MassHealth Health Care Premium Payment (820) Standard Companion Guide Refers to the Implementation Guides Based on ASC X12N version: 005010X218 October 2012 Version 5.0 Disclosure Statement The following Massachusetts Companion Guide is intended to serve as a companion document to the corresponding ASC X12N/005010X218 Health Care Premium Payment (820) - 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 005010X218 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 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 3 SAMPLE PROCESS FLOWS 3 TRANSMISSION ADMINISTRATIVE PROCEDURES 4 COMMUNICATION PROTOCOL SPECIFICATIONS 5 PASSWORDS 5 5. CONTACT INFORMATION 6 EDI CUSTOMER SERVICE 6 EDI TECHNICAL ASSISTANCE 6 PROVIDER SERVICE NUMBER 6 APPLICABLE WEBSITES/EMAIL 6 6. CONTROL SEGMENTS/ENVELOPES 8 ISA-IEA 8 GS-GE 10 ST-SE 11 7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 11 8. ACKNOWLEDGEMENTS AND/OR REPORTS 12 9. TRADING PARTNER AGREEMENTS 12 TRADING PARTNERS 12 10. TRANSACTION SPECIFIC INFORMATION 12 APPENDICES 1 A. IMPLEMENTATION CHECKLIST 1 B. BUSINESS SCENARIOS 2 C. TRANSMISSION EXAMPLES 5 D. FREQUENTLY ASKED QUESTIONS 7 E. CHANGE SUMMARY 8 Editor’s note: This page intentionally left blank. 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 820 Health Care Premium Payment transactions is 005010X218. This Companion Guide assumes compliance with all loops, segments and data elements contained in the 005010X218. This Companion Guide does NOT include any of the required loops, segments or data elements defined in the 005010X218 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. The following types of claims must be submitted in one or more test files: The monthly 820 will be named: 999999999A.820.WEB.HHMMSSSS.312 where: 999999999A Indicates the trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). HHMMSSSS Indicates the hours, minutes, seconds, and subseconds when the file was created. 312 Indicates the Julian date when the file was created when the file was created. ? The 820 file will be sent to providers from the Provider Online Service Center or HTS server. ? 820 transactions adhere to the ASC X12N 820 (005010X218) format. The file is fixed-length ASCII and contains no real numbers. ? One 820 transaction occurs for each trading partner for each processing cycle. ? 997 acknowledgements will not be accepted in response to the 820 file. Please inform the business contact of any problems with the transactions. ? Many optional fields contain no data. These fields have been populated with spaces or zeros. 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). 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/Email 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. 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 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. TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.7 GS Functional Group Header C.7 GS 01 Functional Identifier Code RA 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 005010X218 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. TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 67 ST Transaction Set Header 67 ST 01 Transaction Set Identifier Code 820 67 ST 02 Transaction Set Control Number Identical to the associated functional group trailer SE02. 67 ST 03 Implementation Convention Reference 005010X218 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 functional group 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. 8. Acknowledgements and/or Reports MassHealth does not require an acknowledgement and will ignore the receipt of any 999 transactions. 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. TR3 Page # Loop ID Reference Name Codes Length Notes/Comments Header BPR 01 Transaction Handling Code U, I Code Definition U Split Payment and Remittance I Remittance Information Only Header BPR 02 Financial Information Monetary Amount This field will contain the net sum amount of the processing cycle. Total of all 2300B level RMR04 Header BPR 03 Credit/Debit Flag Code C Code Definition C Credit Header BPR 04 Payment Method Code ACH, CHK Code Definition ACH Automated Clearing House CHK Check - Paper Header BPR 05 Payment Format Code CTX Code Definition CTX Corporate Trade Exchange Header BPR 06 (DFI) Identification Number Qualifier 01 Code Definition 01 ABA transit routing number including check digit (9 digits) Header BPR 07 Identification Number Originator ABA Header BPR 08 Account Number Qualifier DA Code Definition DA Demand Deposit Header BPR 09 Account Number Originator Account Number Header BPR 10 Originating Company Identifier Originator Federal Tax ID number Header BPR 12 (DFI) Identification Number Qualifier 01 Code Definition 01 ABA Transit Routing Number Including Check Digits (9 digits) Header BPR 13 Identification Number Receiver ABA Header BPR 14 Account Number Qualifier Receiver Account Type Header BPR 15 Account Number Receiver Account Number Header BPR 16 Date Check issue date Please Note: The 820s for MCO, MBHP, SCO, and PACE will be held until this information is available. Header TRN 01 Trace Type Code 3 Code Definition 3 Financial Re- association Trace Number Header TRN 02 Reference Identification Check number OR EFT number Please Note: The 820s for MCO, MBHP, SCO, and PACE will be held until this information is available. Header REF 01 Reference Identification Qualifier 14 Code Definition 14 Master Account Number Header REF 02 Reference Identification Displays the type of key and value provided to the Premium Payer by the Premium Receiver. Header DTM 01 Date Time Qualifier 582 Code Definition 582 Report Period Header DTM 05 Date Time Format Qualifier RD8 Code Definition RD8 Range of Dates Header DTM 06 Date Coverage Period Format is CCYYMMDD- CCYYMMDD 1000A N1 01 Entity Identifier Code PE Code Definition PE Payee 1000A N1 02 Premium Receiver’s Name Premium receiver’s name This segment is not required if N103 is sent. 1000A N1 03 Identification Code Qualifier FI Code Definition FI Federal Tax Payer’s Identification Number 1000A N1 04 Identification Code Payee Tax Identification Number 1000B N1 01 Entity Identifier Code PR Code Definition PR Payer 1000B N1 03 Identification Code Qualifier FI Code Definition FI Federal Tax Payer’s Identification Number 1000B N1 04 Identification Code Code Definition 04600 2284 MassHealth Tax ID 2000B ENT 01 Assigned Number Unique Number/ID within transaction set (Incremented by 1 for each Member for example ‘1’, ‘2’, ‘3’, etc). 2000B ENT 02 Entity ID Code 2J Code Definition 2J Individual 2000B ENT 03 Identification Code Qualifier EI Code Definition EI Employee Identification Number 2000B ENT 04 Identification Code Member’s 12-digit MassHealth ID 2100B NM1 01 Entity Identifier Code IL Code Definition IL Insured or subscriber 2100B NM1 02 Entity Type Qualifier 1 Code Definition 1 Person 2100B NM1 03 Last Name Member’s Last Name Length is 20 2100B NM1 04 First Name Member’s First Name Length is 15 2100B NM1 05 Middle Name Member’s Middle Initial 2100B NM1 08 Identification Code Qualifier N Code Definition N Insured’s Unique Identification Number 2100B NM1 09 Identification Code Member’s 12-digit MassHealth ID 2300B RMR 01 Reference Identification Qualifier AZ Code Definition AZ Health Insurance Policy Number 2300B RMR 02 Insurance Remittance Reference Number Member’s Rate Cell 2300B RMR 04 Detail Premium Payment Amount This field is the premium paid amount, or reconciled premium paid amount. 2300B RMR 05 Monetary Amount This field is present and reports zero, only when there is a capitation adjustment amount reported in 2320B:ADX01. 2300B DTM 01 Data Time Qualifier 582 Code Definition 582 Report Period 2300B DTM 05 Date Time Format Qualifier RD8 Code Definition RD8 Range of Dates 2300B DTM 06 Date Period The begin date will be the first day of coverage for the cap month. (Will be the first day of the cap month if coverage was in effect before first day of month, otherwise it will be the specific day of the cap month that coverage began.) The end date will be the last day of coverage for the cap month. (Will be the final day of the cap month if coverage was end-dated after the cap month, otherwise it will be the specific day of the cap month that coverage ended.) (CCYYMMDD-CCYYMMDD format) 2320B This loop is present only when the capitation adjustment amounts are needed to credit for previous payment or Remit for previous underpayment. For normal payment this loop is not reported This loop is present only when the capitation adjustment amounts are needed to credit for previous payment or Remit for previous underpayment. For normal payment this loop is not reported 2320B ADX 01 Monetary Amount Capitation Adjustment Amount 2320B ADX 02 Adjustment Reason Code 52, 53 Code Definition 52 Credit for Previous Overpayment 53 Remittance for Previous Underpayment 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. B.1 Scenario One Scenario one illustrates an 820 transaction with an adjustment that pays (credits) the provider for a previously unpaid member enrollment. ST*820*43001*005010X218~ Start of an 820 transaction set, with control number (43001) BPR*U*99999999.99*C*ACH*CTX*01*011075150*DA*00000000000*1000000000**01*000000000*DA* 0000000*20110608~ The financial institution will send a payment instruction of $99999999.99 separate from the remittance information. The payment will use an ACH CTX credit. The premium payer’s bank transit routing number is 011075150 and their checking account number is 00000000000. The premium receiver’s bank transit routing number is 000000000 and their checking account number is 0000000. The effective date of the payment is June 08, 2011. TRN*3*000000000000000~ The sender’s financial reassociation trace number (000000000000000) REF*14*111111119Z~ The master account number (111111119Z) DTM*582****RD8*20110601-20110630~ The coverage period June 1, 2011 through June 30, 2011 N1*PE**FI*000000000~ The premium payee’s federal Tax ID number (000000000) N1*PR**FI*000000000~ The premium payer’s federal Tax ID number (000000000) ENT*1*2J*EI*100000000000~ The insured’s ID number (100000000000) NM1*IL*1*LAST*FIRST*L***N*100000000000~ The insured’s name (FIRST L LAST) and ID number (100000000000) RMR*AZ*MBAPD**30.48*0~ The health plan’s reference number (MBAPD) for a premium payment of ($30.48) for a billed premium of ($0.00) DTM*582****RD8*20101029-20101031~ The coverage period (October 29, 2010 through October 31, 2010) ADX*30.48*53~ The adjustment amount (30.48) due to a previous underpayment SE*942228*43001~ End of an 820 transaction set, with segment count (942228) and control number (43001) B.2 Scenario Two Scenario two illustrates an 820 transaction with an adjustment that pays (credits) the provider for a previously unpaid member enrollment. ST*820*43001*005010X218~ Start of an 820 transaction set, with control number (43001) BPR*U*9899999.99*C*ACH*CTX*01*011075150*DA*00000000000*1000000000**01*000000000*DA* 000000000000*20110610~ The financial institution will send a payment instruction of $9899999.99 separate from the remittance information. The payment will use an ACH CTX credit. The premium payer’s bank transit routing number is 011075150 and their checking account number is 00000000000. The premium receiver’s bank transit routing number is 000000000 and their checking account number is 000000000000. The effective date of the payment is June 10, 2011. TRN*3*000000000000000~ The sender’s financial reassociation trace number (000000000000000) REF*14*111111119Z~ The master account number (111111119Z) DTM*582****RD8*20110101-20110131~ The coverage period January 1, 2011 through January 31, 2011 N1*PE**FI*000000000~ The premium payee’s federal Tax ID number (000000000) N1*PR**FI*000000000~ The premium payer’s federal Tax ID number (000000000) ENT*1*2J*EI*100000000000~ The insured’s ID number (100000000000) NM1*IL*1*LAST*FIRST*L***N*100000000000~ The insured’s name (FIRST L LAST) and ID number (100000000000) RMR*AZ*MBAPD**311.86~ The health plan’s reference number (MBAPD) for a premium payment of ($311.86) DTM*582****RD8*20110101-20110131~ The coverage period January 1, 2011 through January 31, 2011 SE*53396*43001~ End of an 820 transaction set, with segment count (53396) and control number (43001) B.3 Scenario Three Scenario three illustrates an 820 transaction for monthly capitation with no adjustment. The loop below is taken from the transaction described in scenario 2 above. It shows a normal payment for a member where RMR05 is no longer displayed since it is equal to RMR04. ENT*1*2J*EI*100000000000~ The insured’s ID number (100000000000) NM1*IL*1*LAST*FIRST*L***N*100000000000~ The insured’s name (FIRST L LAST) and ID number (100000000000) RMR*AZ*MBAPD**311.86~ The health plan’s reference number (MBAPD) for a premium payment of ($311.86) DTM*582****RD8*20110101-20110131~ The coverage period January 1, 2011 through January 31, 2011 C. Transmission Examples This appendix contains actual data streams. The business scenarios linked to the data streams are included in Appendix B. C.1 Example One Example one illustrates an 820 transaction with an adjustment that pays (credits) the provider for a previously unpaid member enrollment. ISA*00* *00* *ZZ*DMA7384 *ZZ*111111119Z *110614*0613*^*00501*000128596*0*T*:~ GS*RA*DMA7384*111111119Z *20110614*061313*43*X*005010X218~ ST*820*43001*005010X218~ BPR*U*99999999.99*C*ACH*CTX*01*011075150*DA*00000000000*1000000000**01*000000000*DA* 0000000*20110608~ TRN*3*000000000000000~ REF*14*111111119Z~ DTM*582****RD8*20110601-20110630~ N1*PE**FI*000000000~ N1*PR**FI*000000000~ ENT*1*2J*EI*100000000000~ NM1*IL*1*LAST*FIRST*L***N*100000000000~ RMR*AZ*MBAPD**30.48*0~ DTM*582****RD8*20101029-20101031~ ADX*30.48*53~ SE*942228*43001~ GE*1*43~ IEA*1*000128596~ C.2 Example Two Example two illustrates an 820 transaction with an adjustment that pays (credits) the provider for a previously unpaid member enrollment. ISA*00* *00* *ZZ*DMA7384 *ZZ*111111119Z *110614*1016*^*00501*000020071*0*T*:~ GS*RA*DMA7384*111111119Z *20110614*101612*43*X*005010X218~ ST*820*43001*005010X218~ BPR*U*9899999.99*C*ACH*CTX*01*011075150*DA*00000000000*1000000000**01*000000000*DA* 000000000000*20110610~ TRN*3*000000000000000~ REF*14*111111119Z~ DTM*582****RD8*20110101-20110131~ N1*PE**FI*000000000~ N1*PR**FI*000000000~ ENT*1*2J*EI*100000000000~ NM1*IL*1*LAST*FIRST*L***N*100000000000~ RMR*AZ*MBAPD**311.86~ DTM*582****RD8*20110101-20110131~ SE*53396*43001~ GE*1*43~ IEA*1*000020071~ C.3 Example Three Example three illustrates an 820 transaction for monthly capitation with no adjustment. The loop below is taken from the transaction described in sample 2 above. It shows a normal payment for a member where RMR05 is no longer displayed since it is equal to RMR04. ENT*1*2J*EI*100000000000~ NM1*IL*1*LAST*FIRST*L***N*100000000000~ RMR*AZ*MBAPD**311.86~ DTM*582****RD8*20110101-20110131~ 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 5.0 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 820 Companion Guide October 2012, Version 5.0 iv MassHealth 005010 820 Companion Guide October 2012, Version 5.0 i October 2012, Version 5.0 18 MassHealth 005010 820 Companion Guide October 2012, Version 5.0 Appendix 8