MassHealth Health Care Eligibility/Benefit Inquiry and Information Response (270/271) Standard Companion Guide Refers to the Implementation Guides Based on ASC X12N version: 005010X279A1 October 2012 Version 11.0 Disclosure Statement The following Massachusetts Companion Guide is intended to serve as a companion document to the corresponding ASC X12N/005010X279 Health Care Eligibility/Benefit Inquiry and Information Response (270/271), its related Addenda (005010X279A1) and its related Errata (005010X279E1). The document further specifies the requirements to be used when preparing, submitting, receiving and processing electronic health care administrative data. The document supplements, but does not contradict, disagree, oppose, or otherwise modify the 005010X279 in a manner that will make its implementation by users to be out of compliance. Note: Type 1 TR3 Errata are substantive modifications, necessary to correct impediments to implementation, and identified with a letter ‘A’ in the errata document identifier. Type 1 TR3 Errata were formerly known as Implementation Guide Addenda. Type 2 TR3 Errata are typographical modifications, and identified with a letter ‘E’ in the errata document identifier. About MassHealth MassHealth helps the financially needy obtain high-quality health care that is affordable, promotes independence, and provides customer satisfaction. The MassHealth program provides comprehensive health insurance - or help in paying for private health insurance - to more than one million Massachusetts children, families, seniors, and people with disabilities. MassHealth is the second largest health insurer in the state and is nationally recognized for providing high-quality care in an innovative and cost-effective manner. http://www.mass.gov/masshealth. Medicaid Management Information System and Provider Online Service Center The Medicaid Management Information System (MMIS) and the Provider Online Service Center (POSC) offer a web-based environment that automates functions such as member eligibility verification, claim submission and status, claims processing, prior authorization, referrals, preadmission screening, online remittance advices, and reports. Contact for Further Information on this Companion Guide MassHealth Customer Service PO Box 9118 Hingham, MA 02043 Email: edi@mahealth.net Phone: 1-800-841-2900 Fax: 617-988-8971 2012 MassHealth All rights reserved. This document may be copied. Preface This Companion Guide to the 005010 ASC X12N Implementation Guide and associated errata and addenda adopted under HIPAA clarifies and specifies the data content when exchanging electronically with MassHealth. Transmissions based on this companion guide, used in tandem with the 005010 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. Editor’s note: This page intentionally left blank. Table of Contents 1. INTRODUCTION 5 SCOPE 5 OVERVIEW 5 REFERENCES 5 ADDITIONAL INFORMATION 6 2. GETTING STARTED 6 WORKING WITH MASSHEALTH 6 TRADING PARTNER REGISTRATION 6 CERTIFICATION AND TESTING OVERVIEW 6 3. TESTING WITH THE PAYER 6 4. CONNECTIVITY WITH THE PAYER/COMMUNICATIONS 8 SAMPLE PROCESS FLOWS 8 TRANSMISSION ADMINISTRATIVE PROCEDURES 9 RETRANSMISSION PROCEDURE 10 COMMUNICATION PROTOCOL SPECIFICATIONS 10 PASSWORDS 11 5. CONTACT INFORMATION 11 EDI CUSTOMER SERVICE 11 EDI TECHNICAL ASSISTANCE 11 PROVIDER SERVICE NUMBER 11 APPLICABLE WEBSITES/E-MAIL 12 6. CONTROL SEGMENTS/ENVELOPES 13 ISA-IEA 13 270 (Inbound) 14 271 (Outbound) 15 GS-GE 17 270 (Inbound) 17 271 (Outbound) 18 ST-SE 18 270 (Inbound) 18 271 (Outbound) 19 7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 20 8. ACKNOWLEDGEMENTS AND/OR REPORTS 21 REPORT INVENTORY 28 9. TRADING PARTNER AGREEMENTS 28 TRADING PARTNERS 28 10. TRANSACTION SPECIFIC INFORMATION 28 270 (INBOUND) 29 271 (OUTBOUND) 31 APPENDICES 1 A. IMPLEMENTATION CHECKLIST 1 B. BUSINESS SCENARIOS 2 C. TRANSMISSION EXAMPLES 3 D. FREQUENTLY ASKED QUESTIONS 8 E. CHANGE SUMMARY 10 1. Introduction The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires MassHealth, and all other health insurance payers in the United States to comply with the electronic data interchange (EDI) standards for health care as established by the Secretary of Health and Human Services (HHS). The ANSI X12N implementation guides have been established as the standards of compliance for electronic health care transactions. Scope This section specifies the appropriate and recommended use of the Companion Guide. The standard adopted by HHS for electronic health care transactions is ANSI ASC X12N Version 005010 and is effective January 1, 2012. The unique version/release/industry identifier code for the 270/271 Health Care Eligibility/Benefit Inquiry and Information Response transactions is 005010X279A1. This Companion Guide assumes compliance with all loops, segments and data elements contained in the 005010X279A1. This Companion Guide does NOT include any of the required loops, segments or data elements defined in the 005010X279A1 with the exception of those loops, segments or data elements that require further clarification. Overview This section specifies how to use the various sections of the document in combination with each other. MassHealth created this companion guide for MassHealth trading partners to supplement the X12N Implementation Guide. This guide contains MassHealth-specific instructions related to the following: ? Data formats, content, codes, business rules, and characteristics of the electronic transaction; ? Technical requirements and transmission options; and ? Information on testing procedures that each trading partner must complete before transmitting electronic transactions The information in this document supersedes all previous communications from MassHealth about this electronic transaction. The following standards are in addition to those outlined in the MassHealth provider manuals. These standards in no way supersede MassHealth regulations. Use this guide in conjunction with the information found in your MassHealth provider manual. References The implementation guide specifies in detail the required formats for transactions exchanged electronically with an insurance company, health care payer, or government agency. The implementation guide contains requirements for the use of specific segments and specific data elements within those segments and applies to all health care providers and their trading partners. It is critical that your IT staff, or software vendor, review this document in its entirety and follow the stated requirements to exchange HIPAA-compliant files with MassHealth. The Implementation Guides for X12N and all other HIPAA standard transactions are available electronically at http://www.wpc-edi.com/. Additional Information The intended audience for this document is the technical and operational staff responsible for generating, receiving, and reviewing electronic health care transactions. 2. Getting Started Working with MassHealth This section describes how to interact with MassHealth’s EDI Department. MassHealth trading partners should exchange electronic health care transactions with MassHealth via the Provider Online Service Center (POSC) or system-to-system using the Healthcare Transaction Service (HTS) process. After establishing a transmission method, each trading partner must successfully complete testing. Additional information is provided in the next section of this companion guide. After successful completion of testing, production transactions may be exchanged. Trading Partner Registration This section describes how to register as a trading partner with MassHealth. All MassHealth trading partners are required to sign a trading partner agreement (TPA). If you have elected to use a third party to perform electronic transactions on your behalf, you will also be required to complete a trading partner profile (TPP). If you have already completed these forms, you will not be required to complete them again. Please contact MassHealth Customer Service at 1-800-841-2900 or via email at edi@mahealth.net if you have any questions about these forms. Certification and Testing Overview All trading partners will be certified through the completion of trading partner testing. All trading partners that exchange electronic transactions with MassHealth must complete trading partner testing. This includes billing intermediaries and software vendors and applies to submitters using a national provider identifier (NPI), as well as providers that are defined as atypical by MassHealth. Test transactions that are exchanged with MassHealth should include a representative sample of the various types of transactions that you would normally conduct with MassHealth. The size of the file should be between 25-50 transactions. MassHealth will post a status of billing intermediaries and software vendors, and their progress with testing. If a billing intermediary or software vendor submits electronic transactions for you, please check with them on the status of their testing, or view the posting on our Web site. Providers who use a billing intermediary or software vendor will not need to test for those electronic transactions that their entity submits on behalf of that provider. 3. Testing with the Payer Before exchanging production transactions with MassHealth, each trading partner must complete testing. All trading partners who plan to exchange transactions must contact MassHealth Customer Service at 1-800-841-2900 in advance to discuss the testing process, criteria, and schedule. Trading partner testing includes HIPAA compliance testing as well as validating the use of conditional, optional, and mutually defined components of the transaction. We strongly encourage you to submit any electronic files directly to our Web portal in order to avoid any potential delay in processing your claims. By using our Web portal you can get a faster response on the status of your claims (e.g., if they will be paid or denied; if denied, with what error codes), that will allow you to determine the problem and be able to resubmit the claims electronically in a more timely manner. If you are unable to upload an electronic file to our web site due to a technical outage, we allow submitters to submit hard media to MassHealth for claims submission. If you have data on hard media, you must send it on a CD or diskette with the filename prominently displayed on the label, along with the following information. If this information is not clearly listed on the external label, you risk delays in processing your claims or potentially having the hard media returned to you. The external label on the hard media must appear as follows: Header: MassHealth Submission File Name: As determined by the submitter following the appropriate file-naming convention for test or production claims Transaction Type: Professional MassHealth Submitter / Pay-to-Provider number The MassHealth number of the provider or billing intermediary submitting the hard media Submitter Name: The name of the provider or billing intermediary submitting the hard media Submission Date: MM/DD/YY Contact Name: The name of the person to contact if MassHealth has a problem with the hard media Contact Information: Telephone number and/or email address Please note that providers submitting single claims directly to MassHealth, via the POSC, using direct data entry (DDE), are not required to test. You must however, have a valid trading partner agreement on file with MassHealth to submit claims. Before submitting production claims to MassHealth, each trading partner must be tested. Trading partners planning to submit transactions must contact MassHealth Customer Service at 1-800- 841-2900 in advance to discuss the testing process, criteria, and schedule. Trading partner testing includes HIPAA compliance testing as well as validating the use of conditional, optional, and mutually defined components of the transaction. If you are a first-time submitter and want to test electronically with MassHealth, we require the following: ? The test file must have a minimum of 10 and a maximum of 50 test claims. ? The member and provider data must be valid for a mutually agreed upon effective date. The test files should contain as many types of claims as necessary to cover each of your business scenarios. The following conditions must be addressed in one or more test files: ? the ability to perform a 270 inquiry using the 12-digit member identification (ID number); ? the ability to perform an inquiry by the member’s social security number or other agency ID; and ? the ability to perform an inquiry by the member’s last name, first name, date of birth, and gender. Please note that if you supply data for all of the data elements, then MMIS will process the inquiry based on the hierarchy above. If a match is found, the 271 will return member data. If a match is not found, the 271 will return reject code 75, “Subscriber/Insured Not Found.” MMIS will not perform multiple searches based on the data provided in the 270 request. All test files submitted on hard media, regardless of the type of services provided, must be submitted using the following naming convention for all media types: TYYYYYYYYYY.ZZZ, where: T Indicates test data. YYYYYYYYYY Indicates the trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). ZZZ Indicates the sequence number assigned to the file starting with a value of ‘001’. The sequence number should be increased by one for each subsequent file that is submitted. The sequence number will restart at ‘001’ after it reaches ‘999’. Providers are advised to submit the 835 remittance advice and/or the paper explanation of benefits (EOB) from the other insurer to be used in the testing process for verification of data in the COB loops. Providers must indicate which claims on the 835 remittance advice and/or paper EOB correspond to the claims on the test file. MassHealth will process these transactions in a test environment to verify that the file structure and content meet HIPAA standards and MassHealth-specific data requirements. Once this validation is complete, the trading partner may submit production transactions to MassHealth for adjudication. Test claims are adjudicated in the test system, but will not be adjudicated for payment. 4. Connectivity with the Payer/Communications The below illustrations outline the process flows for each of the message exchange scenarios provided by the Healthcare Transaction Services (HTS) submission method. Sample Process Flows Message exchange scenarios: ? synchronous (real-time) messaging; and ? asynchronous (polled-response) messaging. Figure 1: Real-Time Submission HTS/EDI Transaction Flow: Eligibility (270 & 271) Figure 2: Batch 270 Flow Transmission Administrative Procedures System Availability The system is typically available 24X7 with the exception of scheduled maintenance windows. Transmission File Size The current maximum file size for any file submitted to MassHealth is 16 MB. If you have any questions, or would like to coordinate the processing of larger files, please contact MassHealth Customer Service at 1-800-841-2900. Please note that the POSC does not unzip or decompress files. All files must be transmitted in an unzipped or uncompressed format. Transmission Errors When processing an interactive EDI transaction that has Interchange Header errors a TA1 will be generated. If the Interchange Header is valid, but the transaction fails compliance, 999 will be generated. If the Interchange Header has errors so severe and a TA1 or 999 cannot be generated the following error will be generated (e.g. ISA06 - Trading Partner ID is not on file). Production File-naming Convention Files transmitted to MassHealth using the POSC may use any convenient file-naming convention. The system will rename files upon receipt and issue a tracking number for reference. Files transmitted to MassHealth via hard media must adhere to the following naming convention: HYYYYYYYYYY.ZZZ, where: H Indicates a HIPAA-compliant production file. YYYYYYYYYY Indicates the trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). ZZZ Indicates the sequence number assigned to the file starting with a value of ‘001’. The sequence number should be increased by one for each subsequent file that is submitted. The sequence number will restart at ‘001’ after it reaches ‘999’. Retransmission Procedure MassHealth does not require any identification of a previous transmission of a file. All files sent should be marked as original transmissions. Communication Protocol Specifications Provider Online Service Center (POSC) The Provider Online Service Center is a web-based tool accessible via the internet, which gives providers the tools to effectively manage their business with MassHealth electronically. The POSC can be used to enroll as a MassHealth provider, manage a provider’s profile information, enter claims via direct data entry (DDE), submit and retrieve transactions, or upload and download batch transaction files, access reports and receive messages/communications. Healthcare Transaction Services (HTS) MassHealth provides a Healthcare Transaction Service (HTS) submission method which allows trading partners to submit the 270/271 (Eligibility Inquiry and Response) and the 276/277 (Claims Status Inquiry and Response) transactions from their system directly to the MMIS via a fully automated process. This system-to-system EDI web service is supported by a specific MassHealth schema and Web Services Description Language (WSDL) that are outlined in the MassHealth HTS Guide. Once trading partners develop the web service to the guide’s specification they can test the web client application on the MassHealth test servers prior to being approved for production. Interested trading partners must contact MassHealth at 1-800-841-2900 to obtain a copy of the HTS guide. Passwords Providers using the Provider Online Service Center (POSC) to submit their EDI transactions must adhere to MassHealth’s use of passwords. Providers are responsible for managing their own data. Each provider is responsible for managing access to their organization’s data through the MMIS security function. Each provider must take all necessary precautions to ensure that they are safeguarding their information and sharing their data (i.e. granting access) only with users and entities who meet the required privacy standards. It is equally important that providers know who on their staff is linked to other providers or entities, in order to notify those entities whenever they remove access for that person in your organization. For more information regarding passwords and use of passwords, contact the Customer Service Team (CST) at 1-800-841-2900. 5. Contact Information EDI Customer Service (For written correspondence) MassHealth Customer Service PO Box 9118 Hingham, MA 02043 (Use this MassHealth address only for electronic claims.) MassHealth Customer Service 75 Sgt. William B. Terry Dr. Hingham, MA 02043-1545 Email: edi@mahealth.net Phone: 1-800-841-2900 Fax: 617-988-8971 EDI Technical Assistance MassHealth Customer Service PO Box 9118 Hingham, MA 02043 Email: hipaasupport@mahealth.net Phone: 1-800-841-2900 Fax: 617-988-8971 Provider Service Number MassHealth Customer Service PO Box 9118 Hingham, MA 02043 Email: providersupport@mahealth.net Phone: 1-800-841-2900 Fax: 617-988-8971 Applicable Websites/E-mail Accredited Standards Committee (ASC X12) ? ASC X12 develops and maintains standards for inter-industry electronic interchange of business transactions. www.x12.org Accredited Standards Committee (ASC X12N) ? ASC X12N Develops and maintains X12 EDI and XML standards, standards interpretations and guidelines as they relate to all aspects of insurance and insurance-related business processes. www.x12.org American Hospital Association Central Office on ICD-9-CM (AHA) ? This site is a resource for the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, used in medical transcription and billing, and for Level I HCPCS. www.ahacentraloffice.org American Medical Association (AMA) ? This site is a resource for the Current Procedural Terminology 4th Edition codes (CPT-4). The AMA copyrights the CPT codes. www.ama-assn.org Centers for Medicare & Medicaid Services (CMS) ? CMS is the unit within HHS that administers the Medicare and Medicaid programs. CMS provides the Electronic Health-Care Transactions and Code Sets Model Compliance Plan at www.cms.hhs.gov/HIPAAGenInfo/ ? This site is the resource for information related to the Health-Care Common Procedure Coding System (HCPCS). www.cms.hhs.gov/HCPCSReleaseCodeSets/ ? This site is the resource for Medicaid HIPAA information related to the Administrative Simplification provision. www.cms.gov/medicaid/hipaa/adminsim Committee on Operating Rules for Information Exchange (CORE) ? A multi-phase initiative of CAQH, CORE is a committee of more than 100 industry leaders who help create and promulgate a set of voluntary business rules focused on improving physician and hospital access to electronic patient insurance information at or before the time of care. www.caqh.org/CORE_overview.php Council for Affordable Quality Healthcare (CAQH) ? A nonprofit alliance of health plans and trade associations, working to simplify healthcare administration through industry collaboration on public-private initiatives. Through two initiatives -- the Committee on Operating Rules for Information Exchange (CORE) and Universal Provider Datasource (UPD), CAQH aims to reduce administrative burden for providers and health plans. www.caqh.org Designated Standard Maintenance Organizations (DSMO) ? This site is a resource for information about the standard-setting organizations and transaction change request system. www.hipaa-dsmo.org Health Level Seven (HL7) ? HL7 is one of several ANSI-accredited Standards Development Organizations (SDOs), and is responsible for clinical and administrative data standards. www.hl7.org Healthcare Information and Management Systems (HIMSS) ? An organization exclusively focused on providing global leadership for the optimal use of information technology (IT) and management systems for the betterment of health care. www.himss.org MassHealth (MH) ? The MassHealth Web site assists providers with HIPAA billing and policy questions, as well as enrollment support. www.mass.gov/masshealth Medicaid HIPAA Compliant Concept Model (MHCCM) ? This site presents the Medicaid HIPAA Compliance Concept Model, information, and a toolkit. www.mhccm.org National Committee on Vital and Health Statistics (NCVHS) ? The National Committee on Vital and Health Statistics was established by Congress to serve as an advisory body to the Department of Health and Human Services on health data, statistics and national health information policy. www.ncvhs.hhs.gov National Council of Prescription Drug Programs (NCPDP) ? The NCPDP is the standards and codes development organization for pharmacy. www.ncpdp.org National Uniform Billing Committee (NUBC) ? NUBC is affiliated with the American Hospital Association and develops standards for institutional claims. www.nubc.org National Uniform Claim Committee (NUCC) ? NUCC is affiliated with the American Medical Association. It develops and maintains a standardized data set for use by the non-institutional health-care organizations to transmit claims and encounter information. NUCC maintains the national provider taxonomy. www.nucc.org Office for Civil Rights (OCR) ? OCR is the office within the Department of Health and Human Services responsible for enforcing the Privacy Rule under HIPAA. www.hhs.gov/ocr/hipaa United States Department of Health and Human Services (HHS) ? The DHHS Web site is a resource for the Notice of Proposed Rule Making, rules, and other information about HIPAA. www.aspe.hhs.gov/admnsimp Washington Publishing Company (WPC) ? WPC is a resource for HIPAA-required transaction implementation guides and code sets. http://www.wpc-edi.com/ Workgroup for Electronic Data Interchange (WEDI) ? WEDI is a workgroup dedicated to improving health-care through electronic commerce, which includes the Strategic National Implementation Process (SNIP) for complying with the administrative-simplification provisions of HIPAA. www.wedi.org 6. Control Segments/Envelopes ISA-IEA This section describes MassHealth’s use of the interchange control segments. It includes a description of expected sender and receiver codes, authorization information, and delimiters. 270 (Inbound) TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.3 ISA Interchange Control Header C.4 ISA 01 Authorization Information Qualifier 00 C.4 ISA 02 Authorization Information 10 blanks C.4 ISA 03 Security Information Qualifier 00 C.4 ISA 04 Security Information 10 blanks C.4 ISA 05 Interchange ID Qualifier ZZ C.4 ISA 06 Interchange Sender ID Trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). C.5 ISA 07 Interchange ID Qualifier ZZ C.5 ISA 08 Interchange Receiver ID DMA7384 C.5 ISA 09 Interchange Date Format is YYMMDD C.5 ISA 10 Interchange Time Format is HHMM C.5 ISA 11 Repetition Separator The repetition separator is a delimiter and not a data element. It is used to separate repeated occurrences of a simple data element or a composite data structure. This value must be different from the data element separator, component element separator, and the segment terminator. C.5 ISA 12 Interchange Control Version Number 00501 C.5 ISA 13 Interchange Control Number Must be identical to the associated interchange control trailer IEA02. C.6 ISA 14 Acknowledgement Requested 0 = No interchange acknowledgment requested (TA1) 1 = Interchange acknowledgment requested (TA1) C.6 ISA 15 Interchange Usage Indicator P = production data T = test data C.6 ISA 16 Component Element Separator The component element separator is a delimiter and not a data element. It is used to separate component data elements within a composite data structure. This value must be different from the data element separator and the segment terminator. TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.10 IEA Interchange Control Trailer C.10 IEA 01 Number of Included Functional Groups Must equal ‘1’ for the interactive transaction to qualify for immediate response. C.10 IEA 02 Interchange Control Number The control number assigned by the interchange sender. 271 (Outbound) TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.3 ISA Interchange Control Header C.4 ISA 01 Authorization Information Qualifier 00 C.4 ISA 02 Authorization Information 10 blanks C.4 ISA 03 Security Information Qualifier 00 C.4 ISA 04 Security Information 10 blanks C.4 ISA 05 Interchange ID Qualifier ZZ C.4 ISA 06 Interchange Sender ID DMA7384 C.5 ISA 07 Interchange ID Qualifier ZZ C.5 ISA 08 Interchange Receiver ID Trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). C.5 ISA 09 Interchange Date Format is YYMMDD C.5 ISA 10 Interchange Time Format is HHMM C.5 ISA 11 Repetition Separator Value = ^ C.5 ISA 12 Interchange Control Version Number Value = 00501 C.5 ISA 13 Interchange Control Number Identical to the associated interchange control trailer IEA02. C.6 ISA 14 Acknowledgement Requested 0 = No interchange acknowledgment requested (TA1) C.6 ISA 15 Interchange Usage Indicator P = production data T = test data C.6 ISA 16 Component Element Separator Value = : TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.10 IEA Interchange Control Trailer C.10 IEA 01 Number of Included Functional Groups The number of functional groups included in an interchange. C.10 IEA 02 Interchange Control Number The control number assigned by the interchange sender. GS-GE This section describes MassHealth’s use of the functional group control segments. It includes a description of expected application sender and receiver codes. Also included in this section is a description concerning how MassHealth expects functional groups to be sent and how MassHealth will send functional groups. These discussions will describe how similar transaction sets will be packaged and MassHealth’s use of functional group control numbers. 270 (Inbound) TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.7 GS Functional Group Header C.7 GS 01 Functional Identifier Code HS C.7 GS 02 Application Sender’s Code Trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). C.7 GS 03 Application Receiver’s code DMA7384 C.7 GS 04 Date Format is CCYYMMDD C.8 GS 05 Time Format is HHMM C.8 GS 06 Group Control Number Must be identical to the associated functional group trailer GE02. C.8 GS 07 Responsible Agency Code X C.8 GS 08 Version/Release/Industry Identifier Code 005010X279A1 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.9 GE Functional Group Trailer C.9 GE 01 Number of Transaction Sets Included Must equal ‘1’ for the interactive transaction to qualify for immediate response. C.9 GE 02 Group Control Number Must be identical to the associated functional group header GS06. 271 (Outbound) TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.7 GS Functional Group Header C.7 GS 01 Functional Identifier Code HB C.7 GS 02 Application Sender’s Code DMA7384 C.7 GS 03 Application Receiver’s code Trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). C.7 GS 04 Date Format is CCYYMMDD C.8 GS 05 Time Format is HHMM C.8 GS 06 Group Control Number Identical to the associated functional group trailer GE02. C.8 GS 07 Responsible Agency Code X C.8 GS 08 Version/Release/Industry Identifier Code 005010X279A1 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.9 GE Functional Group Trailer C.9 GE 01 Number of Transaction Sets Included Total number of transaction sets included in the functional group. C.9 GE 02 Group Control Number Identical to the associated functional group header GS06. ST-SE This section describes MassHealth’s use of transaction set control numbers. 270 (Inbound) TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 67 ST Transaction Set Header 67 ST 01 Transaction Set Identifier Code 270 67 ST 02 Transaction Set Control Number Must be identical to the associated transaction set trailer SE02. 67 ST 03 Implementation Convention Reference 005010X279A1 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 488 SE Transaction Set Trailer 488 SE 01 Number of Included Segments Total number of segments included in a transaction set including ST and SE segments. 488 SE 02 Transaction Set Control Number Must be identical to the associated transaction set header ST02. 271 (Outbound) TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 67 ST Transaction Set Header 67 ST 01 Transaction Set Identifier Code 271 67 ST 02 Transaction Set Control Number Identical to the associated transaction set trailer SE02. 67 ST 03 Implementation Convention Reference 005010X212 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 488 SE Transaction Set Trailer 488 SE 01 Number of Included Segments Total number of segments included in a transaction set including ST and SE segments. 488 SE 02 Transaction Set Control Number Identical to the associated transaction set header ST02. 7. Payer Specific Business Rules and Limitations This section describes MassHealth’s business rules, for example: ? Billing for specific services such as DME, Ambulance, Home Health ? Communicating payer specific edits ? CORE Level of Certification Before submitting electronic claims to MassHealth, please review the appropriate HIPAA implementation guide and MassHealth companion guide. In addition, MassHealth recommends that you review the MassHealth billing guides. The CMS-1500 and UB-04 billing guides provide additional billing instructions for specific provider types. These guides are located on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, and then click on Provider Library. The following sections outline recommendations, instructions, and conditional data requirements for claims submitted to MassHealth. This information is designed to help trading partners construct transactions in a manner that will allow MassHealth to efficiently process claims. Additional Information for Member Name The member name segment accepts and returns 60 characters for the last name and 35 characters for the first name as required in the implementation guide. However, if a value is submitted on a transaction that is greater than what is stored in the MassHealth member database, on the return transaction the following would occur. ? If a match is found on the database, the value stored on the database table is returned. ? If no match is found on the database, the value stored on the original incoming transaction will be returned. Example: A provider submits an eligibility verification check (270) with a last name that is 22 characters long, but the database currently stores only 20 of those characters. On the return transaction (271), the provider will receive only the first 20 characters of the last name submitted, if a match is found on the database. If for some reason, the member name submitted is not a MassHealth member, and is not stored on the database (no match found), on the return transaction (271) the last, first, and middle names would be returned exactly as they were originally submitted. The following scenarios must be addressed in one or more test files: ? inquiry by 12-digit member identification (ID number); ? inquiry by member’s social security number or other agency ID; and ? inquiry by last name, first name, middle initial, date of birth, and gender. MassHealth requires testing of the 270 transaction prior to accepting production 270 inquiries. Inquiries will be processed in a test environment to validate that the file structure and content meet HIPAA standards, and MassHealth-specific data requirements. Once this validation is complete, the trading partner may submit production 270 inquiries to MassHealth for eligibility responses. Name Normalization (CORE Standard) In an effort to further simplify the eligibility inquiry and response transaction, and reduce the number of non-matches, MassHealth, in collaboration with the Healthcare Administrative Simplification Collaborative, which consists of a number of health plans across the state of Massachusetts, has adopted the Name Normalization standard developed by the Council for Affordable Quality Healthcare (CAQH). More specifically, MassHealth has adopted the CORE 258: Phase II Normalizing Patient Last Name Rule, where CORE stands for Committee on Operating Rules for Exchange. This applies to the HIPAA adopted X12N 270/271 eligibility inquiry and response transactions and specifies the requirements for a CORE-certified health plan (or information source), to normalize a person’s last name during any name validation or matching process by the health plan (or information source). This CORE rule applies only to certain characters in a person’s last name including: ? punctuation values; ? uppercase letters; ? special characters; and ? name suffixes and prefixes. MassHealth applies these normalization rules to both the patient’s first name and last name. For additional information on CORE 258, refer to http://www.caqh.org/pdf/CLEAN5010/258- v5010.pdf. Please Note: The delimiters that may be used in the Patient Last Name according to the CORE standard are limited to space, comma, and forward slash. Any other non-alphabetic delimiter will be viewed as a special character. Valid examples include: ? SMITH SR ? SMITH, SR ? SMITH/SR 8. Acknowledgements and/or Reports Confirmation numbers are generated for all transaction files uploaded to the POSC, indicating successful file uploads. A TA1 interchange acknowledgment is generated for all batch files with ISA14 set to “1 - Interchange acknowledgment requested (TA1).” A 999 implementation acknowledgement is generated for all batch files that do not fail and includes interchange (ISA) errors. These acknowledgements will be available for download from the POSC. The TA1 Interchange Acknowledgement The TA1 allows the receiver of a file to notify the sender that a valid interchange control structure was received or that problems were encountered. The TA1 verifies only the interchange header (ISA/GS) and trailer (ISE/GE) segments of the file envelope. If the submitted file has an ISA14 value of “1” and contains ISA or GS errors then the generated TA1 report with the Interchange Header errors will be placed on the POSC or HTS for pickup. If the submitted file contains an ISA14 value of “1” and there are no ISA or GS errors detected, then the TA1 will indicate “no errors.” What to look for in the TA1 The TA1 segment indicates whether or not the submitted interchange control structure passed the HIPAA compliance check. If TA104 is “A” then the entire interchange control structure was accepted. The file will then proceed to be checked for compliance. If TA104 is “R” then the transmitted interchange control structure header and trailer were rejected because of errors. The submitter will need to correct the errors and resubmit the corrected file to MassHealth. Example: TA1*900000001*090721*1700*R*006~ The data elements in the TA1 segment are defined as follows: TA101 contains the Interchange Control Number (ISA13) from the file to which this TA1 is responding (“900000001” in the example above). TA102 contains the Interchange Date (“090721” in the example above). TA103 contains the Interchange Time (“1700” in the example above). TA104 code indicates the status of the interchange control structure (“R” in the example above). The definitions of the codes are as follows. “A” - The transmitted interchange control structure header and trailer have been received and have no errors. “R” - The transmitted interchange control structure header and trailer are rejected because of errors. TA105 code indicates the error found while processing the interchange control structure (“006” in the example above). The definitions of the codes are as follows. Code Description 000 No error 001 The Interchange Control Number in the Header and Trailer do not match. The value from the Header is used in the Acknowledgement. 002 This standard as noted in the Control Standards Identifier is not supported. 003 This version of the Controls is not supported. 004 The segment Terminator is invalid. 005 Invalid Interchange ID Qualifier for sender 006 Invalid Interchange Sender ID 007 Invalid Interchange ID Qualifier for receiver 008 Invalid Interchange Receiver ID 009 Unknown Interchange Receiver ID 010 Invalid Authorization Information Qualifier value 011 Invalid Authorization Information value 012 Invalid Security Information Qualifier value 013 Invalid Security Information value 014 Invalid Interchange Date value 015 Invalid Interchange Time value 016 Invalid Interchange Standards Identifier value 017 Invalid Interchange Version ID value 018 Invalid Interchange Control Number value 019 Invalid Acknowledgment Requested value 020 Invalid Test Indicator value 021 Invalid Number of Included Groups value 022 Invalid Control Structure 023 Improper (Premature) End-of-File (Transmission) 024 Invalid Interchange Content (e.g., Invalid GS Segment) 025 Duplicate Interchange Control Number 026 Invalid Data Element Separator 027 Invalid Component Element Separator 028 Invalid Delivery Date in Deferred Delivery Request 029 Invalid Delivery Time in Deferred Delivery Request 030 Invalid Delivery Time Code in Deferred Delivery Request 031 Invalid Grade of Service Code The TA1 segment will be sent within its own interchange (i.e., ISA-TA1-IEA) Example of a TA1 within its own interchange ISA*00* *00* *ZZ*DMA7384 *ZZ*receiver *110721*1701*^*00501*000000001*0*P*~ TA1*900000001*110720*1245*R*006~ IEA*0*000000001~ For additional information, consult the Interchange Control Structures, X12.5 Guide. Implementation guides may be obtained by logging on to http://www.wpc-edi.com/ and following the links to ‘EDI Publications’ and ‘5010 Technical Reports.’ The 999 Implementation Acknowledgement Each time a 5010 X12 file is submitted to MassHealth, a system-generated 999 acknowledgement is sent to the submitter within one business day. A 999 does not guarantee processing of the transaction. It only signifies that MassHealth received the Functional Group. The following sections explain how to read the 999 to find out whether a file is accepted or rejected. If a Functional Group is accepted, no action is required by the submitter. If the Functional Group is rejected, the submitter must correct the errors and submit the corrected file to MassHealth. What to look for in the 999 Locate every AK9 segment. These segments indicate whether or not the submitted Functional Group passed the HIPAA compliance check. If each AK9 segment appears as AK9*A, this means the entire Functional Group was accepted for processing. The transaction will process. If any AK9 segment begins with AK9*R (Rejected), or AK9*P (Partially Accepted - At least one transaction set was rejected), you should review the IK5 segments for any and all IK5*R values. This segment displays which transaction set or sets have been rejected. An Example of the 999 Acknowledgement ST*999*0001*005010X231~ AK1*HC*6454*005010X231~ AK2*837*0001~ IK5*A~ AK2*837*0002~ IK3*CLM*22**8~ CTX*CLM01:123456789~ IK4*2*782*1~ IK5*R*5~ AK9*P*2*2*1~ SE*8*0001~ AK1: This segment refers to the (GS) group set level of the original file sent to MassHealth. AK101 is equal to GS01 from the original file (e.g., the AK101 of an 837 Claims file would be “HC”; the AK101 of a 270 Eligibility Inquiry file would be “HS”). AK102 is equal to GS06 from the original file (Group Control Number). AK103 is equal to GS08 from the original file (EDI Implementation Version). AK2: This segment refers to the (ST) Transaction set level of the original file sent to MassHealth. AK201 is equal to ST01 from the original file (e.g., the AK201 of an 837 Claims file would be “837”; the AK201 for a 270 Eligibility Inquiry file would be “270”). AK202 is equal to ST02 from the original file (Transaction Set Control Number). AK203 is equal to ST03 from the original file (EDI Implementation Version). IK3: This segment reports errors in a data segment. Example: IK3*CLM*22**8~ IK301 contains the segment name that has the error. In the example above, the segment name is “CLM.” IK302 contains the numerical count position of this data segment from the start of the transaction set (a “line count”). The erroneous “CLM” segment in the example above is the 22nd segment line in the Transaction Set. Transaction Sets start with the “ST” segment. Therefore, the erroneous segment in the example is the 24th line from the beginning of the file because the first two segments in the file, ISA and GS, are not part of the transaction set. IK303 may contain the loop ID where the error occurred. IK304 contains the error code and it states the specific error. In the example above, the code ‘8’ states ‘Segment Has Data Element Errors.'” Code Description 1 Unrecognized segment ID 2 Unexpected segment 3 Required segment missing 4 Loop occurs over maximum times 5 Segment Exceeds Maximum Use 6 Segment not in defined transaction set 7 Segment not in proper sequence 8 Segment has data element errors I4 Implementation “Not Used” segment present I6 Implementation Dependent segment missing I7 Implementation loop occurs under minimum times I8 Implementation segment below minimum use I9 Implementation Dependent “Not Used” segment present CTX: This segment describes the Context/Business Unit. The CTX segment is used to identify the data that triggered the situational requirement in the IK3. Example: IK3*CLM*22**8~ CTX*CLM01:123456789~ IK4: This segment reports errors in a data element. Example: IK4*2*782*1~ IK401 contains the data element position in the segment that is in error. “2” in the example above represents the second data element in the segment. IK402 contains the data element reference number as found in the appropriate implementation guide. “782” in the example above represents the CLM02 data element from the 837P. IK403 contains the error code and states the specific error. “1” in the example above represents “Required Data Element Missing.” Code Description 1 Required data element missing 2 Conditional required data element missing 3 Too many data elements 4 Data element too short 5 Data element too long 6 Invalid character in data element 7 Invalid code value 8 Invalid date 9 Invalid time 10 Exclusion condition violated 12 Too many repetitions 13 Too many components I10 Implementation “Not Used” data element present I11 Implementation too few repetitions I12 Implementation pattern match failure I13 Implementation Dependent “Not Used” element present I6 Code value not used in implementation I9 Implementation dependent data element missing IK404 may contain a copy of the bad data element. IK5: This segment reports errors in a transaction set. Example: IK5*R*5~ IK501 indicates whether the transaction set is: A = Accepted R = Rejected Other codes such as M, W, or X are for security decryption purposes but are rarely used. “R” in the example above means the transaction set was rejected due to errors. IK502 indicates the implementation transaction set syntax error. “5” in the example above indicates “One or More Segments in Error.” Below is a sample of IK502 error codes. Please refer to the 999 Implementation Guide for a complete list of these error codes. Code Description 1 Transaction Set not supported 2 Transaction Set trailer missing 3 Transaction Set Control Number in Header/Trailer do not match 5 One or more segments in error AK9: This segment reports the functional group compliance status. Example: AK9*P*2*2*1~ AK901: indicates whether the entire functional group is: A = Accepted P = Partially Accepted, at least one transaction set was rejected. The rejected transaction set within the functional group needs to be corrected and resubmitted. R =Rejected, the functional group was rejected and was NOT forwarded for further processing. The file will need to be corrected and resubmitted. Other codes such as M, W, or X are for security decryption purposes but are rarely used. “P” in the example above means the functional group was partially accepted and at least one transaction set was rejected. AK902: contains the total number of transaction sets. In the example above, two transaction sets were submitted. AK903: contains the number of received transaction sets. In the example above, two transaction sets were received. AK904: contains the number of accepted transaction sets in a Functional Group. In the example above, one transaction set was accepted. AK905: contains the Functional Group Syntax Error Code. Below is a sample of AK905 error codes 1. Please refer to the 999 Implementation Guide for a complete list of error codes. Code Description 1 Functional group not supported 2 Functional group version not supported 3 Functional group trailer missing 4 Group Control Number in the functional group Header and Trailer do not agree 5 Number of included transaction sets does not match actual count 6 Group Control Number violates syntax 17 Incorrect message length (Encryption only) 18 Message authentication code failed 19 Functional Group Control Number not unique within interchange 1 Security-related error codes are not included. For additional information, consult the Implementation Acknowledgment for Health Care Insurance (999) Guide. Implementation guides may be obtained by logging onto www.wpc- edi.com and following the links to “HIPAA” and “HIPAA Guides.” Report Inventory There are no acknowledgement reports at this time. 9. Trading Partner Agreements Providers who intend to conduct electronic transactions with MassHealth must sign the MassHealth Trading Partner Agreements. A copy of the agreement is available at www.mass.gov or contact the Customer Service Team (CST) at 1-800-841-2900. Trading Partners An Electronic Data Interchange (EDI) Trading Partner is defined as any entity (provider, billing service, software vendor, employer group, financial institution, etc.) that conducts electronic transactions with MassHealth. The Trading Partner and MassHealth acknowledge and agree that the privacy and security of data held by or exchanged between them is of utmost priority. Each party agrees to take all steps reasonably necessary to ensure that all electronic transactions between them conform to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and regulations promulgated there under. Payers have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. 10. Transaction Specific Information 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 MassHealth 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 MassHealth In addition to the row for each segment, one or more additional rows are used to describe MassHealth’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. 270 (Inbound) TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 64 BHT 03 Required when the transaction is used in real time. In 270, may be provided at the sender’s discretion. In 271 real-time value received on 270 will be returned on the 271. 91 2000C TRN 02 Reference Identification A maximum of 50 characters received on the 270 will be returned on the 271. 91 2000C TRN 03 Originating Company Identifier A maximum of 10 characters received on the 270 will be returned on the 271. Per 271: note that the first position must be either a “1” if an EIN is used, a “3” if a DUNS is used, or a “9” if a user-assigned identifier is used. 91 2000C TRN 04 Reference Identification A maximum of 50 characters received on the 270 will be returned on the 271. 69 2100A NM1 01 Entity Identifier Code PR Value is PR. 70 2100A NM1 02 Entity Type Qualifier 2 Value is 2. 70 2100A NM1 03 Information Source Name MassHealth 71 2100A NM1 08 Information Source Identification Qualifier 46 46 - electronic transmitter identification number 71 2100A NM1 09 Information Source Identifier DMA7384 123 2100C DTP 01 Date/Time Qualifier 291 Value is 291 – Plan. 123 2100C DTP 02 Date Format D8, RD8 Value is RD8 or D8. 123 2100C DTP 03 Date Time Period To date of service and/or from date of service (270/271) 98 2100C REF 01 Reference Identification Qualifier EJ If EJ is submitted on the 270 request, the 271 response will contain EJ, along with the REF02 value from the 270 request. 99 2100C REF 02 Reference Identification Patient account number or other value is returned on the 271 based on the value in 270. MassHealth supports multiple search criteria for an eligibility inquiry. An inquiry may be submitted using MassHealth member ID, social security number, or last name, first name, date of birth, and gender. The criteria for these options are listed below: Inquiry by Member ID TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 95 2100C NM1 08 Identification Code Qualifier NM108 will be MI if member is found. If member is not found echo back 2100C: NM108 from 270. 96 2100C NM1 09 Identification Code 12-digit MassHealth member ID; however, invalid member ID also will be echoed back from the 270. Inquiry by Social Security Number or Other Agency ID TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 98 2100C REF 01 Identification Code Qualifier SY, NQ Value is SY if SSN is provided, and NQ- for other agency ID. 99 2100C REF 02 Identification Code If REF01 is “SY,” then it is SSN. If REF01 is “NQ,” it is other agency ID (Note agency ID = X- member ID) Inquiry by Last Name, First Name, Date of Birth, and Gender TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 93 2100C NM1 03 Last Name or Organization Name A maximum of 20 characters will be used for the search. 93 2100C NM1 04 Name First A maximum of 15 characters will be used for the search. 94 2100C NM1 05 Name Middle Not used for the search 94 2100C NM1 07 Name Suffix Not used for the search 108 2100C DMG 01 Date Time Period Format Qualifier D8 D8 108 2100C DMG 02 Date Time Period If not found, the values provided for these fields in the 270 will be returned in the 271. 109 2100C DMG 03 Gender Code If not found, the values provided for these fields in the 270 will be returned in the 271. 271 (Outbound) TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 215 2000A AAA 01 Response Code N AAA01 will be N. 216 2000A AAA 03 Reject Reason Code 42 Possible value – 42 216 2000A AAA 04 Follow-up Action Code P Value is P. 226 2100A AAA 01 Response Code N AAA01 will be N. 227 2100A AAA 03 Reject Reason Code 42 Possible value – 42 228 2100A AAA 04 Follow-up Action Code P Value is P. 238 2100B AAA 01 Response Code N AAA01 will be N. 239 2100B AAA 03 Reject Reason Code 51 Possible value – 51 239 2100B AAA 04 Follow-up Action Code C Value is C. 247 2000C TRN 01 Trace Type Code – echo trace number sent in 270 Value 2 is returned if 270 submit is TRN. 247 2000C TRN 01 Trace Type Code – MMIS assigned trace number Value 1 is returned by MassHealth as the type code preceding the verification number. 248 2000C TRN 02 Reference Identification Value submitted on 270 is returned with a maximum of 50 characters. MassHealth returns a verification number with a maximum length of 13 characters when TRN01=1. 248 2000C TRN 03 Originating Company Identifier Value submitted on 270 is returned with a maximum of 10 characters. MassHealth returns the value of 1046002284 when TRN01=1. 250 2100C NM1 03 Last Name or Organization Name A maximum of 20 characters will be used for the search. If not found, the values submitted on the 270 (maximum of 60 characters) will be returned on the 271. 250 2100C NM1 04 Name First A maximum of 15 characters will be used for the search. If not found, the values submitted on the 270 (maximum of 35 characters) will be returned on the 271. 250 2100C NM1 05 Name Middle A maximum of one character will be returned if the member is found. If not found, the values submitted on the 270 (maximum of 25 characters) will be returned on the 271. 269 2100C DMG 01 Date Time Period Format Qualifier D8 D8 269 2100C DMG 02 Date Time Period If member found, MassHealth date of birth is returned. Otherwise, the values provided in the 270 will be returned in the 271 when submitted. 269 2100C DMG 03 Gender Code If member found, MassHealth gender code is returned. Otherwise, the values provided in the 270 will be returned in the 271 when submitted. 254 2100C REF 01 Reference Identification Qualifier 3H Qualifier 3H is associated with local office number for MassHealth. 256 2100C REF 02 Reference Identification The three-digit local office code is returned. 262 2100C AAA 01 Response Code N AAA01 will be N. 263 2100C AAA 03 Reject Reason Code 42, 52, 57, 58, 62, 63, 72, 73, 75, 76 Possible values = 42, 52, 57, 58, 62, 63, 72, 73, 75, 76 264 2100C AAA 04 Follow-up Action Code C Value is C. 283 2100C DTP 01 Date/Time Qualifier 291 Value is 291 – Plan. 284 2100C DTP 02 Date Format RD8 Value is RD8. 293 2110C EB 03 Service Type Code 30 Value is 30. Note: Plan dates represent coverage dates in the plan or program that is being represented in the response. This date does not have to represent the historical beginning of eligibility for the plan, only the most recent plan date(s). For example, Medicaid may report plan dates only in one-month periods of time Eligibility Status TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 291 2110C EB 01 Eligibility or Benefit Information 1, 6 Value is 1 – active. Value is 6 – inactive. 292 2110C EB 02 Coverage Level Code IND Value is IND. 293 2110C EB 03 Service Type Code 30 Value is 30. Note: Plan dates represent coverage dates in the plan or program that is being represented in the response. This date does not have to represent the historical beginning of eligibility for the plan, only the most recent plan date(s). For example, Medicaid may report plan dates only in one-month periods of time. 299 2110C EB 05 Plan Coverage Description If EB01 = 1, member’s eligibility plan is displayed. Eligibility plan is displayed. If EB01 = 6, “Member is not eligible” is displayed. 317 2110C DTP 01 Date/Time Qualifier 291, 307, 346 Value is 291 – Plan. Value is 307 – Eligibility. Value is 346 - Plan begins. 318 2110C DTP 02 Date Format RD8 Value is RD8. 319 2110C DTP 03 Date Time Period Period of eligibility associated with information is returned in the related EB segment. Other Insurance TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 291 2110C EB 01 Eligibility or Benefit Information R Values Other insurance plans – R 293 2110C EB 03 Service Type Code 30 Value is 30. Note: Plan dates represent coverage dates in the plan or program that is being represented in the response. This date does not have to represent the historical beginning of eligibility for the plan, only the most recent plan date(s). For example, Medicaid may report plan dates only in one-month periods of time. 299 2110C EB 05 Plan Coverage Description Name of other insurance plan is listed here (maximum of 50 characters) 315 2110C REF 01 Reference Identification Qualifier IG, 18, 6P, 1L Value is IG, 18, 6P, or 1L. 316 2110C REF 02 Reference Identification If REF01 = IG, other insurance policy number, maximum of 16 characters are sent back. If REF01 = 18, plan number, maximum of 16 characters are sent back. IF REF01 = 6P, group number, maximum of 16 characters are sent back. If REF01 = 1L, other insurance policyholder name, maximum of 16 characters are sent back. 317 2110C DTP 01 Date/Time Qualifier 290 Value is 290 – coordination of benefits. 318 2110C DTP 02 Date Format RD8 Value is RD8. 319 2110C DTP 03 Date Time Period Begin and end date returned in CCYYMMDD format. 323 2110C MSG 01 Free – Form Message Text Restrictive message(s) may be returned in this field if applicable. 328 LS 01 Loop Identifier Code Value is 2120. 330 2120C NM1 01 Entity Identifier Code PRP Value is PRP. 331 2120C NM1 02 Entity Type Qualifier 2 Value is 2. 331 2120C NM1 03 Name Last or Organization Name Other insurance name 332 2120C NM1 08 Identification Code Qualifier PI Value is PI. 333 2120C NM1 09 Identification Code Seven-digit other insurance carrier code 334 2120C NM1 10 Entity Relationship Code Not provided by MassHealth 335 2120C N3 01 Address Information Other insurance address 1 335 2120C N3 02 Address Information Other insurance address 2 336 2120C N4 01 City Name Other insurance city name 337 2120C N4 02 State or Province Code Other insurance state or province code 337 2120C N4 03 Postal Code Other insurance postal code 340 2120C PER 01 Contact Function Code IC Value is IC. 341 2120C PER 03 Communication Number Qualifier TE Value is TE. 341 2120C PER 04 Communication Number Other insurance phone number 346 LE 01 Loop Identifier Code Value is 2120. Long-Term Care TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 291 2110C EB 01 Eligibility or Benefit Information X Value is X – long-term plan. 293 2110C EB 03 Service Type Code 30 Value is 30. Note: Plan dates represent coverage dates in the plan or program that is being represented in the response. This date does not have to represent the historical beginning of eligibility for the plan, only the most recent plan date(s). For example, Medicaid may report plan dates only in one-month periods of time. 299 2110C EB 05 Plan Coverage Description Long-term-care, MMC(1 character, Management Minute Category) followed by a dash, followed by Management Minute Questionnaire (MMQ) score (five characters including a decimal) 317 2110C DTP 01 Date/Time Qualifier 292, 435, 193, 194 Value is 292 – long-term- care begin and end dates. Value is 435 – long-term- care admit date. Value is 193 – case mix begin date. Value is 194 – case mix end date. 318 2110C DTP 02 Date Format D8, RD8 If DTP01 = 292, value is RD8; otherwise value is D8 319 2110C DTP 03 Date Time Period If DTP01 = 292, both begin and end dates returned; otherwise a single date value is returned. 323 2110C MSG 01 Free – Form Message Text Restrictive message(s) may be returned in this field if applicable. 328 LS 01 Loop Identifier Code Value is 2120. 330 2120C NM1 01 Entity Identifier Code FA Value is FA. 331 2120C NM1 02 Entity Type Qualifier 2 Value is 2. 331 2120C NM1 03 Name Last or Organization Name Long-term-care facility name 332 2120C NM1 08 Identification Code Qualifier XX Value is XX. 333 2120C NM1 09 Identification Code Long-term-care facility NPI 334 2120C NM1 10 Entity Relationship Code Not provided by MassHealth 335 2120C N3 01 Address Information Long-term-care facility address 1 335 2120C N3 02 Address Information Long-term-care facility address 2 336 2120C N4 01 City Name Long-term-care facility city name 337 2120C N4 02 State Long-term-care facility state 337 2120C N4 03 Postal Code Long-term-care postal code 340 2120C PER 01 Contact Function Code IC Value is IC. 341 2120C PER 03 Communication Number Qualifier TE Value is TE. 341 2120C PER 04 Communication Number Long-term-care phone number 346 LE 01 Loop Identifier Code Value is 2120. Spend Down TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 291 2110C EB 01 Eligibility or Benefit Information Value is Y-spend down. 293 2110C EB 03 Service Type Code 30 Value is 30. Note: Plan dates represent coverage dates in the plan or program that is being represented in the response. This date does not have to represent the historical beginning of eligibility for the plan, only the most recent plan date(s). For example, Medicaid may report plan dates only in one-month periods of time. 299 2110C EB 05 Plan Coverage Description Blank if EB01 = Y 300 2110C EB 07 Monetary Amount Spend-down amount 323 2110C MSG 01 Free – Form Message Text Restrictive message(s) may be returned in this field if applicable. Patient Paid Amount TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 291 2110C EB 01 Eligibility or Benefit Information Value is G-patient paid amount. 292 2110C EB 02 Coverage Level Code IND Value is IND. 293 2110C EB 03 Service Type Code 30 Value is 30. Note: Plan dates represent coverage dates in the plan or program that is being represented in the response. This date does not have to represent the historical beginning of eligibility for the plan, only the most recent plan date(s). For example, Medicaid may report plan dates only in one-month periods of time. 299 2110C EB 05 Plan Coverage Description Possible values are nursing facility, PACE, SCO, rest home. 300 2110C EB 07 Monetary Amount Patient-paid amount Deductible TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 291 2110C EB 01 Eligibility or Benefit Information C Value is C – deductible. 292 2110C EB 02 Coverage Level Code IND Value is IND. 293 2110C EB 03 Service Type Code 30 Value is 30. Note: Plan dates represent coverage dates in the plan or program that is being represented in the response. This date does not have to represent the historical beginning of eligibility for the plan, only the most recent plan date(s). For example, Medicaid may report plan dates only in one-month periods of time. 300 2110C EB 07 Monetary Amount Deductible amount 317 2110C DTP 01 Date/Time Qualifier 198 Value is 198. 318 2110C DTP 02 Date Format D8 Value is D8. 319 2110C DTP 03 Date Time Period Effective dates of the member’s deductible Co-Pay Cap Status Pharmacy TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 291 2110C EB 01 Eligibility or Benefit Information D Value is D – copay cap status pharmacy. 292 2110C EB 02 Coverage Level Code IND Value is IND. 293 2110C EB 03 Service Type Code 88 Value is 88 – pharmacy. 299 2110C EB 05 Plan Coverage Description Copay cap status for the member, values = met or not met Co-Pay Cap Status Non-Pharmacy TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 291 2110C EB 01 Eligibility or Benefit Information D Value is D – copay cap status non-pharmacy. 292 2110C EB 02 Coverage Level Code IND Value is IND. 293 2110C EB 03 Service Type Code 1 Value is 1 – medical care. 299 2110C EB 05 Plan Coverage Description Copay cap status for the member, values = met or not met Managed Care – MCO or Primary Care Clinician (PCC) TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 291 2110C EB 01 Eligibility or Benefit Information L, MC Value is MC – managed care organization. Value is L – primary care clinician. 292 2110C EB 02 Coverage Level Code IND Value is IND. 293 2110C EB 03 Service Type Code 30 Value is 30. Note: Plan dates represent coverage dates in the plan or program that is being represented in the response. This date does not have to represent the historical beginning of eligibility for the plan, only the most recent plan date(s). For example, Medicaid may only report plan dates in one month periods of time. 299 2110C EB 05 Plan Coverage Description Possible values are any associated managed care, SCO, or PACE. 317 2110C DTP 01 Date/Time Qualifier 291, 307, 346 Value is 291 – plan. Value is 307 – eligibility. Value is 346 - plan begins. 318 2110C DTP 02 Date Format RD8 Value is RD8. 319 2110C DTP 03 Date Time Period Managed care or PCC begin and end dates 323 2110C MSG 01 Free – Form Message Text Restrictive message(s) may be returned in this field if applicable. 328 LS 01 Loop Identifier Code 2120 330 2120C NM1 01 Entity Identifier Code 13 Value is 13. 331 2120C NM1 02 Entity Type Qualifier 1, 2 Value is 1 if legal name is returned in NM104. Otherwise, value is 2. 331 2120C NM1 03 Name Last or Organization Name Managed-care name or PCC site name. 331 2120C NM1 04 First Name PCC legal name 332 2120C NM1 08 Identification Code Qualifier XX Value is XX. 333 2120C NM1 09 Identification NPI is displayed if available. 334 2120C NM1 10 Entity Relationship Code Not provided by MassHealth 335 2120C N3 01 Address Information Managed care or PCC address 1 335 2120C N3 02 Address Information Managed care or PCC address 2 336 2120C N4 01 City Name Managed care or PCC city name 337 2120C N4 02 State or Province Code Managed care or PCC state or province code 337 2120C N4 03 Postal Code Managed care or PCC postal code 340 2120C PER 01 Contact Function Code IC Value is IC. 341 2120C PER 03 Communication Number Qualifier TE Value is TE. 341 2120C PER 04 Communication Number Managed care contact number 346 LE 01 Loop Identifier Code Value is 2120. Behavioral Health TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 291 2110C EB 01 Eligibility or Benefit Information W Value is W – other source of data (MassHealth defines this code as behavioral health) 293 2110C EB 02 Coverage Level Code IND Value is IND. 293 2110C EB 03 Service Type Code 30 Value is 30. Note: Plan dates represent coverage dates in the plan or program that is being represented in the response. This date does not have to represent the historical beginning of eligibility for the plan, only the most recent plan date(s). For example, Medicaid may report plan dates only in one-month periods of time. 299 2110C EB 05 Plan Coverage Description Possible value is behavioral health 317 2110C DTP 01 Date/Time Qualifier 291, 307, 346 Value is 291 – plan. Value is 307 – eligibility. Value is 346 - plan begins. 318 2110C DTP 02 Date Format RD8 Value is RD8. 319 2110C DTP 03 Date Time Period Managed care or PCC behavioral health begin and end date 323 2110C MSG 01 Free – Form Message Text Restrictive message(s) may be returned in this field if applicable. 328 LS 01 Loop Identifier Code 2120 330 2120C NM1 01 Entity Identifier Code 13 Value is 13. 331 2120C NM1 02 Entity Type Qualifier 1, 2 Value is 1 if legal name is returned in NM104. Otherwise, value is 2. 331 2120C NM1 03 Name Last or Organization Name Managed care name or PCC site name behavioral health site name. 331 2120C NM1 04 First Name PCC behavioral health legal name, if available. 332 2120C NM1 08 Identification Code Qualifier XX Value is XX. 333 2120C NM1 09 Identification NPI is displayed if available. 334 2120C NM1 10 Entity Relationship Code Not provided by MassHealth 335 2120C N3 01 Address Information Behavioral health address 1 335 2120C N3 02 Address Information Behavioral health address 2 336 2120C N4 01 City Name Behavioral health city name 337 2120C N4 02 State or Province Code Behavioral health state or province code 337 2120C N4 03 Postal Code Behavioral health postal code 340 2120C PER 01 Contact Function Code IC Value is IC. 341 2120C PER 03 Communication Number Qualifier TE Value is TE. 341 2120C PER 04 Communication Number Behavioral health contact 346 LE 01 Loop Identifier Code 2120 Dependent Level TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 347 2000D The dependent level loops are not used by MassHealth. Appendices A. Implementation Checklist This appendix contains all necessary steps for going live with MassHealth. 1. Call the EDI Help Desk with any questions at the Toll Free Number. 2. Check the EOHHS website for the latest updates regarding our system implementation. 3. Confirm you have an EOHHS User Name and/or Provider ID. 4. Make the appropriate changes to your systems/business processes to support the updated companion guides: ? If you are a NEHEN provider or use third party software, work with your software vendor to have the appropriate software installed ? If testing system-to-system (Health Care Transaction Service) interface the Trading Partner or provider must work with your software vendor to have the appropriate software installed at their site(s) prior to performing testing with MassHealth 5. Identify the functions you will be testing: ? Health Care Eligibility/Benefit Inquiry and Information Response (270/271) ? Health Care Claim Status Request and Response (276/277) ? Health Care Premium Payment (820) ? Health Care Benefit Enrollment and Maintenance (834) ? Health Care Payment/Advice (835) ? Health Care Claim: Institutional (837I) ? Health Care Claim: Professional (837P) ? Crossover/COB Claims 6. Confirm you have reported all the NPIs you will be using for testing by validating them with MassHealth. Make sure your claim(s) successfully pay to your correct Provider ID, if you have associated multiple MassHealth provider IDs to one NPI and/or taxonomy code. ? If the entity testing is a billing intermediary or software vendor, they should use the provider’s identifiers on the test transaction. 7. When submitting test files, make sure the members/claims you submit are representative of the type of service(s) you provide to MassHealth members. 8. Schedule a tentative week for the initial test. 9. Confirm the email/phone number of the testing contact and confirm that the person you are speaking with is the primary contact for testing purposes. B. Business Scenarios This appendix contains typical business scenarios. The actual data streams linked to these scenarios are included in Appendix C. 1. 5010 MassHealth 837P transaction with ambulance pick-up location, ambulance drop-off location, and ambulance patient count all at a claim level: SUBMITTER: Drakes Ambulance Company EDI #: 111111111A CONTACT: Cher TELEPHONE: 617-555-1212 2. 5010 MassHealth 837P transaction with NDC information being billed: 3. 5010 MassHealth 837P transaction with COB: C. Transmission Examples This appendix contains actual data streams. The business scenarios linked to the data streams are included in Appendix B. 1. Example of a MassHealth 270 transaction (Member ID Inquiry) ISA*00* *00* *ZZ*Provider ID *ZZ*DMA7384 *080116*1200*^*00501*000000001*1*P*:~ GS*HS*Provider ID*DMA7384*20080116*1200*1*X*005010X279A1~ ST*270*0001*005010X279A1~ BHT*0022*13*REPW*20110920*1200~ HL*1**20*1~ NM1*PR*2*MASSHEALTH*****PI*842610001~ HL*2*1*21*1~ NM1*1P*2*PROVIDER NAME*****SV*Provider ID~ or if you are required to submit NPI NM1*1P*2*PROVIDER NAME*****XX*Provider ID~ HL*3*2*22*0~ NM1*IL*1******MI*Member ID~ DTP*291*RD8*20110916-20110918~ EQ*30~ SE*11*0001~ GE*1*1~ IEA*1*000000001~ 2. Example of a MassHealth 270 transaction (SSN Number/Other Agency ID) ISA*00* *00* *ZZ*Provider ID *ZZ*DMA7384 *080116*1200*^*00501*000000001*1*P*:~ GS*HS*Provider ID*DMA7384*20080116*1200*1*X*005010X279A1~ ST*270*0001*005010X279A1~ BHT*0022*13*REPW*20110920*1200~ HL*1**20*1~ NM1*PR*2*MASSHEALTH*****PI*842610001~ HL*2*1*21*1~ NM1*1P*2*PROVIDER NAME*****SV*Provider ID~ or if you are required to submit NPI NM1*1P*2*PROVIDER NAME*****XX*Provider ID~ HL*3*2*22*0~ NM1*IL*1~ REF*SY*Social Security Number~ or if Agency id REF*NQ*Other Agency ID~ DTP*291*RD8*20110916-20110918~ EQ*30~ SE*12*0001~ GE*1*1~ IEA*1*000000001~ 3. Example of a MassHealth 270 transaction (Name Inquiry) ISA*00* *00* *ZZ*Provider ID *ZZ*DMA7384 *080116*1200*^*00501*000000001*1*P*:~ GS*HS*Provider ID*DMA7384*20080116*1200*1*X*005010X279A1~ ST*270*0001*005010X279A1~ BHT*0022*13*REPW*20110920*1200~ HL*1**20*1~ NM1*PR*2*MASSHEALTH*****PI*842610001~ HL*2*1*21*1~ NM1*1P*2*PROVIDER NAME*****SV*Provider ID~ or if you are required to submit NPI NM1*1P*2*PROVIDER NAME*****XX*Provider ID~ HL*3*2*22*0~ NM1*IL*1*Member Last Name*Member First Name*~ DMG*D8*19670512*M~ DTP*291*RD8*20110916-20110918~ EQ*30~ SE*12*0001~ GE*1*1~ IEA*1*000000001~ Test transactions In an effort to help trading partners validate their ability to submit transactions to MassHealth; we have established a test 270/271 transaction for you to validate your HIPAA compliance and connectivity to MassHealth. To validate your data submission, follow the 270 format shown below. A successful transmission can be validated by confirming that the 271 response you have received matches the 271 response shown below. If you have confirmed that you have successfully sent the 270 and received the corresponding 271 in the exact format as shown, you are ready to submit production 270/271 transactions to MassHealth. Call MassHealth Customer Service at 1-800-841-2900 and speak with a HIPAA support representative. Indicate that you have followed the procedures for testing and you are ready to process this transaction set in our production environment. MassHealth 270 test transaction ISA*00* *00* *ZZ*Provider ID *ZZ*DMA7384 *080116*1200*^*00501*000000001*1*P*:~ GS*HS*Provider ID*DMA7384*20080116*1200*1*X*005010X279A1~ ST*270*0001*005010X279A1~ BHT*0022*13*REPW*20110920*1200~ HL*1**20*1~ NM1*PR*2*MASSHEALTH*****PI*842610001~ HL*2*1*21*1~ NM1*1P*2*PROVIDER NAME*****SV*Provider ID~ or if you are required to submit NPI NM1*1P*2*PROVIDER NAME*****XX*Provider ID~ HL*3*2*22*0~ NM1*IL*1*NM1*IL*1*Member Last Name*Member First Name****MI*MEMBER ID~ DTP*291*RD8*20110916-20110918~ EQ*30~ HL*4*2*22*0~ NM1*IL*1*MEMBER LAST NAME*MEMBER FIRST NAME****MI*MEMBER ID~ DTP*291*RD8*20110916-20110918~ EQ*30~ SE*15*1234~ GE*1*300000000~ IEA*1*200000000~ MassHealth 271 test transaction ISA*00* *00* *ZZ*Provider ID *ZZ*DMA7384 *080116*1200*^*00501*000000001*1*P*:~ GS*HB*Provider ID*DMA7384*20110920*1200*1*X*005010X279A1~ ST*271*0001*005010X279A1~ BHT*0022*13*REPW*20110920*1200~ HL*1**20*1~ NM1*PR*2*MASSHEALTH*****PI*842610001~ PER*IC*MASSHEALTH CUSTOMER SERVICE*UR*edi@mahealth.net*TE*8008412900~ HL*2*1*21*1~ NM1*1P*1*PROVIDER LAST NAME*PROVIDER FIRST NAME*PROVIDER MIDDLE INITIAL***XX*NPI~ HL*3*2*22*0~ TRN*1*821300000017*1046002284~ NM1*IL*1*MEMBER LAST NAME*MEMBER FIRST NAME****MI*MEMBER ID~ REF*SY*SOCIAL SECURITY NUMBER~ REF*3H*152*Local Office Code~ N3*MEMBER STREET ADDRESS~ N4*NATICK*MA*02124~ DMG*D8*MEMBER DATE OF BIRTH*M~ DTP*472*RD8*20080425-20080425~ EB*1*IND*30**MASSHEALTH STANDARD~ DTP*307*RD8*20110916-20110918~ MSG*EXEMPT FROM COPAY ON PHARMACY SERVICES UNDER 130 CMR 450.130(D).~ MSG*EXEMPT FROM COPAY ON NON-PHARMACY SERVICES UNDER 130 CMR 450.130(D).~ MSG*restrictive message for BNFT~ EB*MC*IND*30~ DTP*307*RD8*20110916-20110918~ MSG*NETWORK HEALTH MEMBER. For Medical Services call 1-888-257-1985. For Behavioral Health Services call 1-888-257-1986.~ LS*2120~ NM1*13*1*NETWORK HEALTH*NETWORK HEALTH~ N3*432 COLUMBIA ST STE 23~ N4*CAMBRIDGE*MA*02141~ LE*2120~ HL*4*2*22*0~ TRN*1*821300000018*1046002284~ NM1*IL*1*MEMBER LAST NAME*MEMBER FIRST NAME****MI*MEMBER ID~ REF*SY*SOCIAL SECURITY NUMBER~ REF*3H*152*Local Office Code~ N3*MEMBER STREET ADDRESS~ N4*NATICK*MA*02124~ DMG*D8*MEMBER DATE OF BIRTH*F~ DTP*472*RD8*20110916-20110918~ EB*1*IND*30**MASSHEALTH STANDARD~ DTP*307*RD8*20110916-20110918~ MSG*EXEMPT FROM COPAY ON PHARMACY SERVICES UNDER 130 CMR 450.130(D).~ MSG*EXEMPT FROM COPAY ON NON-PHARMACY SERVICES UNDER 130 CMR 450.130(D).~ MSG*restrictive message for BNFT~ EB*MC*IND*30~ DTP*307*RD8*20110916-20110918~ MSG*NETWORK HEALTH MEMBER. For Medical Services call 1-888-257-1985. For Behavioral Health Services call 1-888-257-1986.~ LS*2120~ NM1*13*1*NETWORK HEALTH*NETWORK HEALTH~ N3*432 COLUMBIA ST STE 23~ N4*CAMBRIDGE*MA*02141~ PER*IC**TE*8882571985~ LE*2120~ SE*53*1234~ GE*1*158~ IEA*1*000000232~ Provider Online Service Center - True Batch Example This is an example of a true batch file containing three individual inquiries. True batch has the ability to loop at the interchange, functional group, transaction, and hierarchical levels. ISA*00* *00* *ZZ*999999999 *ZZ*DMA7384 *080116*1200*^*00501*000000001*1*P*:~ GS*HS*USERID1*DMA7384 *20110920*1358*1*X*005010X279A1~ ST*270*1234~ BHT*0022*13*EPIC*20031021*135800~ HL*1**20*1~ NM1*PR*2*MASSHEALTH*****PI*842610001~ HL*2*1*21*1~ NM1*1P*2*TEST PROVIDER*****SV*9999999999~or if you are required to submit NPI NM1*1P*2*PROVIDER HL*3*2*22*0~ NM1*IL*1******MI*999999999~ DTP*291*RD8*20110916-20110918~ EQ*30~ SE*11*1234~ GE*1*1~ IEA*1*000000031~ ISA*00* *00* *ZZ*999999999 *ZZ*DMA7384 *080116*1200*^*00401*000000001*1*P*:~ GS*HS*USERID1*DMA7384 *20110920*1358*1*X*005010X279A1~ ST*270*1234~ BHT*0022*13*EPIC*20031021*135800~ HL*1**20*1~ NM1*PR*2*MASSHEALTH*****PI*842610001~ HL*2*1*21*1~ NM1*1P*2*TEST PROVIDER*****SV*9999999999~ or if you are required to submit NPI NM1*1P*2*PROVIDER HL*3*2*22*0~ NM1*IL*1******MI*999999999~ DTP*291*RD8*20110916-20110918~ EQ*30~ SE*10*1234~ GE*1*1~ IEA*1*000000031~ ISA*00* *00* *ZZ*999999999 *ZZ*DMA7384 *080116*1200*^*00401*000000001*1*P*:~ GS*HS*USERID1*DMA7384 *20110920*1358*1*X*005010X279A1~ ST*270*1234~ BHT*0022*13*EPIC*20031021*135800~ HL*1**20*1~ NM1*PR*2*MASSHEALTH*****PI*842610001~ HL*2*1*21*1~ NM1*1P*2*TEST PROVIDER*****SV*9999999999~ or if you are required to submit NPI NM1*1P*2*PROVIDER HL*3*2*22*0~ NM1*IL*1******MI*999999999~ DTP*291*RD8*20110916-20110918~ EQ*30~ SE*10*1234~ GE*1*1~ IEA*1*000000031~ EVSpc Software: EVScall Pass-through Example This is an example of a pass-through file containing one inquiry. ISA*00* *00* *ZZ*110000000A *ZZ*DMA7384 *090427*2018*^*00501*000000905*0*P*:~ GS*HS*USERID1DMA7384*20110427*2018*1*X*005010X279A1~ ST*270*0001*005010X279A1~ BHT*0022*13*REPW*20090427*2018~ HL*1**20*1~NM1*PR*2*MASSHEALTH*****PI*DMA7384~ HL*2*1*21*1~NM1*1P*2*TEST 270*****XX*1000000002~ REF*JD*EVSPC~ REF*EL*PCXNUMBER0040P~ HL*3*2*22*0~ NM1*IL*1******MI*999999999999~ DTP*472*RD8*20110427-20011427~ EQ*30~ SE*11*0001~ GE*1*1~ IEA*1*000000905~ D. Frequently Asked Questions This appendix contains a compilation of questions and answers relative to MassHealth and its providers. Typical question would involve a discussion about code sets and their effective dates. Q: What are the main differences between the EVSpc, Web, and HTS submission methods? A: ? Web access/POSC - This option is best for those providers who have a low volume of MassHealth members, want to check for specific members, or other limited review of MassHealth member data. Web access also allows you to check the history of an earlier eligibility response you received. ? HTS - This option is best for providers who have large volumes of MassHealth members and need an automated way to check eligibility. Typically, software vendors, billing intermediaries, clearinghouses, and providers with a technical team benefit from this option. ? EVSpc - This option is best for those providers who have a large volume of MassHealth members and see them on a regular basis, but don’t have the resources or expertise to use the HTS method. This option can also be used for single queries. ? PC Software Pass-through Option - The PC software pass-through option is similar to bulk processing in real time. This process makes use of the EVScall.exe portion of the EVSpc application. EVSpc can be used in an interactive or batch mode. More details can be located in the EVSpc user guide. An example of a pass-through file appears in Appendix D of this guide. For all options, a 999 will be generated if a 271 is not returned. Q: How are EVScall transactions separated? A: When submitting transactions via pass-through, each interchange is separated by a carriage return/line feed. Q: I have noticed three segments in my 270 that have a date. Which segment's date should I use to define the date of service? A: The DTP segment is used to determine the date of service. If the DTP segment is not included in the transaction, the date of service is determined by the date that is populated in the BHT04 field. Q: What are the main differences between a 271 and a 999? A: 271 is the response to a 270 and contains eligibility information. 999 is an acknowledgement transaction that indicates if a 270 file was accepted or rejected. 999 does not contain any eligibility information. Q: Is there a limit to the number of inquiries I can submit at once? A: We recommend you follow HIPAA requirements for a maximum of 99 inquiries per ST/SE segment. Real-time transactions are limited to one inquiry per interchange. Specific file size limitations are stated at the beginning of this guide. Q: What information is returned on the 271? A: All available information about the member will be returned. This may include: ? member address ? member ID, social security number, and/or other agency ID ? MassHealth benefit plan ? MassHealth assignment plan ? primary care clinician information ? other insurance information ? managed care information ? member payment responsibility information ? long-term-care information ? behavioral health information ? restrictive messages Q: Will I get back different information if I check by member ID vs. name? A: The information sent is specific to the member and the complete details are sent, regardless of inquiry by member ID number or name Q: Are any fields case sensitive? A: No. E. Change Summary This section describes the differences between the current Companion Guide and previous guide(s). Version Date Section/Pages Description 11.0 10/2012 Entire document Complete revision to comply with CAQH® (Council for Affordable Quality Healthcare) CORE™ (Committee on Operating Rules for Information Exchange) v5010 Master Companion Guide Template. Transaction specific data elements, and their values, were not changed. All previous versions are obsolete. MassHealth 005010 270/271 Companion Guide October 2012, Version 11.0 v October 2012, Version 11.0 43 MassHealth 005010 270/271 Companion Guide October 2012, Version 11.0 Appendix 10