MassHealth Health Care Benefit Enrollment and Maintenance (834) Outbound Standard Companion Guide Refers to the Implementation Guides Based on ASC X12N version: 005010X220A1 January 2013 Version 6.1 MassHealth 005010 834 Outbound Companion Guide Disclosure Statement The following Massachusetts Companion Guide is intended to serve as a companion document to the corresponding ASC X12N/005010X220 Health Care Benefit Enrollment and Maintenance (834), its related Addenda (005010X220A1) and its related Errata (005010X220E1). 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 005010X220 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. January 2013, Version 6.1 i MassHealth 005010 834 Outbound Companion Guide 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. January 2013, Version 6.1 ii MassHealth 005010 834 Outbound Companion Guide Editor’s note: This page intentionally left blank. January 2013, Version 6.1 MassHealth 005010 834 Outbound Companion Guide 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 ................................................................................ .......................................................................4 TRANSMISSION ADMINISTRATIVE PROCEDURES...................................................................... ...............................................5 COMMUNICATION PROTOCOL SPECIFICATIONS.................................................................. .....................................................6 PASSWORDS....................................................................... ................................................................................ .....................6 5. CONTACT INFORMATION ................................................................................ ............................................................6 EDI CUSTOMER SERVICE......................................................................... ...............................................................................6 EDI TECHNICAL ASSISTANCE ................................................................................ .................................................................7 PROVIDER SERVICE NUMBER.......................................................................... ........................................................................7 APPLICABLE WEBSITES/EMAIL.................................................................. .............................................................................7 6. CONTROL SEGMENTS/ENVELOPES ................................................................................ ...........................................9 ISA- IEA............................................................................. ................................................................................ ....................9 GS- GE.............................................................................. ................................................................................ ....................10 ST- SE.............................................................................. ................................................................................ .....................11 7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ................................................................................ ....12 8. ACKNOWLEDGEMENTS AND/OR REPORTS......................................................................... ..................................18 9. TRADING PARTNER AGREEMENTS...................................................................... ...................................................18 TRADING PARTNERS ................................................................................ .............................................................................18 10.TRANSACTION-SPECIFIC INFORMATION..................................................................... .........................................18 APPENDICES...................................................................... ................................................................................ .....................1 A. IMPLEMENTATION CHECKLIST ................................................................................ ..........................................................1 B. BUSINESS SCENARIOS ................................................................................ .......................................................................2 C. TRANSMISSION EXAMPLES ................................................................................ ...............................................................3 D. FREQUENTLY ASKED QUESTIONS ................................................................................ .....................................................7 E. CHANGE SUMMARY ................................................................................ ..........................................................................8 January 2013, Version 6.1 iv MassHealth 005010 834 Outbound Companion Guide Editor’s note: This page intentionally left blank. January 2013, Version 6.1 MassHealth 005010 834 Outbound Companion Guide 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 834 Health Care Benefit Enrollment and Maintenance transactions is 005010X220A1. This Companion Guide assumes compliance with all loops, segments and data elements contained in the 005010X220A1. This Companion Guide does NOT include any of the required loops, segments or data elements defined in the 005010X220A1 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. January 2013, Version 6.1 1 MassHealth 005010 834 Outbound Companion Guide The Implementation Guides for X12N and all other HIPAA standard transactions are available electronically at 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 website. Providers January 2013, Version 6.1 2 MassHealth 005010 834 Outbound Companion Guide 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 conditions must be addressed in one or more test files. The outbound daily 834 file will be named: 999999999A.834D.WEB.HHMMSSSS.312 where: 999999999A Indicates the trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). 834D In 834D, D indicates the daily file HHMMSSSS Indicates the hours, minutes, seconds, and subseconds when the file was created 312 Indicates the Julian date when the file was created The outbound monthly (“audit”) 834 will be named: 999999999A.834M.WEB.HHMMSSSS.312 where: Indicates the trading partner ID assigned by MassHealth OR 999999999A 10-digit MMIS provider ID/service location (PID/SL) 834M In 834D, M indicates the monthly file Indicates the hours, minutes, seconds, and subseconds HHMMSSSS when the file was created 312 Indicates the Julian date when the file was created The member fix file 834 (History request/responses) will be named: 999999999A.834W.WEB.HHMMSSSS.312 where: Indicates the trading partner ID assigned by MassHealth OR 999999999A 10-digit MMIS provider ID/service location (PID/SL) 834W In 834D, M indicates the weekly (history response) file Indicates the hours, minutes, seconds, and subseconds HHMMSSSS when the file was created 312 Indicates the Julian date when the file was created • The daily 834 is created each weekday, Monday through Friday (holidays are not excluded), for Managed Care Organization and Behavioral Health (BH), Senior Care January 2013, Version 6.1 3 MassHealth 005010 834 Outbound Companion Guide Options (SCO), and Program of All -inclusive Care for the Elderly (PACE) and Integrated Care Organization (ICO) trading partners. The monthly 834 is created on the first weekend of the month for all trading partners. • 834 transactions adhere to the ASC X12N 834 (005010X220A1) format. • 834 transactions have been created for each member. There are no dependents in any case. • Many optional fields contain no data. • All code values are in compliance with the HIPAA-compliant code sets unless otherwise stated in field-specific notes below. Local codes may be used where HIPAA code sets are unavailable. 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) January 2013, Version 6.1 4 MassHealth 005010 834 Outbound Companion Guide 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). January 2013, Version 6.1 5 MassHealth 005010 834 Outbound Companion Guide 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 MassHealth Customer Service at 1-800-841-2900. 5. Contact Information EDI Customer Service (For written correspondence) MassHealth Customer Service PO Box 9118 Hingham, MA 02043 January 2013, Version 6.1 6 MassHealth 005010 834 Outbound Companion Guide (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 January 2013, Version 6.1 7 MassHealth 005010 834 Outbound Companion Guide 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 website 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 January 2013, Version 6.1 8 MassHealth 005010 834 Outbound Companion Guide 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 website 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 January 2013, Version 6.1 9 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 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 = : 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. January 2013, Version 6.1 10 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.7 GS Functional Group Header C.7 GS 01 Functional Identifier Code BE 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 005010X220A1 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 834 67 ST 02 Transaction Set Control Number Identical to the associated functional group trailer SE02 January 2013, Version 6.1 11 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 67 ST 03 Implementation Convention Reference 005010X220A1 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 website at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, and then click on Provider Library. The following sections outline recommendations, instructions, and conditional data requirements for claims submitted to MassHealth. This information is designed to help trading partners construct transactions in a manner that will allow MassHealth to efficiently process claims. Additional Information for Agency Affiliations and Aid Categories Loop 2000 (Member Level Detail), segment REF (Member Supplemental Identifier) will not report the agency affiliation (appended up to 18 characters [6 * 3]) when 2000:REF01 = DX or the aid category (2 chars) when 2000:REF01 = 17. Instead, aid categories and agency affiliations reporting occur in loop 2700. Loop 2700 Agency Affiliations Agency Description DMH Department of Mental Health DMR Department of Developmental Services (DDS) January 2013, Version 6.1 12 MassHealth 005010 834 Outbound Companion Guide Agency Description DSS Department of Children and Families (DCF) DTA Department of Transitional Assistance DYS Department of Youth Services ELD Executive Office of Elder Affairs HCF Healthcare Finance MCB Massachusetts Commission for the Blind MHO MA21 MassHealth Organization MRC Massachusetts Rehabilitation Commission PAC PACES SSA Social Security Administration Loop 2700 Conditions Crosswalk by Transaction Type Transaction Type Transaction Details Aid Categories Agency Affiliation TRX 021 Enrollment . Send all open managed care aid categories in MC hierarchical order, richest first. . Send managed care aid categories with future end dates (end date > process date). . Send all open agency affiliations. . Send agency affiliations with future end dates (end date > process date). TRX 001 Demographic Change (name, address, gender, DOB, copay total, rate cell, SSN, TPL, GCI, SVC LOC, member link) . Send all open managed care aid categories in hierarchical order, richest first. . Send managed care aid categories with future end dates (end date > process date). . Send all open agency affiliations. . Send agency affiliations with future end dates (end date > process date). TRX 001 Aid Cat Change and/or Agency Affiliation Change . If open managed care aid category closes, send aid category with end date. Do not send all other open aid categories. . If new managed care aid category opens, send aid category with begin date. Do not send all other open aid categories. . If open agency affiliation closes, send agency affiliation with end date. Do not send all other open agency affiliations. . If new agency affiliation opens, send agency affiliation with begin date. Do not send all other open agency affiliations. January 2013, Version 6.1 13 MassHealth 005010 834 Outbound Companion Guide Transaction Type Transaction Details Aid Categories Agency Affiliation TRX 001 Aid Cat Change and/or Agency Affiliation Change and demographic change . If a managed care aid category closes, opens, or reopens, and demographic change takes place, send it in 001, followed by all other open mc aid categories. Send them all in richest order first. . If agency affiliation closes and demographic change occurs, send the changed agency in 001, followed by all other open agency affiliations. Note: For a 001 transaction due to an aid category change, the closed or opened aid categories will display first regardless of hierarchy. Then, the open aid categories will display, richest first. TRX 024 Disenrollment . If disenroll reason = 01 Loss of MC Eligibility, send aid categories that closed since the last roster process date. . If disenroll reason <> 01 Loss of MC Eligibility, send no aid categories. . If disenroll reason = 01 Loss of MC Eligibility, send agency affiliations that closed since the last roster process date. . If disenroll reason <> 01 Loss of MC Eligibility, send no agency affiliations. TRX 001/002 Change/Delete (History) . Send no managed care aid categories. . Send no member agency affiliations. TRX 030 Audit Send managed care aid categories (in hierarchical order, richest first) . that remained open for the entire reporting month; . with an end date during the reporting month; and . with an end date after the reporting month. Send agency affiliations . that remained open for the entire reporting month; . with an end date during the reporting month; and . with an end date after the reporting month. Loop 2700 Aid Categories Hierarchy Managed Aid Description Care Category Hierarchy 1 14 MCB SSI January 2013, Version 6.1 14 MassHealth 005010 834 Outbound Companion Guide Managed Care Hierarchy Aid Category Description 2 15 MCB MA 3 03 SSI disabled 4 TB Disabled - LE 100% FPL TF Disabled - met deductible 6 TM Disabled GE 135% FPL 7 TR Disabled adult child 8 TS Disabled widow 9 UK Kaileigh Mulligan LE $60 UL Kaileigh Mulligan GT $60 11 UP Kaileigh Mulligan GT 135% FPL 12 UT Pickle - disabled 13 07 Disabled 14 42 Disabled UA Mass Rehab (MRC) PCA cases 16 44 SF disabled 17 50 CommonHealth disabled child 18 51 SF CommonHealth disabled child 19 52 CommonHealth disabled working adult 53 CommonHealth disabled nonworking adult 21 54 SF CommonHealth disabled working adult 22 55 SF CommonHealth disabled nonworking adult 23 00 Refugee 24 48 Expansion Standard children 02 TAFDC 26 06 MA-TAFDC (MAOA) 27 VY State adoption subsidy 28 VZ State foster care subsidy 29 08 Multi assistance unit 40 Family 31 41 SF family 32 46 TMA nondisabled 33 AD BCC Standard 34 AE BCC Standard EA Time-limited Standard/ESI investigation 36 EE Time-limited Standard/ESI enrollment 37 VV Independent foster care adolescents 38 VX Operation helping hand 39 VW SF independent foster care adolescents January 2013, Version 6.1 15 MassHealth 005010 834 Outbound Companion Guide Managed Care Hierarchy Aid Category Description 40 84 HIV Family Assistance 41 85 SF HIV Family Assistance 42 93 Family Assistance 43 95 SF Family Assistance 44 90 SF Family Assistance 45 AH SF BCC Fam Assist 46 60 SF- Basic 47 61 Basic 48 AM Essential (requires managed care enrollment) 49 AR Disab alien special status (ESS if in managed care) 50 BB SF Commonwealth Care + Limited LE 100% FPL 51 CN Commonwealth Care LE 100% FPL 52 CP SF Commonwealth Care LE 100% FPL 53 BD SF Commonwealth Care + Limited 100.1% -133% FPL 54 CQ Commonwealth Care 100.1 - 150% FPL 55 CR SF Commonwealth Care 100.1 - 150% FPL 56 CS Commonwealth Care 150.1 - 200% FPL 57 CT SF Commonwealth Care 150.1 - 200% FPL 58 CU Commonwealth Care 200.1 - 250% FPL 59 CV SF Commonwealth Care 200.1 - 250% FPL 60 CW Commonwealth Care 250.1 - 300% FPL 61 CX SF Commonwealth Care 250.1 - 300% FPL 62 TH Disabled with Medicare GT 100% LT 120% - FPL 63 TK Disabled with Medicare GE 120% - LT 135% FPL 64 TQ Disabled adult child with Medicare 65 US Pickle - disabled with Medicare 66 21 Disabled with QMB 67 43 Disabled with QMB 68 45 SF disabled with QMB 69 UJ Kaileigh Mulligan with Medicare LE $60 70 UM Kaileigh Mulligan with Medicare GT 100% LT 120%FPL 71 UN Kaileigh Mulligan with Medicare GE 120% LT 135%FPL 72 UU Kaileigh Mulligan with Medicare LE 100% FPL 73 18 TMA disabled QMB parents 74 EP ESI premium payment plus standard wrap disabled 75 01 SSI aged 76 TA Aged - LE 100% FPL 77 TE Aged - met deductible January 2013, Version 6.1 16 MassHealth 005010 834 Outbound Companion Guide Managed Care Hierarchy Aid Category Description 78 TG Aged with Medicare GT 100% LT 120% FPL 79 TJ Aged with Medicare GE 120% - LT 135% FPL 80 TL Aged GE 135% FPL 81 TN Pickle with Medicare - aged - not disabled 82 TP Pickle - aged - not disabled 83 TX Hermanson with Medicare aged GT 100% LT 120% FPL 84 TY Hermanson with Medicare aged GE 120% LT 135% FPL 85 UB Hermanson aged GE 135% FPL 86 UD Hermanson aged with Medicare LT 135% FPL 87 UE Hermanson aged with Medicare GE 135% FPL 88 UF Hermanson aged 89 05 Aged 90 20 Aged with QMB 91 EB Time limited standard/ESI investigation 92 AA TMA reinstate 93 EF Time limited standard/ESI enrollment 94 EK ESI premium payment plus Standard wrap 95 EJ ESI premium payment plus Standard wrap 96 EC Time-limited CommonHealth/ESI investigation 97 ED SF time-limited CommonHealth/ESI investigation 98 EG Time limited CommonHealth/ESI enrollment 99 EM ESI premium payment plus CommonHealth wrap 100 47 Time limited Standard-presumptive 100 EL ESI premium payment plus CommonHealth wrap 101 91 SF time-limited Family Assistance 101 EH SF time limited CommonHealth/ESI enrollment 102 EN SF ESI premium payment plus CommonHealth wrap 102 92 Time-limited expansion Family Assistance 103 AB Time-limited expansion Fam Assist 103 98 Time-limited expansion Fam Assist (presumptive) 104 86 HIV Family Assistance-prem assist w/wrap 105 59 Time-limited HIV Fam Assist 106 82 HIV Family Assistance 107 79 Time-limited Family Assistance 108 87 SF HIV Fam Assist prem assist w/wrap 109 58 SF Time-limited HIV Fam Assist 110 83 SF HIV Family Assistance 111 AC SF time-limited Fam Assist January 2013, Version 6.1 17 MassHealth 005010 834 Outbound Companion Guide Managed Care Hierarchy Aid Category Description 999 35 Department of Mental Health (DMH) 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 MassHealth Customer Service 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. January 2013, Version 6.1 18 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 32 Header BGN 01 Transaction Set Purpose Code 00,15, 22 Code Definition 00 Original 15 Resubmission 22 Information copy 33 Header BGN 02 Reference Identification Unique ID for this transaction incremented by 1 33 Header BGN 03 Date Current date 33 Header BGN 04 Time Current time 33 Header BGN 05 Time Code ET Code Definition ET Eastern time 35 Header BGN 08 Action Code 2, 4 Code Definition 2 Change/update (daily 834) 4 Verify (monthly 834) 37 Header DTP 01 Date Time Qualifier 007 Code Definition 007 Effective 37 Header DTP 02 Date Time Period Format Qualifier D8 Code Definition D8 Date expressed in CCYYMMDD format 37 Header DTP 03 Date Time Period Current date 39 1000A SPONSOR NAME 39 1000A N1 01 Entity Identifier Code P5 Code Definition P5 Plan sponsor 39 1000A N1 02 Plan Sponsor Name MassHealth 40 1000A N1 03 Identification Code Qualifier FI Code Definition FI MassHealth Tax ID 40 1000A N1 04 Identification Code – Sponsor Identifier Value = MassHealth tax ID January 2013, Version 6.1 19 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 41 1000B N1 01 Entity ID Code IN Code Definition IN Insurer 41 1000B N1 02 Insurer Name 42 1000B N1 03 Identification Code Qualifier FI Code Definition FI Federal taxpayer’s identification number 42 1000B N1 04 Identification Code Provider tax ID number 47 2000 MEMBER LEVEL DETAIL 48 2000 INS 01 Yes/No Condition or Response Code Always reported as a Y, as all data is reported at the member level 48 2000 INS 02 Individual Relationship Code 18 Code Definition 18 Self 49 2000 INS 03 Maintenance Type 001, Code Definition Code 021, 024, 001 Change to existing record 030 021 Addition 024 Cancellation or termination 030 Reconciliation file used for full replace files 49 2000 INS 04 Maintenance Reason Code AI Code Definition AI No reason given The MassHealth disenrollment reason code is provided in 2000 loop in REF02. 51 2000 INS 05 Benefit Status Code A Code Definition A Active January 2013, Version 6.1 20 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 52 2000 INS 08 Employment Status Code AC, TE Code Definition AC Active This will be posted for every roster (834 transaction) other than a TERM roster (024 transaction). TE Terminated 53 2000 INS 10 Handicap Indicator Y, N Code Definition Y Yes N No 54 2000 INS 12 Insured Individual Death Date Member’s date of death 54 2000 INS 13 Confidentiality Code R, U Good cause indicator Code Definition R GCI = Y U GCI = N Null GCI = blank 55 2000 REF 01 Reference Identification Qualifier 0F, 1L, 3H, DX, ZZ Code Definition 0F Subscriber number 1L Group or policy number 3H Case number DX Department/agency number ZZ 17 Mutually defined Client Reporting Category (BH only) January 2013, Version 6.1 21 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments Then, REF02 will be… 0F Member's MassHealth ID number 1L Benefit plan of the member 3H Member's case number DX 1. LWO (local welfare office) 2. HBM ID - Managed care entity or CST user ID ZZ 17 Composite of the following: 1. MassHealth disenrollment reason - 2 characters 2. Pregnancy indicator - 1 character 3. Ethnicity code - 6 characters Provider ID/Service Location (PID/SL) associated with the member’s MassHealth- assigned PCC (BH only) 59 2000 DTP 01 Date Time Qualifier 356, Code Definition 357 356 Assignment plan begins 357 Assignment plan ends 61 2000 DTP 03 Date Time Period Member managed care enroll date 62 2100A MEMBER NAME 62 2100A NM1 01 Entity Identification Code 74, IL Code Definition 74 Corrected insured IL Insured or subscriber 63 2100A NM1 02 Entity Type Qualifier 1 Code Definition 1 Person 63 2100A NM1 03 Last Name Member’s last name Length is 20. January 2013, Version 6.1 22 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 63 2100A NM1 04 First Name Member’s first name Length is 15. 63 2100A NM1 05 Middle Name Member’s middle initial 64 2100A NM1 08 Identification Code Qualifier 34 Code Definition 34 Social security number (if SSN on file) 64 2100A NM1 09 Identification Code Member’s social security number (if SSN on file) 66 2100A PER 01 Contact Function Code IP Code Definition IP Insured party 66 2100A PER 03 Communication Number Qualifier TE, AP, CP Code Definition TE Daytime phone AP Nighttime phone CP Cellular phone 66 2100A PER 04 Communication Number Member’s telephone number (applicable to the type of qualifier used in PER03) 66 2100A PER 05 Communication Number Qualifier TE, AP, CP Code Definition TE Daytime phone AP Nighttime phone CP Cellular phone 67 2100A PER 06 Communication Number Member’s telephone number (applicable to the type of qualifier used in PER05) 67 2100A PER 07 Communication Number Qualifier TE, AP, CP Code Definition TE Daytime phone AP Nighttime phone CP Cellular phone 67 2100A PER 08 Communication Number Member’s telephone number (applicable to the type of qualifier used in PER07) January 2013, Version 6.1 23 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 68 2100A N3 01 Address Information Member’s address line 1 Will send this segment only if enrolling a member or changing a member's address Will not send this segment if disenrolling a member or reporting a non-address member demographic change 68 2100A N3 02 Address Information Member’s address line 2 69 2100A N4 01 City Name Member’s city Will send this segment only if enrolling a member or changing a member's address Will not send this segment if disenrolling a member or reporting a non-address member demographic change 69 2100A N4 02 State Code Member’s state 70 2100A N4 03 Postal Code Member’s postal code 70 2100A N4 05 Location Qualifier CY Code Definition CY County/parish January 2013, Version 6.1 24 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 70 2100A N4 06 Location Identifier 00 - 14 Member’s two-character county code County Code County Name 00 County unknown 01 Barnstable 02 Berkshire 03 Bristol 04 Dukes 05 Essex 06 Franklin 07 Hampden 08 Hampshire 09 Middlesex 10 Nantucket 11 Norfolk 12 Plymouth 13 Suffolk 14 Worcester 71 2100A DMG 01 Date Time Period Format Qualifier D8 Code Definition D8 Date expressed in CCYYMMDD format 71 2100A DMG 02 Date Time Period Member’s date of birth (DOB) 72 2100A DMG 03 Gender Code Member’s gender January 2013, Version 6.1 25 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 72 2100A DMG 05 Race or Ethnicity Code 7, A, C, H, I, N Code Definition 7 Inter 7 Unknown A Asian C White H Hispanic I Indian N Black 81 2100A AMT 01 Amount Qualifier Code C1 Code Definition C1 Copayment amount 81 2100A AMT 02 Monetary Amount Member’s pharmacy copayment accumulation for the calendar year 84 2100A LUI 01 Identification Code Qualifier LE Code Definition LE ISO 639 language codes 85 2100A LUI 02 Language Code F F Member's spoken (primary) language code (ISO format) Member’s written language code (ISO format) Notes: • If Member’s spoken or written language is ENG, it will not be reported in LUI02. • There will be two occurrences of LUI segment in the case if both spoken and written languages are other than English. 85 2100A LUI 04 Use of Language Indicator 7, 6 Code Definition 7 Spoken (primary language) 6 Written language January 2013, Version 6.1 26 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 86 2100B INCORRECT MEMBER NAME Will send member’s last name if sending a demographic change only (a non-name change) 86 2100B NM1 01 Entity Identification Code 70 Code Definition 70 Prior incorrect insured 87 2100B NM1 02 Entity Type Qualifier 1 Code Definition 1 Person 87 2100B NM1 03 Prior Incorrect Last Name Member’s prior last name Length is 20. 87 2100B NM1 04 Prior Incorrect First Name Member’s prior first name Length is 15. 87 2100B NM1 05 Prior Incorrect Middle Initial Member’s prior middle initial 87 2100B NM1 08 Identification Code Qualifier ZZ Code Definition ZZ Mutually defined 88 2100B NM1 09 Identification Code Member’s previous ID (inactive) in the case of a link Member’s previous SSN in the case of an SSN change and no link Member’s previous ID (Inactive) in the case of a link and SSN change Please Note: • This loop is set up to send only one previous ID, so in the case of multiple inactive IDs; the first one available from the database will be sent. 89 2100B DMG 01 Date Time Period Format Qualifier D8 Code Definition D8 Date expressed in CCYYMMDD format January 2013, Version 6.1 27 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 90 2100B DMG 02 Prior Incorrect Birth date Member’s prior DOB Please Note: • If member's birth date is being corrected, will send DMG01 and DMG02. • If there is no change in birth date, DMG01 and DMG02 would be null. 90 2100B DMG 03 Prior Incorrect Gender Code Member’s prior gender Please Note: • If member's gender is being corrected, DMG03 will be populated. • If there is no change in gender, DMG03 would be null. 90 2100B DMG 05 Race Code 7, A, C, H, I, N Member’s race Please Note: • If member's race is being corrected, DMG05 will be sent. • If there is no change in race, DMG05 would be null. Code Definition 7 Inter 7 Unknown A Asian C White H Hispanic I Indian N Black January 2013, Version 6.1 28 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 91 2100B DMG 06 Citizenship Status Code 1 - 7 Please Note: If member's race is being corrected, citizenship code (DMG06) will be sent. If there is no change in race citizenship code (DMG06) would be null. HIP AA Cod e Description MMIS Code 1 U.S. Citizen C=Citizen 2 Non-Resident Alien N/A 3 Resident Alien P=PRUCOL M=Meets 5-year rule S=Special Immigrants – Iraqi & Afghan B=Barred G=Grandfathered 4 Illegal Alien N=Non-citizen 5 Alien N/A 6 U.S. Citizen -Non- Resident N/A 7 U.S. Citizen – Resident N/A 92 2100C MEMBER MAILING ADDRESS This loop is required when the member mailing address is different from the residence address sent in loop 2100A. 92 2100C NM1 02 Entity Type Qualifier 1 Code Definition 1 Person 94 2100C N3 01 Address Information Member’s mailing address line 1 94 2100C N3 02 Address Information Member’s mailing address line 2 January 2013, Version 6.1 29 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 95 2100C N4 01 City Name Member’s mailing address city 95 2100C N4 02 State Code Member’s mailing address state 93 2100C N4 03 Zip Code Member’s mailing address zip code 123 2100G RESPONSIBLE PERSON 130 2100G N4 01 Entity Identifier Code QD Code Definition QD Responsible party 132 2100G NM1 02 Entity Type Qualifier 1 Code Definition 1 Person 133 2100G NM1 03 Last Name Responsible party (Note: If last name not available, value returned will be RESPLAST.) Length is 20. 133 2100G NM1 04 First Name Responsible party first name (Note: If first name not available, value returned will be RESPFIRST.) Length is 15. 133 2100G NM1 05 Middle Initial Responsible party middle initial 140 2300 HEALTH COVERAGE 140 2300 HD 01 Maintenance Type Code 001, 002, 021, 024, 030 Code Definition 001 Change 002 Deletion 021 Addition 024 Cancellation or termination 030 Audit or comparison (for reconciliation files only) 141 2300 HD 03 Insurance Line Code HMO Code Definition HMO Health maintenance organization January 2013, Version 6.1 30 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 141 2300 HD 04 Plan Coverage Description Member’s rate cell (Note: Length is maximum of five.) 143 2300 DTP 01 Date Time Qualifier 348 Note: 2300 DTP is not used to report the Assignment plan ends date. Instead, 2000 DTP (code 357) will be sent. Code Definition 348 Assignment plan begins. 144 2300 DTP 02 Date Format Qualifier D8 Code Definition D8 Date expressed in CCYYMMDD format 144 2300 DTP 03 Coverage Period Begin date and end date. If end date is not known only begin date is sent. 152 2310 PROVIDER INFORMATION Up to 2 occurrences of the 2310 loop can be reported. 152 2310 LX 01 Assigned Number Loop 2310 contains information about the primary care providers for the subscriber. This is a sequential number representing the number of loops for this insured person. Begin with 1 for each insured person. 153 2310 NM1 01 Entity Identifier Code P3 Code Definition P3 Primary care provider – PCP 154 2310 NM1 02 Entity Type Qualifier 1, 2 Code Definition 1 Person (PCP) 2 Non-person entity (group provider) 155 2310 NM1 08 Identification Code Qualifier XX Code Definition XX Centers for Medicare & Medicaid Services national provider identifier January 2013, Version 6.1 31 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 155 2310 NM1 09 Identification Code For MCOs, this will be the NPI of the member's MCO-assigned PCP, if present on MMIS. For behavioral health, this will be the NPI of the member's MassHealth-assigned PCC. 155 2310 NM1 10 Entity Relationship Code 25, 72 If this is the result of a PCC conversion: Code Definition 25 Established patient 72 Unknown 164 2320 COORDINATION OF BENEFITS The TPL information contained in this loop will be comprehensive. 164 2320 COB 01 Payer Responsibility Sequence Number Code U Code Definition U Unknown 164 2320 COB 02 Reference Identification MMIS TPL policy number 164 2320 COB 03 Coordination of Benefits Code 1 Code Definition 1 Coordination of benefits 166 2320 REF 01 Reference ID Qualifier 6P Code Definition 6P Group number 167 2320 REF 02 Reference Identification Group policy number 168 2320 DTP 01 Date Time Qualifier 344, Code Definition 345 344 COB begin 345 COB end 168 2320 DTP 02 Date Format Qualifier D8 Code Definition D8 Date expressed in CCYYMMDD format January 2013, Version 6.1 32 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 168 2320 DTP 03 Date Time Period Begin date and end date. If end date is not known, only begin date is sent. 169 2330 COORDINATION OF BENEFITS RELATED ENTITY 169 2330 NM1 01 Entity Identifier Code Code Definition IN Insurer 170 2330 NM1 02 Entity Type Qualifier 2 Code Definition 2 Non person entity 170 2330 NM1 03 Name Last or Organization Name Organization name 171 2330 N3 01 Address Information COB address line 1 171 2330 N3 02 Address Information COB address line 2 172 2330 N4 01 City Name COB city 172 2330 N4 02 State Code COB state 172 2330 N4 03 Zip Code COB zip code 176 2000 LS ADDITIONAL REPORTING CATEGORIES 176 2000 LS 01 Loop Identifier Code 2700 Code Definition 2700 Mutually defined 177 2700 New loop to report member’s open aid category dates and open agency affiliation dates All managed care entities should refer to: • Loop 2700 Conditions Crosswalk by Transaction Type. January 2013, Version 6.1 33 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 177 2700 LX 01 Assigned Number 1 - 6 7 - 12 Code Definition Loop 1 Value = 1 through 6 Assigned numbers one through six are reserved for reporting member’s aid category data Value = 7 through 12 Assigned numbers seven through 12 are used for reporting open agency affiliation data, However, if less than six member’s aid category data loops are needed, LX01 for the open agency affiliation data loop begins with the last LX01 value + 1. 178 2750 REPORTING CATEGORY 178 2750 N1 01 Entity Identifier Code 75 Code Definition 75 Participant 178 2750 N1 02 Name Value = Aid category description Value = Agency affiliation description 179 2750 REF 01 Reference Identification Qualifier XX1 Value = Agency affiliation description XX1 Special program code Open Agency Affiliation Reference Identification Qualifier ZZ Mutually defined 180 2750 REF 02 Reference Identification All providers should refer to: • Loop 2700 Agency Affiliations All managed care entities should also refer to: • Loop 2700 Aid Categories Hierarchy. 181 2750 DTP 01 Date Time Qualifier 007 Code Definition 007 Effective 181 2750 DTP 02 Date Time Period Format Qualifier RD8 Code Definition RD8 Range of dates January 2013, Version 6.1 34 MassHealth 005010 834 Outbound Companion Guide TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 182 2750 DTP 03 Date Time Period Range of dates expressed in format CCYYMMDD-CCYYMMDD 183 2000 LE ADDITIONAL REPORTING CATEGORIES LOOP TERMINATION 183 2000 LE 01 Loop Identifier Code 2700 Code Definition 2700 Mutually defined 184 Trailer SE 01 Number of Included Segments Total number of segments included in a transaction set including ST and SE segments 184 Trailer SE 02 Transaction Set Control Number Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set The transaction set control numbers in ST02 and SE02 must be identical. January 2013, Version 6.1 35 MassHealth 005010 834 Outbound Companion Guide 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 about 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 e-mail/phone number of the testing contact and confirm that the person you are speaking with is the primary contact for testing purposes. January 2013, Version 6.1 Appendix 1 MassHealth 005010 834 Outbound Companion Guide 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 Monthly Audit File B.2 Scenario Two Daily File; Change Transaction - transaction was triggered by a demographic change B.3 Scenario Three Daily File; Enrollment Transaction B.4 Scenario Four Daily File; Enrollment Transaction B.5 Scenario Five Daily File; Disenrollment Transaction January 2013, Version 6.1 Appendix 2 MassHealth 005010 834 Outbound Companion Guide 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 - 030 / Monthly Audit File ISA*00* *00* *ZZ*DMA7384 *ZZ*100000000C *111017*1719*^*00501*000000479*0*T*:~ GS*BE*DMA7384*100000000C*20111017*171930*445*X*005010X220A1~ ST*834*445001*005010X220A1~ BGN*00*1*20111017*1719*ET***4~ DTP*007*D8*20111015~ N1*P5*MassHealth*FI*000000000~ N1*IN**FI*000000000~ INS*Y*18*030*XN*A***AC**N~ REF*0F*100000000000~ REF*1L*STD~ REF*3H*03000000A~ REF*DX*06000CNV~ REF*ZZ*AZNUNKNOW~ DTP*356*D8*20080701~ DTP*357*D8*22991231~ NM1*IL*1*DOE*JON****34*000000000~ PER*IP**TE*9999999999~ N3*16 FEDERAL ST~ N4*BOSTON*MA*021100000**CY*13~ DMG*D8*19280415*F**C~ AMT*C1*000~ LUI*LE*CHI*7~ HD*030**HMO*PACCC~ DTP*348*D8*20080701~ COB*U*00000000000000*1~ REF*6P*000000000~ DTP*344*D8*19980701~ DTP*345*D8*22991231~ NM1*IN*2*BLUE CROSS BLUE SHIELD OF MA~ N3*PO BOX 000000~ N4*BOSTON*MA*022986015~ LS*2700~ LX*1~ N1*75*Aged GE 135% FPL~ REF*XX1*TL~ DTP*007*RD8*20080601-22991231~ LX*2~ N1*75*MA21 MASSHEALTH ORGANIZATION~ REF*ZZ*MHO~ DTP*007*RD8*20080601-22991231~ LE*2700~ January 2013, Version 6.1 Appendix 3 MassHealth 005010 834 Outbound Companion Guide C.2 Example Two - 001 / Daily File; Change Transaction Scenario= 001 transaction was triggered by a demographic change. *Other change triggers include a change in SSN, gender, race, DOB, copay, rate cell, name, residential address and mailing address, GCI, aid cat, TPL, PCC PMP service loc, agency affiliation, member link. ISA*00* *00* *ZZ*DMA7384 *ZZ*100000000Z *110928*1956*^*00501*000020117*0*T*:~ GS*BE*DMA7384*100000000Z*20110928*195608*465*X*005010X220A1~ ST*834*465001*005010X220A1~ BGN*00*1*20110928*1956*ET***2~ DTP*007*D8*20110928~ N1*P5*MassHealth*FI*000000000~ N1*IN**FI*000000000~ INS*Y*18*001*AI*A***AC**N~ REF*0F*100000000000~ REF*1L*STD~ REF*3H*000000000~ REF*DX*00000DDD~ REF*ZZ*AZZZZZZ~ DTP*356*D8*20040826~ DTP*357*D8*22991231~ NM1*74*1*DOE*JON****34*012608930~ PER*IP**TE*5084592697~ N3*101 FEDERAL ST~ N4*BOSTON*MA*021100000**CY*146~ DMG*D8*19800212*M**C*1~ AMT*C1*000~ LUI*LE*CHI*7~ NM1*70*1*DOE*JANE~ DMG*D8*19790212*F**7*1~ HD*001**HMO*MBAPD~ DTP*348*D8*20040826~ LS*2700~ LX*1~ N1*75*TAFDC~ REF*XX1*02~ DTP*007*RD8*20090803-22991231~ LX*2~ N1*75*DEPT OF TRANSITIONAL ASSISTANCE~ REF*ZZ*DTA~ DTP*007*RD8*20090803-22991231~ LE*2700~ C.3 Example Three - 021 / Daily File; Enrollment Transaction INS*Y*18*021*AI*A***AC**N~ REF*0F*100000000000~ REF*1L*STD~ REF*3H*00000000A~ REF*DX*00000QSAIMA~ REF*ZZ*AZNUNKNOW~ DTP*356*D8*20110926~ DTP*357*D8*22991231~ NM1*IL*1*DOE*JANE*Q***34*000000000~ PER*IP**TE*999999999~ N3*19 FEDERAL ST 1~ January 2013, Version 6.1 Appendix 4 MassHealth 005010 834 Outbound Companion Guide N4*BOSTON*MA*021000000**CY*070~ DMG*D8*19550414*M**N~ AMT*C1*100.00~ LUI*LE*CHI*7~ NM1*QD*1*RESPONSIBLE PERSON*TESTING*X~ HD*021**HMO*MMMMM~ DTP*348*D8*20110926~ LS*2700~ LX*1~ N1*75*Family~ REF*XX1*40~ DTP*007*RD8*20101006-22991231~ LX*2~ N1*75*MA21 MASSHEALTH ORGANIZATION~ REF*ZZ*MHO~ DTP*007*RD8*19980818-22991231~ LE*2700~ C.4 Example Four - 021 / Daily File; Enrollment Transaction INS*Y*18*021*AI*A***AC**N***R~ REF*0F*100000000000~ REF*1L*STD~ REF*3H*01000000A~ REF*DX*00000ARE~ REF*ZZ*AZNUNKNOW~ DTP*356*D8*20110927~ DTP*357*D8*22991231~ NM1*IL*1*DOE*JANE*L***34*00000000~ PER*IP**TE*508999999*AP*0000000000~ N3*37 FEDERAL ST~ N4*BOSTON*MA*021100000**CY*145~ DMG*D8*19730215*F**C~ AMT*C1*000~ LUI*LE*CHI*7~ NM1*31*1~ N3*P O BOX 000~ N4*NORTHBRIDGE*MA*015340000~ HD*021**HMO*MMMMM~ DTP*348*D8*20110927~ LS*2700~ LX*1~ N1*75*Family~ REF*XX1*40~ DTP*007*RD8*20080528-22991231~ LX*2~ N1*75*MA21 MASSHEALTH ORGANIZATION~ REF*ZZ*MHO~ DTP*007*RD8*20060905-22991231~ LE*2700~ C.5 Example Five - 024 / Daily File; Disenrollment Transaction INS*Y*18*024*AI*A***TE**N~ REF*0F*100000000000~ REF*1L*STD~ REF*3H*00000000A~ REF*DX*00000ADE~ January 2013, Version 6.1 Appendix 5 MassHealth 005010 834 Outbound Companion Guide REF*ZZ*ZZNS.AMER~ DTP*356*D8*20101029~ DTP*357*D8*20110922~ NM1*IL*1*DOE*JANE*V***34*000000000~ PER*IP**TE*999999999~ DMG*D8*19460923*F**7~ AMT*C1*149~ LUI*LE*SPA*7~ HD*024**HMO*MMMMM~ DTP*348*D8*20101029~ January 2013, Version 6.1 Appendix 6 MassHealth 005010 834 Outbound Companion Guide 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. January 2013, Version 6.1 Appendix 7 MassHealth 005010 834 Outbound Companion Guide E. Change Summary This section describes the differences between the current Companion Guide and previous guide(s). Version Date Section/Pages Description 6.0 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. 6.1 12/2012 Section 10, pages 22 and 23 2000 REF01 and 2000 REF02 Provider ID/Svc LOC for BH were added. January 2013, Version 6.1 Appendix 8