Vermont Medicaid Carrier Premium Payment Companion Guide

Vermont Medicaid Carrier Premium Payment Companion Guide Vermont Title XIX

06/2021 Carrier Premium Payment Companion Guide 2

Disclosure Statement This document is meant for use by qualified health plans (QHP) that intend to become Trading Partners with the Department of Vermont Health Access (DVHA) in order to receive electronic healthcare payment transactions from the Fiscal Agent for the State (hereafter referred to as Vermont Medicaid). If you are not a Vermont QHP or are not authorized to conduct business on behalf of a QHP, please contact Gainwell at 802 879-4450 and select option 3, for further assistance. 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 the Department of Vermont Health Access (fiscal agent Gainwell Technologies). 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.


Table of Contents SECTION 1 INTRODUCTION ..................................................................................................3

Scope ............................................................................................................................ 3 Overview ....................................................................................................................... 3 References .................................................................................................................... 3 Additional Information .................................................................................................. 3 Advantages and Benefits of EDI .................................................................................... 3

SECTION 2 GETTING STARTED............................................................................................. 4 Working with the Department of Vermont Health Access (DVHA)

Green Mountain Care .................................................................................................... 4 Trading Partner Registration ......................................................................................... 4 Testing Overview........................................................................................................... 4

SECTION 3 TESTING WITH THE PAYER .................................................................................. 5 Downloading Files ......................................................................................................... 5 Reporting Your Test Submission ................................................................................... 5 Test Outcome and Follow-up ........................................................................................ 6 Notes for Gainwell 820 Files.......................................................................................... 6

SECTION 4 CONNECTIVITY WITH THE PAYER/COMMUNICATIONS ......................................... 7 Process Flows ................................................................................................................ 7 File Receipt Administrative Procedures ........................................................................ 7 Re-Transmission Procedure ........................................................................................... 7 Communication Protocol Specifications ...................................................................... 7 Passwords...................................................................................................................... 7

SECTION 5 CONTACT INFORMATION ...................................................................................8 EDI Customer Service.................................................................................................... 8 Mailing Address ............................................................................................................. 8 EDI Technical Assistance ............................................................................................... 8 Provider Services Unit ................................................................................................... 8 Websites & E-Mail Addresses ........................................................................................ 8

SECTION 6 CONTROL SEGMENTS/ENVELOPES .................................................................... 9 ISA-IEA ........................................................................................................................... 9 GS-GE ............................................................................................................................ 9 ST-SE ............................................................................................................................. 9

SECTION 7 820 (X306) PAYER SPECIFIC INFORMATION ...................................................... 10 SECTION 8 ACKNOWLEDGEMENTS AND/OR REPORTS ........................................................ 14 SECTION 9 TRADING PARTNER AGREEMENTS ..................................................................... 15

Trading Partners ........................................................................................................... 15 Transaction Specific Information ................................................................................16

SECTION 10 APPENDICES ................................................................................................... 17 Implementation Checklist ............................................................................................ 17 EDI Registration (for 820 Premium Payment) ...............................................................18 Trading Partner Agreement .........................................................................................19 820 Posting Example ................................................................................................... 29 Frequently Asked Questions ....................................................................................... 29

SECTION 11 CHANGE SUMMARY ........................................................................................ 30


Section 1 Introduction Scope This Companion guide details how to enroll as a Trading Partner with Vermont Medicaid add how you can receive and test the 820 Premium Payment transaction (and the reports available via Vermont Medicaid). In addition, the guide references the Technical Specifications to be used for processing the 820 (X306) Vermont Medicaid transaction.

Overview This document can be used sequentially or searched for specific subject matter. The Guide should be used in conjunction with the Vermont Medicaid Web Portal at http://www.vtmedicaid.com/#/ which houses the Technical Specifications and other EDI resources at http://www.vtmedicaid.com/#/hipaaTools. The technical specifications themselves were developed from the X12N manuals found in References.

References These specifications are to be used in conjunction with the National Electronic Data Interchange (EDI) Transaction Set Implementation Guides, which can be obtained from the Washington Publishing Company at: https://webstore.ansi.org/sdo/wpc. The Vermont Companion Guide provides supplemental information specific to Vermont Medicaid as permitted within the structures of the HIPAA transaction sets. Specifications may be updated as necessary to reflect changes in the HIPAA standard, or changes in Vermont Medicaid billing requirements. Any QHP that wishes to receive electronic payment information will be required to adhere to the HIPAA transaction and code set standards. Additional Information It is helpful for the readers of this document to be familiar with general health care terminology and preferably the applicable X12N standards. However, this is not a requirement for becoming a Trading Partner with Vermont Medicaid. Help is available by calling the EDI Coordinator at 802 879-4450, option 3 or send an email requesting assistance to [email protected].

Advantages and Benefits of EDI The State of Vermont and Gainwell encourage the use of HIPAA Electronic Transactions as they follow standard transaction guidelines, provide for reduced paperwork, allow for consistent and timely delivery and can be processed by the carriers using standard products.

http://www.vtmedicaid.com/

https://webstore.ansi.org/sdo/wpc

mailto:[email protected]


Section 2 Getting Started Working with the Department of Vermont Health Access (DVHA) Green Mountain Care Required set-up and registration documents can be found on the Vermont Medicaid Portal at http://www.vtmedicaid.com/#/ (with the exception of the EDI Registration found in Appendix 10.2 and the Trading Partner Agreement found in Appendix 10.3). As fiscal agent for DVHA, Gainwell Technologies hosts the Vermont Medicaid Web Portal and provides a variety of support services. To contact Gainwell for any information contained in this document please contact the EDI Coordinator by:

• E-mail - [email protected] • Phone - Monday - Friday 8:30a – 5:00p, ET at 802 879 4450, option 3

Trading Partner Registration Any business entity that will utilize the Vermont Medicaid Web Portal to exchange (upload and/or download) X12N data with Vermont Medicaid is required to complete a *Trading Partner Agreement (TPA) and EDI 820 Registration with The Department of Vermont Health Access (DVHA) and its fiscal agent, Gainwell Technologies. To register as a trading partner with Vermont Medicaid for the purpose of Premium Payments, complete the Trading Partner Agreement (see Appendix 10.3). Additionally, you should complete and sign EDI 820 Registration (see Appendix 10.2). Original signed documents should be emailed to [email protected] or mailed to Gainwell Technologies, Attn: EDI Coordinator, PO Box 888, Williston, VT 05495-0888. After receipt of a Trading Partner Agreement and EDI Registration, the EDI Coordinator will set up a test account and email account information and instructions on how to proceed. Going forward, it will be the responsibility of the Trading Partner to update their EDI Registration as needed to notify Gainwell for Adds, Changes, or Deletions. Testing Overview Per the section above, entities wishing to receive electronic premium payment information from Vermont Medicaid must first become a Trading Partner. Trading Partners test with Vermont Medicaid by downloading an 820 transaction made available under their Trading Partner ID in the test environment and running it through their processor. To move to Production, the Trading Partner should be comfortable with the downloaded data (i.e. the processor should not throw errors) and confirm the results match their expectations given the input. Once approved, no further testing is required for that transaction type.





Section 3 Testing with the Payer When a Trading Partner is assigned an Identification (ID) Number by the EDI Coordinator, information will be emailed to the Trading Partner containing the account information and detailed documentation about the testing process. What follows is a summary of that process. All Trading Partners are to logon to User Acceptance Test (UAT) by going to http://www.vtmedicaid.com/#/, clicking on Transactions then Login-UAT. Use the User ID (Trading Partner ID) and default password that was sent to you in your account information email. After initial logon, you will be required to select a new password and security questions/answers for future use of the “Forgot Password” function. Click Update when you have entered your information.

Downloading Files Make sure a test 820 has been made available under your Trading Partner ID by confirming with the EDI Coordinator ([email protected], 802 879 4450 Option 3). Go to http://www.vtmedicaid.com/#/ and click on Transactions, Logon – UAT. After you have logged on, click on Secure Options in the upper right. Then click on Download Files. Then click Search. You should see a page similar to the one below except you should see a file type of 820.

Click on the File Name and open/save the 820 of the type your processor utilizes (typically .txt or .edi). Read / load the 820 data into your 820 processor and check for compliance, reports or other outputs you expect (e.g. 999). Reporting Your Test Submission Vermont Medicaid will not know you downloaded the UAT 820 unless you inform them. Upon successful download please send an email to [email protected] saying you ran a test. Include your Trading Partner ID (901…) in the email. If you experienced errors that you cannot correct, please contact the EDI coordinator via email or at 802 879 4450 Option 3.






Test Outcome and Follow-up The 820 can be downloaded multiple times if necessary. Once the Trading Partner is OK with the processed results, let the EDI Coordinator know. The EDI Coordinator will move the Trading Partner to Production and an email will be sent to the Trading Partner with instructions for cutting over to Production. Note that the test 820 does not represent actual payments. For payment information you will have to download your 820s from the Production environment. Notes for Gainwell 820 Files

• The ISA15 is set to T for test and P for Production • Delimiters are set to * (element separator), : (component separator), ~ (segment terminator) • All data will be in X12N data format with a new line following each segment terminator (~) • All data will be in upper case • The file naming convention for the 820 will consist of the following:

VTBHE_[Carrier Name]_820X306_[Trading Partner ID]_YYYYMMDD_HHMM_[System Assigned Key].dat

• There is no limit to the number of times you can download the file


Section 4 Connectivity with the Payer/Communications Process Flows All files available for Download go through the OXi translator for compliance and to make sure they meet Vermont Medicaid requirements (per the Tech Specs). A file number is issued for each download but has no significance other than to keep track of which files have been downloaded. File Receipt Administrative Procedures

• Go to http://www.vtmedicaid.com/#/ and click on Transactions and select Login • Enter your Trading Partner ID (901…) and password and logon • Click on Secure Options • Click on Download Files • You will see 820 files listed along with a Create Date and a Download Date. If the Download

Date is blank, the file has never been downloaded. • Double click on the file under the File Name to download the file

Re-Transmission Procedure Files are generally not retransmitted as they can be downloaded as many times as necessary. If you are expecting a file that you do not see, contact the EDI Coordinator to check if there are any ongoing system issues. Communication Protocol Specifications As of this writing, the only download option is via the Vermont Medicaid Web Portal under Transaction Services by going to Download Files. The logon process may be automated by the Trading Partner, but that process is not supported by Vermont Medicaid. Passwords Trading Partners are issued a default logon password with their account. After the initial sign on, the password must be changed. Thereafter, the password will expire every 60 days. When the trading partner signs on after 60 days, they will be notified that the password has expired, and be required to put in a new password. Password rules appear with the password expiration notification. If a password does not work, it is recommended that Trading Partners use the Forgot Password option. Failing that, the EDI Coordinator should be contacted.



Section 5 Contact Information EDI Customer Service EDI support is available Monday - Friday, 8:30 AM to 5:00 PM, ET. Please call 802 879 4450, option 3 or send email to [email protected]. Mailing Address Gainwell Technologies Attn: EDI Coordinator PO Box 888 Williston, VT 05495 Overnight mailing, please use our physical address: 312 Hurricane Lane, Ste. 101 Williston, VT 05495 EDI Technical Assistance All clearinghouses, vendors and providers needing EDI technical assistance should use the information appearing above for EDI Customer Service. Provider Services Unit The Provider Services Unit of Gainwell consists of four components: Provider Relations/Field Representatives, Provider Help Desk, Provider Enrollment and the Communications/Publications Coordinator. This unit is available to assist Vermont Medicaid providers, Trading Partners and their billing personnel (at no cost), Monday through Friday from 8:00 AM to 5:00 PM (except for State holidays; see the Holiday Closure Schedule at http://www.vtmedicaid.com/#/bannerMain.)

• Provider Services/Gainwell: Toll-free in Vermont (800) 925-1706 • Local & Out-of-State (802) 878-7871

Websites & E-Mail Addresses

• The Vermont Medicaid Portal http://www.vtmedicaid.com/#/ • Provider Web Services https://www.vtmedicaid.com/#/, TransactionsLogin • PES Software, Upgrades, PES Quick Reference Guide and Provider Electronic Solutions Guide

http://www.vtmedicaid.com/#/pes • HIPPA Tools http://www.vtmedicaid.com/#/hipaaTools

EDI Registration, 835 Enrollment Form, Trading partner Agreement, Companion Guide & 5010 Tech Specs

• EDI Coordinator [email protected]



https://www.vtmedicaid.com/#/

http://www.vtmedicaid.com/#/pes



Section 6 Control Segments/Envelopes ISA-IEA ISA-IEA Interchange control segment information can be found in the respective Technical Specification documents referenced in this guide. If/when removed from the Technical Specifications, the ISA, IEA information will appear here. A typical 820 downloaded on the Vermont Medicaid portal contains one interchange envelope. That is one ISA-IEA pair. The matching control number pair is randomly generated by the translator. GS-GE GS-GE Interchange control segment information can be found in the respective 820 Technical Specification document referenced in this guide. If/when removed from the Technical Specifications, the GS- GE information will appear here. For output files (e.g. 820 transaction) Vermont Medicaid generates one GS-GE pair. The matching control number pair is prefixed with the randomly generated number used in the ISA-IEA pair. ST-SE ST-SE transaction set information can be found in the respective Technical Specification documents referenced in this guide. If/when removed from the Technical Specifications, the ST-SE information will appear here. For output files (e.g. 820 transaction) Vermont Medicaid generates one ST-SE pair per Contract #.


Section 7 820 (X306) Payer Specific Information Most payment information rules can be found in the Comments portion of the Technical Specifications found at http://www.vtmedicaid.com/#/hipaaTools. Included below is a highlighted (in the reference field) subset of the data mapped in the 820 (X306) that will be posted on the web site under Download Files under the Trading Partner ID. Note that two 820s will be posted. One for VCSR data and one for VPA data (see loop 2300, RMR02). Note that page # refers to the ANSI X12N Guide where definitions of all fields can be found. If you do not have a guide, it can be purchased here: https://webstore.ansi.org/sdo/wpc.

Page # Loop ID Reference Name Codes Length Note/Comments

C.4 NA (No Loop Name) ISA Interchange Control Header

C.4 NA (No Loop Name) ISA01 Authorization Information Qualifier 00 DVHA will send "00"

C.4 NA (No Loop Name) ISA02 Authorization Information

C.4 NA (No Loop Name) ISA03 Security Information Qualifier 00 DVHA will send "00"

C.4 NA (No Loop Name) ISA04 Security Information

C.4 NA (No Loop Name) ISA05 Interchange ID Qualifier ZZ DVHA will use qualifier "ZZ"

C.4 NA (No Loop Name) ISA06 Interchange Sender ID Use EIN "822287119"

C.5 NA (No Loop Name) ISA07 Interchange ID Qualifier ZZ DVHA will use qualifier "ZZ"

C.5 NA (No Loop Name) ISA08 Interchange Receiver ID DVHA will send the Trading Partner ID

C.5 NA (No Loop Name) ISA09 Interchange Date

C.5 NA (No Loop Name) ISA10 Interchange Time

C.5 NA (No Loop Name) ISA11 Repetition Separator

C.5 NA (No Loop Name) ISA12 Interchange Control Version Number

C.5 NA (No Loop Name) ISA13 Interchange Control Number

C.6 NA (No Loop Name) ISA14 Acknowledgment Requested

C.6 NA (No Loop Name) ISA15 Interchange Usage Indicator

C.6 NA (No Loop Name) ISA16 Component Element Separator DVHA separators are: ~ = Segment, * = Data Element, : = Composite sub-element

C.7 NA (No Loop Name) GS Functional Group Header

C.7 NA (No Loop Name) GS01 Functional Identifier Code RA DVHA will send “RA”

C.7 NA (No Loop Name) GS02 Application Sender's Code Use EIN "822287119"

C.7 NA (No Loop Name) GS03 Application Receiver's Code DVHA will send the Trading Partner ID

C.7 NA (No Loop Name) GS04 Date

C.8 NA (No Loop Name) GS05 Time

C.8 NA (No Loop Name) GS06 Group Control Number

C.8 NA (No Loop Name) GS07 Responsible Agency Code

C.8 NA (No Loop Name) GS08 Version / Release / Industry Identifier DVHA will use Version 005010X306

34 NA (No Loop Name) ST Transaction Set Header

34 NA (No Loop Name) ST01 Transaction Set Identifier Code

34 NA (No Loop Name) ST02 Transaction Set Control Number

34 NA (No Loop Name) ST03 Implementation Convention Reference

Value will match the GS08

35 NA (No Loop Name) BPR Financial Information

36 NA (No Loop Name) BPR01 Transaction Handling Code I DVHA will use “I”

36 NA (No Loop Name) BPR02 Monetary Amount

36 NA (No Loop Name) BPR03 Credit/Debit Flag Code C DVHA will use “C”

37 NA (No Loop Name) BPR04 Payment Method Code ACH DVHA will use “ACH”

37 NA (No Loop Name) BPR05 Payment Format Code CCP

37 NA (No Loop Name) BPR06 (DFI) ID Number Qualifier


https://webstore.ansi.org/sdo/wpc



37 NA (No Loop Name) BPR07 (DFI) Identification Number

37 NA (No Loop Name) BPR08 Account Number Qualifier

37 NA (No Loop Name) BPR09 Account Number

37 NA (No Loop Name) BPR10 Originating Company Identifier

37 NA (No Loop Name) BPR11 Originating Company Supplemental Code

38 NA (No Loop Name) BPR12 (DFI) ID Number Qualifier 1

38 NA (No Loop Name) BPR13 (DFI) Identification Number Receiving Depository Financial Institution Identifier

38 NA (No Loop Name) BPR14 Account Number Qualifier DA DVHA will use “DA”

39 NA (No Loop Name) BPR15 Account Number Receiver Bank Account Number

39 NA (No Loop Name) BPR16 Date

40 NA (No Loop Name) TRN Re-association Trace Number

41 NA (No Loop Name) TRN01 Trace Type Code 3 DVHA will use “3”

41 NA (No Loop Name) TRN02 Reference Identification

41 NA (No Loop Name) TRN03 Originating Company Identifier

41 NA (No Loop Name) TRN04 Reference Identification

42 NA (No Loop Name) REF Exchange Assigned Qualified Health Plan Identifier

42 NA (No Loop Name) REF01 Reference Identification Qualifier

42 NA (No Loop Name) REF02 Reference Identification

43 NA (No Loop Name) REF Issuer Assigned Qualified Health Plan Identifier



44 NA (No Loop Name) REF Exchange Assigned Employer Group Identifier



45 NA (No Loop Name) REF Issuer Assigned Employer Group Identifier



46 1000A N1 Payee Name

46 1000A N101 Entity Identifier Code PE VT will send “PE”

46 1000A N102 Name BCBS, MVP

46 1000A N103 Identification Code Qualifier FI DVHA will use “FI”

47 1000A N104 Identification Code DVHA will send the Payee Tax Identification Number

48 1000A REF Unique Health Plan Identifier

48 1000A REF01 Reference Identification Qualifier

48 1000A REF02 Reference Identification

49 1000B N1 Payer’s Name

49 1000B N101 Entity Identifier Code RM

49 1000B N102 Name DVHA will send “DVHA”

49 1000B N103 Identification Code Qualifier 58 DVHA will use “58”

50 1000B N104 Identification Code DVHA will send ”822287119”

50 1000B PER Premium Payer’s Administrative Contact

52 1000B PER01 Contact Function Code IC

52 1000B PER02 Name VT will use “EDI Coordinator”

52 1000B PER03 Communication Number Qualifier TE

52 1000B PER04 Communication Number VT will use 8028794450



52 1000B PER05 Communication Number Qualifier EM

52 1000B PER06 Communication Number VT will use [email protected]

53 1000B PER07 Communication Number Qualifier

53 1000B PER08 Communication Number

54 2000 ENT Remittance Information

55 2000 ENT01 Assigned Number

56 2100 NM1 Individual Name

56 2100 NM101 Entity Identifier Code IL DVHA will use "IL"

56 2100 NM102 Entity Type Qualifier 1

57 2100 NM103 Name Last or Organization Name

57 2100 NM104 Name First

57 2100 NM105 Name Middle

57 2100 NM106 Name Prefix

57 2100 NM107 Name Suffix

57 2100 NM108 Identification Code Qualifier C1 DVHA will use "C1”

58 2100 NM109 Identification Code Subscriber Identifier

59 2100 REF Exchange Assigned Qualified Health Plan Identifier

59 2100 REF01 Reference Identification Qualifier

59 2100 REF02 Reference Identification

60 2100 REF Issuer Assigned Qualified Health Plan Identifier

60 2100 REF01 Reference Identification Qualifier TV VT will send “TV”

60 2100 REF02 Reference Identification (line of business)

61 2100 REF Exchange Assigned Employer Group Identifier



62 2100 REF Issuer Assigned Employer Group Identifier



63 2100 REF Exchange Assigned Policy Identifier

63 2100 REF01 Reference Identification Qualifier POL VT will send “POL”

63 2100 REF02 Reference Identification (policy number)

64 2100 REF Issuer Assigned Policy Identifier



65 2100 REF Exchange Assigned APTC Contributor/Tax Payer Identifier



67 2100 REF Issuer Assigned APTC Contributor/Tax Payer Identifier



69 2100 REF Exchange Assigned Dependent Identifier



70 2100 REF Issuer Assigned Dependent Identifier





71 2100 REF Issuer Assigned Subscriber Identifier



72 2300 RMR Remittance Detail

72 2300 RMR01 Reference Identification Qualifier ZZ DVHA will use “ZZ”

73 2300 RMR02 Reference Identification DVHA will send “VCSR” or “VPA”

73 2300 RMR04 Monetary Amount Note: + or - , zero not allowed

74 2300 REF Exchange Report Document Control Number



75 2300 REF03 Description

76 2300 DTM Individual Coverage Period

76 2300 DTM01 Date/Time Qualifier 582 VT will use "582"

76 2300 DTM05 Date Time Period Format Qualifier RD8

77 2300 DTM06 Date Time Period

78 NA (No Loop Name) SE Transaction Set Trailer

78 NA (No Loop Name) SE01 Number of Included Segments

78 NA (No Loop Name) SE02 Transaction Set Control Number

C.9 NA (No Loop Name) GE Functional Group Trailer

C.9 NA (No Loop Name) GE01 Number of Transaction Sets Included

C.9 NA (No Loop Name) GE02 Group Control Number

C.10 NA (No Loop Name) IEA Interchange Control Trailer

C.10 NA (No Loop Name) IEA01 Number of Included Functional Groups

C.10 NA (No Loop Name) IEA02 Interchange Control Number


Section 8 Acknowledgements and/or Reports Since the 820 is a posted (rather than a received) transaction it has already gone through the translator. We will however post the 999 and TA1 showing the associated acceptance reports. The 820 transaction must be pulled (i.e. downloaded) from the web site and run through the Trading Partner’s processor. If errors are incurred in the processor, Gainwell will try and debug the issue. Please contact the EDI coordinator at 802 899 2827 option 3, or send an email to [email protected]. Note that provided the transaction is found to be compliant per the X12N guide, the Trading Partner might have to contact the vendor that supplied the 820 processor and they in turn might have to contact the EDI coordinator to resolve the issue.



Section 9 Trading Partner Agreements Trading Partners An EDI Trading Partner is defined as any Department of Vermont Health Access (DVHA) customer (provider, billing service, software vendor, employer group, financial institution, etc.) that transmits to, or receives electronic data from DVHA. Any business entity who will utilize the Vermont Medicaid Web Portal or Interactive Eligibility Services to exchange or receive data with the Vermont Medicaid, will be required to complete a Trading Partner Agreement (TPA) and EDI Registration with The Department of Vermont Health Access (DVHA) and its fiscal agent, Gainwell Technologies. Trading Partners are required to supply Vermont Medicaid provider numbers and/or contract numbers, and authorizations (i.e. signatures) to submit and receive specific transactions on their behalf. The Trading Partner Agreement can be found in Appendix 10.3. It should be signed and emailed to [email protected] or the original signed document should be mailed to: Gainwell Technologies Attn: EDI Coordinator PO Box 888 Williston, VT 05495-0888 The EDI Registration for the 820 Premium Payment is attached in Appendix 2 and should be signed and emailed/mailed as above. Upon receipt of a valid Trading Partner Agreement and EDI Registration, Gainwell will generate a test account and email a package containing account information and directions on how to proceed.



Transaction Specific Information Formal 820 transaction specific information following the Core requirements can be found in the Vermont Medicaid Technical Specifications on the Vermont Medicaid Portal at http://www.vtmedicaid.com/#/hipaaTools. The Tech Specs are based on the HIPAA X12N Guides and contain field and guide names from the ASC X12N Standards, the page number from the guide on which the fields are based, and MMIS Instructions (i.e. Vermont Medicaid requirements and loop names (where applicable)). The example below is an excerpt from the 820 (X306) technical specifications.



Section 10 Appendices Implementation Checklist Necessary steps for going live with DVHA

1. Complete and email / mail a Trading Partner Agreement and EDI Registration signed by a Vermont Medicaid partner.

2. After you receive your account documentation from Gainwell: a. Logon to User Acceptance Test on the web portal b. DownIoad the test 820 c. Run the 820 through your processor for compliance and test results

Once satisfied with test results send an email to [email protected] saying you are set with testing.

3. The EDI Coordinator will move you to production 4. The following financial cycle you can start downloading your production 820.



EDI Registration (for 820 Premium Payment)


Trading Partner Agreement

820 Transaction Trading Partner Agreement

This Trading Partner Agreement (“Agreement”) is made and entered into by and between _____(“Issuer”) and the State of Vermont Agency of Human Services operating by and through its Department of Vermont Health Access (“State”) (collectively the “Parties”) and is effective as of the date the Agreement is signed (“Effective Date”).

WHEREAS, the Parties have entered into a participation agreement under which Issuer has agreed to offer qualified health and/or dental plans on State’s federally-mandated health benefit exchange (the “Exchange”) to qualified individuals and qualified employers (“Participation Agreement”);

WHEREAS, Gainwell operates and maintains, under the authorization of the State, a paperless transaction system that will process electronic transactions submitted through designated electronic media;

WHEREAS, Gainwell is the fiscal agent intermediary for the State and, on behalf of the Exchange, processes medical assistance payments, Vermont Premium Assistance and Vermont Cost Sharing Reduction payments, for customers who purchase Issuer plans through the Exchange. Gainwell operates the system in which the electronic payment transactions flow. Issuers access Internet-based mechanisms for the receipt and transmission of electronic data with the State and its intermediaries.

WHEREAS, the Participation Agreement requires the Parties to engage in Standard Transactions and exchange electronic Protected Health Information (“ePHI”) through specific mediums and in specific formats containing specific data elements all in conformity with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), including the Standards for Electronic Transactions, 45 CFR Parts 160 and 162 (“Transaction Rule”), the Standards for the Privacy of Individually Identifiable Health Information, 45 CFR Parts 160 and 164 (“Privacy Rule”), and the Security Standards, 45 CFR Parts 160 and 164 (“Security Rule”), as amended by Subtitle D of the Health Information Technology for Economic and Clinical Health Act (HITECH), and any associated federal rules and regulations; and

WHEREAS, in compliance with HIPAA, the Parties wish to delineate the responsibilities of the State, including its contractor intermediary, Gainwell, and the Issuer and to establish in writing the terms and conditions under which they will exchange data, including ePHI and Data for the HIPAA Standard Transactions set forth in Exhibit A;

NOW THEREFORE, in consideration of the foregoing and of the mutual covenants and agreements contained herein, the Parties agree as follows:

Section 1: Definitions.

The following terms shall have the meaning ascribed to them in this Section 1. All other terms used, but not otherwise defined shall be interpreted to permit Parties to comply with HIPAA.

Code Set shall have the same meaning as the term “code set” at 45 CFR § 162.103.


Companion Guide shall refer to a set of special instructions that provide further guidance on how to interpret United States Department of Health and Human Services (HHS) implementation specifications.

Confidential Health Information means information relating to specific Individuals, including Individually Identifiable Health Information and Health Information, that is exchanged by and between the State, Issuer and/or their intermediaries for various business purposes, and that is protected from disclosure to unauthorized persons or entities by Social Security Act § 1171 et seq., HIPAA, the Privacy Act of 1974 (5 U.S.C. § 552A), Privacy and Security of Personally Identifiable Information, 45 CFR 155.260, or other applicable state and federal statutes and regulations, including statutes and regulations protecting the privacy of general medical, mental health and substance abuse records (collectively [Privacy Statutes and Regulations]).

Data shall mean any transaction-related information provided and/or made available by either of the Parties to the other, and includes, but is not limited to, enrollment and eligibility data, claims data, payment data, PII, and PHI as defined herein below. References herein to a Data condition, Data content or Data element shall have the same meaning as those terms at 45 CFR § 160.103.

Electronic Data Interchange (“EDI”) shall mean the Electronic Data Interchange (EDI) Transaction Set Implementation Guide in effect on the date of a Data transmission, pursuant to HIPAA.

Electronically Maintained shall refer to any information stored by a computer or on any electronic medium from which information may be retrieved by a computer, including, but not limited to, electronic memory chips, magnetic tape, magnetic disk, or compact disk optical media.

Electronically Transmitted shall refer to information exchanged with a computer or electronic device using electronic media, such as the movement of information from one location to another by magnetic or optical media, transmissions over the Internet, Extranet, leased lines, dial-up lines, and private networks. However, “Electronically Transmitted” shall exclude information exchanged using paper-to-paper facsimiles, person-to-person telephone calls, video teleconferencing, voice mail messages, telephone voice response, or “fax-back” systems.

Individual shall have the same meaning as the term “individual” in 45 CFR § 160.103 and shall include a person who qualifies as a personal representative in accordance with 45 CFR § 164.502(g), and any amendments thereto.

Personally Identifiable Information (“PII”) Shall mean information created or collected by the Exchange in any medium, including electronic, which can be used to distinguish or trace an individual’s identity, such as his/her name, social security number, biometric records, etc., either alone or when combined with other personal or identifying information that is linked or linkable to a specific individual, such as date and place of birth, mother’s maiden name.

Privacy Rule shall mean the Standards for Privacy of Individually Identifiable Health Information, 45 CFR Part 160 and Part 164, Subparts A and E, and any amendments thereto.

Protected Health Information (“PHI”) shall have the same meaning as the term “Protected Health Information” in 45 CFR § 160.103, including ePHI as that term is defined in 45 CFR § 160.103, limited to the information created or received by State from or on behalf of Issuer.

Security Rule shall mean the Security Standards for the Protection of Electronic PHI, 45 CFR Part 160 and Part 164, Subparts A and C, and any amendments thereto.


Standard Transaction shall have the same meaning as defined in 45 CFR § 162.103.

Transaction Rule shall mean the Standards for Electronic Transactions, 45 CFR Parts 160 and 162, and any amendments thereto.

Section 2: Obligations and Activities of State and Issuer for 820 Transactions.

a. The State and Issuer will electronically transmit documents (as identified in Exhibit A of this agreement) to the other, as specified in this Agreement, directly or through any intermediary with whom a party may contract or who is otherwise legally authorized to conduct a transaction. Gainwell is the intermediary that the State uses as of the date that this Agreement is executed by the Parties. Issuer will provide prior written notice to the State and Gainwell when electing to use or change an intermediary for transactions under this Agreement.

b. Gainwell shall provide Issuer with detailed information and documentation regarding the compatibility requirements of Gainwell’s computer operating system, including Data formatting information such as required file structures and field descriptions. Gainwell shall designate individuals within its organization to serve as liaisons with Issuer regarding technical matters, and user related questions.

c. Each party shall be solely responsible for all costs incurred by it to transmit, access and receive Data

electronically, including, but not limited to, the costs of computers, terminals, servers, connections, modems, software and browsers that have the capability to use HIPAA mandated Code-Set Standard Transactions, and the costs of providing sufficient security measures to safeguard receipt and transmission of Confidential Health Information in accordance with privacy statutes and regulations and the regulatory requirements for Issuer to preserve the integrity and confidentiality of, and to prevent non-permitted use or unlawful disclosure of Confidential Health Information.

d. Prior to the initial Data transmission for each type of Transaction, the Parties will test and cooperate

with one another to ensure the accuracy, timeliness, completeness, compatibility, and confidentiality of each data transmission. Issuer understands it has a responsibility to adequately test all Companion Guide rules appropriate to its activities under the Participation Agreement. Issuer agrees to comply with requirements, scheduling and responsibilities for testing as detailed in Exhibit B. Issuer agrees to bear the costs of Issuer’s testing and to hold the State harmless for any damages caused to Issuer by Issuer’s failure to test.

e. Neither party will obtain access by any means to the other’s operating system or Data for any purpose

other than as set forth in this Agreement. In the event that a party receives misdirected Data, the receiving party will immediately notify the sending party and delete the Data from its operating system.

f. The Issuer shall have the capacity to allow the State and its intermediary to report an incident requiring

technical support during normal business hours.

g. The Issuer shall complete a Vermont EDI Registration Form with Gainwell.

h. The Issuer’s technical support contact information is to be included in Exhibit B. If such information is not available upon the completion of this Agreement, or if there is any change to the information, the Issuer shall provide the information to the State’s intermediary’s contacts in accordance with the notice provisions of Section 7(d) of this Agreement upon the signing of this Agreement.


i. During the term of this Agreement, Issuer shall, on or before each annual anniversary of the Effective

Date of this Agreement, provide the State’s intermediary with a projected schedule of regular preventive maintenance, structured to minimize any interruption, disruption and/or degradation of the Data Exchanges. Issuer shall update and notify the State’s intermediary when any changes to such schedule are required or appropriate based upon updated information.

j. The Issuer shall immediately notify the State’s intermediary via confirmed email or phone if Issuer’s

system is unavailable.

k. Except in the case of regularly scheduled maintenance, if Issuer’s system is unavailable for more than an hour, Issuer must immediately contact Gainwell and explain outage, the cause and extent of its impact and provide an estimate of resolution.

Section 3: Confidentiality, Privacy, and Security.

a. As required in under its Business Partner Agreement with the State, Issuer must report to the State a known breach of confidentiality, privacy, or security pertaining to the subject matter of this Agreement within one (1) hour after the Issuer attains such actual knowledge. In this context, “pertaining to the subject matter of this Agreement” means the electronic transmission of the transactions identified in this Agreement.

b. The Issuer agrees to safeguard all State information, whether verbal, written, or otherwise, received from the State or its intermediary, or acquired by the Issuer in performance of this Agreement, recognizing all such information as privileged communications which shall be held confidential in accordance with the requirements of state and federal laws and regulations.

c. Except as otherwise permitted in this Agreement, the Parties may use or disclose Confidential Health Information only as necessary to fulfill the goals of the Exchange, as may otherwise be permitted in other contracts between State and Issuer, or as required by law, all in accordance with HIPAA, CMS interconnection standards, applicable privacy and data security standards and other applicable laws.

Section 4: Obligations of The State and its intermediary for 820 Transactions

a. Gainwell, as the State’s fiscal agent intermediary for the Exchange, has been granted the authority to approve and enroll Issuers as trading partners to exchange electronic media transactions.

b. Gainwell as the State’s fiscal agent intermediary for the Exchange, has been granted the authority to create, exchange, and distribute to Issuers participating in the Exchange Confidential Health Information necessary for program operations, such as audits.

c. The content, condition and/or elements of the Data exchanged pursuant to this Agreement may change as a result of changes in law or regulation, or actions taken by a third party in accordance with the terms and conditions of certain health care benefits offered, or changes made to those health care benefits or to a health plan. Acceptance by the State or its intermediary of the Data sent by Issuer electronically does not constitute a guarantee to Issuer or to any third party of payment for health care premium amounts contained in the received Data.


d. The State’s intermediary shall provide Companion Guides as appropriate, providing requirements for EDI unique to the State’s intermediary including communication details for establishing connectivity and for transmission of Transactions. The State or its intermediary shall provide no less than sixty (60) days’ notice, unless otherwise mandated by state or federal law, when making changes to a Companion Guide for EDI. The State’s intermediary shall test changes with Issuer prior to the expected go live date of additional requirements.

Section 5: Compliance with Standard Transactions.

a. Regarding compliance with 45 C.F.R. § 162.915, Parties agree NOT to do any of the following, and agrees to prohibit its agents or subcontractors from doing any of the following: (1) change the definition, data condition, or use of a data element or segment in a standard defined by the Transactions Rule; (2) add any data elements or segments to the maximum defined data set; (3) use any code or data elements that are either marked “not used” in the Standard's implementation specification or are not in the Standard's implementation specification; or (4) change the meaning or intent of the Standard's implementation specification.

b. Parties acknowledge and agree that from time-to-time, the Secretary may modify and set compliance dates for the Transaction Standards. 45 CFR § 162.910. Any such modification will be automatically incorporated into this Agreement as if set forth herein.

c. Regarding compliance with 45 C.F.R. §§ 162.402-162.610, Parties shall comply with all applicable provisions for the use of a standard unique health identifier for healthcare providers, health plans, and employer identifier.

Section 6: Term and Termination.

a. Term. The Term of this Agreement shall begin on the Effective Date and shall end upon termination of the Issuer’s participation in the Exchange.

b. Termination for Cause by State. Upon State learning of a material breach of a term(s) of this Agreement by Issuer, State shall do one of the following, in accordance with the compliance monitoring and decertification provisions in its Vermont Qualified Health Plan & Qualified Dental Plan Guidance for Participation (Guidance), as incorporated in the Participation Agreement:

1. Provide an opportunity for Issuer to timely cure the breach or end the violation.

2. If Issuer does not timely cure the breach or end the violation after notice from State that a breach has occurred this Agreement may be terminated and any other Agreement between State and Issuer, including the Participation Agreement which is a prerequisite for certification to offer qualified health plans (QHPs) and/or qualified dental plans (QDPs) on the Exchange;

3. Immediately terminate this and any other agreement between State and Issuer if Issuer has breached a material term of this Agreement and cure is not possible.

c. Termination for Cause by Issuer: Upon learning of a material breach of a term(s) of this Agreement by the State, the Issuer shall do one of the following:

1. Provide an opportunity for the State to timely cure the breach or end the violation.

https://1.next.westlaw.com/Link/Document/FullText?findType=L&pubNum=1000547&cite=45CFRS162.915&originatingDoc=Ia9b04464193211e7a34dd781ce7186da&refType=LQ&originationContext=document&transitionType=DocumentItem&contextData=(sc.Keycite)




2. If the State does not timely cure the breach or end the violation after notice from Issuer that a breach has occurred this Agreement may be terminated and any other Agreement between State and Issuer, including the Participation Agreement;

3. Immediately terminate this and any other agreement between State and Issuer if State has breached a material term of this Agreement and cure is not possible.

4. Notwithstanding the termination of its agreements with the State, Issuer shall remain obligated to provide coverage as required under State and Federal law and as detailed in the Guidance.

d. In the event of termination or expiration of this Agreement, the Parties agree that return or destruction of the Data is not reasonably feasible. Accordingly, the receiving party will extend the protections of this Agreement and any other agreement between the Parties for as long as the party maintains the Data and will limit uses and disclosures of the Data to those purposes that make return or destruction impossible, and in accordance with the “Business Partner Agreement” executed between the State and Issuer.

Section 7: Miscellaneous.

a. This Agreement does not supersede any language or requirement in the Participation Agreement executed by the Issuer and the State. This Agreement may be amended or modified, and any right under this Agreement may be waived, only by a writing signed by an authorized representative of each party.

b. Transitionary provisions: The Parties agree that the Trading Partner Agreement executed by the Parties for Plan Year 2021 and its terms will remain in effect until amended or terminated, except that such agreement will not apply to 820 Transactions or testing with Gainwell as described in this agreement.

c. Interpretation. Any ambiguity in this Agreement shall be resolved to permit the Parties to comply with HIPAA.

d. No Third-Party Beneficiaries. Nothing in this Agreement, either express or implied, is intended to confer, nor shall anything herein confer, upon any person other than the Parties and their respective successors or assigns, any rights, remedies, obligations or liabilities, whatsoever.

e. Notices. Any notice relating to this Agreement shall be in writing and transmitted by either (i) U.S. mail, first class, postage prepaid; or (ii) email to the addresses/telephone numbers in this section below. Notices or communications shall be deemed given in the case of transmittal by U.S. mail, on the date of receipt by the addressee; and in the case of an email, on the date the email is received. The burden is on the sender of an email to ensure an email is received.

For Issuer:

For State: Department of Vermont Health Access Legal Unit 280 State Drive, NOB 1 South Waterbury, Vermont 05671-1010 [email protected] Dana Houlihan, Plan Management Director


280 State Drive, NOB 1 South Waterbury, Vermont 05671-1010 Contact Phone: 802-241-0455 [email protected]

f. Records and Audit. The Parties shall maintain in accordance with applicable law and regulation, but in

any event, for at least a minimum of ten (10) years, true and correct copies of any and all source documents from which they reproduce Data.

g. Force Majeure, Neither party shall be liable to the other party for damages caused by circumstances

beyond its control, including, without limitation: internet hackers who gain access to the party’s system or Data despite that party’s commercially reasonable security measures; a major natural or other disaster; epidemic; the complete or partial destruction of the party’s facilities; riot; civil insurrection; war or similar causes. This section shall survive the termination of this Agreement.

STATE OF VERMONT Department of Vermont Health Access

ISSUER

Cory Gustafson, Commissioner Date NOB 1 South, 280 State Drive Waterbury, VT 05671-1010 Phone: (802) 241-0246 Email: [email protected]



Exhibit A

Transaction Sets

The following transaction sets are made part of this Trading Partner Agreement. All transactions are to be implemented in accordance with the HIPAA Companion Guides and other applicable regulations and standards. The Parties may update this Exhibit A from time to time by written agreement signed by both Parties as additional transaction sets or operating rules are required. Health Plan Enrollment and Payment Transaction Sets:

• 820 Payment files - Transaction, is based on the 005010X306 Type 3 technical Report and its associated 005010X306 addenda as detailed in the Carrier Payment ICD Companion Guide v. 5.0 and the 820 X306 Technical Specification v 1.0 documents.

o 820 Transaction o 999 Functional Acknowledgments


Exhibit B

Testing Requirements for 820 Transactions

All transactions must be formatted in accordance with State provided Implementation Guides, CMS Implementation Guides and/or the HIPAA Implementation Guides/Type 3 Technical Reports (TR3) available at http://www.wpc-edi.com/hipaa, as applicable. State shall provide companion guides for the transactions if necessary, which specify certain situational data elements necessary for State. HIPAA transactions to be transferred and shared between Issuer and State are identified in Exhibit A, Transaction Sets of this Agreement. State and Issuer will exchange any other necessary specifications as agreed upon in order to establish connectivity between the Parties by phone or by document as necessary.

1. Issuer shall complete testing for each of the transactions it is required to implement and shall not transfer and share data with State in production mode until testing is satisfactorily completed, as determined by State.

1. Successful testing means the ability to successfully receive HIPAA compliant transaction tests and to process electronic member health plan enrollment and payment information transmitted by State to Issuer and for Issuer to submit appropriate Acknowledgement reports. 2. A script is considered passed without conditions if no errors occur and all expected outcomes are met. 3. A script is considered conditionally passed if a component is down, unusable, or difficult to use causing some operational impact but where an alternative workaround acceptable to State in its reasonable judgment is available to avoid operational impacts on the user.

2. The functions that comprise “testing” shall include: 1. State and Issuer interfaces operate as a bi-direction bridge. Payment remittance information will be

posted to the Issuer weekly or when data is available.

3. The access phone number to State for asynchronous communication are as set forth in Section 6, below. 4. Electronic communication between the State and the Issuer must be secured with an encryption method. The exact method of encrypting this communication must be agreed upon by the State of Vermont and be compliant to those laws which govern such electronic transactions. 5. The production sign-on procedures once connected to State shall be followed according to instructions issued by State. All such instructions shall be provided in advance to Issuer with time for review and comment prior to implementation.

6. Communications and Contact Information Each party shall provide the other with such technical details, including, but not limited to, Internet Protocol (IP) information, upon request. State Contact Information for EDI Questions and Trouble Shooting: State Tech Support Email: Daniel Fay – [email protected] State Tech Support Contact Phone Number: 802-557-7523 State Tech Support after hours: phone number: Grant Steffens – 802-585-4962


For Testing Assistance (8:30 AM – 5:00 PM Monday-Friday): Amy Wolston Gainwell EDI Coordinator [email protected] (802) 879-4450, option 3 For Production Assistance related to Vermont Health Connect: Issuer is to contact the (Primary) Maximus Contact number during hours of operation: 802.651.1577* Issuer is to contact the after-hours number to be provided by State to Issuer support staff no later than October 15, of each Plan Year. This does not preclude Technical Subject Matter Experts (SMEs) at both State and Issuer from contacting each other directly. If the State SME is not available, then the Issuer must call the primary Maximus Contact number: 802.651.1577.



820 Posting Example For Vermont Medicaid compliant transaction examples, please contact the EDI Coordinator. The EDI Coordinator will provide a transaction example (minus PHI) for review if the Tech Specs and follow-on communications prove inadequate. Frequently Asked Questions

Q. What is your sender ID? A. 822287119 Q. When I send in a Trading Partner Agreement and EDI Registration, what is the turnaround time? A. Typically one business week before the account information is sent out. Q. Where are your Tech Specs? A. On the Vermont Medicaid portal http://www.vtmedicaid.com/#/hipaaTools.



Section 11 Change Summary

Version Date Changed Summary

V1.0 08/24/2020 Initial Draft

V1.1 05/05/2021 Replaced PDP EDI Registration with proposed PP EDI Registration

V1.2 06/03/2021 Added Premium Payment Trading Partner Agreement and changed references to TPA

V1.3 06/14/2021 Added 820 file naming standard and published to www.vtmedicaid.com

V1.4 06/28/2021 Updated Notes for Gainwell 820 files to reflect line breaks after the “~”.


Documents

Vermont Medicaid Carrier Premium Payment Companion Guide