Vendor Specifications ASC X12N Version 5010 for … Companion Guides/CAQH...State of Idaho MMIS COMPANION GUIDE Vendor Specifications 276/277 Eligibility Benefit Inquiry and Response

State of Idaho MMIS COMPANION GUIDE

Vendor Specifications

276/277 Eligibility Benefit Inquiry and Response

ASC X12N Version 5010

for

State of Idaho MMIS

Date of Publication: 1/18/2017 Document Number: TL418 Version: 5.0


January 2017 0050101 2

Revision History

Version Date Author Action/Summary of Changes 1.0 07/01/2011 Molina Initial Document 1.1 12/10/2012 Johnny Decrevel Reformatted to align with the upcoming CAQH

CORE rules requirements. 1.2 01/18/2013 Stacy Zuber Made change to diagram on page 9 1.3 03/07/2013 Doug Greer Reviewed and made a few minor changes

throughout the document. 1.4 07/30/2013 Doug Greer Made further refinements and requested

corrections per DHW comments. 2.0 01/31/2014 TQD DHW approved 01/23/2014 2.1 02/25/2015 Jimmy Phillips Replaced Figure 4-1: Simplified EDI High-Level

Flow and replaced Appendix A verbiage. 2.2 2/27/2015 Hope McCain Minor grammar and syntax updates for clarity;

formatting and figure label updates. 3.0 3/3/2015 TQD DHW validated changes 3/3/15. Promoted to

next whole version. 3.1 10/21/2015 Jimmy Phillips Added verbiage about production certification

for Real-time time transactions, and added the SOAP and MIME links for real-time transaction submission.

4.0 10/23/2015 TQD DHW validated changes 10/22/15. 4.0 5/26/2016 Doug Greer Semi-annual review; no updates necessary 4.1 12/16/2016 Jimmy Phillips Semi-annual review – remove secured FTP

information and replace with VAN 5.0 1/18/2017 TQD DHW validated changes 1/12/17.

Disclosure Statement

It is the responsibility of the trading partner to ensure that the latest version of this guide is used when designing\building X12N 5010 EDI transactions. The trading partner should frequently check for updates to the companion guide. Molina Healthcare accepts no liability for any costs that the trading partner may incur that arise from or are related to changes to the companion guide.


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Preface This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Molina Healthcare. Transmissions based on this companion guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides.


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Table of Contents

1. INTRODUCTION ................................................................................................... 5 2. GETTING STARTED ............................................................................................... 6 3. TESTING WITH THE PAYER .................................................................................... 7 4. CONNECTIVITY WITH THE PAYER/COMMUNICATIONS PROCESS FLOWS ..................... 7 5. CONTACT INFORMATION ....................................................................................... 9 6. CONTROL SEGMENTS AND ENVELOPES ................................................................. 10 7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ............................................ 11 8. ACKNOWLEDGEMENTS AND/OR REPORTS ............................................................. 11 9. TRADING PARTNER AGREEMENTS ........................................................................ 11 10. TRANSACTION SPECIFIC INFORMATION ............................................................ 12 11. APPENDICES .................................................................................................. 35 APPENDIX A. IMPLEMENTATION CHECKLIST ........................................................... 35 APPENDIX B. FREQUENTLY ASKED QUESTIONS ....................................................... 35

Table of Figures FIGURE 1-1: DETAILED DESCRIPTION OF TRANSACTION SET .......................................... 5 FIGURE 4-1: SIMPLIFIED EDI HIGH-LEVEL FLOW ........................................................... 8 FIGURE 10-1: 276 TRANSACTION - HEALTHCARE CLAIM STATUS REQUEST .................... 12 FIGURE 10-2: 277 HEALTHCARE CLAIM STATUS RESPONSE .......................................... 18


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1. INTRODUCTION

This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that Molina Healthcare has something additional, over and above, the information in the IGs. That information can:

• Limit the repeat of loops, or segments • Limit the length of a simple data element • Specify a sub-set of the IGs internal code listings • Clarify the use of loops, segments, composite and simple data elements • Any other information tied directly to a loop, segment, composite or simple data

element pertinent to trading electronically with Molina Healthcare In addition to the row for each segment, one or more additional rows are used to describe Molina Healthcare’s usage for composite and simple data elements and for any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides.

Figure 1-1: Detailed Description of Transaction Set

Page #

Loop ID

Reference Name Codes Length Notes/Comments

193 2100C NM1 Subscriber Name

This type of row always exists to indicate that a new segment has begun. It is always shaded at 10% and notes or comment about the segment itself goes in this cell.

195 2100C NM109 Subscriber Primary Identifier

15 This type of row exists to limit the length of the specified data element.

196 2100C REF Subscriber Additional Identification

197 2100C REF01 Reference Identification Qualifier

18, 49, 6P, HJ, N6

These are the only codes transmitted by Molina Healthcare.

Plan Network Identification Number

N6 This type of row exists when a note for a particular code value is required. For example, this note may say that value N6 is the default. Not populating the first 3 columns makes it clear that the code value belongs to the row immediately above it.

218 2110C EB Subscriber Eligibility or Benefit Information

231 2110C EB13-1 Product/Service ID Qualifier

AD This row illustrates how to indicate a component data element in the Reference column and also how to specify that only one code value is applicable.


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SCOPE This companion guide documents the transaction type listed below and further defines situational and required data elements that are used for processing eligibility inquiries/responses for programs administered by Idaho Medicaid. This document is not the complete EDI transaction format specifications.

• Health Care Claim Status Request and Response (276/277) ASC X12N/005010X212 August 2006

• Health Care Claim Status Request and Response (276/277) ASC X12N/005010X212E1 April 2008

• Health Care Claim Status Request and Response (276/277) ASC X12N/005010X212E2 January 2009

REFERENCES Please refer to the 5010 Technical Report Type 3 Guide for information not supplied in this document, such as code lists, definitions, and edits. ADDITIONAL INFORMATION

• Assumptions regarding the reader: o You are interested in reducing errors, maximizing efficiency, and saving money. o Idaho Medicaid encourages all providers to check claim status by submitting

standard HIPAA 276 transactions. • Advantages/Benefits of EDI: Claim status requests are immediately validated and

claim status information returned to submitters, allowing providers to quickly determine the status of the claims that they have submitted and, in the case of real-time transactions, get an immediate response to their inquiries.

If you do not already submit your claims status inquiries electronically, please contact the EDI Help Desk today at 1 (866) 686-4272 and select option 2 when prompted, for more information.

2. GETTING STARTED

WORKING WITH Molina Healthcare Please visit https://www.idmedicaid.com and click on the Companion Guides link to view the latest versions of this and other X12 Companion Guides. For information on using the portal once you are registered as a trading partner, click the User Guides link. For any questions, or to begin testing, please contact the Molina EDI Helpdesk at 1 (866) 686-4272, option two, or e-mail us at [email protected]. TRADING PARTNER REGISTRATION A trading partner is defined as any entity with which Molina exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Idaho Medicaid’s Health PAS system supports the following categories of trading partner:

• Provider • Billing Agency • Clearinghouse • Health Plan

Molina will assign trading partner IDs to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans.

https://www.idmedicaid.com/

mailto:[email protected]


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To obtain a trading partner ID please visit our website at https://www.idmedicaid.com, click the Provider tab, and then click the Register link; or, contact us at 1 (866) 686-4272, option two. CERTIFICATION AND TESTING OVERVIEW All trading partners must be authorized to submit production EDI transactions. Any trading partner may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of an X12 file, indicates if a file is test or production. Authorization is granted on a per transaction basis. For example, a trading partner may be certified to submit 837P professional claims but not certified to submit 837I institutional claim files. 3. TESTING WITH THE PAYER

Trading partners that submit files through the portal on the https://www.idmedicaid.com website must submit three test files of a particular transaction type, with a minimum of fifteen transactions within each file, and have no failures or rejections to become certified for production. Trading partners that are submitting Real-time transactions using Soap or MIME protocols must submit three test files of a particular transaction type, with one transaction in each file, and have no failures or rejections in order to become certified for production. Users will be notified via e-mail and on the Trading Partner Status page of Health PAS website when testing for a particular transaction has been completed. The Trading Partner Status page is accessed by logging into your trading partner account on the Health PAS website (https://www.idmedicaid.com), clicking the Account Management link on the Trading Partner tab to expand the Account Management menu, and then clicking Trading Partner Status. Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may be found in the 5010 – Appendix A Vendor Specs document on the Molina Medicaid Web site in the Companion Guides section. 4. CONNECTIVITY WITH THE PAYER/COMMUNICATIONS

PROCESS FLOWS

Figure 4-1 is a simplified diagram of the flow of EDI data through the Molina Healthcare system.





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Figure 4-1: Simplified EDI High-Level Flow

TRANSMISSION ADMINISTRATIVE PROCEDURES X12 files can be uploaded via the Health PAS website File Exchange X12 Upload. Acknowledgments and Responses to transactions submitted via the Health PAS website can be accessed by selecting Download/Responses under the File Exchange menu. Trading Partners who have established a VAN connection and submitted X12 transactions via the VAN connection, may retrieve acknowledgements and responses from their designated VAN Pickup locations. A VAN connection is a secure VPN connection through which X12 files are transferred via the FTP protocol.” RE-TRANSMISSION PROCEDURE ISA13 – Interchange Control Number needs to be unique to each file and Trading Partner ID Compliance validation errors will be reported in the 999 Implementation Acknowledgement transactions. Those transactions that pass compliance validation will be processed. Any


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further errors will be reported in a 276 Benefit Eligibility Response transaction, with the error being reported in an AAA segment. Please consult the 277 TR3 Guide for information on errors reported in AAA segments. Any compliance validation or processing errors must be corrected by the trading partner and resubmitted using the normal method for submitting 276 Benefit Eligibility Requests. COMMUNICATION PROTOCOL SPECIFICATIONS The following communications protocols are available for sending and receiving the ASC X12N 276/277 transactions. Batch Mode: HTTPS upload via the Health PAS website. FTP though a secure, dedicated VAN connection. Real-time: HTTP MIME WSDL SOAP CAQH Web service: Authorized trading partners can transmit 276 transactions through CAQH Web Services. The Molina CAQH Web Services have been enhanced to support this functionality. The CAQH Web Services supports two types of transaction protocols. SOAP (simple Object Access protocol), and MIME (Multipurpose Internet Mail extensions). Transactions can be sent in the following links:

• SOAP Transactions: https://www.idmedicaid.com/CAQH_SOAPService/SOAPService.svc

• MIME Transactions: https://www.idmedicaid.com/CAQH_MIMEService/MIMEService.svc

PASSWORDS Trading Partners create their own password at the time of registration and are required to update it every 60 days as per the Health PAS-OnLine requirements. They must consist of at least seven (7) characters, including at least one (1) uppercase letter, at least one (1) numeral, and at least one (1) special character. 5. CONTACT INFORMATION

Molina EDI Helpdesk This section contains detailed information concerning EDI Customer Service. 1 (866) 686-4272, option two (2), or e-mail [email protected]. EDI Technical Assistance This section contains detailed information concerning EDI Technical Assistance. 1 (866) 686-4272, option two (2), or e-mail [email protected]. Provider Service Number This section contains detailed information concerning the payment of claims.

https://www.idmedicaid.com/CAQH_SOAPService/SOAPService.svc

https://www.idmedicaid.com/CAQH_MIMEService/MIMEService.svc

https://www.idmedicaid.com/CAQH_MIMEService/MIMEService.svc




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1 (866) 686-4272, option three (3), or e-mail [email protected]. Applicable Websites/E-mail The Idaho Medicaid Health PAS website contains information such as companion guides, user guides, and other information needed to check the eligibility of Idaho Medicaid members though the submission of X12 276 files. Website: https://www.idmedicaid.com The e-mail addresses below can be used in contacting Idaho Medicaid’s EDI Support, Provider Services, and Provider Enrollment departments. These groups can provide assistance and answer questions relating to EDI file submissions, provider enrollment, and provider services. EDI Support [email protected] Provider Services [email protected] Provider Enrollment [email protected] 6. CONTROL SEGMENTS AND ENVELOPES

DELIMITERS Idaho Medicaid does not require the use of specific values for the delimiters used in electronic transactions. The suggested values are included in the specifications below. ISA-IEA The following ISA/IEA fields are the sender and receiver specific information required for the 276/277 transactions. For all other fields, please see the tables below. 276: ISA06 – Interchange Sender ID should contain the Molina assigned trading partner ID plus three spaces for a total of 15 characters. ISA08 – Interchange Receiver ID should contain ID_MMIS_4MOLINA ISA13 – Sender generated Interchange Control Number. This number must match the number in IEA02. 277: ISA06 – Interchange Sender ID will contain ID_MMIS_4MOLINA. ISA08 – Interchange Receiver ID will contain the Molina assigned trading partner ID. ISA13 – Sender generated Interchange Control Number. This number will match the number in IEA02. Please refer to the tables below for the ISA-IEA specific information for the 276 and 277 transactions. GS-GE The following GS/GE fields are the sender and receiver specific information required for the 276/277 transactions. For all other fields please see the tables below. 276: GS02 – Interchange Sender ID should contain the Molina assigned trading partner ID plus three spaces for a total of 15 characters. GS03 – Interchange Receiver ID should contain ID_MMIS_4MOLINA







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GS06 – Sender generated Group Control Number, must match the number in GE02. 277: GS02 – Interchange Sender ID will contain ID_MMIS_4MOLINA. GS03 – Interchange Receiver ID will contain the Molina assigned trading partner ID. GS06 – Sender generated Group Control Number, will match the number in GE02. Please refer to the tables below for the GS-GE specific information for the 276 and 277 transactions. ST-SE ST02 – Sender generated Transaction Set Control Number. Must match the number in SE02. Please refer to the tables below for the ST-SE specific information for the 276 and 277 transactions 7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS

Please refer to the tables below for the Molina Healthcare specific business rules and information for the 276 and 277 transactions. 8. ACKNOWLEDGEMENTS AND/OR REPORTS

The following acknowledgement and/or reports files, listed below, may be returned in response to an ASC X12N 276 Eligibility Inquiry Request file. For more information on these acknowledgement and/or reports, please see 5010 - Appendix A Vendor Specs. This document can be found on the Health PAS website in the Companion Guides section. REPORT INVENTORY

• TA1 – Interchange Acknowledgement. This acknowledgement is sent if requested by setting ISA14 to ‘1’, or if ISA14 is set to ‘0’ and there is an error that needs to be reported.

• 999 – Functional Acknowledgement. This acknowledgement file reports any errors found while checking compliance against the 276 TR3 specifications, or acceptance of a 276 file that meets the 276 TR3 specifications.

• 824 Application Advice report. This transaction is not mandated by HIPAA, but will be used to report the results of data content edits of transaction sets. It is designed to report rejections based on business rules such as; invalid diagnosis codes, invalid procedure codes, and invalid provider numbers. The 824 Application Advice report does not replace the 999 or TA1 transactions and will only be generated by Health PAS if there are errors within the transaction set.

• BRR – Business Rejection Report. Health PAS also produces a readable version of the 824 called the Business Rejection Report (BRR). This report helps to facilitate the immediate correction and re-bill of claims rejected during HIPAA validation.

9. TRADING PARTNER AGREEMENTS

TRADING PARTNERS A trading partner is defined as any entity with which Molina exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Idaho Medicaid’s Health PAS system supports the following categories of trading partner:


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• Provider • Billing Agency • Clearinghouse • Health Plan

Molina will assign trading partner IDs to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. All trading partners must be authorized to submit production EDI transactions. Any trading partner may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of an X12 file, indicates if a file is test or production. Authorization is granted on a per transaction basis. For example, a trading partner may be certified to submit 837P professional claims but not certified to submit 837I institutional claim files. 10. TRANSACTION SPECIFIC INFORMATION

Listed below in Figure 10-1 are the specific requirements for sending an ASC X12N 276 file to Molina Healthcare to determine Idaho Medicaid member eligibility. In Figure 10-2 are the specific requirements needed for reading and processing an ASC X12N 277 Eligibility Response transaction returned by Molina Healthcare. Please use these guidelines in conjunction with the official ASC X12N 276/277 TR3 document in planning and formatting your 276 Eligibility Request EDI transactions to send to Molina Healthcare for the State of Idaho’s Medicaid program, and to read and process the returned 277 Eligibility Response transactions. Figure 10-1: 276 Transaction - Healthcare Claim Status Request

Page #

Loop ID Reference Name Value Length

C.4 HEADER ISA Interchange Control Header ISA 3

Element Separator * 1 ISA01 Authorization Information

Qualifier 00 - No Authorization Information Present

2

Element Separator * 1 ISA02 Authorization Information Space fill 10 Element Separator * 1 ISA03 Security Information Qualifier 00 - No Security Information Present 2

Element Separator * 1 ISA04 Security Information Space fill 10 Element Separator * 1 ISA05 Interchange ID Qualifier ZZ 2 Element Separator * 1 ISA06 Interchange Sender ID Molina assigned Trading Partner ID

Left justify and space fill 15

Element Separator * 1 C,5 ISA07 Interchange ID Qualifier ZZ 2

Element Separator * 1 ISA08 Interchange Receiver ID ID_MMIS_4MOLINA 15 Element Separator * 1 ISA09 Interchange Date YYMMDD 6 Element Separator * 1 ISA10 Interchange Time HHMM 4 Element Separator * 1 ISA11 Repetition Separator ^ 1


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Page #


Element Separator * 1 ISA12 Interchange Version Number 00501: Draft Standards for Trial Use

Approved for Publication by ASC X12 Procedures Review Board through October 1997

5

Element Separator * 1

ISA13 Interchange Control Number Assigned by Sender - must be identical to interchange trailer IEA02

9

Element Separator * 1 C.6 ISA14 Acknowledgment Requested 1: Interchange Acknowledgment

Requested 1

Element Separator * 1 ISA15 Interchange Usage Indicator P 1 Element Separator * 1 ISA16 Component Element

Separator :

1

Segment End ~ 1 C.7 GS Functional Group Header GS 2

Element Separator * 1 GS01 Functional Identifier Code HR - Health Care Claim Status

Request 2

Element Separator * 1 GS02 Application Sender's Code Molina assigned Trading Partner ID -

Must be identical to the value in the ISA06

2/15

Element Separator * 1 GS03 Application Receiver's Code ID_MMIS_4MOLINA 2/15 Element Separator * 1 GS04 Date CCYYMMDD 8 Element Separator * 1

C.8 GS05 Time HHMM 4/8 Element Separator * 1 GS06 Group Control Number Assigned by Sender 1/9 Element Separator * 1 GS07 Responsible Agency Code X 1/2 Element Separator * 1 GS08 Version / Release Code 005010X212 1/12 Segment End ~ 1

36 ST Transaction Set Header ST 2 Element Separator * 1 ST01 Transaction Set Identifier

Code 276 - Health Care Claim Status Request

3

Element Separator * 1 ST02 Transaction Set Control

Number Sequential number assigned by sender. Must be identical to SE02

4/9

Element Separator * 1 ST03 Implementation Convention

Reference 05010X212 1/35

Segment End ~ 1 37 BHT Beginning Hierarchical

Transaction Segment BHT 3

Element Separator * 1 BHT01 Hierarchical Structure Code 0010 - Information Source,

Information Receiver, Provider of Service, Subscriber, Dependent

4

Element Separator * 1 BHT02 Transaction Set Purpose

Code 13 - Request 2

Element Separator * 1


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Page #


BHT03 Reference Identification Submitter Transaction Identifier 1/50 Element Separator * 1 BHT04 Date CCYYMMDD

- Transaction Set Creation Date 8

Element Separator * 1 38 BHT05 Time HHMM

- Transaction Set Creation Time 4/8

Segment End ~ 1 39 2000A HL Hierarchical Level Segment HL 2 Element Separator * 1 HL01 Hierarchical ID Number 1 1/12 Element Separator * 1 Element Separator * 1

40 HL03 Hierarchical Level Code 20 - Information Source 1/2 Element Separator * 1 HL04 Hierarchical Child Code 1 - Additional Subordinate HL Data

Segment in this Hierarchical Structure

1

Segment End ~ 1 41 2100A NM1 Individual or Organizational

Name NM1 3

Element Separator * 1 NM101 Entity Identifier Code PR - Payer 2/3 Element Separator * 1 NM102 Entity Type Qualifier 2 - Non-Person Entity 1 Element Separator * 1 NM103 Name Last or Organization ID_MMIS_4MOLINA 1/60

42 Element Separator * 1 Element Separator * 1 Element Separator * 1 Element Separator * 1 Element Separator * 1 NM108 Identification Code Qualifier PI - Payer Identification 1/2 Element Separator * 1 NM109 Identification Code ID_MMIS_4MOLINA 2/80 Segment End ~ 1

43 2000B HL Hierarchical Level Segment HL 2 Element Separator * 1 HL01 Hierarchical ID Number 2 1/12 Element Separator * 1 HL02 Hierarchical Parent ID

Number 1 1/12

Element Separator * 1 44 HL03 Hierarchical Level Code 21 - Information Receiver 1/2 Element Separator * 1 HL04 Hierarchical Child Code 1 - Additional Subordinate HL Data

Segment in this Hierarchical Structure

1

Segment End ~ 1 45 2100B NM1 Individual or Organizational

Name NM1 3

Element Separator * 1 NM101 Entity Identifier Code 41 - Submitter 2/3 Element Separator * 1 NM102 Entity Type Qualifier 1 - Person,

2 - Non-Person 1

Element Separator * 1 46 NM103 Name Last or Organization

Name 1/60


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Page #


46 Element Separator * 1 NM104 Name First 1/35 Element Separator * 1 NM105 Name Middle 1/25 Element Separator * 1 Element Separator * 1 Element Separator * 1 NM108 Identification Code Qualifier 46 - Electronic Transmitter

Identification Number 1/2

Element Separator * 1 NM109 Identification Code NPI or Medicaid Provider Number

(“Atypical” providers will continue to use the Medicaid Provider Number.)

10

Segment End ~ 1 47 2000C HL Hierarchical Level Segment HL 2 Element Separator * 1 HL01 Hierarchical ID Number 3 1/12 Element Separator * 1 HL02 Hierarchical Parent ID

Number 2 1/12

Element Separator * 1 48 HL03 Hierarchical Level Code 19 – Provider of Service 1/2 Element Separator * 1 HL04 Hierarchical Child Code 1 - Additional Subordinate HL Data

Segment in this Hierarchical Structure. Required when there are dependent claims related to this subscriber

1

Segment End ~ 1 50 2100C NM1 Individual or Organizational

Name NM1 3

Element Separator * 1 NM101 Entity Identifier Code 1P - Provider 2/3 Element Separator * 1

50 NM102 Entity Type Qualifier 1 - Person, 2 - Non-Person

1

Element Separator * 1 NM103 Name Last or Organization

Name 1/60

Element Separator * 1 NM104 Name First 1/35 Element Separator * 1 NM105 Name Middle 1/25 Element Separator * 1 Element Separator * 1 NM107 Name Suffix 1/10 Element Separator * 1

51 NM108 Identification Code Qualifier SV - Service Provider Number XX - NPI

1/2

Element Separator * 1 NM109 Identification Code XX - NPI.

SV - “Atypical” providers will continue to use the Medicaid Provider Number.

2/80

Segment End ~ 1 53 2000D HL Hierarchical Level Segment HL 2 Element Separator * 1 HL01 Hierarchical ID Number 4 1/12 Element Separator * 1


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Page #


HL02 Hierarchical Parent ID Number

3 1/12

Element Separator * 1 HL03 Hierarchical Level Code 22 - Subscriber 1/2 Element Separator * 1 HL04 Hierarchical Child Code 0 - No Subordinate HL Segment in

This Hierarchical Structure. Required when there are no dependent claim status requests for this subscriber. 1 - Additional Subordinate HL Data Segment in this Hierarchical Structure. Required when there are dependent claims related to this subscriber

1

Segment End ~ 1 54 2000D DMG Demographic Information DMG 3 Element Separator * 1 DMG01 Date Time Period Format

Qualifier D8 - Date Expressed in Format CCYYMMDD

2/3

Element Separator * 1 55 DMG02 Date Time Period Format: CCYYMMDD - Subscriber

date of birth 1/35

Element Separator * 1 DMG03 Gender Code F - Female,

M - Male,

1

Segment End ~ 1 56 2100D NM1 Individual or Organizational

Name NM1 3

Element Separator * 1 NM101 Entity Identifier Code IL – Insured or Subscriber 2/3 Element Separator * 1 NM102 Entity Type Qualifier 1 - Person 1 Element Separator * 1

57 NM103 Name Last or Organization Name

1/60

Element Separator * 1 NM104 Name First 1/35 Element Separator * 1 NM105 Name Middle 1/25 Element Separator * 1 Element Separator * 1 NM107 Name Suffix 1/10

57 Element Separator * 1 NM108 Identification Code Qualifier MI - Member Identification Number 1/2 Element Separator * 1 NM109 Identification Code Enter the Idaho Medicaid member’s

7 or 10 digit identification number as it appears on their ID card.

7/10

Segment End ~ 1 58 2200D TRN Patient Event Tracking

Number Segment TRN 3

Element Separator * 1 TRN01 Trace Type Code 1 - Current Transaction Trace

Numbers 1/2

Element Separator * 1 TRN02 Reference Identification 1/50 Segment End ~ 1


January 2017 0050101 17

Page #


60 2200D REF Reference Identification REF 3 Element Separator * 1 REF01 Reference Identification

Qualifier BLT - Billing Type 2/3

Element Separator * 1 REF02 Reference Identification 1/30 Segment End ~ 1

63 2200D REF Reference Identification REF 3 Element Separator * 1 REF01 Reference Identification

Qualifier EJ – Patient Account Number 2/3

Element Separator * 1 REF02 Reference Identification 1/30 Segment End ~ 1 2200D AMT Monetary Amount AMT 3 Element Separator * 1

66 AMT01 Amount Qualifier Code T3 - Total Submitted Charges 1/3 66 Element Separator * 1 AMT02 Monetary Amount 1/18 Segment End ~ 1

67 2200D DTP Date or Time or Period DTP 3 Element Separator * 1 DTP01 Date/Time Qualifier 472 - Service 3 Element Separator * 1 DTP02 Date Time Period Format

Qualifier D8 - Date Expressed in Format CCYYMMDD RD8 - Range of Dates Expressed in Format CCYYMMDD - CCYYMMDD

2/3

Element Separator * 1 DTP03 Date Time Period format = <CCYYMMDD> if DTP02 =

D8 format = <CCYYMMDD-CCYYMMDD> if DTP02 = RD8

1/35

Segment End ~ 1 98 TRAILER SE Transaction Set Trailer SE 2 Element Separator * 1 SE01 Number of Included

Segments Count includes the ST and SE segments.

1/10

Element Separator * 1 SE02 Transaction Set Control

Number Must be identical to ST02 4/9

Segment End ~ 1 C.9 GE Functional Group Trailer GE 2

Element Separator * 1 GE01 Number of Transaction Sets

Included 1/6

Element Separator * 1 GE02 Group Control Number Must be identical to GS06 1/9 Segment End ~ 1

C.10 IEA Interchange Control Trailer IEA 3 C.10 Element Separator * 1

IEA01 Number of Included Functional Groups

1/5

Element Separator * 1 IEA02 Interchange Control Number Must be identical to ISA13 9 Segment End ~ 1


January 2017 0050101 18

Figure 10-2: 277 Healthcare Claim Status Response

Page #

Loop ID Reference Name Codes Length Notes/Comments

C.4 HEADER ISA Interchange Control Header

ISA 3

Element Separator

* 1

ISA01 Authorization Information Qualifier

00 - No Authorization Information Present

2

Element Separator

* 1

ISA02 Authorization Information

Space fill 10

Element Separator

* 1

ISA03 Security Information Qualifier

00 - No Security Information Present

2

Element Separator

* 1

ISA04 Security Information

Space fill 10

Element Separator

* 1

ISA05 Interchange ID Qualifier

ZZ 2

Element Separator

* 1

ISA06 Interchange Sender ID

ID_MMIS_4MOLINA 15

Element Separator

* 1

C.5 ISA07 Interchange ID Qualifier

ZZ 2

Element Separator

* 1

ISA08 Interchange Receiver ID

Receiver ID Molina assigned Trading Partner ID Left justify and space fill

15

Element Separator

* 1

ISA09 Interchange Date YYMMDD 6 Element

Separator * 1

ISA10 Interchange Time HHMM 4 Element

Separator * 1

ISA11 Repetition Separator

^ 1

Element Separator

* 1

ISA12 Interchange Version Number

00501 5

Element Separator

* 1

ISA13 Interchange Control Number

Assigned by Sender - must be identical to interchange trailer

9


January 2017 0050101 19

Page #


IEA02 Element

Separator * 1

C.6 ISA14 Acknowledgment Requested

0: No Acknowledgment Requested

1

Element Separator

* 1

ISA15 Interchange Usage Indicator

P 1

Element Separator

* 1

ISA16 Component Element Separator

:

1

Segment End ~ 1 GS Functional Group

Header GS 2

Element Separator

* 1

GS01 Functional Identifier Code

Value: HN 2

Element Separator

* 1

C.7 GS02 Application Sender's Code

ID_MMIS_4MOLINA - Must be identical to the value in the ISA06

2/15

Element Separator

* 1

GS03 Application Receiver's Code

Molina assigned Trading Partner ID

2/15

Element Separator

* 1

GS04 Date CCYYMMDD 8 Element

Separator * 1

C.8 GS05 Time HHMM 4/8 Element

Separator * 1

GS06 Group Control Number

Assigned by Sender 1/9

C.8 Element Separator

* 1

GS07 Responsible Agency Code

X 1/2

Element Separator

* 1

GS08 Version / Release Code

005010X212 1/12

Segment End ~ 1 106 ST Transaction Set

Header ST 2

Element Separator

* 1

ST01 Transaction Set Identifier Code

277 – Health Claim Status Notification

3

Element Separator

* 1

ST02 Transaction Set Control Number

Sequential number assigned by sender. Must be identical to

4/9


January 2017 0050101 20

Page #


SE02 Element

Separator * 1

ST03 Implementation Convention Reference

005010X212 1/35

Segment End ~ 1 107 BHT Beginning

Hierarchical Transaction Segment

BHT 3

Element Separator

* 1

BHT01 Hierarchical Structure Code

0010 - Information Source, Information Receiver, Provider of Service, Subscriber, Dependent

4

Element Separator

* 1

BHT02 Transaction Set Purpose Code

08 - Status 2

Element Separator

* 1

BHT03 Reference identification

Submitter Transaction Identifier Must be identical to the BHT03 value from corresponding 276 transaction

1/30

Element Separator

* 1

BHT04 Date CCYYMMDD - Transaction Set Creation Date

8

108 Element Separator

* 1

BHT05 Time HHMM – Transaction Set Creation Time

4/8

Element Separator

* 1

BHT06 Transaction Type Code

DG – Response 2/2

Segment End ~ 1 109 2000A HL Hierarchical Level

Segment HL 2

Element Separator

* 1

HL01 Hierarchical ID Number

1 1/12

Element Separator

* 1

Element Separator

* 1

110 HL03 Hierarchical Level Code

20 - Information Source 1/2

Element Separator

* 1

HL04 Hierarchical Child Code

1 - Additional Subordinate HL Data Segment in this

1/1


January 2017 0050101 21

Page #


Hierarchical Structure Segment End ~ 1 111 2100A NM1 Individual or

Organizational Name

NM1 3

Element Separator

* 1

NM101 Entity Identifier Code

PR - Payer 2/3

Element Separator

* 1

NM102 Entity Type Qualifier

2 - Non-Person Entity 1

Element Separator

* 1

NM103 Name Last or Organization Name

ID_MMIS_4MOLINA 1/60


* 1

Element Separator

* 1

Element Separator

* 1

Element Separator

* 1


* 1

NM108 Identification Code Qualifier

PI - Payer Identification 1/2

Element Separator

* 1

NM109 Identification Code

ID_MMIS_4MOLINA 2/80

Segment End ~ 1 114 2100A PER Administrative

Communications Contact

PER 3

Element Separator

* 1

PER01 Contact Function Code

IC – Information Contact

2

Element Separator

* 1

PER02 Name 1/60 Element

Separator * 1

PER03 Communication Number Qualifier

ED – EDI Access Number EM – Electronic Mail FX – Facsimile TE – Telephone

2

Element Separator

* 1

PER04 Communication Number

1/256

Element Separator

* 1


ED – EDI Access Number

2


January 2017 0050101 22

Page #


EM – Electronic Mail EX – Telephone Extension FX – Facsimile TE – Telephone

Element Separator

* 1

115 PER06 Communication Number

1/256

Element Separator

* 1


ED – EDI Access Number EM – Electronic Mail EX – Telephone Extension FX – Facsimile TE – Telephone

2


* 1

PER08 Communication Number

1/256

Segment End ~ 1 116 2000B HL Hierarchical Level

Segment HL 2

Element Separator

* 1


2 1/12

Element Separator

* 1


1 1/12

Element Separator

* 1

117 HL03 Hierarchical Level Code

21 - Information Receiver

1/2

Element Separator

* 1


1 - Additional Subordinate HL Data Segment in this Hierarchical Structure

1

Segment End ~ 1 118 2100B NM1 Individual or

Organizational Name

NM1 3

Element Separator

* 1


41 - Submitter 2/3

Element Separator

* 1


1 - Person, 2 - Non-Person

1

Element Separator

* 1


1/60

Element * 1


January 2017 0050101 23

Page #


Separator 119 NM104 Name First 1/35 Element

Separator * 1

NM105 Name Middle 1/25 Element

Separator * 1

Element Separator

* 1

Element Separator

* 1


46 - Electronic Transmitter Identification Number

1/2

Element Separator

* 1


2/80

Segment End ~ 1 120 2200B TRN Trace TRN 3 Element

Separator * 1

TRN01 Trace Type Code 2 – Referenced Transaction Trace Numbers

1/2

Element Separator

* 1

TRN02 Reference Identification

Claim Transaction Batch Number

1/50

Segment End ~ 1 121 2200B STC Status

Information STC 3

Element Separator

* 1

STC01 Health Care Claim Status

STC01-1 Industry Code Health Care Claim Status Category Code

1/30

Element Separator

: 1

STC01-2 Industry Code Status Code 1/30 122 Element

Separator : 1

STC01-3 Entity Identifier Code

41 – Submitter AY – Clearinghouse PR – Payor

2/3

Element Separator

* 1

122 STC02 Date CCYYMMDD format 8 Element

Separator * 1

Element Separator

* 1

Element Separator

* 1

Element Separator

* 1

Element Separator

* 1

Element * 1


January 2017 0050101 24

Page #


Separator Element

Separator * 1

Element Separator

* 1



1/30

Element Separator

: 1

STC10-2 Industry Code Status Code 1/30 Element

Separator : 1


2/3

Element Separator

* 1



1/30

Element Separator

: 1


Separator : 1


2/3

Segment End ~ 1 124 2000C HL Hierarchical Level

Segment HL 2

Element Separator

* 1


3 1/12

Element Separator

* 1

124 HL02 Hierarchical Parent ID Number

2 1/12


* 1

HL03 Hierarchical Level Code

19 – Provider of Service 1/2

Element Separator

* 1


1 - Additional Subordinate HL Data Segment in this Hierarchical Structure. Required when there are dependent claims related to this subscriber

1

Segment End ~ 1 127 2100C NM1 Individual or

Organizational Name

NM1 3

Element Separator

* 1


January 2017 0050101 25

Page #



1P - Provider 2/3

Element Separator

* 1


1 - Person, 2 - Non-Person

1

Element Separator

* 1

NM103 Name Last or Organization Name

1/60

Element Separator

* 1

NM104 Name First 1/35 Element

Separator * 1


Separator * 1

Element Separator

* 1

NM107 Name Suffix 1/10 Element

Separator * 1

128 NM108 Identification Code Qualifier

SV - Service Provider Number XX - NPI

1/2

Element Separator

* 1

128 NM109 Identification Code

XX - NPI. SV - “Atypical” providers will continue to use the Medicaid Provider Number.

2/80

Segment End ~ 1 129 2200C TRN Trace TRN 3 Element

Separator * 1

TRN01 Trace Type Code 1 – Current Transaction Trace Number

1/2

Element Separator

* 1


Provider of Service Information Trace Identifier

1/50

Segment End ~ 1 130 2200C STC Status

Information STC 3

Element Separator

* 1



1/30

Element Separator

: 1

STC01-2 Industry Code Status Code 1/30 131 Element

Separator : 1

STC01-3 Entity Identifier 1P – Provider 2/3


January 2017 0050101 26

Page #


Code Element

Separator * 1

STC02 Date CCYYMMDD format 8 Element

Separator * 1

Element Separator

* 1

Element Separator

* 1

Element Separator

* 1

Element Separator

* 1

Element Separator

* 1

Element Separator

* 1

Element Separator

* 1

131 STC10 Health Care Claim Status


1/30

Element Separator

: 1


Separator : 1

132 STC10-3 Entity Identifier Code

2/3

Element Separator

* 1



1/30

Element Separator

: 1


Separator : 1


2/3

Segment End ~ 1 134 2000D HL Hierarchical Level

Segment HL 2

Element Separator

* 1


4 1/12

Element Separator

* 1


3 1/12

Element Separator

* 1

HL03 Hierarchical Level Code

22 - Subscriber 1/2

Element * 1


January 2017 0050101 27

Page #


Separator HL04 Hierarchical Child

Code 0 - No Subordinate HL Segment in This Hierarchical Structure. Required when there are no dependent claim status requests for this subscriber.

1

Segment End ~ 1 135 2100D NM1 Individual or

Organizational Name

NM1 3

Element Separator

* 1


–IL – Insured or Subscriber

2/3

Element Separator

* 1


1 – Person 1

Element Separator

* 1


1/60

Element Separator

* 1

NM104 Name First 1/35 Element

Separator * 1


Separator * 1

Element Separator

* 1

NM107 Name Suffix 1/10 Element

Separator * 1


MI - Member Identification Number

1/2

Element Separator

* 1


Idaho Medicaid Member ID

7/10

Segment End ~ 1 137 2200D TRN Patient Event

Tracking Number Segment

TRN 3

Element Separator

* 1

TRN01 Trace Type Code 2 1/2 Element

Separator * 1


1/50

Segment End ~ 1 138 2200D STC Reference

Identification STC 3


* 1


January 2017 0050101 28

Page #



STC01-1 Claim Category Code

1/30

Component Element Separator

: 1

STC01-2 Claim Status Code 1/30 Component

Element Separator

: 1


2/3


: 1

144 STC01-4 Code List Qualifier Code

RX – National Council for Prescription Drug Programs Reject/Payment Codes

1/3

Element Separator

* 1

145 STC02 Date Format: CCYYMMDD 8 Element

Separator * 1

Element Separator

* 1

STC04 Total Claim Charge Amount

1/18

Element Separator

* 1

STC05 Claim Payment Amount

1/18

Element Separator

* 1

STC06 Adjudication Finalized Date

Format: CCYYMMDD 8

Element Separator

* 1

Element Separator

* 1

146 STC08 Remittance Date Format: CCYYMMDD 8 Element

Separator * 1

STC09 Check Number 1/16 Element

Separator * 1



* 1

STC10-1 Industry Code 1/30 Component

Element Separator

: 1


Element Separator

: 1

147 STC10-3 Entity Identifier 2/3


January 2017 0050101 29

Page #


Code Component

Element Separator

: 1

STC10-4 Code List Qualifier Code


1/3

Element Separator

* 1


Element Separator

* 1


Element Separator

: 1


Element Separator

: 1


2/3


: 1



1/3

Segment End ~ 1 150 2200D REF Reference

Identification REF 3

Element Separator

* 1

REF01 Reference Identification Qualifier

1K - Payer's Claim Number. This data element corresponds to the value given in the ANSI ASC X12N 837 transaction in CLM01.

2/3


* 1

REF02 Reference Identification

1/30



Element Separator

* 1


BLT - Billing Type 2/3

Element Separator

* 1


1/50




January 2017 0050101 30

Page #


Qualifier Element

Separator * 1


EJ – Patient Control Number

2/3

Element Separator

* 1


1/50

Segment End ~ 1 155 2200D DTP Date or Time or

Period DTP 3

Element Separator

* 1

DTP01 Date/Time Qualifier

472 - Service 3

Element Separator

* 1

DTP02 Date Time Period Format Qualifier

D8 - Range of Dates Expressed in Format CCYYMMDD RD8 - Range of Dates Expressed in Format CCYYMMDD - CCYYMMDD

2/3

Element Separator

* 1

156 DTP03 Date Time Period format = <CCYYMMDD> if DTP02 = D8 format = <CCYYMMDD-CCYYMMDD> if DTP02 = RD8

1/35

Segment End ~ 1 157 2220D SVC Service

Information SVC 3

Element Separator

* 1

SVC01 Composite Medical Procedure Identifier

SVC01-1 Product/Service ID Qualifier

Values: AD, HC, HP, N4, NU, WK

2


: 1

159 SVC01-2 Product/Service ID

1/48


: 1

SVC01-3 Procedure Modifier

2


: 1

SVC01-4 Procedure Modifier

2

Component Element

: 1


January 2017 0050101 31

Page #


Separator SVC01-5 Procedure

Modifier 2


: 1

160 SVC01-6 Procedure Modifier

2

Element Separator

* 1

SVC02 Monetary Amount 1/18 Element

Separator * 1

SVC03 Monetary Amount 1/18 Element

Separator * 1

SVC04 Product/Service ID

1/48

Element Separator

* 1

Element Separator

* 1

Element Separator

* 1

160 SVC07 Quantity 1/15 Segment End ~ 1 161 2220D STC Reference

Identification STC 3

Element Separator

* 1


STC01-1 Industry Code Values: Code Source 507

1/30


: 1


1/30


: 1


Values: 13, 17, 1E, 1G, 1H, 1I, 1O-1Z, 28, 2A, 2B, 2D, 2E, 2I, 2K, 2P, 2Q, 2S, 2Z, 30, 36, 3A, 3C-3Z, 40, 43, 44, 4A-4J, 4L-4Z, 5A-5Z, 61, 6A-6S, 6U-6Y, 71-74, 77, 7C, 80, 82, 84, 85, 87, 95, CK, CZ, D2, DD, DJ, DK, DN, DO, DQ, E1, E2, E7, E9, FA, FD, FE, G0, G3, GB, GD, GI, GJ, GK, GM, GY, HF, HH, I3, IJ, IL, IN, LI, LR, MR, MSC, OB, OD, OX, P0, P2, P3, P4, P6, P7, PRP, PT, PV, PW, QA-QE, QH, QK, QL, QN, QO, QS, QV, QY,

2/3


January 2017 0050101 32

Page #


RC, RW, S4, SJ, SU, T4, TL, TQ, TT, TTP, TU, UH, X3, X4, X5, ZZ


: 1



1/3

Element Separator

* 1

168 STC02 Date Format: CCYYMMDD 8 Element

Separator * 1

Element Separator

* 1

Element Separator

* 1


* 1

Element Separator

* 1

Element Separator

* 1

Element Separator

* 1

Element Separator

* 1



1/30


: 1


1/30


: 1


See STC01-3 2/3


: 1



1/3

Element Separator

* 1


Element Separator

* 1


1/30


: 1


January 2017 0050101 33

Page #



1/30


: 1


See STC01-3 2/3


: 1



1/3



Element Separator

* 1


FJ - Line Item Control Number

2/3

Element Separator

* 1


1/50

Segment End ~ 1 172 2220D DTP Date or Time or

Period DTP 3

Element Separator

* 1

DTP01 Date/Time Qualifier

472 - Service 3

Element Separator

* 1

DTP02 Date Time Period Format Qualifier

D8 - Range of Dates Expressed in Format CCYYMMDD RD8 - Range of Dates Expressed in Format CCYYMMDD - CCYYMMDD

2/3

Element Separator

* 1

DTP03 Date Time Period format = <CCYYMMDD> if DTP02 = D8 format = <CCYYMMDD-CCYYMMDD> if DTP02 = RD8

1/35

Segment End ~ 1 213 TRAILER SE Transaction Set

Trailer SE 2

Element Separator

* 1

SE01 Number of Included Segments

Count includes the ST and SE segments.

1/10

Element Separator

* 1

SE02 Transaction Set Must be identical to 4/9


January 2017 0050101 34

Page #


Control Number ST02 Segment End ~ 1 C.9 GE Functional Group

Trailer GE 2

C.9 Element Separator

* 1

GE01 Number of Transaction Sets Included

1/6

Element Separator

* 1

GE02 Group Control Number

Must be identical to GS06

1/9

Segment End ~ 1 C.10 IEA Interchange

Control Trailer IEA 3

Element Separator

* 1

IEA01 Number of Included Functional Groups

1/5

Element Separator

* 1

IEA02 Interchange Control Number

Must be identical to ISA13

9

Segment End ~ 1


January 2017 0050101 35

11. APPENDICES

Appendix A. Implementation Checklist

The Trading Partner Account (TPA) User Guide under the User Guides link on the Health PAS website, contains information on how to select the correct trading partner entity type and answer some preliminary questions concerning trading partner registration. Appendix B. Frequently Asked Questions

This appendix contains a compilation of questions and answers relative to Molina Healthcare and its providers. Typical questions would involve a discussion about code sets and their effective dates. See https://www.idmedicaid.com/Lists/FAQs/Current.aspx for answers to frequently asked questions.

https://www.idmedicaid.com/User%20Guides/Forms/AllItems.aspx

https://www.idmedicaid.com/User%20Guides/Forms/AllItems.aspx

https://www.idmedicaid.com/Lists/FAQs/Current.aspx

Documents

Vendor Specifications ASC X12N Version 5010 for … Companion Guides/CAQH...State of Idaho MMIS COMPANION GUIDE Vendor Specifications 276/277 Eligibility Benefit Inquiry and Response