FL MMIS 270/271 Batch and Interactive Health Care Eligibility and

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FL MMIS 270/271 Batch and Interactive Health Care Eligibility and Response Transaction Companion Guide

005010X279A1

Florida Medicaid Management Information System

Fiscal Agent Services Project

Version 1.1

Disclaimer: The information contained in this Companion Guide is subject to change. EDI submitters are advised to check the EDI-Submission Information page on the “My Medicaid Florida” Web site (www.mymedicaid-florida.com) for the latest updates before and after go-live of version 5010.

270/271 Eligibility

Page 2 HP Confidential

© 2011 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

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Document Control

Modification Log

Version Date Modified By Change/Update Details

#

1 1/3/11 Daniel Gray Creation of document – 1st Draft.

1.1 3/17/11 Carl Bunche

Updated version number of transaction from “005010X279” to “005010X279A1”. This change impacts the following data elements:

• GS08 • ST03

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Document Information Document ID

Location iTRACE

QA Reviewer

QA Date

Owner HP Enterprise Services FLMMIS PMO

Author Daniel Gray

Approved By

Approval Date

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Table of Contents

1. Introduction .................................................................................................................................... 7

1.1 Purpose ................................................................................................................................................................... 7

1.2 Implementation Timeline for HIPAA 5010 standard ............................................................................................... 7 2. 270/271 Transmission and Data Retrieval Methods.................................................................... 8

2.1 File/System Specifications ...................................................................................................................................... 8 3. Transmission Responses ............................................................................................................. 9 4. EDI Support .................................................................................................................................... 9 5. Control Segment Definitions for Florida Medicaid 270/271 Transaction(s) ............................ 10

5.1 ISA - Interchange Control Header Segment ........................................................................................................ 10 5.2 IEA - Interchange Control Trailer .......................................................................................................................... 11 5.3 GS – Functional Group Header ............................................................................................................................ 12 5.4 GE – Functional Group Trailer .............................................................................................................................. 13 5.5 ST – Transaction Set Header ............................................................................................................................... 13 5.6 SE – Transaction Set Trailer ................................................................................................................................. 14 5.7 Valid Delimiters ..................................................................................................................................................... 14

6. X12N 270 Business Scenarios – Inbound Transactions ......................................................... .15 7. X12N 270 Loop And Data Element Specific Information For Florida Medicaid ...................... 18 8. X12N 271 Loop And Data Element Specific Information For Florida Medicaid ..................... 21 9. 4010-5010 Change Log ................................................................................................................ 38 10. Frequently Asked Questions (FAQ) ........................................................................................... 39

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1. Introduction

The Health Insurance Portability and Accountability Act (HIPAA) requires that Medicaid and all other health insurance payers in the United States comply with the EDI standards for health care as established by the Secretary of Health Services. The ANSI X12N implementation guides have been established as the standards of compliance for claim transactions. The following information is intended to serve only as a companion guide to the HIPAA ANSI X12N implementation guides. The use of this guide is solely for the purpose of clarification. The information describes specific requirements to be used for processing data. This companion guide supplements, but does not contradict any requirements in the X12N implementation guide. Additional companion guides/trading partner agreements will be developed for use with other HIPAA standards, as they become available.

Additional information on the Final Rule for Standards for Electronic Transactions can be found at http://aspe.hhs.gov/admnsimp/final/txfin00.htm . The HIPAA Implementation Guides can be accessed at http://www.wpc-edi.com/hipaa/HIPAA_40.asp.

1.1 Purpose

This is the technical report document for the ANSI ASC X12N 270 Health Care Eligibility Inquiry and the ANSI ASC X12N 271 Health Care Eligibility Response transactions. This document provides a definitive statement of what trading partners must be able to support in this version of the 270/271. This document is intended to be compliant with the data standards set out by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its associated rules. All required segments within the 270 transactions must always be sent by the submitter and received by the payer. Optional information will be sent when it is necessary for processing. Segments that are conditional are only sent when special criteria are met. Additionally, all required segments within the 271 transactions must always be sent back to the submitter by the payer.

1.2 Implementation Timeline for the HIPAA 5010 standard

Per Federal mandate, beginning on January 1, 2012, any electronic transaction files submitted by providers to a payer must be in the new HIPAA standard 5010 X12 format. In the interest of providing a needed transition period between the current HIPAA 4010 standard and the incoming HIPAA 5010 standard, starting on July 1, 2011, Florida Medicaid will accept electronic medical transactions in both the current 4010 X12 and the new 5010 X12 format. In line with the Federal mandate, however, this transition period will end on December 31, 2011, and all files submitted after that date must be in the new 5010 X12 standard format.

http://aspe.hhs.gov/admnsimp/final/txfin00.htm�

http://www.wpc-edi.com/hipaa/HIPAA_40.asp�

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2. 270/271 Transmission and Data Retrieval Methods

HP supports several types of data transport depending upon the trading partner’s need. Providers and their representatives can submit and receive data via: Web portal, Remote Access Server (RAS), and Value Added Network (VAN)/Switch Vendors for interactive transactions.

1. Web portal: Transaction files are uploaded/downloaded in the Trade Files menu on the secure Web portal. 2. Remote Access Server (RAS): This option is available to trading partners who do not have an existing Internet

connection. The RAS server typically supports those who need a dial-up option. Once the RAS connection is established, transaction files are uploaded/downloaded in the Trade Files menu on the secure Web portal.

3. Value Added Networks (VANs) or Switch Vendors: VANs or Switch Vendors typically support interactive

transactions through a dedicated connection to the fiscal agent. VANs sign a contract with the State and have unique, VAN specific communication arrangements with the fiscal agent. A list of approved vendors is listed on the fiscal agent Web site.

Detailed information to assist with EDI related processes are available on the Provider Public Web site at: http://www.mymedicaid-florida.com.

Information available includes:

1. Remote Access Server connectivity instructions for submitters without an existing Internet connection; 2. Trading Partner Testing Procedures (Ramp Manager) for all new trading partners, or trading partners adding

a new transaction; and 3. Web Upload/Download instructions for submitters uploading/downloading via the secure Web portal.

2.1 File/System Specifications

EDI only accepts Windows\PC\DOS formatted files. Any file transmitted to EDI must be named in accordance to standard file naming conventions, including a valid three character file extension. EDI allows for the upload and download of zipped or compressed files. Any data file contained within the zipped file must contain a valid three character file extension. The recommended extension is .txt or .dat. Zipped files must not contain directory folders or structures and should contain only individual files. Note: Only one X12 transaction file is permitted in each zipped file. Any data file that is 5MB or larger is required to be zipped or compressed before transmitting it to EDI. The Web portal is designed to support the following Internet browsers:

1. Internet Explorer, version 6 or later;

2. Firefox, version 1.5 or later; and

3. Opera, version 8.5 or later.

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3. Transmission Responses

For every transaction received, there is an expected response. The available responses are an Interchange Acknowledgement (TA1), Functional Acknowledgement (997), and an Unsolicited Claim Status (277U). Once a transaction is received, it will go through a ‘front end’ compliance check called a TA1. The TA1 Acknowledgement is a means of replying to an interchange or transmission that has been sent. The TA1 verifies the envelopes only. The TA1 is a single segment and is unique in the sense that this single segment is transmitted without the GS/GE envelope structure. The TA1 segment provides the capability for the receiving trading partner to notify the sending trading partner of problems that were encountered in the interchange control structure. Once the transaction has passed the ‘front end’ compliance check it then goes through a syntax compliance edit. This edit is to verify the compliance within the ANSI X12 syntax according to the HIPAA Implementation Guides. The transaction will receive a Functional Acknowledgement (997) to provide feedback on the transaction. The 997 functional acknowledgement contains accepted or rejected information. If the transaction contains any syntactical errors, the segments and elements in which the error occurred will be reported in a rejected acknowledgement. If the transaction contained no syntactical errors, a positive 997 response will be generated and the transaction is passed on for processing.

4. EDI Support

The HP EDI Operations Team is available to support trading partners and providers that exchange transactions electronically. Support functions include:

1. Enrollment processing for trading partners requesting to submit transactions electronically;

2. Installation assistance and submission support for Provider Electronic Solutions (PES) software;

3. Provide assistance to billing agents, clearinghouses and software vendors;

4. Identifying and troubleshooting technical issues; and

5. Data Exchange help.

The providers may reach EDI staff Monday through Friday 8:00 a.m. to 5:00 p.m. EST (Eastern Standard Time) at the EDI Helpdesk, (866) 586-0961.

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5. Control Segment Definitions for Florida Medicaid 270/271 Transaction

Note the page numbers listed below in each of the tables represent the corresponding page number in the X12N 270/271 HIPAA Implementation Guide [270/271_5010_x279]. Note: New/Updated Information is highlighted.

X12N EDI Control Segments

ISA – Interchange Control Header Segment IEA – Interchange Control Trailer Segment GS – Functional Group Header Segment GE – Functional Group Trailer Segment ST – Transaction Set Header SE – Transaction Set Trailer TA1 – Interchange Acknowledgement

5.1 SA - Interchange Control Header Segment

Communications transport protocol interchange control header segment. This segment within the X12N implementation guide identifies the start of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file header record.

270/271 Health Care Claim Status Request and Response

Page Loop ID Reference Name Code/Value Notes/Comments C.3 N/A ISA Interchange Control

Header Segment

C.4 N/A ISA01 Authorization Information Qualifier

00 '00' – No Authorization Information Present

C.4 N/A ISA02 Authorization Information [space fill] C.4 N/A ISA03 Security Information

Qualifier 00 '00' – No Security Information Present

C.4 N/A ISA04 Security Information [space fill] C.4 N/A ISA05 Interchange ID Qualifier ZZ 'ZZ' – Mutually Defined C.4 N/A ISA06 Interchange Sender ID 270 = Trading Partner ID as supplied by Florida

Medicaid, left justified and space filled. 271 = ‘77027’ left justified and space filled. Florida Medicaid Sender ID.

C.5 N/A ISA07 Interchange ID Qualifier ZZ 'ZZ' – Mutually Defined

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Page Loop ID Reference Name Code/Value Notes/Comments C.5 N/A ISA08 Interchange Receiver ID 77027 270 = ‘77027’ left justified and space filled.

Florida Medicaid Sender ID. 271 = Trading Partner ID as supplied by Florida Medicaid, left justified and space filled.

C.5 N/A ISA09 Interchange Date The date format is YYMMDD. C.5 N/A ISA10 Interchange Time The time format is HHMM. C.5 N/A ISA11 Repetition Separator ^ ‘^’

C.5 N/A ISA12 Interchange Control Version Number

00501 ‘00501’ – Control Version Number

C.5 N/A ISA13 Interchange Control Number

Interchange Unique Control Number – Must be identical to IEA02

C.6 N/A ISA14 Acknowledgement Requested

1, 0 ‘1’ – Acknowledgement Requested ‘0’ – No Acknowledgement Requested

C.6 N/A ISA15 Usage Indicator T, P ‘T’ – Test Data ‘P’ – Production Data

C.6 N/A ISA16 Component Element Separator

: ‘:’ – Component Element Separator

5.2 IEA – Interchange Control Header

Communications transport protocol interchange control trailer segment. This segment within the X12N implementation guide defines the end of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file trailer record.


Page Loop ID Reference Name Code/Value Notes/Comments C.10 N/A IEA Interchange Control

Trailer

C.10 N/A IEA01 Number of Included

Functional Groups Number of included Functional Groups

C.10 N/A IEA02 Interchange Control Number.

Must be identical to the value in ISA13

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5.3 GS – Functional Group Header

Communications transport protocol functional group header segment. This segment within the X12N implementation guide indicates the beginning of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch header record.


Page Loop ID Reference Name Code/Value Notes/Comments C.7 N/A GS Functional Group

Header

C.7 N/A GS01 Functional ID Code HS, HB 270 = ‘HS’ - Eligibility, Coverage or Benefit Inquiry 271 = ‘HB’ – Eligibility Coverage or Benefit Information

C.7 N/A GS02 Application Sender’s Code

270 = Trading Partner ID Supplied by FL Medicaid, left justified, do not space fill. 271 = ‘77027’ - Florida Medicaid Sender ID

C.7 N/A GS03 Application Receiver’s Code

270 = ‘77027’ left justified do not space fill. Florida Medicaid Receiver ID 271 = Trading Partner Supplied by Florida Medicaid.

C.7 N/A GS04 Date The date format is CCYYMMDD.

C.8 N/A GS05 Time The time format is HHMM. C.8 N/A GS06 Group Control Number Group Control Number – Must be identical

to GE02. C.8 N/A GS07 Responsible Agency

Code X ‘X’ – Responsible Agency Code

C.8 N/A GS08 Version/ Release/ Industry ID Code

005010X279A1 Version/ Release/ Industry Identifier Code

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5.4 GE – Functional Group Trailer

Communications transport protocol functional group trailer segment. This segment within the X12N implementation guide indicates the end of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch trailer record.


Page Loop ID Reference Name Code/Value Notes/Comments C.9 N/A GE Functional Group

Trailer

C.9 N/A GE01 Number of Transaction Sets Included

Number of included Transaction Sets

C.9 N/A GE02 Group Control Number Must be identical to the value in GS06. 5.5 ST – Transaction Set Header

Communications transport protocol transaction set header segment. This segment within the X12N implementation guide indicates the start of the transaction set and assigns a control number to the transaction. This segment may be thought of traditionally as the claim header record.


Page Loop ID Reference Name Code/Value Notes/Comments 65 N/A ST Transaction Set

Header

65 N/A ST01 Transaction Set Identifier Code

270, 271 270 = Eligibility, Coverage or Benefit Inquiry 271 = Eligibility, Coverage or Benefit Information

65 N/A ST02 Transaction Set Control Number

Transaction Control Number

Increment by 1 when multiple transaction sets are submitted. Must be identical to SE02.

65 N/A ST03 Implementation Convention Reference

Must be identical to the value in GS08.

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5.6 SE – Transaction Set Trailer

Communications transport protocol transaction set trailer. This segment within the X12N implementation guide indicates the end of the transaction set and provides the count of transmitted segments (including the beginning (ST) and ending (SE) segments). This segment may be thought of traditionally as the claim trailer record.


Page Loop ID Reference Name Code/Value Notes/Comments 353 N/A SE Transaction Set

Trailer

353 N/A SE01 Number of Included Segments

Total number of segments included in Transaction Set including ST and SE

353 N/A SE02 Transaction Set Control Number

Must be identical to the value in ST02

5.7 Valid Delimiters

The delimiters documented below will be used for Florida Medicaid, unless otherwise requested by a trading partner.

Definition ASCII Decimal Hexadecimal Segment Separator ~ 126 7E Element Separator * 42 2A Compound Element Separator : 58 3A Repetition Separator ^ 94 5E

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6. X12N 270 Business Scenarios – Inbound Transactions

Note: New/Updated Information is highlighted. This section contains Payer-specific business rules and limitations for the 270 Claim Status Inquiry transactions. 1. Subscriber, Insured = Recipient in the Florida Medicaid Eligibility Verification System:

The Florida Medicaid Eligibility Verification System does not allow for dependents to be enrolled under a primary subscriber, rather all enrollees/members are primary subscribers within each program or Managed Care Organization.

2. Provider Identification = NPI or Medicaid ID (Providers without an NPI only): The Health Insurance Portability and Affordability Act (HIPAA) of 1996 mandated the implementation of a National Provider Identifier (NPI). Most health care providers must register with the National Plan and Provider Enumeration System and receive a unique NPI. The intent of the HIPAA regulations was to require all health plans to convert their claims processing systems to use only the NPI for claims processing and reporting for providers required to obtain an NPI. Because of the complexities of this conversion by health care plans and providers, the use of the NPI has not yet been strictly enforced. However, Medicaid claims submitted on and after January 1, 2011, will have new requirements for the use of the NPI. Beginning on January 1, 2011, the NPI will be required on all electronic transactions and paper claims from providers who qualify for an NPI. Florida Medicaid will still accept transactions containing the Provider’s Medicaid ID, but any qualifying claims that lack the NPI will denied. Starting on April 1, 2011, however, Florida Medicaid will no longer accept electronic claim transactions (837D, 837I, and 837P) containing the Florida Medicaid ID submitted by providers who qualify for an NPI. Any electronic claims sent by qualifying providers on or after April 1, 2011 that contain the provider’s Florida Medicaid Provider ID will be denied, even if they also contain the NPI. Please note that paper claims will not be affected by this change. For all non- healthcare providers where an NPI is not assigned, the claim must contain the Florida Medicaid Provider Number with the appropriate loops within the REF segment where REF01 equals G2.

3. Logical File Structure:

a. For Batch 270/271 transactions, there can be only one interchange (ISE/IEA) per logical file. The interchange can contain multiple functional groups (GS/GE) however; the functional groups must be the same type.

b. For Interactive 270/271 transactions, there can be only one interchange (ISA/IEA), one functional group (GS/GE) and one transaction (ST/SE) per logical file. Within the transaction (ST/SE) there can only be one request. This has been defined as the EQ segment within Loop 2110C.

c. For Batch 270/271 transactions, if multiple information source loops (1000A) are received within the 270 transaction (ST/SE) multiple 271 transactions (ST/SE) will be generated. For example: 270 submitted with 1 ST/SE, within that ST/SE there are 2 information source loops, the 271 returned will contain 2 ST/SE’s.

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d. For Batch 270/271 transactions, if multiple information receiver loops (1000B) are received within the 270 transaction (ST/SE) multiple 271 transactions (ST/SE) will be generated. For example: 270 submitted with 1 ST/SE, within that ST/SE there are 2 information receiver loops, the 271 returned will contain 2 ST/SE’s.

e. “To ensure a timely response, it is suggested that the submitter sends more than one inquiry (EQ segment) within a transaction set (ST/SE), but no more than 5,000 inquiries (EQ segments) per transaction set (ST/SE). For example: A 270 batch submitted with 10,000 inquiries would have 1 ISA-ISE, 1 GS-GE and 2 ST-SE (5,000 inquiries per ST/SE).” Should you have a system limitation that requires you to send 1 transaction (EQ) per ST/SE then we recommend you limit your file to reflect 5,000 ST/SE.

4. Valid Combinations of Subscriber Data for Eligibility Requests:

There are five valid data combinations that can be used to determine a recipient’s eligibility in the Florida Medicaid Management System:

a. Date of service and the recipient’s Medicaid ID number b. Date of service, the recipient’s name and Social Security Number c. Date of service, the recipient’s Social Security Number and date of birth d. Date of service, the recipient’s name, gender and date of birth e. Date of service and the recipient’s Gold Card Number

For each 270 inquiry transmitted, the system will look for each of these data combinations in the order presented above. The system will check each combination of data until it is able to find a Medicaid recipient that matches the data presented or until it has exhausted all five data combinations. In cases where no valid match can be found, the system will return a AAA*N*75 in the 271, noting that the recipient in question could not be found. NOTE: If a date of service is not received, the system will use the date of transmission as the default date.

5. Multiple Birth Situations:

The Florida Medicaid system does not store birth sequence identifiers. The system will use the first seven (7) positions of recipient’s first name and first five (5) positions of recipient’s last name when searching for eligibility information to distinguish between individuals in a multiple birth situation.

6. Submitter:

Submissions by non-approved trading partners will be rejected.

7. Claims and Encounters:

Claims and Encounters must be submitted in separate ISA/IEA envelopes.

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8. Response/997 Functional Acknowledgement:

A response transaction will be returned to the trading partner that is present within the ISA06 data element. The Agency for Health Care Administration will provide a 997 Functional Acknowledgment for all transactions that are received. You will receive this acknowledgment within 48 hours unless there are unforeseen technical difficulties. If the transaction submitted was translated without errors for a request type transaction, i.e., 270 or 276, you will receive the appropriate response transaction generated from the request. If the transaction submitted was a claim transaction, i.e., 837, you will receive either the 835 or the unsolicited 277. Note: The 835 and unsolicited 277 are only provided weekly.

9. Document Level:

The Agency for Health Care Administration processes 270 eligibility transaction files at the batch level. Should of the inquiries on the submitted batch fail to pass HIPAA compliance, the Florida Medicaid Management Information System (FMMIS) will mark the entire batch as failing compliance and the erroneous data will be reported on the 997.

10. Dependent Loop:

For the Agency for Health Care Administration, the subscriber is always the same as the patient (dependent). Claims containing data in the Dependent Hierarchical Level (2000D loop) will not process correctly.

11. Compliance Checking:

Inbound 270 transactions are validated through Strategic National Implementation Process (SNIP) Level 4 .

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7. X12N 270 Loop and Data Element Specific Information for Florida Medicaid

This section specifies X12N 270 fields for which Florida Medicaid has specific requirements. Note: New/Updated Fields are highlighted.

270 Health Care Claim Status Request and Response

Page Loop

ID Reference Name Codes/Value Notes/Comments 61 N/A BHT Beginning of Hierarchal

Transaction

62 N/A BHT02 Hierarchal Structure Code 13 13 – Request

64

HL Information Source Level

65 2000A HL01 Hierarchical ID Number 1 Hierarchical ID Number

65 2000A HL03 Hierarchical Level Code 20 Information Source 66 2000A HL04 Hierarchical Child Code 1 Additional subordinate HL data

segment exists in this hierarchical structure

67 2100A NM1 Information Source Name 68 2100A NM102 Entity Type Qualifier 2 Non-Person Entity

68 2100A NM103 Last Name or Organization Name See Note ‘STATE OF FLORIDA MEDICAID’ 69 2100A NM108 Identification Code Qualifier PI Payer Identification

69 2100A NM109 Identification Code 77027 Florida Medicaid Payer ID

70 2000B HL Information Receiver Level

71 2000B HL01 Hierarchical ID Number 2 Hierarchical ID number

71 2000B HL02 Hierarchical Parent ID number 1 Parent ID number

72 2000B HL03 Hierarchical Level Code 21 Information Source

72 2000B HL04 Hierarchical Child Code 1 Additional subordinate HL data segment in structure

73 2100B NM1 Information Receiver Name

73 2100B NM101 Entity Identifier Code 1P Provider

75 2100B NM108 Identification Code Qualifier SV, XX SV – Service Provider Number XX - NPI

76 2100B NM109 Identification Code If NM108 = SV, then Florida Medicaid Provider ID If NM108 = XX, then NPI

80 2100B N4 Information Receiver City, State, ZIP Code

81 2100B N403 Postal Code Information Receiver ZIP Code+4

82 2100B PRV Information Receiver Provider Information

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Page Loop

ID Reference Name Codes/Value Notes/Comments 82 2100B PRV01 Provider Code Provider Code

83 2100B PRV02 Reference Identification Code PXC Health Care Provider Taxonomy Code

83 2100B PRV03 Reference Identification Provider’s Taxonomy Code

Subscriber Level

Note: For Florida Medicaid, the insured and the patient are always the same person. Use this HL segment to identify the recipient and proceed to Loop 2110C. Do not send the Dependent Level (Loop 2000D). Inquiries received with the 2000D Loop may not process correctly. 84 2000C HL Subscriber Level 86 2000C HL01 Hierarchical ID number 3 Hierarchical ID Number

86 2000C HL02 Hierarchical Parent ID number 2 Parent ID Number

87 2000C HL03 Hierarchical Level code 22 Subscriber

87 2000C HL04 Hierarchical Child Code 0 No subordinate HL segment in structure

Subscriber Information

Note: Florida Medicaid can perform eligibility inquiries with different combinations of information. Each of those methods are outlined below.

Eligibility Inquiry by Recipient ID

90 2100C NM1 Subscriber Name

90 2100C NM101 Entity Identifier Code IL Insured or Subscriber

91 2100C NM102 Entity Type Qualifier 1 Person

93 2100C NM108 Identification Code Qualifier MI Member Identification Number

94 2100C NM109 Identification Code Florida Recipient 10-digit Medicaid ID

Eligibility Inquiry by Card Control ID Number 96 2100C REF Subscriber Additional

Identification

96 2100C REF01 Reference Identification Qualifier HJ Identity Card Number

97 2100C REF02 Reference Identification Card Control Number

Eligibility Inquiry by Name, Date of Birth and Gender 90 2100C NM1 Subscriber Name



91 2100C NM103 Name Last or Organization Name Recipient’s Last Name

91 2100C NM104 Name First Recipient’s First Name

106 2100C DMG Subscriber Demographic Information

106 2100C DMG01 Date / Time Period Format Qualifier

D8 Date expressed as CCYYMMDD

106 2100C DMG02 Date / Time Period Recipient Birth Date

107 2100C DMG03 Gender Code M, F Recipient’s Gender

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Page Loop

ID Reference Name Codes/Value Notes/Comments Eligibility Inquiry by Name and Social Security Number

90 2100C NM1 Subscriber Name



91 2100C NM103 Name Last or Organization Name Recipient’s Last Name

91 2100C NM104 Name First Recipient’s First Name

96 2100C REF Subscriber Additional Identification

96 2100C REF01 Reference Identification Qualifier SY Social Security Number

97 2100C REF02 Reference Identification Recipient’s Social Security Number

Eligibility Inquiry by Social Security Number and Date of Birth 90 2100C NM1 Subscriber Name




96 2100C REF01 Reference Identification Qualifier SY Social Security Number

97 2100C REF02 Reference Identification Recipient’s Social Security Number


106 2100C DMG01 Date / Time Period Format Qualifier D8 Date expressed as CCYYMMDD

106 2100C DMG02 Date / Time Period Recipient’s Birth Date

NOTE: The DTP (Subscriber Date) segment in the 2100C loop can be included in any of the above documented inquiries. It is, however, required when performing an inquiry by recipient Name, Date of Birth and Gender. In other cases, if a date of service is not submitted on the inquiry, the date of submission will be used as the requested date of service. 122 2100C DTP Subscriber Date 122 2100C DTP01 Date / Time Qualifier 291 Plan Date

122 2100C DTP02 Date / Time Period Format Qualifier D8, RD8 D8 – single date: CCYYMMDD RD8 – Date range: CCYYMMDD-CCYYMMDD

122 2100C DTP03 Date / Time Period Date or date range in the format indicated in DTP02

123 2110C EQ Subscriber Benefit or Eligibility Inquiry

2110C EQ01 Service Type Code 30 Health Benefit Plan Coverage (Florida only supports generic eligibility requests)

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8. X12N 271 Loop and Data Element Specific Information for Florida Medicaid

This section specifies X12N 271 fields for which Florida Medicaid has specific requirements.

Note: New/Updated Fields are highlighted.


Page Loop ID Reference Name Code/Value Notes/Comments 211 BHT Beginning of

Hierarchical Transaction

211 BHT BHT02 Transaction Set Purpose Code

11 11 - Response

213 2000A HL Information Source Level

214 2000A HL01 Hierarchical ID number

1 Hierarchical ID

214 2000A HL03 Hierarchical Level Code

20 Information Source

214 2000A HL04 Hierarchical Child Code

1 Additional subordinate HL data segments exist in this structure

215 2000A AAA Request Validation

215 2000A AAA01 Yes/No condition or response code

N No

216 2000A AAA03 Reject reason code 42 Unable to respond at current time 218 2100A NM1 Information Source

Name

219 2100A NM103 Name Last or Organization Name

See Notes ‘STATE OF FLORIDA MEDICAID’

220 2100A NM108 Identification Code Qualifier

PI Payer Identifier

220 2100A NM109 Identification Code 77027 Florida Medicaid Electronic Payer ID

229 2000B HL Information Receiver Level

230 2000B HL01 Hierarchical ID Number

2 Hierarchical ID

230 2000B HL02 Hierarchical Parent ID number

1 Parent ID

231 2000B HL03 Hierarchal Level Code

21 Information Receiver

231 2000B HL04 Hierarchical Child Code

1 Additional subordinate HL data segments exist in this structure

232 2100B NM1 Information Receiver Name

234 2100B NM108 Identification Code Qualifier

SV, XX SV – Florida Medicaid Provider ID number XX - NPI

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271 Health Care Claim Status Request and Response Page Loop ID Reference Name Code/Value Notes/Comments

234 2100B NM109 Identification Code See notes If an NPI exists for a valid Service Provider Number, the NPI is returned even when the Florida Medicaid Provider Number was used in the 270 request.

238 2100B AAA Request Validation

238 2100B AAA01 Yes / No condition or response code

N No

239 2100B AAA03 Reject Reason code 50,51 50 – Provider ineligible for inquiries 51 – Provider not on file

243 2000C HL Subscriber Level

244 2000C HL01 Hierarchical ID number

3 Hierarchical ID Number

244 2000C HL02 Hierarchical Parent ID number

Parent ID number (varies based on responses place in batch)

245 2000C HL03 Hierarchical Level code

22 Subscriber

245 2000C HL04 Hierarchical Child Code

0 No subordinate HL segments in structure

Repeating Segment: TRN (Subscriber Trace Number) Note: The TRN segment in the 2000C loop can repeat up to two times in a 271 response

TRN segment - First Repetition Echo Trace Number submitted in 270

247 2000C TRN Subscriber Trace Number

247 2000C TRN01 Trace Type Code 1 Current Transaction Trace Numbers 248 2000C TRN02 Reference

Identification See notes This will be equal to the value in the 2000C -

TRN02 data element received on the 270. 248 2000C TRN03 Originating Company

Identifier See notes This will be equal to the value in the 2000C –

TRN03 data element received on the 270. TRN segment - Second Repetition

FMMIS assigned Trace number 247 2000C TRN Subscriber Trace

Number

247 2000C TRN01 Trace Type Code 1 Current Transaction Trace Numbers 248 2000C TRN02 Reference

Identification See notes Sender assigned trace number

248 2000C TRN03 Originating Company Identifier

‘977027’ Originating Company (FMMIS) identifier

Repeating Segment: REF (Subscriber Additional Information) Note: The REF segment in the 2100C loop can repeat up to five times in a 271 response

REF segment - First Repetition Patient Account Number

253 2100C REF Subscriber Additional Information

253 2100C REF01 Reference Identification Qualifier

EJ Patient Account Number

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REF segment - Second Repetition Social Security Number



SY Social Security Number

REF segment - Third Repetition Medicare HIC



F6 Health Insurance Claim (HIC) Number

REF segment - Fourth Repetition Card Control Number



HJ Identity Card number

REF segment - Fifth repetition Previous ID

Note: If the submitted 270 contains a previous (out of date) ID for the recipient, this occurrence will return that number, and the newer recipient ID will be contained in the NM109 of this loop.



NQ

238 2100C AAA Request Validation

262 2100C AAA01 Yes/No Condition or Response Code

N No

263 2100C AAA03 Reject Reason Code See Notes Reference 270/271 Implementation Guide for codes and descriptions


269 2100C DMG02 Date Time Period See notes Recipient Date of Birth

285 2100C DTP Subscriber Date

285 2100C DTP01 Date / Time Qualifier 102 Card Issue Date

285 2100C DTP02 Date / Time Period Qualifier

D8 Date should be expressed in format: CCYYMMDD

Repeating Loop Begins: Subscriber Eligibility or Benefit Information The Eligibility Information Loop (2110C) may repeat up to twenty times in a 271 response.

270/271 Eligibility




Loop 2110C - First Repetition Medicaid Eligibility Information

292 2110C EB Subscriber Eligibility or Benefit Information

292 2110C EB01 Eligibility or Benefit Information Code

1, 6, 7 1 – Active Coverage 6 – Inactive (the recipient was found in the database, but has no active coverage) 7 – Inactive pending update: The recipient ID or card control number used has been deactivated. In order to obtain accurate eligibility information, the inquiry will need to be resubmitted with the recipient’s active ID or card control number

294 2110C EB02 Coverage Level Code IND Individual

294 2110C EB03 Service Type Code 30 Health Benefit Plan Coverage

299 2110C EB04 Insurance Type Code MC Medicaid

300 2110C EB05 Plan Coverage Description

See Notes One of the following will occur: EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is

present, it will only contain four positions and will be followed by | then the description)

317 2110C DTP Subscriber Eligibility/ Benefit Date

317 2110C DTP01 Date / Time Qualifier 307 Eligibility

318 2110C DTP02 Date Time Period Format Qualifier

RD8 RD8 – Range of dates will be expressed in format CCYYMMDD-CCYYMMDD

318 2110C DTP03 Date Time Period See Notes Date(s) of service, expressed in the format CCYYMMDD-CCYYMMDD

Loop 2110C - Second Repetition QMB (Qualified Medicare Beneficiary)





270/271 Eligibility





299 2110C EB04 Insurance Type Code QM Qualified Medicare Beneficiary









Loop 2110C - Third Repetition Medicare Part A






299 2110C EB04 Insurance Type Code MA Medicare Part A






270/271 Eligibility







Loop 2110C – Fourth Repetition Medicare Part B






299 2110C EB04 Insurance Type Code MB Medicare Part B




299 2110C EB04 Insurance Type Code MA Medicare Part A









270/271 Eligibility




Loop 2110C - Fifth Repetition Third Party Liability



R Other or additional payer



299 2110C EB04 Insurance Type Code C1 Commercial






IL, 18 IL – Group or Policy Number 18 – Plan Number

316 2110C REF02 Reference Identification

See Notes Subscriber’s eligibility or benefit number

316 2110C REF03 Description See Notes Plan Sponsor Name






328 2110C LS Loop Header

328 2110C LS01 Loop Header 2120 Identifier of nested loop

330 2120C NM1 Subscriber Benefit Related Entity Name

330 2120C NM101 Entity Identifier Code IL Subscriber


346 2110C LE Loop Trailer

346 2110C LE01 Loop Identifier Code 2110 Identifier of nested loop

270/271 Eligibility




Loop 2110C - Sixth Repetition Lock-In






299 2110C EB04 Insurance Type Code OT Other







RD8 Range of dates will be expressed in format CCYYMMDD-CCYYMMDD


328 2110C LS Loop Header

328 2110C LS01 Loop Header 2120 Identifier of nested loop

330 2120C NM1 Subscriber Benefit Related Entity Name

330 2120C NM101 Entity Identifier Code 1P Provider

331 2120C NM102 Entity Type Qualifier 1, 2 1 – Person 2 – Non-Person

340 2120C PER Subscriber Benefit Related Entity Contact Information

340 2120C PER01 Contact Function Code

IC Information Contact

341 2120C PER03 Communication Number Qualifier

TE Telephone Number

270/271 Eligibility




341 2120C PER04 Communication Number

See Notes Contact Telephone Number

346 2110C LE Loop Trailer

346 2110C LE01 Loop Identifier Code 2110 Identifier of nested loop

Loop 2110C - Seventh Repetition Hearing



F Limitations


294 2110C EB03 Service Type Code 71 Audiology Exam

299 2110C EB04 Insurance Type Code MC Medicaid


See Notes One of the following will occur: 05=Blank 05=Description Only 05=Category Code |

scription (Note: When category code is

esent, it will only contain four positions and will followed by | then the description)


317 2110C DTP01 Date / Time Qualifier 472 Date of Service


RD8 Date range expressed in format CCYYMMDD-CCYYMMDD

318 2110C DTP03 Date Time Period See notes Date(s) expressed in the format indicated in DTP02

Loop 2110C - Eighth Repetition Vision



F Limitations


294 2110C EB03 Service Type Code AL Optometry

270/271 Eligibility



271 Health Care Claim Status Request and Response Page Loop ID Reference Name Code/Value Notes/Comments 299 2110C EB04 Insurance Type

Code MC Medicaid


See Notes One of the following will occur: EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it will only contain four positions and will be followed by | then the description)

300 2110C EB06 Time Period Qualifier

21 Years


317 2110C DTP01 Date / Time Qualifier

472 Date of Service


RD8 Date range expressed in format CCYYMMDD-CCYYMMDD

318 2110C DTP03 Date Time Period See notes Date(s) expressed in the format indicated in DTP02

Loop 2110C - Ninth Repetition EPSDT



D Benefit Description

294 2110C EB02 Coverage Level Code

IND Individual

294 2110C EB03 Service Type Code 68 Well Baby Care 299 2110C EB04 Insurance Type

Code MC Medicaid



472 Date of Service


D8 Date of service will be expressed in format CCYYMMDD

318 2110C DTP03 Date Time Period See notes Date expressed in format CCYYMMDD Loop 2110C - Tenth Repetition

Hospice 292 2110C EB Subscriber

Eligibility or Benefit Information

270/271 Eligibility



271 Health Care Claim Status Request and Response Page Loop ID Reference Name Code/Value Notes/Comments 292 2110C EB01 Eligibility or Benefit

Information Code 1, F, CB 1 – Active Coverage

F – Limitations CB – Coverage Basis


IND Individual

294 2110C EB03 Service Type Code 45 Hospice 299 2110C EB04 Insurance Type

Code MC Medicaid




29 Remaining

302 2110C EB09 Quantity Qualifier DY Days 317 2110C DTP Subscriber

Eligibility/ Benefit Date


307 Eligibility


RD8 Date range will be expressed in format CCYYMMDD-CCYYMMDD

318 2110C DTP03 Date Time Period See notes Date range expressed in the format CCYYMMDD-CCYYMMDD

Loop 2110C - Eleventh Repetition Managed Care



L Primary Care Provider


IND Individual

294 2110C EB03 Service Type Code 96 Professional (Physician) 299 2110C EB04 Insurance Type

Code MC Medicaid



270/271 Eligibility



271 Health Care Claim Status Request and Response Page Loop ID Reference Name Code/Value Notes/Comments 317 2110C DTP Subscriber



307 Eligibility




328 2110C LS Loop Header 328 2110C LS01 Loop Header 2120 Identifier of nested loop 330 2120C NM1 Subscriber

Benefit Related Entity Name

330 2120C NM101 Entity Identifier Code

1P Provider

331 2120C NM102 Entity Type Qualifier

1, 2 1 – Person 2 – Non-Person

340 2120C PER Subscriber Benefit Related Entity Contact Information

340 2120C PER01 Contact Function Code

IC Information Contact

341 2120C PER03 Communication Number Qualifier

TE Telephone Number

341 2120C PER04 Communication Number

See Notes Contact Telephone Number

346 2110C LE Loop Trailer 346 2110C LE01 Loop Trailer 2120 Identifier of nested loop

Loop 2110C - Twelfth Repetition Waiver





IND Individual

294 2110C EB03 Service Type Code 30 Health Benefit Plan Coverage 299 2110C EB04 Insurance Type

Code MC Medicaid

270/271 Eligibility



271 Health Care Claim Status Request and Response Page Loop ID Reference Name Code/Value Notes/Comments 300 2110C EB05 Plan Coverage

Description See Notes One of the following will occur:

EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it will only contain four positions and will be followed by | then the description)



307 Eligibility




Loop 2110C - Thirteenth Repetition MEDIKIDS





IND Individual


Code OT Other





307 Eligibility

270/271 Eligibility



271 Health Care Claim Status Request and Response Page Loop ID Reference Name Code/Value Notes/Comments 318 2110C DTP02 Date Time Period

Format Qualifier RD8 Date range will be expressed in format

CCYYMMDD-CCYYMMDD 318 2110C DTP03 Date Time Period See notes Date range expressed in the format

CCYYMMDD-CCYYMMDD Loop 2110C - Fourteenth Repetition

Spend Down 292 2110C EB Subscriber





IND Individual


Code OT Other





307 Eligibility



Loop 2110C - Fifteenth Repetition Dental



F Limitations


IND Individual

294 2110C EB03 Service Type Code 39 Prosthodontics

270/271 Eligibility



271 Health Care Claim Status Request and Response Page Loop ID Reference Name Code/Value Notes/Comments 299 2110C EB04 Insurance Type

Code MC Medicaid




21 Years



472 Dates of Service




Loop 2110C - Sixteenth Repetition Home Health



F Limitations


IND Individual

294 2110C EB03 Service Type Code 44 Home Health Visits 299 2110C EB04 Insurance Type

Code MC Medicaid




29 Remaining

302 2110C EB09 Quantity Qualifier VS Visits 317 2110C DTP Subscriber



307 Eligibility

270/271 Eligibility



271 Health Care Claim Status Request and Response Page Loop ID Reference Name Code/Value Notes/Comments 318 2110C DTP02 Date Time Period



CCYYMMDD-CCYYMMDD Loop 2110C - Seventeenth Repetition

Inpatient Days 292 2110C EB Subscriber



F Limitations


IND Individual

294 2110C EB03 Service Type Code 71 Hospital - Inpatient 299 2110C EB04 Insurance Type

Code MC Medicaid




29 Remaining

302 2110C EB09 Quantity Qualifier DY Days



307 Eligibility




Loop 2110 C - Eighteenth Occurrence Outpatient Benefits



F Limitations


IND Individual

294 2110C EB03 Service Type Code 50 Hospital - Outpatient 299 2110C EB04 Insurance Type

Code MC Medicaid

270/271 Eligibility



271 Health Care Claim Status Request and Response Page Loop ID Reference Name Code/Value Notes/Comments 300 2110C EB05 Plan Coverage

Description See Notes One of the following will occur:

EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it will only contain four positions and will be followed by | then the description)


29 Remaining

301 2110C EB07 Monetary Amount See Notes Remaining benefit amount for the year 317 2110C DTP Subscriber



307 Eligibility




Loop 2110 C - Nineteenth Repetition Long Term Care



CB Coverage Basis


IND Individual

294 2110C EB03 Service Type Code 54 Long Term Care 299 2110C EB04 Insurance Type

Code MC Medicaid




317 2110C DTP01 Date / Time Qualifier 307 Eligibility 318 2110C DTP02 Date Time Period



CCYYMMDD-CCYYMMDD

270/271 Eligibility




Loop 2110C - Twentieth Repetition Patient Liability



G Out of Pocket (Stop Loss)


IND Individual

294 2110C EB03 Service Type Code 54 Long Term Care 299 2110C EB04 Insurance Type

Code MC Medicaid




29 Remaining

301 2110C EB07 Monetary Amount See Notes Remaining benefit amount for the year 317 2110C DTP Subscriber


317 2110C DTP01 Date / Time Qualifier 307 Eligibility 318 2110C DTP02 Date Time Period



CCYYMMDD-CCYYMMDD

270/271 Eligibility



9. 4010-5010 Change Log

This section specifies X12N 270/271 fields that have changed with the implementation of version 5010 (as it pertains to Florida Medicaid).

CG Page Loop ID Reference Name 4010 Value 5010 Change

9 ISA11 Repetition Separator

N/A Added: This field is now a repetition separator which is a delimiter and not a data element. This field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure. This value must be different than the data element separator, component element separator and the segment terminator. The 4010 name was Interchange Control Standards Identifier.

10 ISA12 Interchange Control Version Identifier

00401 Updated: Changed to “00501.”

10 GS08 Version/ Release/ Industry Identifier Code

004010X092A1 Updated: Changed to “005010X279A1”

11 ST03 Implementation Convention Reference

N/A Added: Must be identical to the value in GS08, which is 005010X279A1.

15 2100B PRV Provider Specialty Information Qualifier (Taxonomy Code)

ZZ Updated: Changed Taxonomy Code qualifier from “ZZ” to “PXC.”

16 2100C DTP Subscriber Date

N/A Added this loop as it is now required when using certain search criteria.

28 2110C (Dental)

DTP01 Date / Time Qualifier

307 - Eligibility Updated: Changed to 472 – Date(s) of Service

29 2110C (Inpatient Days)

EB03 Service Type Code

71 - Audiology Updated: Changed to 48 – Inpatient Days

270/271 Eligibility



10. Frequently Asked Questions

Please reference the following link:

http://portal.flmmis.com/FLPublic/Provider_EDI/Provider_EDI_SubmissionInformation/tabId/66/Default.aspx

http://portal.flmmis.com/FLPublic/Provider_EDI/Provider_EDI_SubmissionInformation/tabId/66/Default.aspx�

Documents

FL MMIS 270/271 Batch and Interactive Health Care Eligibility and