HIPAA Transaction Standard Companion Guide Refers to the ...€¦ · AUGUST 2016 005010X279A1 1.6 877.565.5457 • [email protected] 11 6 - CONTROL SEGMENTS / ENVELOPES 6.1

HeW COMPANION GUIDE

877.565.5457 • [email protected]

AUGUST 2016 005010X279A1 1.6 www.hewedi.com

HeW

HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 Version 005010 270/271 Version 005010X279A1 276/277 Version 005010X212 August 2016

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AUGUST 2016 005010X279A1 1.6

877.565.5457 • [email protected] www.hewedi.com

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Disclaimer Statement:

This document may be redistributed in its entirety or in parts. The content of this document may not be altered by

external entities and is copy written by Health-e-Web, Inc. (HeW). The information in this document is subject to

change at any time. It is the responsibility of the reader to verify the correct version is referencing a downloaded

copy. The most recent versions of HeW Companion Guides will be posted on the HeW web site:

www.hewedi.com.

http://www.hewedi.com/

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AUGUST 2016 005010X279A1 1.6


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2015 © HeW All rights reserved.

Preface

This Companion Guide to the v5010 ASC X12N Implementation Guides adopted under HIPAA clarifies and

specifies the data content being requested when data is transmitted electronically to the HeW clearinghouse.

Transmissions based on this companion document, used in tandem with the v5010 ASC X12N Implementation

Guides, are compliant with both 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.

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This page is intentional left blank.

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Table of Contents

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

1.1 Scope ................................................................................................................................. 7

1.2 Overview ............................................................................................................................. 7

1.3 References ......................................................................................................................... 7

1.4 Additional Information ......................................................................................................... 7

2 - GETTING STARTED ............................................................................................................ 7

2.1 Working with HeW .............................................................................................................. 7

2.2 Trading Partner Registration ............................................................................................... 8

2.3 Certification and Testing Overview ...................................................................................... 8

3 - TESTING WITH HEW .......................................................................................................... 8

3.1 Testing and Training ........................................................................................................... 8

3.2 Test File Requirements ....................................................................................................... 8

4 - CONNECTIVITY WITH THE SENDER/COMMUNICATIONS .............................................. 8

4.1 Process Flows..................................................................................................................... 8

4.2 Transmission Administrative Procedures ............................................................................ 9

System Availability .................................................................................................................................... 9 File Naming Convention ............................................................................................................................. 9 Special Characters .................................................................................................................................... 9

4.3 Re-Transmission Procedures .............................................................................................. 9

4.4 Communication Protocol Specifications .............................................................................. 9

4.5 Passwords ........................................................................................................................ 10

5 - CONTACT INFORMATION ................................................................................................ 10

5.1 EDI Customer Service ....................................................................................................... 10

5.2 EDI Technical Assistance ................................................................................................. 10

5.3 Provider Service Number .................................................................................................. 10

5.4 Applicable Web Sites/E-mail Addresses............................................................................ 10

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6 - CONTROL SEGMENTS / ENVELOPES ............................................................................ 11

6.1 ISA – IEA (270/271) .......................................................................................................... 11

6.2 GS – GE (270/271) ........................................................................................................... 11

6.3 ST – SE (270/271) ............................................................................................................ 12

6.4 ISA – IEA (276/277) .......................................................................................................... 12

6.5 GS – GE (276/277) ........................................................................................................... 12

6.6 ST – SE (276/277) ............................................................................................................ 13

7 - HEW SPECIFIC BUSINESS RULES AND LIMITATIONS .................................................. 13

8 - ACKNOWLEDGEMENTS AND/OR REPORTS ................................................................. 13

8.1 Report Inventory ............................................................................................................... 13

9 – TRADING PARTNER AGREEMENTS .............................................................................. 13

9.1 Trading Partners ............................................................................................................... 13

10 – TRANSACTION SPECIFIC INFORMATION ................................................................... 13

10.1 Eligibility Enrollment .......................................................................................................... 13

10.2 Subscriber ID’s for BCBSMT ............................................................................................. 14

APPENDICES ......................................................................................................................... 21

Appendix A – Implementation Checklist ........................................................................................ 21

Appendix B – Business Scenarios ................................................................................................ 22

Appendix C – 270 Request Example ............................................................................................ 22

Appendix D – 271 Response Example .......................................................................................... 22

Appendix F – 277 Response Example .......................................................................................... 28

Appendix G – Frequently Asked Questions ................................................................................... 29

Appendix H – Change Summary ................................................................................................... 29

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1 - Introduction

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carry provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care senders and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard.

1.1 Scope

The intended purpose of this HIPAA EDI Transaction Standard Companion Guide is to explain the procedures

necessary for Trading Partners of HeW to transmit Electronic Data Interchange (EDI) transactions. These transactions

include:

o Health Care Eligibility Benefit Inquiry and Response – 270/271

o Health Care Claim Status Request and Response – 276/277

This Companion Guide is not intended to replace the v5010 ASC X12N Implementation Guides; rather it is intended

to be used in conjunction with them. Additionally, the Companion Guide is intended to convey information that is

within the framework and structure of the X12N Implementation Guides and not to contradict or exceed them.

1.2 Overview

This document will replace any previous HeW 270/271 and 276/277 companion guide(s) and must be used in

conjunction with the TR3 instructions. This document’s intent is to assist trading partners of HeW in implementing

the 270/271 and/or 276/277 transactions and meet the processing standards of HeW, by identifying necessary

structural and/or data requirements and recommendations.

1.3 References

For detailed information and standards for electronic submission of ANSI transactions, please reference the following

documents:

ANSI v5010 ASC X12N Implementation Guides, which can be purchased at http://www.wpc-edi.com.

1.4 Additional Information

The intended audiences for this document are technical and operational staff responsible for generating, receiving,

and reviewing electronic health care transactions.

2 - GETTING STARTED 2.1 Working with HeW

http://www.wpc-edi.com/

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An entity that wants to send or receive transactions via the HeW Clearinghouse must contract with HeW. This is done

by contacting the HeW Support Center (see Section 5.1) for coordination of all Trading Partner Agreements, Service

Agreement Amendments (for existing clients), contracting and site setup, which includes assignment of a submitter ID and password. The HeW clearinghouse offers connectivity to multiple payers for 270/271 and 276/277

transactions. Payer availability is dependent on contract provisions with HeW.

2.2 Trading Partner Registration

An EDI Trading Partner is defined by HeW as any clearinghouse, billing service, software vendor, payer etc. that

transmits to, or receives electronic data from HeW. (See section 2.1 for information on contracting with HeW.)

2.3 Certification and Testing Overview

Each Trading Partner must go through a testing phase to validate the format of the data being produced. The length

of the testing phase and the final approval of the sender for production are governed by HeW. Once a sender is

placed in production status, the ability to submit test data must be coordinated with HeW. Significant changes in the

sender’s system may require another test phase.

3 - TESTING WITH HEW 3.1 Testing and Training

When the Trading Partner’s setup is complete, testing and training staff will be assigned. This staff will assist the

Trading Partner during the testing phase and arrange any necessary system training.

3.2 Test File Requirements

Test files should consist of a variety of scenarios that represent the types or varieties of transactions the Trading Partner will be submitting once production status is achieved.

Test transactions will not be processed in a production environment but will be validated against production tables,

so they must contain valid procedure, diagnosis, eligibility/claim status payer IDs and sender information. HeW will

provide test subscriber ID data that must be used in the test transactions to produce realistic responses. Payer IDs to

be used in 270 / 276 files are located on the HeW web site Payer List page (www.hewedi.com/payer-list).

4 - CONNECTIVITY WITH THE SENDER/COMMUNICATIONS 4.1 Process Flows

Trading Partner

Registration

Testing Phase

Production Status

270 / 276 Transactions

Submitted

271 / 277 Transactions

Returned

http://www.hewedi.com/payer-list

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4.2 Transmission Administrative Procedures

System Availability

The HeW servers are available for transaction submission 24 hours a day, 7 days a week, including Holidays

where our Support Center is closed (see Section 5.1).

HeW Systems maintenances are scheduled from 6:00 a.m. to 12:00 p.m. Mountain Time Zone on Saturday

and notification is made available on the HeW web site home page (www.hewedi.com) and via e-mail

addresses we have on file.

File Naming Convention All Trading Partners exchanging transactions via FTP will need to adhere to the following naming convention:

File names must be unique beginning with the 4-character Submitter ID, as assigned by HeW, followed

by a unique sequence number and the applicable file extension. The full file name, including the

extension, is not to exceed 30 characters. Please note that file names must be unique for 366 days.

File extensions have intelligence for identification of type of file

Inbound:

.270 = Eligibility Request

.276 = Claim Status Request

Special Characters Files should not contain trailing spaces.

Significant characters as a tilde (~), colon (:), asterisk (*), parenthesis ( ), tick (`) or ( ‘ ) or quote ( “ )

cannot be used. Example: A telephone number (406) 555-3333. HeW recommends using no special

characters if at all possible.

4.3 Re-Transmission Procedures

Trading Partners can re-transmit a transaction at any time. Trading Partners exchanging transactions via FTP will

need to adhere to the HeW file naming convention (see Section 7.1).

4.4 Communication Protocol Specifications

HeW currently maintains the following communication protocols for batch and real-time transactions. The options

are listed in order of preference for use:

FTP – File Transfer Protocol.

HTTPS POST (single, real-time transactions)

Web Service (single, real-time transactions)


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Setup and support fees may be charged for any of the options listed. Charges will depend on the initial work efforts

required to establish communications and the amount of continued support required to maintain the

communications link. HeW will work with each client to determine which protocol will work best for them and identify

any associated costs. Contact HeW for alternative communication methods (see Section 5.1).

4.5 Passwords

HeW will assign a username and password to the Trading Partner during testing.

5 - CONTACT INFORMATION 5.1 EDI Customer Service

The HeW Support Center is staffed between the hours of 6:00 AM and 6:00 PM Mountain Time, Monday through

Friday, excluding Holidays. HeW recognizes the following Holidays each year: New Year’s Day, Dr. Martin Luther King

Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, the day after Thanksgiving Day, Christmas Eve,

and Christmas Day. Transactions can still be sent on Holidays even though our Support Center is closed. See

Section 4.2 for HeW System maintenance schedules.

Phone: 1-877-565-5457

E-mail: [email protected]

The Contact HeW Staff feature on the HeW website (www.hewedi.com) under the Support link is available, 24 hours a

day, 7 days a week.

5.2 EDI Technical Assistance

See Section 5.1

5.3 Provider Service Number

See Section 5.1

5.4 Applicable Web Sites/E-mail Addresses

HeW Web Site - www.hewedi.com

HeW Companion Guides - http://support.availity.com/articles/FAQ/HIPAA-Companion-Guides-for-ANSI/

HeW Support Center – [email protected]

HeW Enrollment Department – [email protected]

ASC X12 Guides – http://store.x12.org/

Washington Publishing Company – http://www.wpc-edi.com

mailto:[email protected]



http://support.availity.com/articles/FAQ/HIPAA-Companion-Guides-for-ANSI/



http://store.x12.org/


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6 - CONTROL SEGMENTS / ENVELOPES 6.1 ISA – IEA (270/271)

Page Loop ID

Ref Name Codes Length Notes

C.4 ISA05 Interchange ID

Qualifier ZZ Mutually Defined

C.4 ISA06 Interchange Sender ID Sender Tax ID The sender is the entity that

physically transmits a file.

C.4 &

C.5 ISA07

Interchange ID

Qualifier 30

US Federal Tax Identification

Number

C.5 ISA08 Interchange Receiver

ID 810525733

HeW’s Tax ID, designated as the

Receiver ID

C.5 ISA13 Interchange Control

Number Must be identical to IEA02

C.10 IEA02 Interchange Control

Number Must be identical to ISA13

6.2 GS – GE (270/271)

Page Loop ID


C.7 GS01 Functional Identifier

Code HS / HB 2 HS=270 / HB=271

C.7 GS02 Application Sender

Code Sender Tax ID Same as ISA06.

C.7 GS03 Application Receiver

Code 810525733 Same as ISA08.

C.8 GS06 Group Control Number Must be identical to GE02

93 2000C TRN02 Subscriber Trace

Number

152 2000D TRN02 Dependent Trace

Number

71 2100A NM101

Payer Name -

Information Source

Qualifier

PR Payer is currently the only value

accepted by HeW

73 2100A NM108 Payer Identifier PI

Payer ID is currently the only value

accepted by HeW

73 2100A NM109 Information Source

Primary Identifier

Payer ID – see HeW Eligibility

Payer List

79 2100B NM108 Identification Code

Qualifier XX Qualifier for NPI



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79-80 2100B NM109 Information Receiver

ID Number NPI Number

HeW is only accepting the NPI

number of the requestor.

521 GE02 Group Control Number Must be identical to the GS06

6.3 ST – SE (270/271)

HeW has no further information required outside of the normal IG requirements.

6.4 ISA – IEA (276/277)

Page Loop ID



Qualifier ZZ Mutually Defined

C.4 ISA06 Interchange Sender ID Sender Tax ID The sender is the entity that

physically transmits a file.


Qualifier 30

US Federal Tax Identification

Number

C.5 ISA08 Interchange Receiver

ID 810525733

HeW’s Tax ID, designated as the

Receiver ID

C.5 ISA13 Interchange Control

Number Must be identical to IEA02

C.10 IEA02 Interchange Control

Number Must be identical to ISA13

6.5 GS – GE (276/277)

Page Loop ID Ref Name Codes Length Notes

C.7 &

D.1 GS01

Functional Identifier

Code HR / HN 2 HR=276 / HN = 277

C.7 GS02 Application Sender’s

Code Sender Tax ID Same as ISA06.

C.7 GS03 Application Receiver

Code 810525733 Same as ISA08.

C.8 GS06 Group Control Number Must be identical to GE02

46 2100B NM108 Identification Code

Qualifier 46

46 2100B NM109 Information Receiver

ID Number

HeW Submitter

ID

58 2200D TRN02 Current Transaction

Trace Number

81 2200E TRN02 Current Transaction

Trace Number

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111 2100A NM101 Payer Name – Entity

Identifier Qualifier PR

112 2100A NM108 Identification Code

Qualifier PI

Payer is currently the only value

accepted by HeW

112 2100A NM109 Payer Identifier Payer ID – see HeW Eligibility Payer

List

128 2100C NM108 Identification Code

Qualifier XX Qualifier for NPI

128 2100C NM109 Provider Identifier HeW is only accepting the NPI

number.

C.9 GE02 Group Control Number Must be identical to GS06

6.6 ST – SE (276/277)

HeW has no further information required outside of the normal IG requirements.

7 - HEW SPECIFIC BUSINESS RULES AND LIMITATIONS

None at this time.

8 - ACKNOWLEDGEMENTS AND/OR REPORTS 8.1 Report Inventory

999 reports

9 – TRADING PARTNER AGREEMENTS 9.1 Trading Partners

An EDI Trading Partner is defined as any HeW customer (provider, facility, billing service, software vendor, employer

group, financial institution, etc.) that transmits to, or receives electronic data from HeW.

The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an

entity or a part of a later agreement, between each party to the agreement.

For example a Trading Partner Agreement may specify among other things, the roles and responsibilities of each party

to the agreement in conducting standard transmissions.

10 – TRANSACTION SPECIFIC INFORMATION

10.1 Eligibility Enrollment



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Please see our Payer List web page on our web site for any Eligibility and Claim Status payers that require enrollment.

10.2 Subscriber ID’s for BCBSMT

When submitting eligibility or claim status requests to BCBSMT the appropriate prefix must be used on the subscriber

ID. Transactions submitted without the appropriate prefix may not receive accurate responses.

10.3 Place of Treatment for BCBSMT

To receive eligibility response data that is specific to a Place of Treatment, it is recommended that an III segment be

used.

If the patient relationship to the insured is self (18), send the III segment in the 2110C Loop.

If the patient relationship to the insured is not self (18), send the III segment in the 2110D Loop.

These are the codes that are allowed to use for service type 30 (Sent in the EQ segment).

III01 is ZZ

III02 will either be 11, 21, 22 or 23.

For other service types please contact HeW for assistance.

10.4 Service Types and Place of Treatment for HCSC

EQ01 Service Type Place of Treatment

1 - Medical Care

Inpatient

Outpatient

Office

Home

Other

2 - Surgical

Inpatient

Outpatient

Emergency Room

Office

3 - Consultation

Inpatient

Outpatient

Emergency Room

Office

Home

Other

4 - Diagnostic X-Ray

Inpatient

Outpatient

Emergency Room

Office

Home


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Other

5 - Diagnostic Lab

Inpatient

Outpatient

Emergency Room

Office

Home

Other

6 - Radiation Therapy

Inpatient

Outpatient

Emergency Room

Office

7 - Anesthesia

Inpatient

Outpatient

Emergency Room

Office

8 - Surgical Assistance

Inpatient

Outpatient

Emergency Room

Office

Inpatient

10 - Blood Charges

Inpatient

Outpatient Emergency Room

Office

Home

Other

12 - Durable Medical Equipment Purchase

Inpatient

Outpatient

Emergency Room

Office

Home

Other

13 - Ambulatory Service Center Facility Outpatient

18 - Durable Medical Equipment Rental

Inpatient

Outpatient

Emergency Room

Office

Home

Other

20 - Second Surgical Opinion

Inpatient

Outpatient Emergency Room

Office

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Home

Other

30 - Health Benefit Plan Coverage

Inpatient

Outpatient

Emergency Room

Office

33 - Chiropractic

Inpatient

Outpatient

Office

40 - Oral Surgery

Inpatient

Outpatient

Office

42 - Home Health Care Home

Other

44 - Home Health Visits Home

Other

45 - Hospice

Inpatient

Outpatient

Home

Other

47 - Hospital

Inpatient

Outpatient

Emergency Room

Office

48 - Hospital - Inpatient Inpatient

49 - Hospital - Room and Board Inpatient

50 - Hospital - Outpatient

Outpatient

Emergency Room

Office

51 - Hospital - Emergency Accident Outpatient

Emergency Room

52 - Hospital - Emergency Medical Outpatient

Emergency Room

53 - Hospital - Ambulatory Surgical Outpatient

57 - Air Transportation Home

Other

59 - Licensed Ambulance Home

Other

60 - General Benefits

Inpatient

Outpatient

Emergency Room

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Office

Home

Other

61 - In-vitro Fertilization Outpatient

Office

62 - MRI/CAT Scan

Inpatient

Outpatient

Emergency Room

Office

Other

64 - Acupuncture

Inpatient

Outpatient

Emergency Room

Office

65 - Newborn Care Inpatient

66 - Pathology

Inpatient

Outpatient

Emergency Room

Office

Home

Other

68 - Well Baby Care Outpatient

Office

69 - Maternity Inpatient

Office

71 - Audiology Exam

Inpatient

Outpatient

Office

72 - Inhalation Therapy

Inpatient

Outpatient

Emergency Room

Office

73 - Diagnostic Medical

Inpatient

Outpatient

Office

Home

Other

74 - Private Duty Nursing

Outpatient

Home

Other

75 - Prosthetic Device

Inpatient

Outpatient

Emergency Room

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Office

Home

Other

76 - Dialysis

Inpatient

Outpatient

Home

Other

78 - Chemotherapy Outpatient

Office

79 - Allergy Testing

Inpatient

Outpatient

Emergency Room

80 - Immunizations Outpatient Office

81 - Routine Physical Outpatient

Office

82 - Family Planning

Inpatient

Outpatient

Office

83 - Infertility Outpatient

Office

84 - Abortion Inpatient Outpatient

Office

86 - Emergency Services

Outpatient

Emergency Room

Office

88 - Pharmacy

Inpatient

Outpatient

Emergency room

Office

Home

Other

93 - Podiatry

Inpatient

Outpatient

Office

97 - Anesthesiologist

Inpatient

Outpatient

Office

98 - Professional (Physician) Visit - Office Office

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99 - Professional (Physician) Visit - Inpatient Inpatient

A0 - Professional (Physician) Visit - Outpatient Outpatient

A3 - Professional (Physician) Visit - Home Home

Other

A6 - Psychotherapy

Inpatient

Outpatient

Office

A7 - Psychiatric – Inpatient Inpatient

A8 - Psychiatric – Outpatient Outpatient

Office

AD - Occupational Therapy

Inpatient

Outpatient

Office

AE - Physical Medicine

Inpatient

Outpatient

Office

AF - Speech Therapy

Inpatient

Outpatient

Office

AG - Skilled Nursing Care Inpatient

AH - Skilled Nursing Care - Room and Board Inpatient

AI - Substance Abuse

Inpatient

Outpatient

Emergency room

Office

AL - Vision (Optometry) Outpatient

Office

AM - Frames Outpatient

Office

AN - Routine Exam Outpatient

Office

AO - Lenses Outpatient

Office

BB - Partial Hospitalization (Psychiatric) Outpatient

Emergency room

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BC - Day Care (Psychiatric) Outpatient

Emergency room

BG - Cardiac Rehabilitation

Inpatient

Outpatient

Office

BH - Pediatric Outpatient

Office

BT - Gynecological

Inpatient

Outpatient

Office

BU - Obstetrical Inpatient

Office

BV - Obstetrical/Gynecological

Inpatient

Outpatient

Office

BY - Physician Visit - Office: Sick Office

BZ - Physician Visit - Office: Well Office

CA - Private Duty Nursing Inpatient Inpatient

CB - Private Duty Nursing Home Home

Other

CC Surgical Benefits Professional (Physician)

Inpatient

Outpatient

Emergency Room

Office

CD Surgical Benefits Facility Inpatient

Outpatient

CE - MH Provider - Inpatient Inpatient

CF - MH Provider - Outpatient Outpatient

Office

CG - MH Provider Facility - Inpatient Inpatient

CH - MH Provider Facility - Outpatient Outpatient

CI - Substance Abuse Facility - Inpatient Inpatient

CJ - Substance Abuse Facility - Outpatient Outpatient

Emergency Room

CK - Screening X-ray Outpatient

Office

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CL - Screening Laboratory Outpatient

Office

CM - Mammogram, HR Patient

Outpatient

Office

Other

CN - Mammogram, LR Patient

Outpatient

Office

Other

CO - Flu Vaccination Outpatient Office

Other

DM - Durable Medical Equipment

Inpatient

Outpatient

Emergency Room

Office

Home

Other

MH - Mental Health

Inpatient

Outpatient

Office

ON - Oncology

Inpatient

Outpatient

Emergency Room

Office

PT - Physical Therapy

Inpatient

Outpatient

Office

UC - Urgent Care Outpatient

Office

APPENDICES

Appendix A – Implementation Checklist

Obtain ASC X12 5010 Implementation Guides on the Washington Publishing Company web site (http://www.wpc-edi.com) and the ASC X12 TR3 Implementation Guides at http://store.x12.org).

Signed HeW Service Agreement

Pass testing for each line of business

Complete Payer EDI Paperwork


http://store.x12.org/

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Training (if applicable)

Appendix B – Business Scenarios

No business scenarios at this time.

Appendix C – 270 Request Example

ISA*00* *00* *ZZ*223333333 *30*810525733

*130221*0000*^*00501*000000000*0*P*:~

GS*HS*223333333*CMS*20130426*1417*0*X*005010X279A1~

ST*270*0001*005010X279A1~

BHT*0022*13*9876543213*20130426*14172364~

HL*1**20*1~

NM1*PR*2*MEDICARE*****PI*10001~ HL*2*1*21*1~

NM1*1P*1*JONES*JOE*J***XX*1234567893~

N3*1234 MAIN STREET~

N4*PHOENIX*AZ*65000~

HL*3*2*22*0~

TRN*1*109834652831*WXYZCLEARH~

NM1*IL*1*SMITH*JANE****MI*999999999A~

REF*SY*999999999~

DMG*D8*19500101*F~

DTP*291*D8*20130426~

EQ*30~

SE*16*0001~

GE*1*0~

IEA*1*000000000~

Appendix D – 271 Response Example

ISA*00* *00* *ZZ*888888888 *ZZ*810525733

*130506*1429*^*00501*232323232*0*P*:~

GS*HB*888888888*810525733*20130506*1429*232323232*X*005010X279A1~

ST*271*232323232*005010X279A1~

BHT*0022*11*232323232*20130506*1429~ HL*1**20*1~

NM1*PR*2*SOMEONE INSURANCE*****PI*88888~

HL*2*1*21*1~

NM1*1P*2*WE CARE FOR YOU CLINIC*****XX*1234567893~

HL*3*2*22*0~

TRN*2*20130506-22222222*9PASSPORTH~

NM1*IL*1*DOE*JOHN****MI*111111111~

REF*6P*2003035~

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DMG*D8*19500101~

DTP*346*D8*20130101~

EB*1**1^30^59^86^50^98^UC^48^CG^33^CF^47^MH**EMPLOYER PLAN NAME~

EB*G*IND*30**EMPLOYER PLAN NAME*29*1500*****Y~ MSG*TIER1~

EB*G*FAM*30**EMPLOYER PLAN NAME*29*-40.1599999999999*****Y~

MSG*TIER1~

EB*G*IND*30**EMPLOYER PLAN NAME*29*3000*****Y~

MSG*TIER2~

EB*G*FAM*30**EMPLOYER PLAN NAME*29*2459.84*****Y~

MSG*TIER2~

EB*G*IND*30**EMPLOYER PLAN NAME*29*9100*****N~

EB*G*FAM*30**EMPLOYER PLAN NAME*29*19100*****N~

EB*C*IND*30**EMPLOYER PLAN NAME*29*300*****Y~

MSG*TIER1~

EB*C*FAM*30**EMPLOYER PLAN NAME*29*166.38*****Y~

MSG*TIER1~


MSG*TIER2~

EB*C*FAM*30**EMPLOYER PLAN NAME*29*366.38*****Y~

MSG*TIER2~

EB*C*IND*30**EMPLOYER PLAN NAME*29*0*****N~

EB*C*FAM*30**EMPLOYER PLAN NAME*29*0*****N~


MSG*TIER1~

EB*G*FAM*30**EMPLOYER PLAN NAME*22*2500*****Y~

MSG*TIER1~


MSG*TIER2~

EB*G*FAM*30**EMPLOYER PLAN NAME*22*5000*****Y~

MSG*TIER2~

EB*G*IND*30**EMPLOYER PLAN NAME*22*10000*****N~

EB*G*FAM*30**EMPLOYER PLAN NAME*22*20000*****N~ EB*C*IND*30**EMPLOYER PLAN NAME*22*300*****Y~

MSG*TIER1~

EB*C*FAM*30**EMPLOYER PLAN NAME*22*600*****Y~

MSG*TIER1~


MSG*TIER2~

EB*C*FAM*30**EMPLOYER PLAN NAME*22*1000*****Y~

MSG*TIER2~

EB*C*IND*30**EMPLOYER PLAN NAME*22*700*****N~

EB*C*FAM*30**EMPLOYER PLAN NAME*22*1400*****N~

EB*B**59***27*0.00*****Y~

MSG*TIER2~

EB*A**59*****0.3****Y~

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MSG*TIER2~

EB*B**59***27*0.00*****N~

EB*A**59*****0.3****N~

EB*B**86***27*150.00*****Y~ MSG*TIER1~

MSG*EMERGENCY~

EB*A**86*****0.0****Y~

MSG*TIER1~

MSG*EMERGENCY~

EB*B**86***27*150.00*****Y~

MSG*TIER2~

MSG*EMERGENCY~

EB*A**86*****0.0****Y~

MSG*TIER2~

MSG*EMERGENCY~

EB*B**86***27*150.00*****N~

MSG*EMERGENCY~

EB*A**86*****0.0****N~

MSG*EMERGENCY~

EB*B**50***27*0.00*****Y~

MSG*TIER1~

EB*C*IND*50****300.00*****Y~

MSG*TIER1~

EB*C*FAM*50****600.00*****Y~

MSG*TIER1~

EB*A**50*****0.1****Y~

MSG*TIER1~

EB*B**50***27*0.00*****N~

EB*C*IND*50****700.00*****N~

EB*C*FAM*50****1400.00*****N~

EB*A**50*****0.5****N~

EB*B**98***27*20.00*****Y~

MSG*TIER1~ MSG*PRIMARY CARE~

EB*B**98***27*40.00*****Y~

MSG*TIER1~

MSG*SPECIALIST~

EB*A**98*****0.0****Y~

MSG*TIER1~

EB*B**98***27*20.00*****Y~

MSG*TIER2~

MSG*PRIMARY CARE~

EB*B**98***27*40.00*****Y~

MSG*TIER2~

MSG*SPECIALIST~

EB*A**98*****0.0****Y~

…………………………………………………………………………………


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MSG*TIER2~

EB*B**98***27*0.00*****N~

MSG*PRIMARY CARE~

EB*C*IND*98****700.00*****N~ EB*C*FAM*98****1400.00*****N~

EB*A**98*****0.5****N~

EB*B**UC***27*40.00*****Y~

MSG*TIER1~

EB*A**UC*****0.0****Y~

MSG*TIER1~

EB*B**UC***27*40.00*****Y~

MSG*TIER2~

EB*A**UC*****0.0****Y~

MSG*TIER2~

EB*B**UC***27*0.00*****N~

EB*C*IND*UC****700.00*****N~

EB*C*FAM*UC****1400.00*****N~

EB*A**UC*****0.5****N~

EB*B**48***27*150.00*****Y~

MSG*TIER1~

EB*C*IND*48***23*300.00*****Y~

MSG*TIER1~

EB*C*FAM*48***23*600.00*****Y~

MSG*TIER1~

EB*A**48*****0.1****Y~

MSG*TIER1~

EB*B**48***27*150.00*****Y~

MSG*TIER1~

EB*C*IND*48***23*300.00*****Y~

MSG*TIER1~

EB*C*FAM*48***23*600.00*****Y~

MSG*TIER1~

EB*A**48*****0.1****Y~ MSG*TIER1~

EB*B**48***27*300.00*****Y~

MSG*TIER2~

EB*C*IND*48***23*500.00*****Y~

MSG*TIER2~

EB*C*FAM*48***23*1000.00*****Y~

MSG*TIER2~

EB*A**48*****0.3****Y~

MSG*TIER2~

EB*B**48***27*600.00*****N~

EB*C*IND*48***23*700.00*****N~

EB*C*FAM*48***23*1400.00*****N~

EB*A**48*****0.5****N~

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EB*B**CG***27*150.00*****Y~

MSG*TIER1~

EB*C*IND*CG***23*300.00*****Y~

MSG*TIER1~ EB*C*FAM*CG***23*600.00*****Y~

MSG*TIER1~

EB*A**CG*****0.1****Y~

MSG*TIER1~

EB*B**CG***27*150.00*****Y~

MSG*TIER1~

EB*C*IND*CG***23*300.00*****Y~

MSG*TIER1~

EB*C*FAM*CG***23*600.00*****Y~

MSG*TIER1~

EB*A**CG*****0.1****Y~

MSG*TIER1~

EB*B**CG***27*300.00*****Y~

MSG*TIER2~

EB*C*IND*CG***23*500.00*****Y~

MSG*TIER2~

EB*C*FAM*CG***23*1000.00*****Y~

MSG*TIER2~

EB*A**CG*****0.3****Y~

MSG*TIER2~

EB*B**CG***27*600.00*****N~

EB*C*IND*CG***23*700.00*****N~

EB*C*FAM*CG***23*1400.00*****N~

EB*A**CG*****0.5****N~

EB*B**33***27*40.00*****Y~

MSG*TIER2~

EB*F**33***23***VS*20**Y~

MSG*TIER2~

EB*A**33*****0.0****Y~ MSG*TIER2~

EB*B**33***27*40.00*****Y~

MSG*TIER1~

EB*F**33***23***VS*20**Y~

MSG*TIER1~

EB*A**33*****0.0****Y~

MSG*TIER1~

EB*B**33***27*0.00*****N~

EB*F**33***23***VS*20**N~

EB*C*IND*33***23*700.00*****N~

EB*C*FAM*33***23*1400.00*****N~

EB*A**33*****0.5****N~

EB*B**CF***27*40.00*****Y~

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MSG*TIER1~

EB*F**CF***23***VS*20**Y~

MSG*TIER1~

EB*A**CF*****0.0****Y~ MSG*TIER1~

EB*B**CF***27*0.00*****N~

EB*F**CF***23***VS*20**N~

EB*C*IND*CF***23*700.00*****N~

EB*C*FAM*CF***23*1400.00*****N~

EB*A**CF*****0.5****N~

EB*B**CF***27*40.00*****Y~

MSG*TIER2~

EB*F**CF***23***VS*20**Y~

MSG*TIER2~

EB*A**CF*****0.0****Y~

MSG*TIER2~

EB*B**50***27*0.00*****Y~

MSG*TIER2~

EB*C*IND*50****300.00*****Y~

MSG*TIER2~

EB*C*FAM*50****600.00*****Y~

MSG*TIER2~

EB*A**50*****0.3****Y~

MSG*TIER2~

EB*G*IND*30**EMPLOYER-RXD*24*0*****Y~

MSG*TIER1~

EB*G*FAM*30**EMPLOYER-RXD*24*0*****Y~

MSG*TIER1~

EB*G*IND*30**EMPLOYER-RXD*24*0*****Y~

MSG*TIER2~

EB*G*FAM*30**EMPLOYER-RXD*24*0*****Y~

MSG*TIER2~

EB*G*IND*30**EMPLOYER-RXD*24*0*****N~ EB*G*FAM*30**EMPLOYER-RXD*24*0*****N~

EB*C*IND*30**EMPLOYER-RXD*24*0*****Y~

MSG*TIER1~

EB*C*FAM*30**EMPLOYER-RXD*24*0*****Y~

MSG*TIER1~

EB*C*IND*30**EMPLOYER-RXD*24*0*****Y~

MSG*TIER2~

EB*C*FAM*30**EMPLOYER-RXD*24*0*****Y~

MSG*TIER2~

EB*C*IND*30**EMPLOYER-RXD*24*0*****N~

EB*C*FAM*30**EMPLOYER-RXD*24*0*****N~

SE*239*232323232~

GE*1*232323232~

…………………………………………………………………………………


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IEA*1*232323232~

Appendix E – 276 Request Example

ISA*00* *00* *ZZ*999999999 *30*810525733

*130227*1050*^*00501*000230002*0*P*>~

GS*HR*743032373*BCBS*20130227*1050*120001*X*005010X212~

ST*276*00023*005010X212~

BHT*0010*13*00023*20130227*1050~

HL*1**20*1~

NM1*PR*2*BLUE CROSS BLUE SHIELD MT*****PI*BCBS~

HL*2*1*21*1~

NM1*41*2*WE CARE FOR YOU CLINIC*****46*HEW1~

HL*3*2*19*1~

NM1*1P*2*WE CARE FOR YOU CLINIC*****XX*1234567893~

HL*4*3*22*0~

DMG*D8*19800101*F~

NM1*IL*1*QUEUE*SUZIE*A***MI*XYZ123456789~

TRN*1*00023_C0112229001BB1~

REF*EJ*C0112229001BB1~

REF*BLT*131~

AMT*T3*71~

DTP*472*RD8*20130205-20130205~

SE*17*00023~

GE*1*120001~

IEA*1*000230002~

Appendix F – 277 Response Example

ISA*00* *00* *30*810525733 *ZZ*HEW1 *130104*1514*^*00501*000000002*1*P*:~

GS*HN*810525733*1234*20130104*151455*1*X*005010X214~

ST*277*0001*005010X214~

BHT*0085*08*HEW102S9.EAP|028691377*20130104*1514*TH~

HL*1**20*1~

NM1*PR*2*HEALTH E WEB*****46*810525733~ TRN*1*20130104151234~

DTP*050*D8*20130104~

DTP*009*D8*20130104~

HL*2*1*21*1~

NM1*41*2*WE CARE FOR YOU CLINIC*****46*HEW1~

TRN*2*HEW102S9.EAP|028691377~

STC*A1:20*20130104*WQ*134.00~

QTY*AA*1~

AMT*YY*134.00~

HL*3*2*19*1~

NM1*85*2*WE CARE FOR YOU CLINIC*****XX*1234567893~

…………………………………………………………………………………


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TRN*1*0~

STC*A1:20**U*134.00~

QTY*QC*1~

AMT*YY*134.00~ HL*4*3*PT~

NM1*QC*1*QUEUE*SUZIE*R***MI*999999999~

TRN*2*000402029999~

STC*A3:21*20130104*U*134.00~

REF*D9*00000000000099999999~

DTP*472*RD8*20120124-20120124~

SE*26*0001~

GE*1*1~

IEA*1*000000002~

Appendix G – Frequently Asked Questions

Q: Do you accept batch transactional files?

A: Yes, HeW can accept single transaction files through our Real Time server or batch transaction files through sFTP.

Appendix H – Change Summary

Version # Page Date Reason Author

V 1.0 All 07/26/2012 Initial 5010 document HeW

V 1.1 All 05/10/2013 Revised for CORE specifications Michelle Palermo

V 1.2 Pages 9 & 10 08/22/2013 Updated sections to add Holiday

information Michelle Palermo

V 1.3 Page 9 11/27/2013 Updated Process Flows & Added III

Information Michelle Palermo

V 1.4 Pages 14-21 06/03/2014 Added Section 10.4 Michelle Palermo

V 1.5 Page 10 08/13/2015 Updated Companion Guide web page

link and HeW email addresses Michelle Palermo

V 1.6 Page 11, cover,

footers 08/16/2016

Removed phone number extension.

Adjusted Support Email.

Michelle Palermo /

DL

Documents

HIPAA Transaction Standard Companion Guide Refers to the ...€¦ · AUGUST 2016 005010X279A1 1.6 877.565.5457 • [email protected] 11 6 - CONTROL SEGMENTS / ENVELOPES 6.1