Real Time Transactions - 5010 Companion Guide Time Transactions - 5010 Companion Guide ... o ELIG_CUSTOM_XML_FORMAT ... backward compatibility when

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Real Time Transactions - 5010 Companion Guide

Health Care Eligibility Benefit Inquiry and Response

ASC X12N-005010X279A1 270/271

Health Care Claim Status Request and Response

ASC X12N-005010X212A1 276/277

Capario’s Proprietary Health Care Eligibility Benefit Inquiry and Response

Capario’s ELIG_PIPE_DELIMITED/ELIG_CUSTOM_XML_FORMAT



Table of Contents

Real Time Transactions - 5010 Companion Guide ....................................................................................... 1

Health Care Eligibility Benefit Inquiry and Response ............................................................................... 1

Health Care Claim Status Request and Response .................................................................................. 1

Capario’s Proprietary Health Care Eligibility Benefit Inquiry and Response ............................................ 1

1. Introduction ........................................................................................................................................... 4

2. Capario Real Time Implementation Steps ........................................................................................... 4

3. Communications ................................................................................................................................... 5

The following section describes each connectivity option in detail. .............................................................. 5

CORE II Complaint Connection ................................................................................................................ 5

CORE II HTTPS and SOAP Metadata requirement: ............................................................................ 6

CORE II Compliant Production URLs:.................................................................................................. 7

CORE II Specific System/Error Messages: .......................................................................................... 7

Capario HTTPS POST .............................................................................................................................. 7

Production URL for ANSI X12N Transaction submitters: ..................................................................... 7

Production URL for Capario Proprietary Eligibility Transaction submitters: ......................................... 7

Batch Protocol Using Secure File Transfer .............................................................................................. 7

Processing Timeframe ......................................................................................................................... 8

Batch Size ............................................................................................................................................ 8

Batch Formatting .................................................................................................................................. 8

4. ANSI X12 Real Time Elements ............................................................................................................ 8

Interchange Control Header (ISA) ............................................................................................................ 8

Functional Group Header ......................................................................................................................... 9

Beginning of Hierarchical Transaction ...................................................................................................... 9

Delimiters .................................................................................................................................................. 9

Transaction Specific Information - Applicable to All Real Time Transactions .......................................... 9

270-271 Eligibility Benefit Request ......................................................................................................... 10

276-277 Claim Status Request and Response ...................................................................................... 10

5. Capario Proprietary Eligibility Real Time Parameters ........................................................................ 10

Delimiters ................................................................................................................................................ 11

Transaction Specific Information - Applicable to All Real Time Transactions ........................................ 11

Capario Proprietary Eligibility Benefit Request ....................................................................................... 11

Capario Proprietary Eligibility Response ................................................................................................ 13

6. Scheduled and Unscheduled Maintenance Downtime ....................................................................... 16

7. Frequently Asked Questions .............................................................................................................. 16

Getting Started ........................................................................................................................................ 16



Troubleshooting ...................................................................................................................................... 16

8. Appendix ............................................................................................................................................. 17

270 – 2110C / 2110D EQ01 Service Type Code List ............................................................................. 17

271 – 2110C / 2110D EB01 Code list ..................................................................................................... 17

271 – Request Validation – AAA03 Code list ......................................................................................... 18

277 - 2200D/E and 2220D/E Claim/Service Line Level Status Information code lists (STC01-1 and 01-2) ............................................................................................................................................................. 20

Eligibility 4010 to 5010 Side-By-Side Download:.................................................................................... 20

Claim Status Inquiry 4010 to 5010 Side-By-Side Download: ................................................................. 20

Capario’s 4010 to 5010 translation business rules for 270/271 and 276/277 ........................................ 20



1. Introduction

This implementation guide is for users working with Capario for real time and batch transactions. Users of this guide will need to have:

A complete understanding of, and experience with, the ANSI ASC X12 Implementation Guides.

A detailed knowledge and implementation experience with at least one of the following protocols -HTTPS, CORE II compliant HTTPS multi-part MIME, CORE II compliant SOAP, SFTP, and FTPS protocols.

This information in this guide is:

Specific to the following transactions

A supplement to the transaction implementation guides of these transactions. o ANSI ASC X12N-005010X212A1 276/277 – Health Care Claim Status

Request/Response o ANSI ASC X12N-005010X279A1 270/271 – Health Care Eligibility Benefit

Inquiry/Response

Capario’s implementation guide for Capario’s proprietary eligibility request and response. o ELIG_PIPE_DELIMITED – Health Care Eligibility Benefit Inquiry o ELIG_CUSTOM_XML_FORMAT – Health Care Eligibility Benefit Response

Key Implementation Milestones:

Select and implement a communications protocol

Select and implement a transaction type

Review payer list, select payers, and review payer search option documentation

Create and test transactions with Capario EDI Implementation Team

Production testing

Move to Production Status

2. Capario Real Time Implementation Steps You will work with a Capario EDI analyst to complete most of these steps: a) Review this User Guide b) Work with the Capario EDI analyst to determine your communication protocol.

Review the communications section of this guide for more information on available communication protocols.

Capario will issue a logon and password for transaction testing. c) Identify the payers and transactions

Identify transactions: Eligibility (270/271), Claim Status Inquiry (276/277), or both Identify transaction format: ANSI X12 Eligibility (270/271) or Capario Proprietary Eligibility

(ELIG_PIPE_DELIMITED/ELIG_CUSTOM_XML_FORMAT) To view and/or download the Capario Real Time Payer – Click here Review individual transaction search options documents linked on the payer list Some payers require enrollment for Real Time transactions

d) Format test your transactions with the Capario EDI analyst to verify it meets basic transaction and payer requirements For ANSI X12, implement Interchange requirements (ISA, GS, BHT segments) as defined in

the ANSI X12 Real Time elements section. For Capario Proprietary Eligibility, implement HTTP POST parameters as defined in the

Capario Proprietary Real Time parameters section.

http://www.capario.com/resource-center/payer-list.aspx



e) Test Connectivity Create test transaction(s) for connection testing The Capario EDI Team will provide information needed to submit test transactions (URL or

FTP information). f) Production Testing

Production data is submitted to the selected communication platform and then on to the payer’s production system. This allows you to see “real” responses and get an idea of payer nuances, benefit details returned by a payer, etc.

Please limit your test transactions to 100. Transactions submitted over the limit of 100 are subject to billing.

Any data content or format issues should be addressed prior to moving to production status. It is recommended that you test all payers/transactions expected to be used

g) Production Monitoring Production monitoring begins once you can successfully submit transactions and receive

valid responses from the selected payer(s). Monitoring continues for 30 days, The EDI analyst will handle all production issues during this

30-day period. h) EDI Support Services

The Capario EDI analyst will provide you with appropriate contact information and escalation procedures for ongoing support.

3. Communications Capario offers following connectivity options: a) ANSI Format Transactions in Real-Time mode, where client submits single eligibility/Claim Status

Inquiry request and response is returned in the same session: a. CORE II Compliant connection (either HTTPS multi-part MIME or SOAP). b. Capario HTTPS Post

b) Capario Proprietary Eligibility Format Transactions in Real-Time mode, where client submits single eligibility/Claim Status Inquiry request and response is returned in the same session:

a. Capario HTTPS POST c) ANSI Format Transactions in Batch mode, where client submit multiple eligibility/Claim Status

Inquiry requests in a file and responses are processed offline: a. SFTP (Secure File Transfer Protocol)

The following section describes each connectivity option in detail.

CORE II Complaint Connection

The Council for Affordable Quality Healthcare (CAQH) launched the Committee on Operating Rules for Information Exchange (CORE) with the vision of giving providers access to eligibility and benefits information before or at the time of service using the electronic system of their choice for any patient or health plan.

CORE is more than 115 industry stakeholders – health plans, providers, vendors, CMS and other government agencies, associations, regional entities, standard-setting organizations and other healthcare entities. CORE participants maintain eligibility and benefits data for more than 130 million commercially insured lives plus Medicare and Medicaid beneficiaries. Working in collaboration they are building consensus on a set of operating rules that will:

Enhance interoperability between providers and payers

Streamline eligibility, benefits, and claim data transactions



Reduce the amount of time and resources providers spend on administrative functions – time better spent with patients.

For more information regarding CORE, please visit http://www.caqh.org/CORE_faq.php

Capario offers 2 (two) protocols for CORE compliant communications for ANSI X12 transactions:

HTTPS multipart MIME

SOAP

For both protocols authentication is completed via a logon and password issued by your Capario EDI analyst.

CORE II HTTPS and SOAP Metadata requirement:

Field Name Description Format Example

Payload Type

Payload Type specifies the type of payload included within a request

One of these values: “005010X212A1” for CSI 276/277 Transactions “005010X279A1” for ELG 270/271 Transactions

Processing Mode

Processing Mode indicates Batch or Real Time processing mode.

Value will be: Real Time

Real Time

PayloadID This is an Identifier that you will use to identify the request submitted.

AlphaNumeric, may contain hyphen.

TimeStamp Time and Date specifying when a message is created and sent to a receiver.

Universal Time (UTC) time http://www.w3.org/TR/xmlschema11-2/#dateTime

UserName

This is the user name to log into the account. A Password will be associated with the User which allows a request to complete. Your User ID will be assigned.

8-10 AlphaNumeric characters. Case sensitive.

Capario issued user name

Password

This is the password that pairs with the User field to allow access to the Eligibility request system. Your password will be assigned.

8-10 AlphaNumeric characters. Case sensitive.

Capario issued password.

SenderID Capario submitter ID/Client ID 8 AlphaNumeric characters.

ReceiverID Capario’s Tax ID 9 Numeric Capario’s Tax ID is: 263086998

CORERuleVersion

The CORE Rule version that this envelope is using. This value can be used to maintain backward compatibility when parsing/processing messages.

2.01 2.01

Payload This contains the file with the X12 270 request data

HIPAA X12 270 Compliant

http://www.caqh.org/CORE_faq.php



CORE II Compliant Production URLs: SOAP https://webservices.capario.net/capariodataws/CAQH_CORE_WS WSDL (Web Service Description Language)

https://webservices.capario.net/capariodataws/CAQH_CORE_WS?wsdl

HTTP Multipart Mime https://webservices.capario.net/capariodataws/CAQH_CORE_Servlet

CORE II Specific System/Error Messages: The following are the different message responses and error notifications that may be received when submitting CORE II compliant requests.

HTTP 200 OK - Returned when authorization is passed and interface is successful with the real time production system. A response with X12 data content will be returned.

HTTP 403 Forbidden - If the username and/or password included in the request are not valid an HTTP 403 Forbidden error response with no data will be returned.

Server Errors - When the real time production system is not able to process a real-time request due to interface failures or other system unavailability a standard 5xx series error such as HTTP 500 Internal Server Error or HTTP 503 Service will be returned by the application. In this scenario, the submitter will need to resubmit the request once the error has been resolved.

Capario HTTPS POST

Long before industry adopted CORE compliant communication standards, Capario has supported real-time connectivity using HTTPS Post for ANSI transactions.

This method allows for the transfer of data securely over the Internet with 128 bit SSL enabled encryption/decryption. Capario system expects the ANSI ASC X12 request transaction data in the HTTP body. The submitter’s system must establish a secure connection with the Capario system before sending data. Capario will supply the necessary server certificate that is needed to establish secure connection from submitter system. Capario utilizes certificates signed by Entrust.

Submitters will be issued a user ID and password during the implementation process. For ANSI X12 transactions, the Capario Login ID and password are passed in the Author Information (ISA02) and Security Information (ISA04) elements, respectively. For Capario Proprietary Eligibility transactions, the Capario Login ID and password are passed in the HTTP Post parameters as UserID and Password, respectively. Please note that Capario expects only a single transaction per connection and authentication information in expected in every ISA or Post Parameters.

Production URL for ANSI X12N Transaction submitters:

https://b2b.Capario.net/b2b/X12Transaction

Production URL for Capario Proprietary Eligibility Transaction submitters:

https://b2b.Capario.net/b2b/PipeDelimitedTransaction

Batch Protocol Using Secure File Transfer

Capario real-time EDI Gateway supports data exchange through Secure file Transfer Protocol (SFTP) with SSH transmission method. This transmission method is more suitable for submitters who would

https://webservices.capario.net/capariodataws/CAQH_CORE_Servlet

https://b2b.capario.net/b2b/X12Transaction

https://b2b.capario.net/b2b/PipeDelimitedTransaction

https://b2b.capario.net/b2b/PipeDelimitedTransaction



prefer to submit large number of transactions in a batch file and expect the processed responses in a batch file. This method is also referred as Batch Mode.

Submitters will be issued a user ID and password during the implementation process. The Capario Login ID and password are passed in the Author Information (ISA02) and Security Information (ISA04) elements, respectively. Capario expects authentication information in every Interchange Control Header (ISA).

Processing Timeframe Capario allows a 24 hour window to process a batch. However, we return the compiled response report as soon as we receive the last response.

Batch Size Although no batch size is enforced, Capario recommends that you process batches in blocks of 200 transactions for efficient processing. There is no limit to the number of batches that can be submitted each day.

Batch Formatting Multi-Interchange Control Header (ISA) format

This format contains multiple batch requests. Each transaction is formatted to contain a single Interchange Control Header (ISA), a single Functional Group Header (GS), and a single Transaction Set (ST/SE).

Single Interchange Control Header (ISA) format

This format contains a single batch request. Each request is formatted to contain a single Interchange Control Header (ISA), a single Functional Group Header (GS), and multiple Transaction Sets (ST/SE).

4. ANSI X12 Real Time Elements ANSI X12 real time transactions submitted to Capario must contain the following elements:

Interchange Control Header

Functional Group Header

Transaction Set Header

Beginning Of Hierarchical Transaction

Information Source Loop

Information Receiver Loop

Other elements can also be added as needed and as required by the ANSI ASC X12 Implementation Guides. Capario enforces the length, character set, and code set for transactions based on the ANSI ASC X12 Implementation Guides. It is the submitter’s responsibility to ensure their system can correctly format and populate the request before submission.

The tables below detail the requirements for the Interchange Control Header (ISA), Functional Group Header (GS), and Beginning of Hierarchical Transaction (BHT) segments.

Interchange Control Header (ISA)

ASC X12 Element Real Time and Batch CORE II

ISA01 “03” “00”

ISA02 Capario Login ID padded out to 10 bytes with trailing spaces

10 Spaces

ISA03 “01” “00”



ISA04 Capario Login ID padded out to 10 bytes with trailing spaces.

10 Spaces

ISA05 “ZZ”

ISA06 Capario 8 character client ID padded out to 15 bytes using trailing spaces

ISA07 “ZZ”

ISA08 “263086998” padded out to 15 byes using trailing spaces

ISA09 Current date in “YYMMDD” format

ISA10 Current time in “HHMM” format

ISA11 “^” – Repetition Separator (U no longer valid in 5010)

ISA12 “00501”

ISA13 Submitter generated control number, must match value in IEA02

ISA14 “0”

ISA15 “T” – Test, “P” – Production

ISA16 “:” (Colon)

Functional Group Header

ASC X12 Element Notes

GS01 270 Eligibility– “HS” 276 Claim Status – “HR”

GS02 Same as value submitted in ISA06

GS03 Same as value submitted in ISA08

GS04 Current date in “CCYYMMDD” format

GS05 Current time in “HHMMSSDD” format

GS06 Submitter generated control number, must match value in GE02

GS07 “X”

GS08 270/271 Eligibility - “005010X279A1” 276/277 Claim Status - “005010X212A1”

Beginning of Hierarchical Transaction

ASC X12 Element Notes

BHT01 270 Eligibility – “0022”, 276 Claim Status – “0010”

BHT02 “13”

BHT03 Correlation ID set by sender. Capario ensures that this value is present in any response documents generated by this request. The requirement is that this identifier is unique within the sending system.

BHT04 Current date in “CCYYMMDD” format

BHT05 Current time in “HHMM” format

Delimiters

Capario will accept any delimiters compliant with the ASC X12N-005010X212A1 276/277 and ASC X12N-005010X279A1 270/271 implementation guides.

Transaction Specific Information - Applicable to All Real Time Transactions

Payer Identifier – Review and identify the payer from Capario’s Real Time payer list.

Provider Identifiers - While most payers now require NPI some payers allow for, or require, a Tax ID or legacy provider ID. Refer to the individual payer Search Option Guides to review these requirements



Member / Subscriber / Patient ID Number - Many payers issue member identifiers that include suffixes or prefixes. For best results be sure to submit the entire member ID including any suffixes or prefixes.

270-271 Eligibility Benefit Request

Search Options o Most payers provide more than one search option. Typically, the more data that is

submitted the high the probability the payer will make a match. o Some payers do not support dependent searches. For those payers that do not support

dependent searches the patient should always be submitted as the subscriber.

Eligibility / Service Dates (2100C/D and 2110C/D DTP segments) o Capario will accept a single date (R8) or a date range (RD8). Not all payers accept a date

range and will return a response with the “from” date only. o Transactions submitted without an Eligibility/Service date will default to the current date. o The DTP01 can be submitted with either “102” Service or “291” Eligibility, Capario will

modify the value to meet the payer’s requirements.

Service Type Codes (2110C/D EQ01) o All payers accept Service Type Code 30 - “Health Benefit Plan Coverage”. If an EQ

segment or Service Type Code is not submitted, Capario will insert an EQ segment with a service type code of 30.

o Some payer’s support Service Type Codes other than 30, refer to the payer Search Option Guides for codes known to be accepted by the payer.

o Most payers will respond with Service Type Code 30 if an unsupported Service Type Code is submitted.

o A list of Service Type Codes is available in the appendix.

276-277 Claim Status Request and Response

Search Options o Most payers provide more than one search option. Typically, the more data submitted the

higher the probability the payer will make a match. o Some payers do not support dependent searches. For those payers that do not support

dependent searches the patient should always be submitted as the subscriber.

5. Capario Proprietary Eligibility Real Time Parameters Capario proprietary eligibility real time transactions submitted to Capario must contain the following parameters:

User ID

Password

Request Type

Response Type

Request Data

The table below details the requirements for HTTP POST.

HTTP Post Parameter

Required/Optional Values

UserID Required Capario Assigned

Password Required Capario Assigned

TrackingID Optional (Max 50 in length) Submitter Supplied (will be returned in Response <Tracking> section as Submitter Trace ID)

RequestType Required ELIG_PIPE_DELIMITED

ResponseType Required ELIG_CUSTOM_XML_FORMAT



RequestData Required Pipe delimited Eligibility request data

Delimiters

Capario will only accept pipe ‘|’ delimiter in the Capario proprietary eligibility request.

Transaction Specific Information - Applicable to All Real Time Transactions

Payer Identifier – Review and identify the payer from Capario’s Real Time payer list.

Provider Identifiers - While most payers now require NPI some payers allow for, or require, a Tax ID or legacy provider ID. Refer to the individual payer Search Option Guides to review these requirements

Member / Subscriber / Patient ID Number - Many payers issue member identifiers that include suffixes or prefixes. For best results be sure to submit the entire member ID including any suffixes or prefixes.

Capario Proprietary Eligibility Benefit Request

Search Options o Most payers provide more than one search option. Typically, the more data that is

submitted the high the probability the payer will make a match. Even though there are numerous optional fields in the request, populate as many fields as you can to have a better chance of identifying the Subscriber/Patient at the payer.

o Some payers do not support dependent searches. For those payers that do not support dependent searches the patient should always be submitted as the subscriber.

o DO NOT POPULATE DEPENDENT INFORMATION WITH THE SAME SUBSCRIBER INFORMATION.

Eligibility / Service Dates o Capario will only accept a single date in the proprietary request format. o Transactions submitted without an Eligibility/Service date will default to the current date.

Service Type Codes o All payers accept Service Type Code 30 - “Health Benefit Plan Coverage”. Capario

proprietary format does not contain Service Type Code and will default the request to Service Type Code 30.

Request Data Payload

Field Order Field Content Required/Optional

1 Doctor or Practice Name Required

2 Payer Name Required

3 Subscriber Member ID Optional

4

Relationship Code S-self D-dependent 01-spouse 19-child

Optional

5 Current Date (date to check, defaults to today’s date) Optional

6 Account Number (Partner’s specific Acct ID, to be returned with response)

Optional

7 Payer ID (Capario’s Payer ID from Payer List) Required

8 EIN Number for practice or provider S – required if NPI not present

9 NPI Number for practice or provider S – required if EIN not present

10 Subscriber Last Name Optional



11 Subscriber First Name Optional

12 Subscriber Gender Optional

13 Subscriber Date of Birth Optional

14 Subscriber Policy Number Optional

15 Subscriber Identify Card Number Optional

If the relationship code is NOT ‘S’ (indicates a spouse or dependent/child), then format patient fields. DO NOT populate Patient Information with Subscriber Information – both fields have same information)

16 Last Name of Patient Optional

17 First Name of Patient Optional

18 Date of Birth of Patient Optional

19 Social Security Number of Patient Optional

Each field is delimited by ‘|’ (tab) even if the field is blank.

Example:

INTERNALMEDICINE|AETNA|124596878|S|06/22/2012|PRO.6244|60054||1234567893|SMITH|JOHN|M|04/04/1927|124596878|||||

The RequestType ELIG_PIPE_DELIMITED payload will be converted into the payer's expected format of 4010 or 5010. Default service type to '30' for all requests.

Subscriber vs Dependent (patient) Logic o If any of the dependent (patient) data elements are supplied, Capario will create a

dependent request otherwise Capario will create a subscriber request in the ANSI X12 270 (fields 16, 17, 18 or 19 in text delimited request)

o If a dependent request is created, relationship code is required. Capario will handle that field as:

If dependent data supplied and relationship code is missing -> Capario will create dependent request with relationship code of 34 (other)

If dependent data supplied and relationship code S or D -> Capario will create dependent request with relationship code of 34 (other)

If dependent data supplied and relationship code is anything other than S or D -> Capario will create dependent request with relationship code from the request

o If relationship code is missing and no dependent data supplied, Capario will assume the request is for the subscriber and only create a subscriber request. Relationship code will default to '18' or self.

HTTP post parameters and corresponding payload example:

UserID=testuser Password=testpass TrackingID=123456789 RequestType=ELIG_PIPE_DELIMITED RequestData=PRACTICE NAME INC SERVICES, INC|PRINCIPAL MUTUAL INSURANCE CO|995622242|19|06/08/2012|AAA.101|87726|650541909|HPI1710233775|SMITH|JOHN|M|06/18/1983|995622242|995622242|SMITH|JOHN|02/12/1973|| ResponseType=ELIG_CUSTOM_XML_FORMAT

The RequestType ELIG_PIPE_DELIMITED payload will be converted into the payer's expected format of 4010 or 5010. Default service type to '30' for all requests.



Capario Proprietary Eligibility Response

Payers ANSI X12 271/999/997 and Capario Errors are converted from 4010 or 5010 into Capario’s proprietary 'ELIG_CUSTOM_XML_FORMAT'.

The trace id that was submitted in HTTPS Post parameters as TrackingID is included in the response format.

The response layout of the’ELIG_CUSTOM_XML_FORMAT’ is broken into 7 sections; <Status>, <Tracking>, <Payer>, <RequestPatientData>, <ResponsePatientData>, <EligibilityBenefitInfo>, <ErrorDetails> where <ErrorDetails> is an Error section that would not be returned if <EligibilityBenefitInfo> section was returned.

ELIG_CUSTOMER_XML_FORMAT Payload

Section Field Description

<Status> Text Description Contains the human readable status that Capario returns. See status column in chart following.

<Tracking> Date Time Message date time stamp

Submitter Trace ID Submitter tracking number

Capario Message ID Capario’s internal tracking number

<Payer> PayerID Payer id from outbound eligibility request unless transaction fails then payer id is from inbound request (field 7)

Payer Name Payer name from outbound eligibility request unless transaction fails then payer name is from inbound request (field 2)

Service Date(s) From outbound eligibility request unless transaction fails then from inbound request (field 5)

<RequestPatientData> Practice Name Fields from Inbound Eligibility Request (if supplied in request)

EIN Number

NPI Number

Member ID

Group Number

Identity Card Number

Member Date of Birth

Member Gender

Member Last Name

Member First Name

Provider Inquiry Reference Number

Patient Date of Birth

Patient Last Name

Patient First Name

Patient SSN

<ResponsePatientData> Fields from Eligibility Response (if returned by payer)

Member ID

Member Group



Number

Member Date of Birth

Member Gender

Member Last Name

Member First Name

Member Address 1 and 2

(ANSI X12 271 N301 + N302)

Member City

Member State

Member Zip

Patient Date of Birth

Patient Last Name

Patient First Name

Plan Begin Date

<EligibilityBenefitInfo> ANSI X12 271 EB Info Contains the human readable Eligibility and Benefit Information that the Payer returned.

<ErrorDetails> See Error Chart Following

Error responses are returned in human readable plain text when possible. Some responses may contain ANSI X12 language which may be ‘as is’ in the status section in the error details.

<ErrorDetails> Chart

Status Message

Sections Returned In Response Benefit Information Detail

Section

ErrorDetails or HTTP Status

Code Message

Member Active

6 sections; <Status>, <Tracking>, <Payer>, <RequestPatientData>, <ResponsePatientData> and <EligibilityBenefitInfo>

Details of Eligibility and Benefit Information received from payer

N/A

Member Inactive



N/A

Review Plan Details



N/A

Invalid Payer ID sent in the request

<Status>, <Tracking>, <ErrorDetails>

No Additional Information Translate 997 to English

Payer System Error: Did not get response from payer

<Status>, <Tracking>, <Payer>, <RequestPatientData> and <ErrorDetails>

No Additional Information

Payer System Error: Did not get response from payer

Error In Provider data or Provider not found

<Status>, <Tracking>, <Payer>, <RequestPatientData>, <ResponsePatientData> and <ErrorDetails>

No Additional Information. If rejected by Capario then <ResponsePatientData> will not be present

Translate AAAs to English text



Error In Subscriber data or Subscriber not found




Error In Dependent data or Dependent not found




Other Data Error

<Status>, <Tracking> and <ErrorDetails>

Details of the Error based on the error


Processing Error at Capario


Processing error occurred at Capario

Invalid Request Received


Incomplete Pipe Delimited Format

Invalid TrackingID Received


TrackingID exceeds max length of 50




Authentication Failed


Invalid username or password

Authentication Failed


Authentication Service unavailable. Please retry later




Status Code (400) Invalid Request

Status Code (503) Service Unavailable, Please retry later

Status Code (400) Invalid Request: Failed to identify message format.

Status Code (400) Invalid Request: Unrecognized Response Type.

Status Code (500) Internal Server Error

Based on the type of error, not all of these sections will be returned in the error details section. For example, if Authentication fails due to login/password then only the <Status>, <Tracking> and



<ErrorDetails> section with a status of 'Authentication failed. Invalid username or password' would be returned in response.

For Example: <?xml version="1.0"?> <Response> <Status>Authentication Failed</Status> <Tracking><![CDATA[Date/Time: 04/02/2012 10:42:00 AM Submitter Trace ID: 1234567890]]> </Tracking> <ErrorDetails><![CDATA[Invalid username or password]]></ErrorDetails> </Response>

6. Scheduled and Unscheduled Maintenance Downtime

Capario real time services undergo regularly scheduled in-service maintenance every Saturday from 5am to 7am Eastern Standard Time. During this two hour period we anticipate there will be periods of short, intermittent service outages and/or slow responses.

Any maintenance or service interruptions that occur outside of the regularly scheduled window will be preceded by a minimum 1 week notice to be distributed via a Capario Customer Notification email and a posting on the Capario Web Portal.

Emergency maintenance or service interruptions will be distributed via a Capario Customer notification email and a posting on the Capario Web Portal as soon as the interruption is identified.

7. Frequently Asked Questions

Getting Started

We want to be contracted for real time transactions. Who do we contact? o Contact Capario Inside Sales at: [email protected] – (800) 586-6870 o Or you Sales Representative or Account Manager.

Who do I contact for support with real time transactions? o Capario EDI Support team at: [email protected] – (800) 792-5256

Where can I obtain the Capario real time payer list? o To download the Capario Real Time Payer – Click here

When can I obtain payer CSI and eligibility search option documentation? o Search option documentation is accessed via the links found in the “Payer Search

Options” column of the Capario real time payer list.

Where can I view which payers require enrollment or prior authorization? o Payers requiring enrollment or prior authorization can be identified by reviewing the

“Enrollment / Authorization” column of the Capario real time payer list.

Troubleshooting

I’ve received a TA1 Interchange Acknowledgement response for my transaction, what does it mean?

o A TA1 is returned when there is an issue with the Interchange Header or Trailer (ISA/IEA). This can include invalid User ID and password information in the ISA02 / ISA04 location. The TA1-05 element returns an error code that may be helpful in diagnosing the issue. If the problem persists after checking the validity of the Interchange Header and Trailer please contact the Capario EDI Team for further assistance.



I’ve received a 997/999 Functional Acknowledgment response for my transaction, what does it mean?

o A 997/999 is returned when there is a data or formatting issue within the transaction. Typically the issue can be determined with the information returned in the 997/999. A common cause of 997/999 responses is invalid payer ID. If the problem persists after making changes based on the 997/999 or you are unable to interpret the 997/999 please contact the Capario EDI Team for further assistance.

What does it mean when my 270 Eligibility inquiry was returned with a AAA*N**15*C~segment. o 270 transactions that do not meet the payer defined minimum search criteria are

acknowledged by Capario with a 271. The 271 will include the following AAA and MSG segments: AAA*N**15*C MSG*YOUR SEARCH CRITERIA DOES NOT MATCH PAYER REQUIREMENTS, PLEASE REVIEW TRANSACTION DOCUMENTATION

o Please review the Capario Payer Search Option documentation and verify that the required information is submitted.

What does it mean when my 276 Claims Status Inquiry was returned with a STC*D0:484***0*0~ segment?

o 276 transactions that do not meet the payer defined minimum search criteria are acknowledged by Capario with a 277. The 277 will include the following STC segment: STC*D0:484***0*0~

o Please review the Capario Payer Search Option documentation and verify that required information is submitted.

8. Appendix

270 – 2110C / 2110D EQ01 Service Type Code List

A list of valid Service Type Codes can be obtained by visiting the Washington Publishing Company’s website at: http://www.wpc-edi.com/codesand click on the “Health Care Service Type Codes” link.

Please note that not all payers accept all of these codes. Please refer to the individual payer Search Option Companion guides for any known restrictions.

271 – 2110C / 2110D EB01 Code list

Using a single code will not determine coverage. The code must be taken in the context of the entire 271.

1 Active Coverage 2 Active - Full Risk Capitation 3 Active - Services Capitated 4 Active - Services Capitated to Primary Care Physician 5 Active - Pending Investigation 6 Inactive 7 Inactive - Pending Eligibility Update 8 Inactive - Pending Investigation A Co-Insurance B Co-Payment C Deductible CB Coverage Basis D Benefit Description E Exclusions F Limitations G Out of Pocket (Stop Loss) H Unlimited

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



I Non-Covered J Cost Containment K Reserve L Primary Care Provider M Pre-existing Condition MC Managed Care Coordinator N Services Restricted to Following Provider O Not Deemed a Medical Necessity P Benefit Disclaimer 1321 not recommended; see section 1.3.10 Disclaimers within the

Transaction. Q Second Surgical Opinion Required R Other or Additional Payer S Prior Year(s) History T Card(s) Reported Lost/Stolen U Contact Following Entity for Eligibility or Benefit Information V Cannot Process W Other Source of Data X Health Care Facility Y Spend Down

271 – Request Validation – AAA03 Code list

When reviewing AAA segments to determine the payer’s response to an eligibility query it is critical to consider the loop and location within the loop in which it appears.

Error Code Reason

04 Authorized Quantity Exceeded

10 Administrative Cancellation

15 Required appl. data missing

33 Input Error

35 Out of Network

36 Testing not Included

37 Request Forwarded To and Decision Response Forthcoming From an External Review Organization

41 Authorization/Access Restrictions

42 Unable to Respond at Current Time

43 Invalid/Missing Provider Id

44 Invalid/Missing Provider Name

45 Invalid/Missing Provider Specialty

46 Invalid/Missing Provider Phone

47 Invalid/Missing Provider State

48 Invalid/Missing Referring Provider Id

49 Provider is Not PCP

50 Provider Ineligible for Inquiries

51 Provider Not on File

52 Service Dates Not Within Provider Plan Enrollment

53 Inquired Benefit Inconsistent with Provider Type

54 Inappropriate Product/Service ID Qualifier



55 Inappropriate Product/Service ID

56 Inappropriate Date

57 Invalid/Missing Date(s) of Service

58 Invalid/Missing Date of Birth

60 Date of Birth Follows Date(s) of Service

61 Date of Death Precedes Date(s) of Service

62 Date of Service Not Within Allowable Inquiry Period

63 Date of Service in Future

64 Invalid/Missing Patient ID

65 Invalid/Missing Patient Name

66 Invalid/Missing Patient Gender

67 Patient Not Found

68 Duplicate Patient ID

69 Inconsistent with Age of Patient

70 Inconsistent with Gender of Patient

71 Patient DOB Does Not Match That for the Patient on the Database

72 Invalid/Missing Subscriber/Insured ID

73 Invalid/Missing Subscriber/Insured Name

74 Invalid/Missing Subscriber/Insured Gender

75 Subscriber/Insured Not Found

76 Duplicate Subscriber/Insured ID

77 Subscriber Found, Patient Not Found

78 Subscriber/Insured Not in Group/Plan Identified

79 Invalid Participant Identification

80 No Response received - Transaction Terminated

82 Not Medically Necessary

83 Level of Care Not Appropriate

84 Certification Not Required for this Service

85 Certification Responsibility of External Review Organization

86 Primary Care Service

87 Exceeds Plan Maximums

88 Non-covered Services

89 No Prior Approval - No Referrals Found

90 Requested Information Not Received

91 Duplicate Request

92 Service Inconsistent with Diagnosis

95 Patient Not Eligible

96 Pre-existing Condition

97 Invalid/Missing Provider Address

98 Experimental Service or Procedure



E8 Requires Medical Review

T4 Payer Name or Identifier Missing

T5 Certification Information Missing

277 - 2200D/E and 2220D/E Claim/Service Line Level Status Information code lists (STC01-1 and 01-2)

A list of codes returned in the STC01-1 and STC01-2 sub elements can be obtained from the Washington Publishing Company’s website: http://www.wpc-edi.com/codes

The STC01-1 code set is accessed by clicking on the “Claim Status Category Codes” link.

The STC01-2 code set is accessed by clicking on the “Claim Status Codes” link.

Eligibility 4010 to 5010 Side-By-Side Download:

http://www.cms.gov/ElectronicBillingEDITrans/Downloads/Eligibility4010A1to5010.pdf

Claim Status Inquiry 4010 to 5010 Side-By-Side Download:

http://www.cms.gov/ElectronicBillingEDITrans/Downloads/ClaimStatus4010A1to5010.pdf

Capario’s 4010 to 5010 translation business rules for 270/271 and 276/277

To view Capario’s 4010 to 5010 translation business rules for 270/271 and 276/277 transactions: Click Here

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

http://www.cms.gov/ElectronicBillingEDITrans/Downloads/Eligibility4010A1to5010.pdf

http://www.cms.gov/ElectronicBillingEDITrans/Downloads/ClaimStatus4010A1to5010.pdf

http://www.capario.com/resource-center/5010-translation-business-rules.aspx

Documents

Real Time Transactions - 5010 Companion Guide Time Transactions - 5010 Companion Guide ... o ELIG_CUSTOM_XML_FORMAT ... backward compatibility when