Appendix A Vendor Specifications-5010 for State of Idaho MMIS Date of Publication: 1/18/2017 Document Number: TL428 Version: 6.0
Revision History Version Date Author Action/Summary of Changes 1.0 07/01/2011 Molina Initial document 1.1 04/22/2014 M McFadden Replaced references of 997 with 999 2.0 5/19/2014 TQD DHW approved 5/9/2014 2.1 7/31/2014 M McFadden 824 Application Advice upgraded to 005010X186 2.2 8/7/2014 Megan Lloyd Updated the document based on Cindy Day s feedback related to CCF 10735B1. 3.0 8/15/2014 TQD DHW validated changes 8/15/14 3.1 5/20/2015 M McFadden Semi-annual review performed made format changes 3.2 5/26/2015 Hope McCain Corrections to make content match current portal functionality and appearance 4.0 6/16/2015 TQD DHW validated changes 6/15/15 4.1 7/23/15 Doug Greer Clarified what the Secured FTP connection 5.0 08/06/2015 TQD DHW validated changes 8/4/15 5.1 12/15/2016 Jimmy Phillips Semi-annual review remove secured FTP information and replace with VAN, update Table of Contents 6.0 1/28/2017 TQD DHW validated changes 1/12/17 DISCLAIMER The Molina Healthcare Companion Guide for Idaho is subject to change prior to January 1, 2012 or at the instruction of the Department. Therefore, it is the responsibility of the trading partner to ensure that the latest version of this guide is used when designing /building X12N 5010 EDI transactions. The trading partner should frequently check for updates to the companion guide. Molina Healthcare accepts no liability for any costs that the trading partner may incur that arise from or are related to changes to the companion guide. Last Updated: 1/18/2017 Page ii
Table of Contents Appendix A.... 1 A.1 Retrieving Acknowledgments for X12 Transactions That Were Uploaded Via Health PAS-Online... 1 A.2 Retrieving Acknowledgements for X12 Transactions Submitted Via a VAN Connection... 1 A.2.1 Acknowledgements Generated By X12 HIPAA Validation... 2 Table of Figures Figure A-1: Older Acknowledgements and Responses via Search Button... 1 Figure A-2: Interchange Acknowledgement Code... 2 Figure A-3: IBP - Insurance Business Process Application Error Codes... 4 Figure A-4: Sample Business Rejection Report (BRR)... 9 Last Updated: 1/18/2017 Page iii
Appendix A. A.1 Retrieving Acknowledgments for X12 Transactions That Were Uploaded Via Health PAS-Online Acknowledgments and Responses to transactions submitted via Health PAS-Online can be accessed by selecting Responses under the File Exchange menu. Acknowledgment for the most recently submitted transactions are automatically displayed in the list for download. Each can be viewed separately by clicking on the appropriate hyperlink or all acknowledgements for a transaction can be downloaded at once by using the Download All button. Older acknowledgements and responses can be located by using the Search button (Figure A-1). Figure A-1: Older Acknowledgements and Responses via Search Button A.2 Retrieving Acknowledgements for X12 Transactions Submitted Via a VAN Connection Trading Partners who have submitted X12 transactions via a VAN connection, may retrieve acknowledgements and responses from their designated VAN Pickup location. Any validation responses to the original submission (TA1, 999, 824 and BRR) will be based on the Molina internal file naming convention. This naming convention is as follows: <Input Class>-<Sender ID>-<Receiver ID>-<Date: CCYYMMDD>-<Time: HHMMSS>-<File ID>-<Transaction Type>-<Usage: T for Test, P for Production>.edi For example: An inbound Request for Health Care Services Review file from Trading Partner ID IDTPID000011, would be assigned an internal name of: VAN-IDTPID000011-ID_MMIS_4MOLINA-20110616-112750-1367-005010X217-P.edi The HIPAA validation acknowledgements would appear in this trading partner s VAN pickup location named: VAN-IDTPID000011-ID_MMIS_4MOLINA-20110616-112750-1367-005010X217-P.edi-1367-TA1.edi VAN-IDTPID000011-ID_MMIS_4MOLINA-20110616-112750-1367-005010X217-P.edi-1367-999.edi VAN-IDTPID000011-ID_MMIS_4MOLINA-20110616-112750-1367-005010X217-P.edi-1367-824.edi VAN-IDTPID000011-ID_MMIS_4MOLINA-20110616-112750-1367-005010X217-P.edi-1367-BRR.edi Last Updated: 1/18/2017 Page 1 of 9
A.2.1 Acknowledgements Generated By X12 HIPAA Validation A.2.1.1 TA1 Interchange Acknowledgement The TA1 interchange acknowledgement is used to verify the syntactical accuracy of the envelope of the X12 interchange. The TA1 interchange will indicate that the file was successfully received, as well as indicate what errors existed within the envelope segments of the received X12 file. The structure of a TA1 interchange acknowledgement depends on the structure of the envelope of the original EDI document. When the envelope of the EDI document does not contain an error, then the interchange acknowledgement will contain the ISA, TA1, and IEA segments. The TA1 segment will have an Interchange Acknowledgement Code of A (Accepted) followed by a three-digit code of 000 which indicates that there were not any errors. If the EDI document contains an error at the interchange level, such as in the Interchange Control Header (ISA) segment or the interchange control trailer (IEA), then the interchange acknowledgement will also only contain the ISA, TA1, and IEA segments. The TA1 segment will have an Interchange Acknowledgement Code of R (Rejected), which will be followed by a three-digit number that corresponds to one of the following codes: Figure A-2: Interchange Acknowledgement Code Code Description 000 No error 001 The Interchange Control Number in the Header and Trailer Do Not Match. The Value From the Header is Used in the Acknowledgment 002 This Standard as Noted in the Control Standards Identifier is Not Supported 003 This Version of the Controls is Not Supported 005 Invalid Interchange ID Qualifier for Sender 006 Invalid Interchange Sender ID 007 Invalid Interchange ID Qualifier for Receiver 009 Unknown Interchange Receiver ID 010 Invalid Authorization Information Qualifier Value (ISA01 is not 00 or 03 ) 012 Invalid Security Information Qualifier Value 013 Invalid Security Information Value 018 Invalid Interchange Control Number Value 019 Invalid Acknowledgment Requested Value 020 Invalid Test Indicator Value 021 Invalid Number of Included Groups Value 023 Improper (Premature) End-of-File (Transmission) 024 Invalid Interchange Content (e.g., Invalid GS Segment) 025 Duplicate Interchange Control Number A.2.1.2 999 Functional Acknowledgement for Health Care Insurance The ASC X12 999 transaction set is designed to report only on conformance against a Technical Report Type 3 guideline (TR3). Last Updated: 1/18/2017 Page 2 of 9
The 999 is not limited to only IG errors. It can report standard syntax errors, as well as IG errors. The 999 can NOT be used for any application level validations. The ASC X12 999 transaction set is designed to respond to one and only one functional group (i.e. GS/GE), but will respond to all transaction sets (i.e. ST/SE) within that functional group. This ASC X12 999 Implementation Acknowledgment can NOT be used to respond to any management transaction sets intended for acknowledgments, i.e. TS 999, or interchange control segments related to acknowledgments, i.e. TA1 and TA3. Each segment in a 999 functional acknowledgment plays a specific role in the transaction. For example, the AK1 segment starts the acknowledgment of a functional group. Each AKx segment has a separate set of associated error codes. The 999 functional acknowledgment includes, but is not limited to, the following required segments: ST Transaction Set Header AK1 Functional Group Response Header AK2 Transaction Set Response Header IK3 Error Identification CTX Segment Context CTX Business Unit Identifier IK4 Implementation Data Element Note CXT Element Context IK5 Transaction set response trailer AK9 Functional Group Response Trailer SE Transaction Set Trailer For additional information regarding the 999 transaction, please see the Technical Report Type 3 Acknowledgement Section of the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 Implementation Guideline for the transaction you are submitting. A.2.1.3 824 Application Advice This transaction is not mandated by HIPAA, but will be used to report the results of data content edits of transaction sets. It is designed to report rejections based on business rules such as invalid diagnosis codes, invalid procedure codes, and invalid provider numbers. The 824 Application Advice does not replace the 999 or TA1 transactions and will only be generated by Health PAS if there are errors within the transaction set. The 824 acknowledgment is divided into two levels of segments: header and detail. The header level contains general information, such as the transaction set control reference number of the previously sent transaction, date, time, submitter, and receiver. The detail level reports the results of an application system s data content edits. The 824 Application Advice includes, but is not limited to, the following segments and their roles: Last Updated: 1/18/2017 Page 3 of 9
Header Segments: ST segment Transaction Set Header BGN segment Beginning Segment N1 segment Submitter Name N1 segment Receiver Name Detail Segments: OTI segment Original Transaction Identification TED segment Error or Informational Message Location RED segment Error or Informational Message SE segment Transaction Set Trailer Health PAS Application errors in the RED segment of the 824 Application Advice would display one or more of the following codes: Figure A-3: IBP - Insurance Business Process Application Error Codes Error Code E001 E002 E003 E004 E005 E006 E007 E008 E009 E010 E011 E012 E013 E014 E015 E016 E017 E018 E019 E020 E021 E022 E023 E024 E025 E026 E027 E028 Error Code Description Missing/Invalid submitter identifier Missing/Invalid receiver identifier Missing/Invalid member identifier Missing/Invalid subscriber identifier Missing/Invalid patient identifier Missing/Invalid plan sponsor identifier Missing/invalid payee identifier Missing/Invalid TPA/broker identifier Missing/Invalid premium receiver identifier Missing/Invalid premium payer identifier Missing/Invalid payer identifier Missing/Invalid billing provider identifier Missing/Invalid pay to provider identifier Missing/Invalid rendering provider identifier Missing/Invalid supervising provider identifier Missing/Invalid attending provider identifier Missing/Invalid other provider identifier Missing/Invalid operating provider identifier Missing/Invalid referring provider identifier Missing/Invalid purchased service provider identifier Missing/Invalid service facility identifier Missing/Invalid ordering provider identifier Missing/Invalid assistant surgeon identifier Amount/Quantity out of balance Duplicate Billing date predates service date Business application currently not available Sender not authorized for this transaction Last Updated: 1/18/2017 Page 4 of 9
Error Code E029 E030 E031 E032 E033 E034 E035 E036 E037 E038 E039 E040 E041 E042 E043 E044 E045 E046 E047 E048 E049 E050 E051 E052 E053 E054 E055 E056 E057 E058 E059 E060 E061 E062 E063 E064 E065 E066 E067 E068 E069 Error Code Description Number of errors exceeds permitted threshold Required loop missing Required segment missing Required element missing Situational required loop is missing Situational required segment is missing Situational required element is missing Data too long Data too short Invalid external code value Data value out of sequence "Not Used" data element present Too many sub-elements in composite Unexpected segment Missing data Out of range Invalid date Not matching Invalid combination Customer identification number does not exist Duplicate batch Incorrect data Incorrect date Duplicate transmission Invalid claim amount Invalid identification code Missing or invalid issuer identification Missing or invalid item quantity Missing or invalid item identification Missing or unauthorized transaction type code Unknown claim number Bin segment contents not in MIME format Missing/invalid MIME header Missing/Invalid MIME boundary Missing/Invalid MIME transfer encoding Missing/Invalid MIME content type Missing/Invalid MIME content disposition (filename) Missing/Invalid file name extension Invalid MIME base64 encoding Invalid MIME quoted-printable encoding Missing/Invalid MIME line terminator (should be CR+LF) Last Updated: 1/18/2017 Page 5 of 9
Error Code E070 E071 E072 E073 E074 E075 E076 E077 E078 E079 E080 E081 E082 E083 E084 E085 E086 E087 E088 E089 E090 E091 E092 W001 W002 W003 W004 W005 W006 W007 W008 W009 W010 W011 W012 W013 W014 W015 W016 W017 Error Code Description Missing/Invalid "end of MIME" headers Missing/Invalid CDA in first MIME body parts Missing/Invalid XML tag Unrecoverable XML error Invalid Data format for HL7 data type Missing/Invalid required LOINC answer part(s) in the CDA Missing/Invalid Provider information in the CDA Missing/Invalid Patient information in the CDA Missing/Invalid Attachment Control information in the CDA Missing/Invalid LOINC Missing/Invalid LOINC Modifier Missing/Invalid LOINC code for this attachment type Missing/Invalid LOINC Modifier for this attachment type Situational prohibited element is present Duplicate qualifier value in repeated segment within a single loop Situational required composite element is missing Situational required repeating element is missing Situational prohibited loop is present Situational prohibited segment is present Situational prohibited composite element is present Situational prohibited repeating element is present Transaction successfully received but not processed as applicable business function not performed. Missing/Invalid required SNOMED CT answer part(s) in the CDA Missing/Invalid submitter identifier Missing/Invalid receiver identifier Missing/Invalid member identifier Missing/Invalid subscriber identifier Missing/Invalid patient identifier Missing/Invalid plan sponsor identifier Missing/invalid payee identifier Missing/Invalid TPA/broker identifier Missing/Invalid premium receiver identifier Missing/Invalid premium payer identifier Missing/Invalid payer identifier Missing/Invalid billing provider identifier Missing/Invalid pay to provider identifier Missing/Invalid rendering provider identifier Missing/Invalid supervising provider identifier Missing/Invalid attending provider identifier Missing/Invalid other provider identifier Last Updated: 1/18/2017 Page 6 of 9
Error Code W018 W019 W020 W021 W022 W023 W024 W025 W026 W027 W028 W029 W030 W031 W032 W033 W034 W035 W036 W037 W038 W039 W040 W041 W042 W043 W044 W045 W046 W047 W048 W049 W050 W051 W052 W053 W054 W055 W056 W057 W058 Error Code Description Missing/Invalid operating provider identifier Missing/Invalid referring provider identifier Missing/Invalid purchased service provider identifier Missing/Invalid service facility identifier Missing/Invalid ordering provider identifier Missing/Invalid assistant surgeon identifier Amount/Quantity out of balance Duplicate Billing date predates service date Business application currently not available Sender not authorized for this transaction Number of errors exceeds permitted threshold Required loop missing Required segment missing Required element missing Situational required loop is missing Situational required segment is missing Situational required element is missing Data too long Data too short Invalid external code value Data value out of sequence "Not Used" data element present Too many sub-elements in composite Unexpected segment Missing data Out of range Invalid date Not matching Invalid combination Customer identification number does not exist Duplicate batch Incorrect data Incorrect date Duplicate transmission Invalid claim amount Invalid identification code Missing or invalid issuer identification Missing or invalid item quantity Missing or invalid item identification Missing or unauthorized transaction type code Last Updated: 1/18/2017 Page 7 of 9
Error Code W059 W060 W061 W062 W063 W064 W065 W066 W067 W068 W069 W070 W071 W072 W073 W074 W075 W076 W077 W078 W079 W080 W081 W082 W083 W084 W085 W086 W087 W088 W089 W090 W091 W092 Error Code Description Unknown claim number Bin segment contents not in MIME format Missing/Invalid MIME header Missing/Invalid MIME boundary Missing/Invalid MIME transfer encoding Missing/Invalid MIME content type Missing/Invalid MIME content disposition (filename) Missing/Invalid file name extension Invalid MIME base64 encoding Invalid MIME quoted-printable encoding Missing/Invalid MIME line terminator (should be CR+LF) Missing/Invalid "end of MIME" headers Missing/Invalid CDA in first MIME body parts Missing/Invalid XML tag Unrecoverable XML error Invalid Data format for HL7 data type Missing/Invalid required LOINC answer part(s) in the CDA Missing/Invalid Provider information in the CDA Missing/Invalid Patient information in the CDA Missing/Invalid Attachment Control information in the CDA Missing/Invalid LOINC Missing/Invalid LOINC Modifier Missing/Invalid LOINC code for this attachment type Missing/Invalid LOINC Modifier for this attachment type Situational prohibited element is present Duplicate qualifier value in repeated segment within a single loop Situational required composite element is missing Situational required repeating element is missing Situational prohibited loop is present Situational prohibited segment is present Situational prohibited composite element is present Situational prohibited repeating element is present Transaction successfully received but not processed as applicable business function not performed. Missing/Invalid required SNOMED CT answer part(s) in the CDA Last Updated: 1/18/2017 Page 8 of 9
A.2.1.4 Business Rejection Report (BRR) Health PAS also produces a readable version of the 824 called the Business Rejection Report (BRR). This report helps to facilitate the immediate correction and re-bill of claims rejected during HIPAA validation (Figure A-4). Figure A-4: Sample Business Rejection Report (BRR) Last Updated: 1/18/2017 Page 9 of 9