claim file to pdsupport@cardinalinnovations.org Send the password for your test file in a separate email to pdsupport@cardinalinnovations.org. It is helpful if your provider name and number are placed in this email. You will be notified by email as to the status of the testing as it progresses. You have 2 options to submit 276 files: Each provider may upload files via the File Transfer link inside Provider Direct. If you would like to submit your 276 files via FTP, you may request FTP access and we will provide a form for you to complete. We are contracted with Emdeon. If you currently submit through Emdeon, a test file is not required but you will need to provide your 5 digit Provider Direct ID# to them. If you do not have your 5 digit Submitter ID#, you will need to contact pdsupport@cardinalinnovations.org If you wish to submit through an alternate clearinghouse, you will need to go through file testing as described above and name the clearinghouse on the authorized users section of the FTP Access Change Request Form. Provider Direct Provider Direct is a web-based system available to Providers upon completion of a Trading Partner Agreement. Billing through the Provider Direct System is Direct Data Entry (DDE) where an electronic CMS1500 or UB04 form is accessed and billing information is entered and submitted for reimbursement. Secure FTP (SFTP) SFTP is a terminal program that transfers files and encrypts/decrypts the files that you send and receive to a remote system. SFTP is a secure form of the FTP command. Whenever a user opens up a regular FTP session or most other TCP/IP connections, the entire transmission made between the host and the user is sent in plain text. When using SFTP instead of the FTP, the entire login session, including transmission of password is encrypted. An outsider, sneaking the connection would only see encrypted information, not the clear text ID and password transmitted to access the FTP server. Submitters are expected to provide their own Secure FTP client that supports SSH (Secure Shell). Page 7

3.1.1 PROCESS FLOWS Page 8

4. Control Segments/Envelopes 4.1 ISA-IEA Transactions transmitted during a session are identified by interchange header segment (ISA) and trailer segment (IEA) which form the envelope enclosing the transmission. Each ISA marks the beginning of the transmission (batch) and provides sender and receiver identification. 4.2 GS-GE EDI transactions of a similar nature and destined for one trading partner may be gathered into a functional group, identified by a functional group header segment (GS) and a functional group trailer segment (GE). Each GS segment marks the beginning of a functional group. There can be many functional groups within an interchange envelope. 4.3 ST-SE The beginning of each individual transaction is identified using a transaction set header segment (ST) and the end of every transaction is marked by a transaction set trailer segment (SE). 5. Acknowledgements For all inbound transactions, a 999 Acknowledgement report will be sent to the trading partner s OUTBOX for retrieval. This report serves as the acknowledgement of the submission of a file. Typically, 999 Acknowledgement reports are available within moments of submission. 6. Trading Partner Agreements EDI Trading Partner Agreements ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. The Trading Partner Agreement may specify among other things, the roles and responsibilities of each party to the agreement in conducting standard transactions. The Trading Partner Agreement information may be obtained from http://www.cardinalinnovations.org/providers/credentialing-enrollment/trading-partner-agreement Page 9

7. Transaction Specific Information The following tables contain one or more rows for each segment for which a supplemental instruction is needed. 005010X212 Health Care Claim Status Request and Response (276/277) 7.1 276 Transaction Map Loop SEG ID Element Element HEADER INFORMATION Header ISA R INTERCHANGE CONTROL HEADER ISA01 R Authorization Information Qualifier 00 ISA02 R Authorization Information 10 Spaces ISA03 R Security Information Qualifier 00 ISA04 R Security Information 10 Spaces ISA05 R Interchange ID Qualifier ZZ ISA06 R Interchange Sender ID Submitter ID assigned by LME followed by trailing spaces up to 15 bytes ISA07 R Interchange ID Qualifier ZZ ISA08 R Interchange Receiver ID Receiver ID provided by LME ISA09 R Interchange Date YYMMDD ISA10 R Interchange Time HHMM ISA11 R Repetition Separator ^ (caret character) ISA12 R Interchange Control Version Number 00501 ISA13 R Interchange Control Number Follow rules of the Implementation Guide ISA14 R Acknowledgment Requested Follow rules of the Implementation Guide ISA15 R Usage Indicator P production data T - Test data ISA16 R Component Element Separator : Page 10

Loop SEG ID Element Element Header GS R FUNCTIONAL GROUP HEADER GS01 R Healthcare Claim Status Request HR GS02 R Application Sender's Code Submitter ID assigned by LME GS03 R Application Receiver's Code Receiver ID provided by LME GS04 R Date CCYYMMDD GS05 R Time HHMM GS06 R Group Control Number First GS in ISA = 1 Subsequent GS will increment +1 per file GS07 R Accredited Standards Committee X12 X GS08 R Version / Release Industry Identifier Code 005010X212 Header ST R TRANSACTION SET HEADER ST01 R Transaction Set Identifier Code 276 ST02 R Transaction Set Control Number First ST in GS = 0001 Subsequent ST will increment +1 per GS ST03 R Implementation Convention Reference 005010X212 Header BHT R BEGINNING OF HIERARCHICAL TRANSACTION BHT01 R Hierarchical Structure Code 0010 BHT02 R Transaction Set Purpose Code 13 BHT03 R Reference Identification The number assigned by the originator to identify the transaction within the originator s business application system BHT04 R Date CCYYMMDD BHT05 R Time HHMM BHT06 R Transaction Type code Not Used Page 11

Loop SEG ID Element Element 2000A INFORMATION SOURCE 2000A HL R HL INFORMATION SOURCE LEVEL HL01 R Hierarchical ID Number HL01 must begin with 1within each ST/SE envelope and be Implemented by one each time an HL is used in transaction. HL02 NU Hierarchical Parent ID Number Not Used HL03 R Hierarchical Level Code 20 HL04 R Hierarchical Level Code 1 2100A NM1 R PAYER NAME NM01 R Entity Identifier Code PR NM02 R Entity Type Qualifier 2 NM103 R Name Last or Organization Name Payer Name NM104 NU Name First Element not used NM105 NU Name Middle Element not used NM106 NU Name Prefix Element not used NM107 NU Name Suffix Element not used NM108 R Identification Code Qualifier PI Payer Identification XV Centers for Medicare and Medicaid Services Plan Id. NM109 R Identification Code Submitter ID assigned by LME 2000B INFORMATION RECEIVER 2000B HL R HL INFORMATION RECEIVER LEVEL HL01 R Hierarchical ID Number HL01 must be incremented by one each time an HL is used within each ST/SE envelope. Only numeric values are allowed in HL01 HL02 R Hierarchical Parent Id Number Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL03 R Hierarchical Level Code 21 Information Receiver HL04 R Hierarchical child Code 1 Additional Subordinate HL Data Segment in this Hierarchical structure 2100B NM1 R INFORMATION RECEIVER NAME NM01 R Entity Identifier Code 41 - Submitter NM02 R Entity Type Qualifier 1 person 2 Non person entity Page 12

Loop SEG ID Element Element NM103 S Name Last or Organization Name Information Receiver last or organization name NM104 S Name First Information receiver first name NM105 S Name Middle Information receiver middle name NM106 NU Name Prefix Element not used NM107 NU Name Suffix Element not used NM108 R Identification Code Qualifier 46 Electronic Transmitter Identification number (ETIN) NM109 R Identification Code The ETIN is established through trading partner agreement 2000C SERVICE PROVIDER LEVEL 2000C HL R HL SERVICE PROVIDER LEVEL HL01 R Hierarchical ID Number HL01 must be incremented by one each time an HL is used within each ST/SE envelope. Only numeric values are allowed in HL01 HL02 R Hierarchical Parent Id Number Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL03 R Hierarchical Level Code 19 Provider of service HL04 R Hierarchical child Code 1 Additional Subordinate HL Data Segment in this Hierarchical structure 2100C NM1 R PROVIDER NAME NM01 R Entity Identifier Code 1P- Provider NM02 R Entity Type Qualifier 1 person 2 Non person entity NM103 S Name Last or Organization Name Information Receiver last or organization name NM104 S Name First Information receiver first name NM105 S Name Middle Information receiver middle name NM106 NU Name Prefix Element not used NM107 NU Name Suffix Element not used NM108 R Identification Code Qualifier XX Centers for Medicare and Medicaid Service National Provider Identifier Page 13

Element Loop SEG ID Element NM109 R Identification Code NPI Number 2000D SUBSCRIBER LEVEL 2000D HL R HL SERVICE PROVIDER LEVEL HL01 R Hierarchical ID Number HL01 must be incremented by one each time an HL is used within each ST/SE envelope. Only numeric values are allowed in HL01 HL02 R Hierarchical Parent Id Number Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL03 R Hierarchical Level Code 22 Subscriber HL04 R Hierarchical child Code 1 Additional Subordinate HL Data Segment in this Hierarchical structure Required when there are dependent claim status request for this subscriber) 0 No Subordinate HL segment in this hierarchical structure ((Required when there are no dependent claim status requests for this subscriber) 2100D DMG S SUBSCRIBER DEMOGRAPHIC INFORMATION DMG01 R Date Time Period Format qualifier D8 date expressed in format CCYYMMDD DMG02 R Date Time Period Subscriber Birth date DMG03 S Gender Code F- Female, M- Male 2100D NM1 R SUBSCRIBER NAME NM01 R Entity Identifier Code IL Insured or Subscriber NM02 R Entity Type Qualifier 1 person 2 Non person entity NM103 S Name Last or Organization Name NM104 S Name First NM105 S Name Middle NM106 NU Name Prefix Element not used NM107 S Name Suffix Page 14

Loop SEG ID Element Element NM108 R Identification Code Qualifier 24 Employer s Identification Number ; MI Member Identification Number NM109 R Identification Code Subscriber Identifier 2200D CLAIM STATUS TRACKING NUMBER 2200D TRN S TRN Claim status tracking number TRN01 R Trace Type code 1 Current Transaction trace Number TRN02 R Reference Identification Transaction Trace Number 2200D REF S PAYER CLAIM CONTROL NUMBER REF01 R Reference Identification Qualifier FJ Line Control Number REF02 R Reference Identification Patient claim control Number 2200D REF S Claim Identification Number for clearinghouse and other Transmission intermediaries REF01 R Reference Identification Qualifier D9 Claim Number REF02 R Reference Identification Clearinghouse Trace number 2200D DTP S CLAIM SERVICE DATE DTP01 R Date Time Qualifier 472 Service DTP02 R Date Time Period Format Qualifier D8 Date Expressed in Format CCYYMMDD RD8 Range of date Expressed in Format CCYYMMDD. DTP03 R Date Time Period Claim service Period 2200D SERVICE LINE INFORMATION 2210D SVC S Service Line Information SVC01 R Composite Medical Procedure Identifier Page 15

Element Loop SEG ID Element SVC01 1 R Product/Service ID Qualifier Product or Service ID Qualifier HC - HCPCS Code NU NUBC Revenue Code SVC01 2 R Product /Service ID Procedure Code SVC01 3 S Procedure Modifier Required when modifiers have been applied to adjudicate. SVC02 R Monetary Amount This amount is the original Submitted charge SVC03 NU Monetary Amount Not Used SVC04 S Product/Service ID Required on institutional claims when an NUBC revenue code needs to be Reported in addition to a HCPCS or HIPPS code reported in SVC01-2 SVC05 NU Quantity Not Used SVC06 NU Composite Medical Procedure Identifier Not Used SVC07 R Quantity Units of Service Count 2210D REF S SERVICE LINE IDENTIFICATION REF01 R Reference Identification Qualifier FJ Line Control Number REF02 R Reference Identification Line Control Number 2210D DTP R SERVICE LINE DATE DTP01 R Date Time Qualifier 472 - Service DTP02 R Date Time Period Format Qualifier D8 Date Expressed in Format CCYYMMDD RD8 Range of date Expressed in Format CCYYMMDD. DTP03 R Date Time Period Service line Date 2000E - DEPENDENT LEVEL Required only when patient is a dependent whose does not have a unique identification number. 2000E HL S HL SERVICE PROVIDER LEVEL HL01 R Hierarchical ID Number HL01 must be incremented by one each time an HL is used within each ST/SE envelope. Only numeric values are allowed in HL01 HL02 R Hierarchical Parent Id Number Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL03 R Hierarchical Level Code 23 Dependent Page 16

Loop SEG ID Element Element 2000E DMG R DEPENDENT DEMOGRAPHIC INFORMATION DMG01 R Date Time Period Format qualifier D8 date expressed in format CCYYMMDD DMG02 R Date Time Period Patient Birth Date DMG03 S Gender Code F- Female, M- Male 2100E NM1 R Dependent Name NM101 R Entity Identifier Code QC Patient NM102 R Entity Type Qualifier 1 person NM103 R Name Last or Organization Name Patient Last Name NM104 S Name First Patient First Name NM105 S Name Middle Patient Middle Name NM106 NU Name Prefix Element not used NM107 S Name Suffix 2200E CLAIM STATUS TRACKING NUMBER 2200E TRN R TRN Claim status tracking number TRN01 R Trace Type code 1 Current Transaction trace Number TRN02 R Reference Identification Referenced transaction Trace Number 2200E REF S PATIENT CONTROL NUMBER REF01 R Reference Identification Qualifier FJ Line Control Number REF02 R Reference Identification Patient claim control Number 2200E REF S Claim Identification Number for clearinghouse and other Transmission intermediaries REF01 R Reference Identification Qualifier D9 Claim Number REF02 R Reference Identification Clearinghouse Trace number 2200E DTP S CLAIM SERVICE DATE DTP01 R Date Time Qualifier 472 Service DTP02 R Date Time Period Format Qualifier D8 Date Expressed in Format CCYYMMDD RD8 Range of date Expressed in Format CCYYMMDD. DTP03 R Date Time Period Claim service Period Page 17

Loop SEG ID Element Element 2210E SERVICE LINE INFORMATION 2210E SVC S Service Line Information SVC01 R Composite Medical Procedure Identifier SVC01 1 R Product/Service ID Qualifier Product or Service ID Qualifier HC - HCPCS Code NU NUBC Revenue Code SVC01 2 R Product /Service ID Procedure Code SVC01 3 S Procedure Modifier Required when modifiers have been Applied to adjudicate. SVC02 R Monetary Amount This amount is the original Submitted charge SVC03 NU Monetary Amount Not Used SVC04 S Product/Service ID Required on institutional claims when an NUBC revenue code needs to be reported in addition to a HCPCS or HIPPS code reported in SVC01-2 SVC05 NU Quantity Not Used SVC06 NU Composite Medical Procedure Identifier Not Used SVC07 R Quantity Units of Service Count 2210E REF S SERVICE LINE ITEM IDENTIFICATION REF01 R Reference Identification Qualifier FJ Line Control Number REF02 R Reference Identification Patient claim control Number 2210E DTP R SERVICE LINE DATE DTP01 R Date Time Qualifier 472 Service DTP02 R Date Time Period Format Qualifier D8 Date Expressed in Format CCYYMMDD RD8 Range of date Expressed in Format CCYYMMDD. DTP03 R Date Time Period Claim service Period Page 18

Loop SEG ID Element Element SE- TRANSACTION SET TRAILER Trailer SE R TRNSACTION SET TRAILER SE01 R Number of Included Segments Total number of segments included in a transaction set including ST and SE SE02 R Transaction Set Control number Data value in SE02 must be identical to ST02 Trailer GE R FUNCTIONAL GROUP TRAILER GE01 R Number of Transactions Sets Included Total number of transaction set included in the functional group or Interchange group terminated by the trailer containing this data element. GE02 R Group Control Number D8 Date Expressed in Format CCYYMMDD RD8 Range of date Expressed in Format CCYYMMDD. Trailer IEA R INTERCHANGE CONTROL TRAILER IEA01 R Number Of Included Functional Groups A count of the number of functional groups included in an interchange IEA02 R Interchange Control Number A control number assigned by the interchange sender (000000001) Page 19

7.2 277 Transaction Map Loop SEG ID Element Element HEADER INFORMATION Header ISA R INTERCHANGE CONTROL HEADER ISA01 R Authorization Information Qualifier 00 ISA02 R Authorization Information 10 Spaces ISA03 R Security Information Qualifier 00 ISA04 R Security Information 10 Spaces ISA05 R Interchange ID Qualifier ZZ ISA06 R Interchange Sender ID Submitter ID assigned by LME followed by trailing spaces up to 15 Bytes. ISA07 R Interchange ID Qualifier ZZ ISA08 R Interchange Receiver ID Receiver ID provided by LME ISA09 R Interchange Date YYMMDD ISA10 R Interchange Time HHMM ISA11 R Repetition Separator ^ (caret character) ISA12 R Interchange Control Version Number 00501 ISA13 R Interchange Control Number The Interchange Control Number, ISA13, must be identical to the associated Interchange trailer IEA02 ISA14 R Acknowledgment Requested 0 No Interchange Acknowledgement Requested 1 Interchange Acknowledgment Requested. ISA15 R Usage Indicator P production data T - Test data ISA16 R Component Element Separator : Page 20

Loop SEG ID Element Element Header GS R FUNCTIONAL GROUP HEADER GS01 R Healthcare Claim Status Request HN GS02 R Application Sender's Code Submitter ID assigned by LME GS03 R Application Receiver's Code Receiver ID provided by LME GS04 R Date CCYYMMDD GS05 R Time HHMM GS06 R Group Control Number First GS in ISA = 1 Subsequent GS will increment +1 per file GS07 R Accredited Standards Committee X12 X GS08 R Version / Release Industry Identifier Code 005010X212 Header ST R TRANSACTION SET HEADER ST01 R Transaction Set Identifier Code 277 ST02 R Transaction Set Control Number First ST in GS = 0001 Subsequent GS will increment +1 per file ST03 R Implementation Convention Reference 005010X212 Header BHT R BEGINNING OF HIERARCHICAL TRANSACTION BHT01 R Hierarchical Structure Code 0010 BHT02 R Transaction Set Purpose Code 08 BHT03 R Reference Identification The number assigned by the originator to identify the transaction within the originator s business application system BHT04 R Date CCYYMMDD BHT05 R Time HHMM BHT06 R Transaction Type code DG Page 21

Loop SEG ID Element Element 2000B INFORMATION RECEIVER 2000B HL R HL INFORMATION RECEIVER LEVEL HL01 R Hierarchical ID Number HL01 must be incremented by one each time an HL is used within each ST/SE envelope. Only numeric values are allowed in HL01 HL02 R Hierarchical Parent Id Number Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL03 R Hierarchical Level Code 21 HL04 R Hierarchical child Code 0 No Subordinate HL segment in this hierarchical structure (Required when rejecting the status request. 1 Additional Subordinate HL data Segment in this hierarchical structure.(required when reporting status responses at the lower hierarchical levels). 2100B NM1 R INFORMATION RECEIVER NAME NM01 R Entity Identifier Code 41 NM02 R Entity Type Qualifier 1 person 2 Non person entity NM103 S Name Last or Organization Name Information Receiver last or organization name NM104 S Name First NM105 S Name Middle NM106 NU Name Prefix Element not used NM107 NU Name Suffix Element not used NM108 R Identification Code Qualifier 46 Electronic Transmitter Identification number (ETIN) NM109 R Identification Code The ETIN is established through trading partner agreement Page 23

Loop SEG ID Element Element 2000C SERVICE PROVIDER LEVEL 2000C HL S HL SERVICE PROVIDER LEVEL HL01 R Hierarchical ID Number HL01 must be incremented by one each time an HL is used within each ST/SE envelope. Only numeric values are allowed in HL01 HL02 R Hierarchical Parent Id Number Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL03 R Hierarchical Level Code 19 Provider of Service HL04 R Hierarchical child Code 1 Additional Subordinate HL Data Segment in this Hierarchical structure (Required when rejecting the claim status request) 0 No Subordinate HL segment in this hierarchical structure 2100C NM1 R PROVIDER NAME NM01 R Entity Identifier Code 1P Provider NM02 R Entity Type Qualifier 1 person 2 Non person entity NM103 S Name Last or Organization Name Information Receiver last or organization name NM104 S Name First NM105 S Name Middle NM106 NU Name Prefix Element not used NM107 NU Name Suffix Element not used NM108 R Identification Code Qualifier FI Federal Taxpayer s Identification Number SV Service Provider Number XX Centers for Medicare and Medicaid Service National Provider Identifier NM109 R Identification Code Provider Identifier 2000D SUBSCRIBER LEVEL 2000D HL S HL SERVICE PROVIDER LEVEL HL01 R Hierarchical ID Number HL01 must be incremented by one each time an HL is used within each ST/SE envelope. Only numeric values are allowed in HL01 HL02 R Hierarchical Parent Id Number Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL03 R Hierarchical Level Code 22 Subscriber HL04 R Hierarchical child Code 1 Additional Subordinate HL Data Segment in this Hierarchical structure Required when there are dependent claim status request for this subscriber) 0 No Subordinate HL segment in this hierarchical structure ((Required when there are no dependent claim status requests for this subscriber) Page 24

Loop SEG ID Element Element 2100D NM1 R SUBSCRIBER NAME NM01 R Entity Identifier Code IL Insured or Subscriber NM02 R Entity Type Qualifier 1 person 2 Non person entity NM103 S Name Last or Organization Name Information Receiver last or organization name NM104 S Name First NM105 S Name Middle NM106 NU Name Prefix Element not used NM107 NU Name Suffix Element not used NM108 R Identification Code Qualifier 24 Employer s Identification Number MI Member Identification Number NM109 R Identification Code Subscriber Identifier 2200D CLAIM STATUS TRACKING NUMBER 2200D TRN S TRN Claim status tracking number TRN01 R Trace Type code 2 Referenced Transaction trace Number TRN02 R Reference Identification Referenced transaction Trace Number 2200D STC R Claim status Tracking Information STC01 R Health Care claim Status Used to convey status of the entire claim or a specific service line STC01-1 R Industry Code Health Care claim status category code STC01-2 R Industry Code Status Code STC01 3 s Entity Identifier Code Follow the implementation Guide for the codes STC01-4 S Code List qualifier code STC02 R Date Status Information effective date STC03 NU Action Code Not Used STC04 S Monetary Amount Total Claim Charge Amount Page 25

Loop SEG ID Element Element STC05 S Monetary Amount Claim Payment Amount STC06 S Date Adjudication Finalizes date STC07 NU Payment Method Code Not Used STC08 S Date Remittance Date STC09 S Check Number Remittance Trace Number STC10 S Healthcare claim status Required when a second claim status is needed STC10-1 R Industry Code Category code STC10-2 R Industry code Status code STC10-3 S Entity Identifier Code Required when an entity must be identified to further clarify the code message in STC 10-2 STC10-4 S Code List qualifier code STC11 S Healthcare claim status Required when a second claim status is needed STC11-1 R Industry Code Category code STC11-2 R Industry code Status code STC11 3 S Entity Identifier Code Required when an entity must be identified to further clarify the code message in STC 11-2 STC11-4 S Code List qualifier code 2200D REF S PAYER CLAIM CONTROL NUMBER REF01 R Reference Identification Qualifier FJ Line Control Number REF02 R Reference Identification Payer claim control Number 2200D REF S INSTITUTIONAL BILL TYPE IDENTIFICATION REF01 R Reference Identification Qualifier BLT Bill Type REF02 R Reference Identification Payer claim control Number Page 26

Loop SEG ID Element Element 2200D REF S PATIENT CONTROL NUMBER REF01 R Reference Identification Qualifier FJ Line Control Number REF02 R Reference Identification Patient claim control Number 2200D REF S Claim Identification Number for clearinghouse and other Transmission intermediaries REF01 R Reference Identification Qualifier D9 Claim Number REF02 R Reference Identification Clearinghouse Trace number 2200D DTP S CLAIM SERVICE DATE DTP01 R Date Time Qualifier 472 Service DTP02 R Date Time Period Format Qualifier D8 Date Expressed in Format CCYYMMDD RD8 Range of date Expressed in Format CCYYMMDD. DTP03 R Date Time Period Claim service Period Page 27

Loop SEG ID Element Element 2200D SERVICE LINE INFORMATION 2220D SVC S Service Line Information SVC01 R Composite Medical Procedure Identifier SVC01 1 R Product/Service ID Qualifier Product or Service ID Qualifier HC - HCPCS Code NU NUBC Revenue Code SVC01 2 R Product /Service ID Procedure Code SVC01 3 S Procedure Modifier Required when modifiers have been applied to adjudicate. SVC02 R Monetary Amount This amount is the original Submitted charge SVC03 NU Monetary Amount Not Used SVC04 S Product/Service ID Required on institutional claims when an NUBC revenue code needs to be Reported in addition to a HCPCS or HIPPS code reported in SVC01-2 SVC05 NU Quantity Not Used SVC06 NU Composite Medical Procedure Identifier Not Used SVC07 R Quantity Units of Service Count 2220D REF S Service Line Identification REF01 R Reference Identification Qualifier FJ Line Control Number REF02 R Reference Identification Line Control Number 2220D DTP R SERVICE LINE DATE DTP01 R Date Time Qualifier 472 - Service DTP02 R Date Time Period Format Qualifier D8 Date Expressed in Format CCYYMMDD RD8 Range of date Expressed in Format CCYYMMDD. DTP03 R Date Time Period Service line Date 200D SERVICE LINE STATUS INFORMATION 2220D STC R Claims Status Tracking Information STC01 R Health Care claim Status Used to convey status of the entire claim or a specific service line STC01-1 R Industry Code Health Care claim status category code STC01-2 R Industry Code Status Code HIPAA 276/277 Companion Page 28 Guide Version1.1

Loop SEG ID Element Element STC01 3 s Entity Identifier Code Follow the implementation Guide for the codes STC01-4 S Code List qualifier code STC02 R Date Status Information effective date STC03 NU Action Code Not Used STC04 S Monetary Amount Total Claim Charge Amount STC05 S Monetary Amount Claim Payment Amount STC06 S Date Adjudication Finalizes date STC07 NU Payment Method Code Not Used STC08 S Date Remittance Date STC09 S Check Number Remittance Trace Number STC10 S Healthcare claim status Required when a second claim status is needed STC10-1 R Industry Code Category code STC10-2 R Industry code Status code STC10-3 S Entity Identifier Code Required when an entity must be identified to further clarify the code message in STC 10-2 STC10-4 S Code List qualifier code STC11 S Healthcare claim status Required when a second claim status is needed STC11-1 R Industry Code Category code STC11-2 R Industry code Status code STC11 3 S Entity Identifier Code Required when an entity must be identified to further clarify the code message in STC 11-2 STC11-4 S Code List qualifier code 2220D REF S Service Line Identification REF01 R Reference Identification Qualifier FJ Line Control Number REF02 R Reference Identification Line Control Number 2200D DTP S SERVICE LINE DATE DTP01 R Date Time Qualifier 472 - Service DTP02 R Date Time Period Format Qualifier D8 Date Expressed in Format CCYYMMDD RD8 Range of date Expressed in Format CCYYMMDD. DTP03 R Date Time Period Service line Date HIPAA 276/277 Companion Page 29 Guide Version1.1

Loop SEG ID Element Element 2000E - DEPENDENT LEVEL Required only when patient is a dependent whose does not have a unique identification number. 2000E HL S HL DEPENDENT LEVEL HL01 R Hierarchical ID Number HL01 must be incremented by one each time an HL is used within each ST/SE envelope. Only numeric values are allowed in HL01 HL02 R Hierarchical Parent Id Number Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL03 R Hierarchical Level Code 23 Dependent 2100E NM1 R Dependent Name NM101 R Entity Identifier Code QC Patient NM102 R Entity Type Qualifier 1 person NM103 R Name Last or Organization Name Patient Last Name NM104 S Name First Patient First Name NM105 S Name Middle Patient Middle Name NM106 NU Name Prefix Element not used NM107 S Name Suffix 2200E CLAIM STATUS TRACKING NUMBER 2200E TRN S TRN Claim status tracking number TRN01 R Trace Type code 2 Referenced Transaction trace Number TRN02 R Reference Identification Referenced transaction Trace Number 2200E STC R TRN Claim status tracking Information STC01 R Health Care claim Status Used to convey status of the entire claim or a specific service line STC01-1 R Industry Code Health Care claim status category code STC01-2 R Industry Code Status Code HIPAA 276/277 Companion Page 30 Guide Version1.1

Loop SEG ID Element Element STC01-3 S Entity Identifier Code Follow the implementation Guide for the codes STC01-4 S Code List qualifier code Status Information effective date STC02 R Date STC03 NU Action Code Not Used STC04 S Monetary Amount Total Claim Charge Amount STC05 S Monetary Amount Claim Payment Amount S Date Adjudication Finalizes date STC06 STC07 NU Payment Method Code Not Used STC08 S Date Remittance Date STC09 S Check Number Remittance Trace Number STC10 S Healthcare claim status Required when a second claim status is needed STC10-1 R Industry Code Category code STC10-2 R Industry Code Status code STC10-3 S Entity Identifier Code Required when an entity must be identified to further clarify the code message in STC 10-2 STC10-4 S Code List qualifier code STC11 S Healthcare claim status Required when a second claim status is needed. STC11-1 R Industry Code Category code STC11-2 R Industry code Status code STC11-3 S Entity Identifier Code Required when an entity must be identified to further clarify the code message in STC 11-2 STC11-4 S Code List qualifier code 2200E REF S PAYER CLAIM CONTROL NUMBER Claim level REF01 R Reference Identification Qualifier 1K Payer s Claim Number REF02 R Reference Identification 1K Payer s Claim Number 2200E REF S INSTITUTIONAL BILL TYPE IDENTIFICATION claim level REF01 R Reference Identification Qualifier BLT Bill Type REF02 R Reference Identification Payer claim control Number HIPAA 276/277 Companion Page 31 Guide Version1.1

Loop SEG ID Element Element 2200E REF S PATIENT CONTROL NUMBER Claim level REF01 R Reference Identification Qualifier EJ Patient Account Number REF02 R Reference Identification Patient Control Number 2200E REF S Claim Identification Number for clearinghouse and other Transmission intermediaries REF01 R Reference Identification Qualifier D9 Claim Number REF02 R Reference Identification Clearinghouse Trace number 2200E DTP S CLAIM SERVICE DATE DTP01 R Date Time Qualifier 472 Service DTP02 R Date Time Period Format Qualifier D8 Date Expressed in Format CCYYMMDD RD8 Range of date Expressed in Format CCYYMMDD. DTP03 R Date Time Period Service line Date 2200E SERVICE LINE INFORMATION 2220E SVC S Service Line Information SVC01 R Composite Medical Procedure Identifier SVC01 1 R Product/Service ID Qualifier Product or Service ID Qualifier HC - HCPCS Code NU NUBC Revenue Code SVC01 2 R Product /Service ID Procedure Code SVC01 3 S Procedure Modifier Required when modifiers have been Applied to adjudicate. SVC02 R Monetary Amount This amount is the original Submitted charge SVC03 NU Monetary Amount Not Used SVC04 S Product/Service ID Required on institutional claims when an NUBC revenue code needs to be reported in addition to a HCPCS or HIPPS code reported in SVC01-2 SVC05 NU Quantity Not Used SVC06 NU Composite Medical Procedure Identifier Not Used SVC07 R Quantity Units of Service Count HIPAA 276/277 Companion Page 32 Guide Version1.1

Loop SEG ID Element Element 2220E STC R Service Line Status Information STC01 R Healthcare claim status Used to convey status of the entire claim or a specific service line STC01-1 R Industry Code Health Care claim status Category code STC01-2 R Industry code Status code STC01-3 S Entity Identifier Code Follow the implementation guide for codes STC01-4 S Code List qualifier code STC02 R Date Status Information effective date STC03 NU Action Code Not Used STC04 S Monetary Amount Total Claim Charge Amount STC05 S Monetary Amount Claim Payment Amount STC06 S Date Adjudication Finalizes date STC07 NU Payment Method Code Not Used STC08 S Date Remittance Date STC09 S Check Number Remittance Trace Number STC10 S Healthcare claim status Required when a second claim status is needed STC10-1 R Industry Code Category code STC10-2 R Industry Code Status code STC10-3 S Entity Identifier Code Required when an entity must be identified to further clarify the code message in STC 10-2 STC10-4 S Code List qualifier code STC11 S Healthcare claim status Required when a second claim status is needed STC11-1 R Industry Code Category code STC11-2 R Industry Code Status code STC11-3 S Entity Identifier Code Required when an entity must be identified to further clarify the code message in STC 11-2 STC11-4 S Code List qualifier code HIPAA 276/277 Companion Page 33 Guide Version1.1

Loop SEG ID Element Element 2220E REF S Service Line Information REF01 R Reference Identification Qualifier FJ Line Control Number REF02 R Reference Identification Line Control Number 2200E DTP S SERVICE LINE DATE DTP01 R Date Time Qualifier 472 - Service DTP02 R Date Time Period Format Qualifier D8 Date Expressed in Format CCYYMMDD RD8 Range of date Expressed in Format CCYYMMDD. DTP03 R Date Time Period Service line Date Transaction Set Trailer Trailer SE R TRNSACTION SET TRAILER SE01 R Number of Included Segments Total number of segments included in a transaction set including ST and SE SE02 R Transaction Set Control number Data value in SE02 must be identical to ST02 Trailer GE R FUNCTIONAL GROUP TRAILER GE01 R Number of Transactions Sets Included Total number of transaction set included in the functional group or Interchange group terminated by the trailer containing this data element. GE02 R Group Control Number D8 Date Expressed in Format CCYYMMDD RD8 Range of date Expressed in Format CCYYMMDD. Trailer IEA R INTERCHANGE CONTROL TRAILER IEA01 R Number Of Included Functional Groups A count of the number of functional groups included in an interchange IEA02 R Interchange Control Number A control number assigned by the interchange sender (000000001) HIPAA 276/277 Companion Page 34 Guide Version1.1

7.3. Category code and status code Below are the category and status code which comes out in 277 responses from cardinal innovations. Description CC:SC:EC Not yet Adjudicated P1:40 Approved but not yet paid F0:3 Approved/ capitated (paid 0) F0 :105 Approved and paid F1:65 Denied F2:585 Pended P0:0 Reverted F5:0 Claim not found A4:35 Claim contains both approved and denied service lines. Provider did not match/entity not found Dependent not found A2:72 D0:26:1P D0:26:03 (Note:- CC Category code; SC Status code; EC- Entity Identifier code) HIPAA 276/277 Companion Page 35 Guide Version1.1

8. Sample Files 8.1 276 Transaction ISA*00* *00* *ZZ*12345 *ZZ*06607 *140819*1806*^*00501*000000001*0*T*:~ GS*HR*12345*06607*20141103*1400*1*X*005010X212~ ST*276*0001*005010X212~ BHT*0010*13*ABC276XXX*20050915*1425~ HL*1**20*1~ NM1*PR*2*ABC INSURANCE*****PI*12345~ HL*2*1*21*1~ NM1*41*2*XYZ SERVICE*****46*X67E~ HL*3*2*19*1~ NM1*1P*2*HOME HOSPITAL*****XX*1666666661~ HL*4*3*22*0~ DMG*D8*19301210*M~ NM1*IL*1*SMITH*FRED****MI*123456789A~ TRN*1*ABCXYZ1~ HIPAA 276/277 Companion Page 36 Guide Version1.1

REF*BLT*111~ REF*EJ*SM123456~ AMT*T3*8513.88~ DTP*472*RD8*20050831-20050906~ HL*5*3*22*0~ DMG*D8*19301115*F~ NM1*IL*1*JONES*MARY****MI*234567890A~ TRN*1*ABCXYZ2~ REF*BLT*111~ REF*EJ*JO234567~ AMT*T3*7599~ DTP*472*RD8*20050731-20050809~ HL*6*2*19*1~ NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1666666666~ HL*7*6*22*1~ NM1*IL*1*MANN*JOHN****MI*345678901~ HIPAA 276/277 Companion Page 37 Guide Version1.1

HL*8*7*23~ DMG*D8*19951101*M~ NM1*QC*1*MANN*JOSEPH~ TRN*1*ABCXYZ3~ REF*EJ*MA345678~ SVC*HC:99203*150*****1~ DTP*472*D8*20050501~ SE*36*0001~ GE*1*1~ IEA*1*000000001~ HIPAA 276/277 Companion Page 38 Guide Version1.1

8.2 277 Response transaction ISA*00*...*00*...*ZZ*06607 *ZZ*24759 *141110*1407*^*00501*000000029*1*T*:~ GS*HN*06607*12345*20141110*1407*1*X*005010X212~ ST*277*0001*005010X212~ BHT*0010*08*277X212*20050916*0810*DG~ HL*1**20*1~ NM1*PR*2*ABC INSURANCE*****PI*12345~ HL*2*1*21*1~ NM1*41*2*XYZ SERVICE*****46*X67E~ HL*3*2*19*1~ NM1*1P*2*HOME HOSPITAL*****XX*1666666661~ HL*4*3*22*0~ NM1*IL*1*SMITH*FRED****MI*123456789A~ TRN*2*ABCXYZ1~ STC*P3:317*20050913**8513.88~ REF*1K*05347006051~ REF*BLT*111~ HIPAA 276/277 Companion Page 39 Guide Version1.1

REF*EJ*SM123456~ DTP*472*RD8*20050831-20050906~ HL*5*3*22*0~ NM1*IL*1*JONES*MARY****MI*234567890A~ TRN*2*ABCXYZ2~ STC*F0:3*20050915**7599*7599~ REF*1K*0529675341~ REF*BLT*111~ REF*EJ*JO234567~ DTP*472*RD8*20050731-20050809~ HL*6*2*19*1~ NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1666666666~ HL*7*6*22*1~ NM1*IL*1*MANN*JOHN****MI*345678901~ HL*8*7*23~ NM1*QC*1*MANN*JOSEPH~ HIPAA 276/277 Companion Page 40 Guide Version1.1

TRN*2*ABCXYC3~ STC*F2:88:QC*20050612**150*0~ REF*1K*051681010827~ REF*EJ*MA345678~ SVC*HC:99203*150*0****1~ STC*F2:88:QC*20050612~ DTP*472*D8*20050501~ SE*38*0001~ GE*1*1~ IEA*1*000000029~ HIPAA 276/277 Companion Page 41 Guide Version1.1

Summary Version Issued Updater Comments 1.0 11/17/2014 Kavitha Lakshminarayanan Initial Review 1.1 02/01/2017 Kavitha Lakshminarayanan Updated the logo HIPAA 276/277 Companion Page 42 Guide Version1.1