Vendor Specifications 270/271 Eligibility Benefit Inquiry and Response ASC X12N Version 5010 for State of Idaho MMIS Date of Publication: 7/27/2017 Document : TL419 Version: 8.0
Revision History Version Date Author Action/Summary of Changes 1.0 07/01/2011 Molina Initial document 1.1 12/21/2011 Eric Harvey Updated the BHT03 segment length from 1/30 to 1/50 2.0 01/05/2012 TQD Promoted to next whole version 2.1 12/10/2012 Johnny Decrevel Reformatted to align with the upcoming CAQH CORE rules requirements. 2.2 01/18/2013 Stacy Zuber Made change to diagram on page 10 2.3 03/07/2013 Doug Greer Reviewed and made a few minor changes throughout the document. 2.4 07/30/2013 Doug Greer Made further refinements and requested corrections per DHW comments. 3.0 01/31/2014 TQD DHW approved 01/23/2014 3.1 02/25/2015 Jimmy Phillips Replaced Figure 4-1: Simplified EDI High-Level Flow, corrected spelling and replaced Appendix A verbiage. 3.2 2/27/2015 Hope McCain Minor changes to verbiage for grammar and syntax; formatting updates. Added Table of Figures. 4.0 3/3/2015 TQD DHW validated changes on 3/3/15. Promoted to next whole version. 4.1 10/21/2015 Jimmy Phillips Added verbiage about production certification for Real-time time transactions, and added the SOAP and MIME links for real-time transaction submission. 5.0 10/23/2015 TQD DHW validated changes 10/22/15. 5.1 12/22/2015 Douglas Greer Per CCF 10768B1, added information for the flag in the EB segment to indicate network information was being reported. Added additional segments in the 2120 loop of the 271 response for returning PCP Network information. Added information for real-time certification requirements. 6.0 03/28/2016 TQD Finalized and published per 30-day Notification response agreement 6.0 5/26/2016 J Phillips Semi-annual review no changes 6.1 12/19/2016 J Richardson Semi-annual review remove secured FTP information and replace with VAN 7.0 1/18/2017 TQD DHW validated changes 1/12/17. 7.1 6/5/2017 Douglas Greer Semi-annual review - Corrections in Figures 10-1 and 10-2 8.0 7/27/2017 TQD DHW validated changes 7/27/17. Disclosure Statement 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. July 2017 0050101 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 Molina Healthcare. 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. July 2017 0050101 3
Table of Contents INTRODUCTION... 5 GETTING STARTED... 7 TESTING WITH THE PAYER... 7 CONNECTIVITY WITH THE PAYER/COMMUNICATIONS PROCESS FLOWS... 8 CONTACT INFORMATION... 10 CONTROL SEGMENTS AND ENVELOPES... 10 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS... 11 ACKNOWLEDGEMENTS AND/OR REPORTS... 11 TRADING PARTNER AGREEMENTS... 12 TRANSACTION SPECIFIC INFORMATION... 12 APPENDICES... 31 Appendix A. Implementation Checklist... 31 Appendix B. Business Scenarios... 31 Appendix C. Frequently Asked Questions... 31 Table of Figures Figure 4-1: Simplified EDI High-Level Flow... 8 Figure 10-1: 270 Transaction -- Eligibility Benefit Inquiry Transaction... 12 Figure 10-2: 271 Transaction -- Eligibility Benefit Response Transaction... 19 July 2017 0050101 4
INTRODUCTION This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that Molina Healthcare has something additional, over and above, the information in the IGs. That information can: Limit the repeat of loops, or segments Limit the length of a simple data element Specify a sub-set of the IGs internal code listings Clarify the use of loops, segments, composite and simple data elements Any other information tied directly to a loop, segment, composite or simple data element pertinent to trading electronically with Molina Healthcare In addition to the row for each segment, one or more additional rows are used to describe Molina Healthcare s usage for composite and simple data elements and for any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. Reference Name Codes Length Notes/ 193 2100C NM1 Subscriber Name This type of row always exists to indicate that a new segment has begun. It is always shaded at 10%, and notes or comment about the segment itself goes in this cell. 195 2100C NM109 Subscriber Primary Identifier 196 2100C REF Subscriber Additional 197 2100C REF01 Reference Identification Plan Network Identification 218 2110C EB Subscriber Eligibility or Benefit 231 2110C EB13-1 Product/Servic e 18, 49, 6P, HJ, N6 N6 AD 15 This type of row exists to limit the length of the specified data element. These are the only codes transmitted by Molina Healthcare. This type of row exists when a note for a particular code value is required. For example, this note may say that value N6 is the default. Not populating the first three columns makes it clear that the code value belongs to the row immediately above it. This row illustrates how to indicate a component data element in the Reference column, and also how to specify that only one code value is applicable. July 2017 0050101 5
SCOPE This companion guide documents the transaction type listed below and further defines situational and required data elements that are used for processing eligibility inquiries/responses for programs administered by Idaho Medicaid. This document is not the complete EDI transaction format specifications. Eligibility Benefit Inquiry and Response ASC X12N 270/271 (005010X279A1) OVERVIEW Data elements, segments, and loops not included in this guide are not used for processing eligibility inquiries by Idaho Medicaid, but must still be sent if the information is required for compliance with the ASC X12N version 5010A1 format. Idaho Medicaid requires two of the following data elements for request processing: o First name/last name (first three characters/first five characters) o Date of Birth o Social Security o Medicaid Member Idaho Medicaid will be returning limitations information if it is available for the procedure code. Idaho Medicaid will not process eligibility requests with Dates of Service fields that contain date values greater than the current date. Idaho Medicaid will not use Procedure Modifiers when processing requests. Idaho Medicaid will not process eligibility requests for dates greater than 12 months in the past. REFERENCES Please refer to the 5010 Technical Report Type 3 Guide for information not supplied in this document, such as code lists, definitions, and edits. ADDITIONAL INFORMATION Assumptions regarding the reader: o You are interested in reducing error, maximizing efficiency, and saving money. o Idaho Medicaid encourages all providers to verify eligibility by submitting standard HIPAA 270 transactions. Advantages / Benefits of EDI o Eligibility data elements are immediately validated and eligibility information returned to submitters, allowing providers to quickly determine the eligibility status of their patients and, in the case of realtime transactions, get an immediate response to their inquiries. By using EDI transactions to check eligibility, the eligibility information for multiple patients can be check at once, versus other methods that only allow for checking one patient at a time. If you do not already submit your eligibility requests electronically, please contact the EDI Help Desk today at 1 (866) 686-4272 and select option 2 when prompted, for more information. July 2017 0050101 6
GETTING STARTED WORKING WITH MOLINA HEALTHCARE Please visit https://www.idmedicaid.com and click on the Companion Guides link to view the latest versions of this and other X12 Companion Guides. For information in using the portal once you are registered as a trading partner, click the User Guides link. For any questions, or to begin testing, please contact the Molina EDI Helpdesk at 1 (866) 686-4272, option two or e-mail us at idedisupport@molinahealthcare.com. TRADING PARTNER REGISTRATION A trading partner is defined as any entity with which Molina exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Idaho Medicaid s Health PAS system supports the following categories of trading partner: Provider Billing Agency Clearinghouse Health Plan Molina will assign trading partner s to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. To obtain a trading partner please visit our website at: https://www.idmedicaid.com, then click the provider tab and then click the Register link. You may also contact us at 1 (866)- 686-4272, option two. CERTIFICATION AND TESTING OVERVIEW All trading partners must be authorized to submit production EDI transactions. Any trading partner may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of an X12 file, indicates if a file is test or production. Authorization is granted on a per transaction basis. For example, a trading partner may be certified to submit 837P professional claims but not certified to submit 837I institutional claim files. TESTING WITH THE PAYER Trading partners that submit files through the portal on the https://www.idmedicaid.com website must submit three test files of a particular transaction type, with a minimum of fifteen transactions within each file, and have no failures or rejections in order to become certified for production. Trading partners that are submitting Real-time transactions using Soap or MIME protocols must submit three test files of a particular transaction type, with one transaction in each file, and have no failures or rejections in order to become certified for production. Users will be notified via e-mail and the Trading Partner Status page of Health PAS website when testing for a particular transaction has been completed. The Trading Partner Status page is accessed by logging into your trading partner account on the Health PAS website (https://www.idmedicaid.com), clicking the Account Management link on the Trading Partner tab to expand the Account Management menu, and then clicking Trading Partner Status. Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may be found in the 5010 Appendix A Vendor Specs document on the Molina Medicaid website in the Companion Guides section. July 2017 0050101 7
CONNECTIVITY WITH THE PAYER/COMMUNICATIONS PROCESS FLOWS Figure 4-1 is a simplified diagram of the flow of EDI data through the Molina Healthcare system. Figure 4-1: Simplified EDI High-Level Flow July 2017 0050101 8
TRANSMISSION ADMINISTRATIVE PROCEDURES X12 files can be uploaded via the Health PAS website File Exchange X12 Upload. Acknowledgments and Responses to transactions submitted via the Health PAS website can be accessed by selecting Download/Responses under the File Exchange menu. Trading Partners who have established a VAN connection and submitted X12 transactions via the VAN connection, may retrieve acknowledgements and responses from their designated VAN Pickup locations. A VAN connection is a secure VPN connection through which X12 files are transferred via the FTP protocol. RE-TRANSMISSION PROCEDURE ISA13 Interchange Control needs to be unique to each file and Trading Partner Compliance validation errors will be reported in the 999 Implementation Acknowledgement transactions. Those transactions that pass compliance validation will be processed. Any further errors will be reported in a 271 Benefit Eligibility Response transaction, with the error being reported in an AAA segment. Please consult the 271 TR3 Guide for information on errors reported in AAA segments. Any compliance validation or processing errors must be corrected by the trading partner and resubmitted using the normal method for submitting 270 Benefit Eligibility Requests. COMMUNICATION PROTOCOL SPECIFICATIONS The following communications protocols are available for sending and receiving the ASC X12N 270/271 transactions. Batch Mode: HTTPS upload via the Health PAS website. FTP though a secure, dedicated VAN connection. Real-time: HTTP MIME WSDL SOAP CAQH Web service: Authorized trading partners can transmit 270 transactions through CAQH Web Services. The Molina CAQH Web Services have been enhanced to support this functionality. The CAQH Web Services supports two types of transaction protocols. SOAP (simple Object Access protocol), and MIME (Multipurpose Internet Mail extensions). Transactions can be sent in the following links: SOAP Transactions: https://www.idmedicaid.com/caqh_soapservice/soapservice.svc MIME Transactions: https://www.idmedicaid.com/caqh_mimeservice/mimeservice.svc PASSWORDS Trading Partners create their own password at time of registration and are required to update it every 60 days as per the Health PAS-Online requirements. Password must be July 2017 0050101 9
at least seven (7) characters long, contain at least one (1) uppercase character, at least one (1) numeral, and at least one (1) special character. CONTACT INFORMATION This section contains detailed information concerning EDI Customer Service. Molina EDI Helpdesk 1(866)686-4272, option two (2) or e-mail idedisupport@molinahealthcare.com. EDI TECHNICAL ASSISTANCE This section contains detailed information concerning EDI Technical Assistance. 1 (866) 686-4272, option two (2), or e-mail idedisupport@molinahealthcare.com. PROVER SERVICE NUMBER This section contains detailed information concerning the payment of claims. Provider Services 1 (866) 686-4272, option three (3), or e-mail idproviderservices@molinahealthcare.com. APPLICABLE WEBSITES/E-MAIL The Idaho Medicaid Health PAS website contains information such as companion guides, user guides, and other information needed to check the eligibility of Idaho Medicaid members though the submission of X12 270 files. Website: https://www.idmedicaid.com The e-mail addresses below can be used in contacting Idaho Medicaid s EDI Support, Provider Services, and Provider Enrollment departments. These groups can provide assistance and answer questions relating to EDI file submissions, provider enrollment, and provider services. EDI Support Provider Services Provider Enrollment idedisupport@molinahealthcare.com idproviderservices@molinahealthcare.com idproviderenrollment@molinahealthcare.com CONTROL SEGMENTS AND ENVELOPES DELIMITERS Idaho Medicaid does not require the use of specific values for the delimiters used in electronic transactions. The suggested values are included in the specifications below. ISA-IEA The following ISA/IEA fields are the sender and receiver specific information required for the 270/271 transactions. For all other fields please see the tables below. 270: ISA06 Interchange Sender should contain the Molina assigned trading partner plus three spaces for a total of 15 characters. ISA08 Interchange Receiver should contain _MMIS_4MOLINA ISA13 Sender generated Interchange Control. This number must match the number in IEA02. 271: July 2017 0050101 10
ISA06 Interchange Sender will contain _MMIS_4MOLINA. ISA08 Interchange Receiver will contain the Molina assigned trading partner. ISA13 Sender generated Interchange Control. This number will match the number in IEA02. Please refer to the tables below for the ISA-IEA specific information for the 270 and 271. GS-GE The following GS/GE fields are the sender and receiver specific information required for the 270/271 transactions. For all other fields please see the tables below. 270: GS02 Interchange Sender should contain the Molina assigned trading partner. GS03 Interchange Receiver should contain _MMIS_4MOLINA GS06 Sender generated Group Control, must match the number in GE02. 271: GS02 Interchange Sender will contain _MMIS_4MOLINA. GS03 Interchange Receiver will contain the Molina assigned trading partner. GS06 Sender generated Group Control, will match the number in GE02. Please refer to the tables below for the GS-GE specific information for the 270 and 271 transactions. ST-SE ST02 Sender generated Transaction Set Control. Must match the number in SE02. Please refer to the tables below for the ST-SE specific information for the 270 and 271 transactions. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS For Molina Healthcare specific business rules and limitation in association with the ASC X12N 270/271 Eligibility Request/Response transaction sets, please refer to the tables below. Also see the information in Appendix B in this document for a listing of the Service Types support in sending 270 Eligibility Requests. ACKNOWLEDGEMENTS AND/OR REPORTS The following acknowledgement and/or reports files listed below, may be returned in response to an ASC X12N 270 Eligibility Inquiry Request file. For more information on these acknowledgement and/or reports, please see 5010 - Appendix A Vendor Specs. This document can be found on the Health PAS website in the Companion Guides section. REPORT INVENTORY TA1 Interchange Acknowledgement. This acknowledgement is sent, if requested, by setting ISA14 to 1, or if ISA14 is set to 0 and there is an error that needs to be reported. July 2017 0050101 11
999 Functional Acknowledgement. This acknowledgement file reports any errors found while checking compliance against the 270 TR3 specifications, or acceptance of a 270 file that meets the 270 TR3 specifications. 824 Application Advice report. 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 report does not replace the 999 or TA1 transactions and will only be generated by Health PAS if there are errors within the transaction set. BRR Business Rejection Report. 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. TRADING PARTNER AGREEMENTS TRADING PARTNERS A trading partner is defined as any entity with which Molina exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Idaho Medicaid s Health PAS system supports the following categories of trading partner: Provider Billing Agency Clearinghouse Health Plan Molina will assign trading partner s to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. All trading partners must be authorized to submit production EDI transactions. Any trading partner may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of an X12 file, indicates if a file is test or production. Authorization is granted on a per transaction basis. For example, a trading partner may be certified to submit 837P professional claims but not certified to submit 837I institutional claim files. TRANSACTION SPECIFIC INFORMATION Listed below in Figure 10-1 are the specific requirements for sending an ASC X12N 270 file to Molina Healthcare to determine Idaho Medicaid member eligibility. In Figure 10-2 are the specific requirements needed for reading and processing a ASC X12N 271 Eligibility Response transaction returned by Molina Healthcare. Please use these guidelines in conjunction with the official ASC X12N 270/271 TR3 document in planning and formatting your 270 Eligibility Request EDI transactions to send to Molina Healthcare for the State of Idaho s Medicaid program, and to read and process the returned 271 Eligibility Response transactions. Figure 10-1: 270 Transaction -- Eligibility Benefit Inquiry Transaction Reference Name Codes Length Notes / C.4 HEADER ISA Interchange Control Header ISA 3 ISA01 Authorization Information 00 2 July 2017 0050101 12
Reference Name Codes Length Notes / ISA02 Authorization Information 10 ISA03 Security Information 00 2 ISA04 Security Information 10 C.4 ISA05 Interchange ZZ 2 ISA06 Interchange Sender Molina assigned Trading Partner + 3 spaces 15 Molina Assigned when registering C.5 ISA07 Interchange ZZ 2 ISA08 Interchange Receiver _MMIS_4MOLINA 15 Payer ISA09 Interchange Date YYMMDD 6 ISA10 Interchange Time HHMM 4 ISA11 Repetition Separator ^ 1 Suggested value ISA12 Interchange Version 00501 5 ISA13 Interchange Control Assigned by Sender C.6 ISA14 Acknowledgement 1 - Interchange 1 Requested Acknowledgment Requested C.6 ISA15 Usage Indicator P 1 ISA16 Component Element : 1 Separator C.7 GS Functional Group Header GS 2 GS01 Functional Identifier Code HS 2 9 Pad Left with Zeros must be identical to interchange trailer IEA02 GS02 Application Sender's Code Molina assigned Trading Partner 2/15 Must be identical to the value in the ISA06 GS03 Application Receiver's Code _MMIS_4MOLINA 2/15 July 2017 0050101 13
Reference Name Codes Length Notes / GS04 Date CCYYMMDD 8 C.8 GS05 Time HHMM -Time based 4/8 on a 24-hour clock GS06 Group Control Assigned by Sender. 1/9 Must be identical to the value in the GE02 GS07 Responsible Agency Code X 1/2 C.8 GS08 Version / Release Code 005010X279A1 1/12 61 ST Transaction Set Header ST 2 ST01 Transaction Set Identifier 270 3 Code ST02 Transaction Set Control Must be identical to 4/9 SE02 62 ST03 Implementation Convention 005010X279A1 1/35 Reference 63 BHT Beginning Hierarchical BHT 3 Transaction Segment BHT01 Hierarchical Structure Code 0022 4 64 BHT02 Transaction Set Purpose 13 2 Code BHT03 Reference identification Submitter 1/30 Transaction Identifier. BHT04 Date CCYYMMDD - 8 Transaction Set Creation Date 65 BHT05 Time HHMM - 4/8 Transaction Set Creation Time 67 2000A HL Hierarchical Level (Information Source) HL HL01 Hierarchical 1 1 HL03 Hierarchical Level Code 20 2 68 HL04 Hierarchical Child Code 1 1 69 2100A NM1 Information Source Name NM1 3 NM101 Entity Identifier Code PR 2 July 2017 0050101 14
Reference Name Codes Length Notes / 70 NM102 Entity Type 2 1 NM103 Organization Name _MMIS_4MOLINA 1/60 70 71 NM108 Identification Code PI 2 NM109 Identification Code _MMIS_4MOLINA 2/80 Payer 73 2000B HL Hierarchical Level HL 2 (Service Provider Information) HL01 Hierarchical 2 1 HL02 Hierarchical Parent 1 1 74 HL03 Hierarchical Level Code 21 - Information 2 Receiver HL04 Hierarchical Child Code 1 1 75 2100B NM1 Service Provider Name NM1 3 75 76 NM101 Entity Identifier Code 1P - Provider 2 80 - Hospital FA - Facility NM102 Entity Type 2 - Non-Person 1 Entity NM103 Name Last or Organization 1/60 Name 77 NM108 Identification Code SV - Service Provider Medicaid XX - NPI 1/2 Use SV for Atypical Provider s 78 NM109 Identification Code SV - Atypical providers will continue to use the Medicaid Provider 2/80 Use SV for Atypical Provider s. XX NPI 79 REF Service Provider REF 3 Identification 79 REF01 Reference Identification EO - Submitter 2 July 2017 0050101 15
Reference Name Codes Length Notes / 80 REF02 Reference Identification Molina assigned 1/50 Trading Partner 88 2000C HL Hierarchical Level HL 2 (Service Recipient Information) HL01 Hierarchical 3 1 HL02 Hierarchical Parent 2 1 89 HL03 Hierarchical Level Code 22 - Subscriber 2 HL04 Hierarchical Child Code 0 1 90 TRN Subscriber Trace TRN 3 TRN01 Trace Type Code 1 -Current 1 Transaction Trace 91 TRN02 Reference Identification Trace : 1/50 Assigned by information receiver or information receiver s clearing house. 91 TRN03 Originating Company of the 10 Identifier company that assigned the trace number TRN04 Reference Identification 1/50 Used to further identify a specific component of the company identified in the previous data element TRN Subscriber Trace TRN 3 TRN01 Trace Type Code 1 - Current 1 Transaction Trace TRN02 Reference Identification Trace : 1/50 Assigned by information receiver or July 2017 0050101 16
Reference Name Codes Length Notes / information receiver s clearing house. TRN03 Originating Company of the 10 Identifier company that assigned the trace number. TRN04 Reference Identification 1/50 Used to further identify a specific component of the company identified in the previous data element. 92 2100C NM1 Subscriber/Recipient Name NM1 3 NM101 Entity Identifier Code IL Subscriber 2 93 NM102 Entity Type 1 Person 1 NM103 Subscriber Last Name 1/60 NM104 Subscriber First Name 1/35 94 NM105 Subscriber Name Middle 1/25 95 NM108 Identification Code MI - Member 2 96 NM109 Identification Code Enter the Idaho 7/10 Medicaid member s 7 or 10 digit identification number as it appears on their card. 98 REF Reference REF 3 (Recipient Identification) REF01 Reference Identification SY - Social Security 2 99 REF02 Reference Identification Social Security 1/50 104 PRV Provider Information PRV 3 PRV01 Provider Code 1/3 July 2017 0050101 17
Reference Name Codes Length Notes / 105 PRV02 Reference Identification 9K - Service Provider HPI - NPI 2/3 Use 9K for Atypical Provider s 106 PRV03 Reference Identification NPI. 1/50 Atypical providers will continue to use the Medicaid Provider. 108 DMG Subscriber/Recipient DMG 3 Demographic Information DMG01 Date Time Period Format D8 - Date Format 2 DMG02 Date Time Period CCYYMMDD - 8 Recipient Date of Birth 123 DTP Date or Time or Period DTP 3 DTP01 Date/Time 291 - Plan 3 123 DTP02 Date Time Period Format RD8 - Date Format 3 DTP03 Date Time Period CCYYMMDD- 17 CCYYMMDD Dates of Service 125 2110C EQ Subscriber Eligibility/Benefit Inquiry Information EQ 2 EQ01 Service Type Code 1 See Appendix 2 Not used if EQ02 is used 130 EQ02-1 Procedure Code 2/2 Not used if EQ01 is used Sub Element Separator : 1 131 EQ02-2 Procedure Code 1/48 Sub Element Separator : 1 132 EQ02-3 Procedure Modifier 2/2 144 DTP Date or Time or Period DTP 3 DTP01 Date/Time 291 - Plan 3 145 DTP02 Date Time Period Format RD8 - Date Format] 3 July 2017 0050101 18
Reference Name Codes Length Notes / 145 DTP03 Date Time Period CCYYMMDD- 17 CCYYMMDD - Dates of Service] 200 TRAILER SE Transaction Set Trailer SE 2/3 SE01 of Included (Total of 1/10 Segments ST thru SE segments) SE02 Transaction Set Control Must be identical to 4/9 ST02 C.9 GE Functional Group Trailer GE 2 GE01 of Transaction Sets 1 1/6 Included GE02 Group Control Must be identical to 1/9 the value in the GS06 C.10 IEA Interchange Control Trailer IEA 3 IEA01 of Included 1 1/5 Functional Groups IEA02 Interchange Control Must be identical to 9 the value in the ISA13 Figure 10-2: 271 Transaction -- Eligibility Benefit Response Transaction Referenc e Name Codes Length Notes / C.4 HEADER ISA Interchange Control Header ISA 3 ISA01 Authorization Information 00 2 ISA02 Authorization Information Space Fill 10 ISA03 Security Information 00 2 ISA04 Security Information [Not Used - Filled 10 with Spaces] ISA05 Interchange ZZ 2 ISA06 Interchange Sender _MMIS_4MOLIN 15 A C.5 ISA07 Interchange ZZ - Mutually Defined] 2 July 2017 0050101 19
Referenc e Name Codes Length Notes / ISA08 Interchange Receiver Molina assigned Trading Partner C.5 ISA09 Interchange Date YYMMDD 6 ISA10 Interchange Time HHMM 4 ISA11 Repetition Separator ^ 1 ISA12 Interchange Version 00501 5 ISA13 Interchange Control Assigned by Sender C.6 ISA14 Acknowledgement Requested 0 - No Ack. 1 Requested ISA15 Usage Indicator P 1 ISA16 Component Element : 1 Separator C.7 GS Functional Group Header GS 2 GS01 Functional Identifier Code HB 2 C.7 GS02 Application Sender's Code Must be identical 6 to the value in the ISA06 GS03 Application Receiver's Code Molina assigned Trading Partner 15 Molina assigned at registration 9 (must be identical to interchange trailer IEA02) 2/15 This is assigned during trading partner registration GS04 Date CCYYMMDD 8 C.8 GS05 Time HHMM 4/8 Time based on a 24- hour clock GS06 Group Control (Assigned by 1/9 Sender) Must be identical to the value in the GS02 GS07 Responsible Agency Code X 1/2 GS08 Version / Release Code 005010X279A1 1/12 209 ST Transaction Set Header ST 2 July 2017 0050101 20
Referenc e ST01 209 ST02 Transaction Set Control Name Codes Length Notes / Transaction Set Identification 271 3 Code Sequential 4/9 number assigned by sender ST02 and SE02 must be equivalent/identic al 210 ST03 Implementation Convention 005010X279A1 1/35 Reference 211 BHT Beginning Hierarchical BHT 3 Transaction Segment BHT01 Hierarchical Structure Code 0022 4 BHT02 Transaction Set Purpose Code 11 - Response 2 212 BHT03 Reference identification (Submitter 1/50 Transaction Identifier) Must be identical to corresponding 270 transaction BHT04 Date CCYYMMDD - 8 Transaction Set Creation Date BHT05 Time HHMMSS - 4/8 Transaction Set Creation Time 214 2000A HL Hierarchical Level HL 2 214 HL01 Hierarchical 1 1 HL03 Hierarchical Level Code 20 - Source 2 HL04 Hierarchical Child Code 1 1 215 AAA Request Validation AAA 3 AAA01 Yes/No Condition or Y= Request Valid 1 Response Code or N = Request Not Valid 216 AAA03 Reject Reason Code 2 (Code to indicate reason transaction was unable to be processed) July 2017 0050101 21
Referenc e Name Codes Length Notes / AAA04 Follow-up Action Code 1 Code identifying follow-up actions 218 2100A NM1 Information Source Name NM1 3 NM101 Entity Identifier Code PR 2 219 NM102 Entity Type 2 1 NM103 Organization Name _MMIS_4MOLIN 1/60 A 220 NM108 Identification Code PI 2 NM109 Identification Code _MMIS_4MOLIN 2/80 A 226 AAA Request Validation AAA 3 AAA01 Yes/No Condition or Response Code Y= Request Valid or N = Request Not Valid 227 AAA03 Reject Reason Code 2 (Code to indicate reason transaction was unable to be processed) 228 AAA04 Follow-up Action Code 1 Code identifying follow-up actions 230 2000B HL Hierarchical Level HL 2 HL01 Hierarchical 2 1 231 HL02 Hierarchical Parent 1 1 HL03 Hierarchical Level Code 21 - Receiver 2 HL04 Hierarchical Child Code 1 1 232 2100B NM1 Information Receiver Name NM1 3 NM101 Entity Identifier Code 1P - Provider 2 233 NM102 Entity Type 1 Person 1 1 July 2017 0050101 22
Referenc e NM103 Name Codes Length Notes / 2 Non Person Entity Provider Name Last or Organization Provider Last Name or Organization 233 NM104 Provider First Name Provider First (Not 35 needed for Organization) 234 NM105 Provider Middle Name Provider Middle 1 (Not needed for Organization) NM108 Identification Code SV - Service 2 Provider XX - NPI 235 NM109 Identification Code NPI. 7/10 Atypical providers will continue to use the Medicaid Provider. 236 REF Information Receiver REF 3 Additional Identification REF01 Reference Identification EO Submitter 2 237 REF02 Reference Identifier Molina assigned 1/50 Trading Partner AAA Request Validation AAA 3 238 AAA01 Yes/No Condition or Y= Request Valid 1 Response Code or N = Request Not Valid 239 AAA03 Reject Reason Code 2 Code to indicate reason transaction was unable to be processed AAA04 Follow-up Action Code 1 Code identifying follow-up actions 244 2000C HL Hierarchical Level HL 2 60 July 2017 0050101 23
Referenc e Name Codes Length Notes / HL01 Hierarchical 3 1 HL02 Hierarchical Parent 2 1 245 HL03 Hierarchical Level Code 22 - Subscriber 2 HL04 Hierarchical Child Code 0 1 247 TRN Subscriber Trace TRN 3 Element Separator * F TRN01 Trace Type Code 2 - Referenced 1 transaction trace numbers sent in the 270 transaction returned in the 271 response 248 TRN02 Reference Identification Trace number 1/50 received from the 270 inquiry TRN03 Originating Company Identifier number of the company that assigned the trace TRN04 Reference Identification Used to further 1/50 identify a specific component of the company identified in the previous data element TRN Subscriber Trace TRN 3 Element Separator * F TRN01 Trace Type Code 2 - Referenced 1 transaction trace numbers sent in the 270 transaction returned in the 271 response TRN02 Reference Identification Trace number 1/50 received from the 270 inquiry TRN03 Originating Company number of the 10 Identifier company that assigned the trace TRN04 Reference Identification Used to further identify a specific component of the company identified in the previous data element 1/50 10 July 2017 0050101 24
Referenc e Name Codes Length Notes / TRN Subscriber Trace TRN 3 TRN01 Trace Type Code 1 - Current trace 1 number TRN02 Reference Identification Idaho Verification 1/50 TRN03 Originating Company Identifier number of the company that assigned the trace TRN04 Reference Identification Used to further 1/50 identify a specific component of the company identified in the previous data element 249 2100C NM1 Subscriber Name NM1 3 NM101 Entity Identifier Code IL - Subscriber 2 250 NM102 Entity Type 1 - Person 1 NM103 Client Last Name Client Last Name 1/60 NM104 Client First Name Client First Name 1/35 NM105 Client Middle Name Client Middle 1/25 Name NM106 251 NM107 Name Suffix Client Suffix 1/10 NM108 Identification Code MI - Member 2 252 NM109 Identification Code Enter the Idaho 7/10 Medicaid member s 7 or 10 digit identification number as it appears on their card. 254 2100C REF Reference REF 3 (Subscriber Identification) REF01 Reference Identification SY SSN 2 256 REF02 Reference Identification Client SSN 1/50 257 2100C N3 Subscriber Address N3 2 N301 Subscriber Address Line 1/55 258 N302 Subscriber Address Line 1/55 10 July 2017 0050101 25
Referenc e 260 2100C N4 Subscriber City/State/Zip Name Codes Length Notes / N4 2 Code N401 Subscriber City Name 2/30 N402 Subscriber State Code 2 N403 Subscriber Postal Zone or Zip Code 3/15 N404 Subscriber Country Code Only use for 2/3 subscribers with addresses located outside the U.S. 262 AAA Request Validation AAA 3 AAA01 Yes/No Condition or Response Code Y= Request Valid or N = Request Not Valid 263 AAA03 Reject Reason Code Code to indicate 2 reason transaction was unable to be processed AAA04 Follow-up Action Code Code identifying 1 follow-up actions 269 DMG Subscriber Demographic DMG 3 Information DMG01 Date Time Period Format D8 - Date Format 2 DMG02 Date Time Period CCYYMMDD 8 - Member Date of Birth DMG03 Gender Code F Female 1 M Male U Unknown 291 2110C EB Subscriber Information EB 2 ** Note The following segments will repeat for each eligibility segment the member has on file that meets the Service Date inquiry sent 1 July 2017 0050101 26
Referenc e EB01 Name Codes Length Notes / on the 270 [ 2110C EB, 2110C DTP, 2115 LS, 2120C NM1, 2120C PER, 2120C LE] Eligibility or Benefit Information 1 = active 6 = inactive B = Co- Payment F = Limitations L = Primary Care Provider R = Other or Additional Payer 292 EB02 Coverage Level Code 3 293 EB03 Service Type Code 1/2 Value is returned if service type code was sent in the EQ01 in the 270 ( See appendix 2 ) 298 EB04 Insurance Type Code Insurance Type 1/3 Code 299 EB05 Plan Coverage Description Description or 1/50 that identifies Plan or Coverage 300 EB07 Monetary Amount Co-Payment 1/18 amount 303 EB12 Yes/no Condition or Response Code For EB01 = F, Y indicates part of benefit. N indicates not part of benefit. For EB01 = L, Y indicates that the Primary Care Provider is a part of a network. 304 EB13-1 Product/Service 2/2 Element Separator : 1 305 EB13-2 Procedure Code 1/48 1/2 1/1 Used in conjunction with EB01 = F or L July 2017 0050101 27
Referenc e Name Codes Length Notes / 317 DTP Date or Time or Period DTP 3 DTP01 Date/Time 307 - Eligibility 3 318 DTP02 Date Time Period Format RD8 - Date 2 Format DTP03 Date Time Period CCYYMMDD- CCYYMMDD 319 AAA Request Validation AAA 3 AAA01 Yes/No Condition or Response Code Y= Request Valid or N = Request Not Valid 17 Eligibility Date 320 AAA03 Reject Reason Code Code to indicate 2 reason transaction was unable to be processed 321 AAA04 Follow-up Action Code Code identifying 1 follow-up actions 328 2110C LS Subscriber Eligibility/ Benefit LS 2 Information 328 LS01 Identifier Code 2120-4 330 2120C NM1 Subscriber Benefit Related NM1 3 Entity Name NM101 Entity Identifier Code P3 Primary Care 2 Provider P5 - Plan Sponsor 1I Provider Network 331 NM102 Entity Type 2 - Non Person 1 Entity NM103 Organization Name Primary Care 1/60 Provider, Plan Sponsor Organization Name, or Network Name 340 PER Administrative Communications Contact PER 3 Segment can repeat up to 3 times per Plan Sponsor if necessary to convey contact 1 July 2017 0050101 28
Referenc e Name Codes Length Notes / information 2 Contact PER01 Contact Function Code IC - Information PER02 Name 1/60 341 PER03 Communication 2 341 PER04 Communication AAABBBCCCC 1/256 AAA Area Code BBBCCCC Local 342 PER05 Communication 2 PER06 Communication AAABBBCCCC 1/256 AAA Area Code BBBCCCC Local 343 PER07 Communication 2 PER08 Communication AAABBBCCCC 1/256 AAA Area Code BBBCCCC Local 344 PRV Subscriber Benefit Related PRV 3 Provider Information PRV01 Provider Code 1/3 345 PRV02 Reference Identification PXC 2/3 PRV03 Provider Identifier 1/50 346 LE Trailer LE 2 LE01 Identifier Code 2120-4 450 TRAILER SE Transaction Set Trailer SE 2/3 SE01 of Included Segments Total number of ST thru SE segments SE02 Transaction Set Control Assigned by 4/9 Sender Must be identical to value in ST02 C.9 GE Functional Group Trailer GE 2 GE01 of Transaction Sets 1 1/6 1/10 July 2017 0050101 29
Referenc e Name Codes Length Notes / Included GE02 Group Control Assigned by Sender Must be identical to value in GS06 1/9 C.10 IEA Interchange Control Trailer IEA 3 IEA01 of Included 1 1/5 Functional Groups IEA02 Interchange Control Assigned by 9 Sender - Pad Left with Zeros Must be identical to value ISA13 July 2017 0050101 30
APPENDICES Appendix A. Implementation Checklist The Trading Partner Account (TPA) User Guide under the User Guides link on the Health PAS website, contains information on how to select the correct trading partner entity type and answer some preliminary questions concerning trading partner registration. Appendix B. Business Scenarios This appendix contains free format text descriptions of typical business scenarios. The transmission examples for these scenarios are included in Appendix 3 of the ASC X12N 270/271 TR3 documentation. Service Type Code Description 1 Medical Care 30 Health Benefit Plan Coverage 33 Chiropractic 35 Dental Care 47 Hospital 48 Hospital Inpatient 50 Hospital Outpatient 86 Emergency Services 88 Pharmacy 98 Professional (Physician) Visit Office AL Vision (Optometry) MH Mental Health UC Urgent Care Appendix C. Frequently Asked Questions This appendix contains a compilation of questions and answers relative to Molina Healthcare and its providers. Typical questions would involve a discussion about code sets and their effective dates. See https://www.idmedicaid.com/lists/faqs/current.aspx for answers to frequently asked questions. July 2017 0050101 31