MassHealth

Health Care Claim Status Request and 
Response (276/277)

Standard Companion Guide

Refers to the Implementation Guides
Based on ASC X12N version: 005010X212














October 2012
Version 10.0



Disclosure Statement

The following Massachusetts Companion Guide is intended to serve as a companion document to the 
corresponding ASC X12N/005010X212 Health Care Claim Status Request and Response (276/277) - 
at the time of publication, there were no related addenda or errata.  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 005010X212 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:

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Table of Contents

1.	INTRODUCTION	1
SCOPE	1
OVERVIEW	1
REFERENCES	1
ADDITIONAL INFORMATION	2
2.	GETTING STARTED	2
WORKING WITH MASSHEALTH	2
TRADING PARTNER REGISTRATION	2
CERTIFICATION AND TESTING OVERVIEW	2
3.	TESTING WITH THE PAYER	3
4.	CONNECTIVITY WITH THE PAYER/COMMUNICATIONS	4
SAMPLE PROCESS FLOWS	5
TRANSMISSION ADMINISTRATIVE PROCEDURES	6
RETRANSMISSION PROCEDURE	6
COMMUNICATION PROTOCOL SPECIFICATIONS	7
PASSWORDS	7
5.	CONTACT INFORMATION	7
EDI CUSTOMER SERVICE	7
EDI TECHNICAL ASSISTANCE	8
PROVIDER SERVICE NUMBER	8
APPLICABLE WEBSITES/E-MAIL	8
6.	CONTROL SEGMENTS/ENVELOPES	10
ISA-IEA	10
276 (Inbound)	10
277 (Outbound)	12
GS-GE	13
276 (Inbound)	13
277 (Outbound)	14
ST-SE	15
276 (Inbound)	15
277 (Outbound)	16
7.	PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS	17
8.	ACKNOWLEDGEMENTS AND/OR REPORTS	18
REPORT INVENTORY	25
9.	TRADING PARTNER AGREEMENTS	25
TRADING PARTNERS	25
10.	TRANSACTION SPECIFIC INFORMATION	26
276 (INBOUND)	26
277 (OUTBOUND)	29
APPENDICES	1
A.	IMPLEMENTATION CHECKLIST	1
B.	BUSINESS SCENARIOS	2
C.	TRANSMISSION EXAMPLES	3
D.	FREQUENTLY ASKED QUESTIONS	6
E.	CHANGE SUMMARY	7



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 Health Care Claim Status Request and Response transactions is 005010X212.

This Companion Guide assumes compliance with all loops, segments and data elements 
contained in the 005010X212.

This Companion Guide does NOT include any of the required loops, segments or data elements 
defined in the 005010X212 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 837P 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 following conditions must be addressed in one or more test files.

?	Provider ID/service location (PID/SL) or NPI
?	Member ID
?	Payer claim control number (MassHealth-assigned ICN)
?	Billed amount
?	Claim service date

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 is the 10-character MassHealth submitter ID/pay-to-provider number.
?	ZZZ is the sequence number assigned to the file by the trading partner, starting with a value 
of “001.”
?	This sequence number should be increased by one for each subsequent test 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.

276 (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


The number of functional 
groups included in an 
interchange.
C.10
IEA
02
Interchange Control Number


The control number 
assigned by the interchange 
sender.

277 (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


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.

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.

276 (Inbound)

TR3 
Page #
Loop ID
Reference
Name
Codes
Length
Notes/Comments
C.7
GS

Functional Group Header



C.7
GS
01
Functional Identifier Code


HR
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


005010X212

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.

277 (Outbound)

TR3 
Page #
Loop ID
Reference
Name
Codes
Length
Notes/Comments
C.7
GS

Functional Group Header



C.7
GS
01
Functional Identifier Code


HN
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


005010X212

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.
276 (Inbound)

TR3 
Page #
Loop ID
Reference
Name
Codes
Length
Notes/Comments
67
ST

Transaction Set Header



67
ST
01
Transaction Set Identifier  
Code


276 
67
ST
02
Transaction Set Control 
Number


Must be 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


Must be identical to the 
associated transaction set 
header ST02.

277 (Outbound)

TR3 
Page #
Loop ID
Reference
Name
Codes
Length
Notes/Comments
67
ST

Transaction Set Header



67
ST
01
Transaction Set Identifier  
Code


277 
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.

HL Segment

As noted in the 276 Implementation Guide, “If the subscriber and the patient are the same person, do 
not use the next HL (HL23) for the dependent information.” MassHealth does not recognize the 
dependent. 

Please Note: MassHealth does not reject claims at the provider level. All claims are processed at the 
claim level.

NM1 Segment

When the member identification number is used as the inquiry variable, NM108 must equal MI and 
NM109 must contain the member ID. 

REF Segment

?	When REF01 equals 1K, the value in the REF02 needs to contain the correct claim reference 
number (ICN), which is available to the provider on the remittance advice.
?	If the value in REF01 is other than 1K, it will not be used when selecting claims from MassHealth.
 
DMG Segment

For the 276 claim status request transaction, the 2000D:DMG segment is required when the 
subscriber is the patient. This segment is always required because in the MassHealth implementation 
of HIPAA, the subscriber is always the patient. 

TRN Segment

?	For the 276 claim status request transaction, the TRN segment is required when the subscriber is 
the patient. Because in the MassHealth implementation of HIPAA, the subscriber is always the 
patient, this segment is always required. 
?	The TRN segment received on the 276 claim status request transaction will be returned unaltered 
on the 277 response transaction, except that TRN01 will be changed to “2.”

AMT Segment

?	For the 276 claim status request transaction, the AMT segment is required to refine the search 
criteria for a specific claim. Do not send if not required. 
?	For the 276 claim status request transaction submitted with the AMT segment, the AMT02 value 
will be used as one of the primary searches when selecting claims to include on the response. 
Only claims that have an exact dollar amount match will be returned. 
?	For the 276 claim status request transaction submitted without the AMT segment, all claims 
matching the other search criteria will be returned.
?	For the 276 claim status request transaction submitted with the AMT segment, AMT02 must 
contain a decimal point if it contains a non-integer value. 

2220D Loop (Service Line Information)

?	MassHealth ignores the 2210D loop (Service Line Information) submitted on the 276 transaction 
and will not perform the search using any of the information submitted in 2210D of the 276 
transaction.
?	MassHealth will always return service line information stored in the database when claims are 
found and returned on the response transaction.

Reporting

Detailed claim status reports are available on the POSC and can be produced using the EVSpc 
software.
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.
276 (Inbound)

TR3 
Page #
Loop ID
Reference
Name
Codes
Length
Notes/Comments
37

BHT 03
Reference Identification


The number assigned by the 
originator to identify the 
transaction within the 
originator’s business 
application system.
38

BHT 05
Transaction Set Creation 
Time


Format is HHMM
41
2100A
NM1 03
Name Last or Organization 
Name


Payer organization’s name 
The system will validate the 
first three characters of the 
last name.
42
2100A
NM1 09
Identification Code


Must equal 46002284
45
2100B
NM1 02
Entity Type Qualifier
1, 2

Code
Definition






1
Person






2
Nonperson Entity
46
2100B
NM1 03
Name Last or Organization 
Name


Information receiver’s last 
name or organization name
46
2100B
NM1 04
Name First


Information receiver first 
name 
This is required when the 
value in NM102 is “1.”
46
2100B
NM1 08
Identification Code Qualifier
46

Must equal 46
46
2100B
NM1 09
Identification Code


Information receiver’s ETIN 
(Electronic Transmitter 
Identification Number). 
This is the Trading Partner 
ID assigned by MassHealth 
or 10-digit MMIS provider 
ID/service location (PID/SL).
50
2100C
NM1 01
Entity Identifier Code
1P

Must equal 1P
50
2100C
NM1 02
Entity Type Qualifier
1, 2

Code
Definition






1
Person






2
Nonperson Entity
51
2100C
NM1 08
Identification Code Qualifier
SV, XX

Must equal XX if NM109 
equals NPI. 
Must be SV if NM109 equals 
to a MassHealth atypical 
provider ID/service location 
(PID/SL).
51
2100C
NM1 09
Identification Code


Enter NPI or, if an atypical 
provider, MassHealth 
provider ID/service location 
(PID/SL).
54
2000D
DMG 01
Date Time Period Format 
Qualifier
D8

Must be D8
55
2000D
DMG 02
Date Time Period


Date of birth
55
2000D
DMG 03
Gender Code
F, M, U

Code
Definition






F
Female






M
Male






U
Unknown
56
2100D
NM1 01
Entity Identifier Code
IL

Must equal IL
56
2100D
NM1 02
Entity Type Qualifier
1

Must equal 1
57
2100D
NM1 03
Name Last or Organization 
Name


Member’s last name 
submitted on 276 is 
validated against the last 
name on file. The value 
must be capitalized.
57
2100D
NM1 04
Name First


Member’s first name 
submitted on 276 is 
validated against the first 
name on file. The value 
must be capitalized.
57
2100D
NM1 08
Identification Code Qualifier
MI

Must equal MI
57
2200D
NM1 09
Identification Code


Must be a valid Member ID
53
2200D
TRN 02
Reference Identification


Claim Status Tracking 
number
MassHealth will display what 
is entered on the 277.
59
2200D
REF 01
Payer Claim Control Number 
/ Reference Identification 
Qualifier
1K

The search criteria can be 
narrowed to a specific claim.






Code
Definition






1K
Payer’s Claim 
Number
59
2200D
REF 02
Payer Claim Control Number 
/ Reference Identification


MassHealth ICN
66
2200D
AMT 02
Monetary Amount


The search criteria can be 
narrowed to specific claims 
for the member with a 
matching Total Claim 
Charge Amount.
67
2200D
DTP 01
Claim Service Date / 
Date/Time Qualifier
472

Code
Definition






472
Service
67
2200D
DTP 02
Claim Service Date / Date 
Time Period Format 
Qualifier
D8, RD8

Code
Definition






D8
Date: CCYYMMDD






RD8
Date Range: 
CCYYMMDD-
CCYYMMDD






Please Note: A maximum of 
500 claims will be returned 
for this Date Range search.
68
2200D
DTP 03
Claim Service Date / Date 
Time Period


The search criteria can be 
narrowed to specific claims 
within this date of service.

277 (Outbound)

TR# 
Page #
Loop ID
Reference
Name
Codes
Length
Notes/Comments
107

BHT 03
Reference Identification


The number assigned by the 
originator to identify the 
transaction within the 
originator’s business 
application system.
108

BHT 05
Transaction Set Creation 
Time


Format is HHMM
111
2100A
NM1 03
Name Last or Organization 
Name


MassHealth returns the 
value sent in the 276 
transaction.
112
2100A
NM1 09
Identification Code


MassHealth returns the 
value sent in the 276 
transaction.
114
2100A
PER 02
Name


EOHHS CUSTOMER 
SERVICE
114
2100A
PER 03
Communication Number 
Qualifier
TE

TE
114
2100A
PER 04
Communication Number  


8002412900
114
2100A
PER 05
Communication Number 
Qualifier
EM

EM
115
2100A
PER 06
Communication Number  


edi@mahealth.net
118
2100B
NM1 02
Entity Type Qualifier


MassHealth returns the 
value sent on the 276 
transaction.
119
2100B
NM1 03
Name Last or Organization 
Name


MassHealth returns the 
value sent on the 276 
transaction.
119
2100B
NM1 04
Name First


MassHealth returns the 
value sent on the 276 
transaction.
119
2100B
NM1 08
Identification Code Qualifier


MassHealth returns the 
value sent on the 276 
transaction.
119
2100B
NM1 09
Identification Code


MassHealth returns the 
value sent on the 276 
transaction.
127
2100C
NM1 01
Entity Identifier Code


MassHealth returns the 
value sent on the 276 
transaction.
127
2100C
NM1 02
Entity Type Qualifier


MassHealth returns the 
value sent on the 276 
transaction.
128
2100C
NM1 08
Identification Code Qualifier


MassHealth returns the 
value sent on the 276 
transaction.
128
2100C
NM1 09
Identification Code


MassHealth returns the 
value sent on the 276 
transaction.
135
2100D
NM1 01
Entity Identifier Code


MassHealth returns the 
value sent on the 276 
transaction.
136
2100D
NM1 03
Name Last or Organization 
Name


MassHealth returns the 
value sent on the 276 
transaction.
136
2100D
NM1 04
Name First


MassHealth returns the 
value sent on the 276 
transaction.
136
2100D
NM1 05
Name Middle


MassHealth returns the 
value sent on the 276 
transaction.
136
2100D
NM1 09
Identification Code


MassHealth returns the 
value sent on the 276 
transaction.
137
2200D
TRN 02
Reference Identification


MassHealth returns the 
value sent on the 276 
transaction.
139
2200D
STC 01-3
Claim Submitter Trace 
Number – Entity Identifier 
Code


In addition to the values in 
the table, the program will 
return the value "1P" 
(provider) when the provider 
or service location is missing 
from the 276 request or not 
found on file.
145
2200D
STC 02
Claim Submitter Trace 
Number - Date


Date inquiry was made 
(MassHealth sets it to the 
current system date), if the 
claim is not found. If claim is 
found, it will be set to the 
date the claim was 
processed.
145
2200D
STC 04
Monetary Amount


The amount of charges 
originally submitted
145
2200D
STC 05
Monetary Amount


The amount paid
146
2200D
STC 08
Claims Payment Type - Date 
Check issued


For paid claims only
Check Issue or EFT 
Effective Date
146
2200D
STC 09
Claims Payment Type - 
Check Number


For paid claims only
Check or EFT Trace 
Number
147
2200D
STC 10-3
Entity Identifier Code


MassHealth will return the 
value "1P" (provider) when 
the provider or service 
location is missing from the 
276 request or not found on 
file.
148
2200D
STC11-3
Entity Identifier Code


MassHealth will return the 
value "1P" (provider) when 
the provider or service 
location is missing from the 
276 request or not found on 
file.
149
2200D
REF 01
Payer Claim Control Number 
/ Reference Identification 
Qualifier
1K

Code
Definition






1K
Payer’s Claim 
Number
149
2200D
REF 02
Payer Claim Control Number 
/ Reference Identification


If the claim is not found, 
MassHealth returns the 
value sent on the 276 
transaction. If the claim is 
found, MassHealth’s ICN will 
be returned
150
2200D
REF 01
Institutional Bill Type / 
Reference Identification 
Qualifier
BLT

Code
Definition






BLT
Billing Type
150
2200D
REF 02
Institutional Bill Type / 
Reference Identification


If the claim is not found, 
MassHealth returns the 
value sent on the 276 
transaction. If the claim is 
found, the type of bill stored 
with the claim will be 
returned.
151
2200D
REF 01
Patient Control Number / 
Reference Identification 
Qualifier
EJ

Code
Definition






EJ
Patient Account 
Number
151
2200D
REF 02
Patient Control Number / 
Reference Identification


If the claim is not found, 
MassHealth returns the 
value sent on the 276 
transaction. If the claim is 
found, the patient account 
number submitted with the 
claim is returned.
155
2200D
DTP 01
Date and Time Qualifier
472

Code
Definition






472
Service
155
2200D
DTP 02
Date and Time Period 
Format Qualifier
D8, RD8

Code
Definition






D8
Date: CCYYMMDD






RD8
Date Range: 
CCYYMMDD-
CCYYMMDD
156
2200D
DTP 03
Date Time Period


If the claim is not found, 
MassHealth returns the 
value sent on the 276 
transaction. If the claim is 
found, the DOS value stored 
with the claim is returned.
157
2220D
SVC 01-1
Service Lines Information / 
Product/ Service ID Qualifier
AD, HC, 
NU, N4

This field must contain any 
of the following values.






Code
Definition






AD
American Dental 
Association Code






HC
HCPCS Code






NU
NUBC Code






N4
National Drug Code 
in 5-4-2 format
162
2220D
STC 01-3
Entity Identifier Code
1P

MassHealth will return the 
value "1P" (provider) when 
the provider or service 
location is missing from the 
276 request or not found on 
file.
168
2220D
STC 04
Monetary Amount


The amount of charges 
submitted originally
168
2220D
STC 05
Monetary Amount


The amount paid
169
2220D
STC 10-3
Entity Identifier Code
1P

MassHealth will return the 
value "1P" (provider) when 
the provider or service 
location is missing from the 
276 request or not found on 
file.
170
2220D
STC 11-3
Entity Identifier Code
1P

MassHealth will return the 
value "1P" (provider) when 
the provider or service 
location is missing from the 
276 request or not found on 
file.
171
2220D
REF 01
Reference Identification 
Qualifier
FJ

Code
Definition






FJ
Line Item Control 
Number
171
2220D
REF 02
Reference Identification


If the claim is found, the Line 
Item Control Number stored 
with the service line of the 
claim will be returned.
172
2220D
DTP 01
Date and Time Qualifier
472

Code
Definition






472
Service
172
2220D
DTP 02
Date and Time Period 
Format Qualifier
D8, RD8

Code
Definition






D8
Date: CCYYMMDD






RD8
Date Range: 
CCYYMMDD-
CCYYMMDD
172
2220D
DTP 03
Date Time Period


If the claim is found, the 
DOS stored with the service 
line of the claim is returned.





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. Scenario of a medical service inquiry on a single date of service. 
Note the line item detail request is ignored and the claim level date is used for inquiry.

SUBMITTER: Drakes Ambulance Company 
EDI #: 111111111A
CONTACT: Cher
TELEPHONE: 617-555-1212

2. Scenario of an outpatient hospital claim status inquiry and response

SUBMITTER: Drakes Ambulance Company 
EDI #: 111111111A
CONTACT: Cher
TELEPHONE: 617-555-1212



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 Medical service inquiry on a single date of service. Note the line item detail 
request is ignored and the claim level date is used for inquiry.

276 (Inbound)

ISA*00*          *00*          *ZZ*999999999A     *ZZ*DMA7384        *110720*1705*^*00501*987618673*0*T*:~
GS*HR*999999999A*DMA7384*20110720*1705*8673*X*005010X212~
ST*276*68673*005010X212~
BHT*0010*13*ABC276XX1*20110720*1425~
HL*1**20*1~
NM1*PR*2*MASSHEALTH*****PI*12345~
HL*2*1*21*1~
NM1*41*1*PLNAME*PFNAME****46*999999999A~
HL*3*2*19*1~
NM1*1P*1*PLNAME*PFNAME****XX*9999999999~
HL*4*3*22*0~
DMG*D8*19990101*M~
NM1*IL*1*MBRLNAME*FNAME****MI*999999999999~
TRN*1*TRANSNUM~
REF*D9*CLRHSTRANNO~
DTP*472*D8*20110515~
SVC*HC:99214*50*****1~
REF*FJ*LINEITEMCTLNUM~
DTP*472*D8*20110515~
SE*18*68673~
GE*1*8673~
IEA*1*987618673~



277 (Outbound)

ISA*00*          *00*          *ZZ*DMA7384        *ZZ*999999999A     *110811*1235*^*00501*000000252*0*T*:~
GS*HN*DMA7384*999999999A*20110811*123506*37*X*005010X212~
ST*277*68673*005010X212~
BHT*0010*08*999999999A201108111235*20110811*1235*DG~
HL*1**20*1~
NM1*PR*2*MASSHEALTH*****PI*12345~
HL*2*1*21*1~
NM1*41*1*PLNAME*PFNAME****46*999999999A~
HL*3*2*19*1~
NM1*1P*1*PLNAME*PFNAME****XX*9999999999~
HL*4*3*22*0~
NM1*IL*1*MBRLNAME*FNAME****MI*999999999999~
TRN*2*TRANSNUM~
STC*F1:3*20110706**155*0*20110621~
REF*1K*9999999999999~
REF*EJ*999999~
REF*D9*CLRHSTRANNO~
DTP*472*D8*20110515~
SVC*HC:82270*5*0****1~
STC*F2:400*20110706~
DTP*472*RD8*20110515-20110515~
SVC*HC:99214*50*0****1~
STC*F1:20*20110706~
DTP*472*RD8*20110515-20110515~
SVC*HC:99215*100*0****1~
STC*F2:400*20110706~
DTP*472*RD8*20110515-20110515~
SE*26*68673~
GE*1*37~
IEA*1*000000252~


2. Example of an outpatient hospital claim status inquiry and response

276 (Inbound)

ISA*00*          *00*          *ZZ*999999999G     *ZZ*DMA7384        *110720*1705*^*00501*987618673*0*T*:~
GS*HR*999999999G*DMA7384*20110720*1705*8673*X*005010X212~
ST*276*68673*005010X212~
BHT*0010*13*ABC276XX1*20110720*1425~
HL*1**20*1~
NM1*PR*2*MASSHEALTH*****PI*12345~
HL*2*1*21*1~
NM1*41*2*HOSPNAME*****46*999999999G~
HL*3*2*19*1~
NM1*1P*2*HOSPNAME*****XX*9999999999~
HL*4*3*22*0~
DMG*D8*19990101*M~
NM1*IL*1*PLNAME*PFNAME****MI*999999999999~
TRN*1*TRANSNUM~
REF*D9*CLRHSTRANNO~
DTP*472*RD8*20110615-20110620~
SE*15*68673~
GE*1*8673~
IEA*1*987618673~


277 (Outbound)

ISA*00*          *00*          *ZZ*DMA7384        *ZZ*999999999G     *110815*1035*^*00501*004354787*0*T*:~
GS*HN*DMA7384*999999999G*20110815*103516*21682*X*005010X212~
ST*277*68673*005010X212~
BHT*0010*08*ABC276XX1201108151035*20110815*1035*DG~
HL*1**20*1~
NM1*PR*2*MASSHEALTH*****PI*12345~
HL*2*1*21*1~
NM1*41*2*HOSPNAME*****46*999999999G~
HL*3*2*19*1~
NM1*1P*2*HOSPNAME*****XX*9999999999~
HL*4*3*22*0~
NM1*IL*1*PLNAME*PFNAME****MI*999999999999~
TRN*2*TRANSNUM~
STC*F2:688*20110725**5000*0*20110725****F2:688*F2:258~
STC*F2:1*20110725**5000*0*20110725~
REF*1K*9999999999999~
REF*EJ*9999999~
REF*D9*CLRHSTRANNO~
DTP*472*RD8*20110615-20110620~
SVC*NU:100*5000*0****5~
STC*F2:20*20110725~
DTP*472*RD8*20110615-20110615~
SE*21*68673~
GE*1*21682~
IEA*1*004354787~


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.






Note: At the time of publication, there were no frequently asked questions.



E.	Change Summary

This section describes the differences between the current Companion Guide and previous guide(s).

Version
Date
Section/Pages
Description
10.0
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 276/277 Companion Guide					
		
October 2012, Version 10.0				v
			
MassHealth 005010 276/277 Companion Guide				
October 2012, Version 10.0				i
October 2012, Version 10.0				34
MassHealth 005010 276/277 Companion Guide					
			
October 2012, Version 10.0				Appendix 7