Molina Medicaid Solutions

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1 Molina Medicaid Solutions Louisiana Medicaid Management Information Systems (LA MMIS) Vendor Specifications Document for the Claims Status Inquiry System (CSI) April 11, 2011 Version 1.4 Document 0239 EDI-VSD-LA-CSI Prepared by: Molina Medicaid Solutions 477 Viking Drive, Suite 310 Virginia Beach, Virginia 23452

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3 Title: Louisiana Medicaid Management Information Systems (LA MMIS) Vendor Specifications Document for the Claims Status Inquiry System (CSI) EDI-VSD-LA-CSI : Issued: April 11, 2011 Recertified: Supersedes: Version 1.3 dated January 18, 2011 Contact: Neill Alford Approved: Michael Luettel, EDI Solutions Group Manager Signature Date LOUISIANA MEDICAID MANAGEMENT INFORMATION SYSTEMS (LA MMIS) VENDOR SPECIFICATIONS DOCUMENT FOR THE CLAIMS STATUS INQUIRY SYSTEM (CSI) MOLINA MEDICAID SOLUTIONS April 11, 2011

4 Molina Medicaid Solutions and the Louisiana Department of Health and Hospitals Proprietary Notice The information contained in this document is proprietary to Molina Medicaid Solutions and the Louisiana Department of Health and Hospitals. The information in this document shall not be reproduced, shown or disclosed outside the Molina Medicaid Solutions or Louisiana DHH/BHSF without written permission. Information contained in this document is highly sensitive and of a competitive nature. NO WARRANTIES OF ANY NATURE ARE EXTENDED BY THIS DOCUMENT. Any product and related material disclosed herein are only furnished pursuant and subject to the terms and conditions of a duly executed license or agreement to purchase services or equipment. The only warranties made by Molina Medicaid Solutions, if any, with respect to the products, programs or services described in this document are set forth in such license or agreement. Molina Medicaid Solutions cannot accept any financial or other responsibility that may be the result of your use of the information in this document, including but not limited to direct, indirect, special or consequential damages. Exercise caution to ensure the use of this information and/or software material complies with the laws, rules, and regulations of the jurisdictions with the respect to which it is used. The information contained herein is subject to change without notice. Revisions may be issued to advise of such changes and/or additions. April 11, 2011

5 PROJECT INFORMATION Document Title Louisiana Medicaid Management Information System (LA MMIS) Vendor Specifications for CSI Author Technical Communications Group, Molina Medicaid Solutions Revision History Date Description of Change By 7/14/2003 Initial draft Neill Alford 8/29/2006 Updated contact information; formatted per TCG standards; corrected 4.1 from xxx services to CSI services. Randy Sheehan 2/20/2007 Updated for NPI changes Karyn Grimes 4/17/2007 Updated to clarify NPI changes. Cindy Daniel 5/8/2007 Updated with changes from Core Team related to NPI Cindy Daniel 5/28/2007 Changed references to payor to payer spelling for consistency. Updated 13.2 Marketing language to match MEVS change. Updated 14.1 to remove Pharmacy and replace with CSI. 1/11/2011 Changed references to Unisys to Molina Medicaid Solutions Cindy Daniel Medy Alexander 3/15/2011 Updated for 5010 changes Medy Alexander 5/2/2011 Defined Acronym TCP Updated references to NAEC Made clarifications in Section 5 Updated Glossary Cindy Daniel, Medy Alexander, John Dempsey April 11, 2011

6 TABLE OF CONTENTS 1.0 INTRODUCTION OVERVIEW CSI VENDOR QUALIFICATION REQUIREMENTS CSI OPERATIONS SERVICES AND PROCEDURES REGISTRATION FORM TELECOMMUNICATIONS VENDOR CONTRACT CSI VENDOR COMMUNICATIONS SPECIFICATIONS REQUIREMENTS FOR NETWORK CONNECTIONS DEDICATED LINES WAN PROTOCOLS FOR TCP CONNECTIONS NUMBER OF TCP CONNECTIONS TO MMS TRANSACTION PROCESSING SINGLE THREADED/MULTI THREADED TRANSACTION PROCESSING TIMEOUTS HEADER INFORMATION DEFAULT RESPONSE FORMATS COORDINATION WITH MOLINA MEDICAID SOLUTIONS HEALTH CARE CLAIM STATUS TRANSACTION SPECIFICATIONS HEALTH CARE CLAIM STATUS REQUEST HEALTH CARE CLAIM STATUS RESPONSE (OUTPUT) FUNCTIONAL ACKNOWLEDGEMENT (OUTPUT) CLAIM STATUS REQUEST SEARCH CRITERIA CLAIM AND SERVICE LINE INFORMATION MAXIMUM 277 CLAIM STATUS RESPONSE SAMPLE INPUT AND RESPONSES CLAIM STATUS REQUEST EXAMPLES CLAIM RESPONSE EXAMPLE REJECT RESPONSE EXAMPLES REJECT RESPONSE EXAMPLES MAXIMUM RESPONSE REJECT RESPONSE 507/508 CODES ACKNOWLEDMENT CODES MARKETING PROVIDER INFORMATION AVAILABLE TO VENDORS VENDOR MARKETING MATERIAL APPROVAL PROBLEM RESOLUTION CSI AVAILABILITY PROBLEM ESCALATION PROCEDURES GLOSSARY CONTACT INFORMATION April 11, 2011

7 1.0 INTRODUCTION The Molina Medicaid Solutions (MMS) Louisiana Medicaid Management Information System (LA MMIS) provides access for Medicaid providers to verify claim status information in a real time environment, in conjunction with commercial network vendors. Network vendors are provided specifications for the communications interface protocol and ansaction formats. Network vendor software will allow a provider to request a claim status and receive a claim status response using the ANSI ASC X.12 EDI Health Care Claim Status Request ansaction set 276 for inquiry and set 277 for the responses to the claim status inquiry. For HIPAA compliance, version X212 of the X12 telecommunications standards is being used. The Claims Status Inquiry (CSI) system reports claim status information on claims in various acknowledgement stages: pre-adjudication, pended or a finalized stage. Finalized claims are further defined as paid, paid (no payment forth coming) or denied. April 11,

8 2.0 OVERVIEW The CSI system is a real-time multi-faceted product that allows Medicaid providers to inquire on the status of a claim (i.e. paid, deny, pending) and receive response ansactions via personal computer or web applications using the HIPPA compliant Transaction Set 276/277. Vendors who market their services to individual service providers process Claims Status Inquiry requests originated by providers and the corresponding CSI system responses. The Health Care Claim Status requests and associated responses are ansferred using paired ansaction sets in an Eleconic Interchange (EDI) environment, specifically the Health Care Claim Status Request (276) and the Health Care Claim Status (277). The format and data content of these ansaction sets are specified in the National Eleconic Interchange Transaction Set Implementation Guide for Health Care Claim Status Request (276) and (277), ASC X12N 276/277 (005010X212) document. April 11,

9 3.0 CSI VENDOR QUALIFICATION REQUIREMENTS Each telecommunications network vendor must meet the following specifications and criteria prior to being granted authorization to provide Claim Status services: 1. Prospective vendor must have two (2) years of prior experience providing telecommunications network vendor services. erences are required. 2. Prospective vendor must obtain a Vendor ID from Molina Medicaid Solutions. 3. Prospective vendor must sign a telecommunications conact with Molina Medicaid Solutions. 4. Vendor must comply with communications specifications (section 5.0) April 11,

10 4.0 CSI OPERATIONS SERVICES AND PROCEDURES The process for becoming a Louisiana CSI vendor is depicted in Figure 1: MOLINA Decision to be a CSI Telecomunications Vendor for Louisiana Contact Molina and receive the Louisiana CSI Vendor Manual and Regisation Form With DHH approval, sign conactual agreement Procure and Establish a connection with the Western Regional Services Center in accordance with documented specifications. Develop a software product to meet the documented specification Test software connectivity and processing Schedule implementation into the producation system Ready to be an official Louisiana CSI vendor Figure 1 Vendor Certification Process April 11,

11 4.1 REGISTRATION FORM The vendor regisation form notifies Molina Medicaid Solutions that a vendor wants to become an authorized Louisiana CSI vendor and offer CSI services to the provider community. A business contact is requested for conact negotiations, etc. A project conact is requested for the dissemination of information regarding new options, changing requirements, scheduled downtime, vendor conferences, etc. A technical contact may also be listed. The Technical Specifications Information section requests the following information to enable appropriate scheduling. 1. Whether a new or existing telecommunications line to Unisys North American Enterprise Computing (NAEC) facility is to be used for the Louisiana project; 2. Whether an existing telecommunications line upgrade is planned. It should be noted that submittal of the vendor regisation form is not a guarantee that the submitting vendor shall be accepted by the State authority and/or Molina Medicaid Solutions. Submittal of the vendor regisation form in no way obligates the State or Molina Medicaid Solutions regarding the submittal of claims inquiries through Molina Medicaid Solutions CSI program. Please mail the Vendor Regisation form to: Molina Medicaid Solutions 8591 United Plaza Boulevard, Suite 300 Baton Rouge, LA Attn: Gloria Gardner FAX: (225) April 11,

12 Name of Vendor VENDOR REGISTRATION FORM Vendor Proc. ID Mailing Address of Vendor City State Zip Phone FAX Name (Business Contact) LIST OF CONTACTS Phone/FAX Address City/State/ZIP Name (Project Manager) Phone/FAX Address City/State/ZIP Name (Technical Contact) Phone/FAX Address City/State/ZIP TECHNICAL SPECIFICATIONS INFORMATION Marketing & Research Provider Information Requested: Yes: No: Signature (Project Manager) April 11,

13 4.2 TELECOMMUNICATIONS VENDOR CONTRACT Direct questions concerning Vendor Conact status to: Molina Medicaid Solutions 8591 United Plaza Boulevard, Suite 300 Baton Rouge, LA Attn: Gloria Gardner FAX: (225) April 11,

14 5.0 CSI VENDOR COMMUNICATIONS SPECIFICATIONS The vendor communications specifications for the CSI systems are detailed in the following sections. 5.1 REQUIREMENTS FOR NETWORK CONNECTIONS This section describes the requirements for network vendors to be able to send Louisiana Medicaid ansactions for CSI to Molina Medicaid Solutions (MMS). Telecommunications coordination can begin prior to the execution of a Trading Partner agreement with approval from MMS or State Provider Services/Relations. However, no telecommunication equipment or services will be installed or connected without a signed agreement. 5.2 DEDICATED LINES Network vendors are required to provide telecommunications connectivity from their sending facilities to the Unisys North American Enterprise Computing (NAEC) center in Salt Lake City, UT. To set up dedicated lines, network vendors must provide: A terminating CSU/DSU modem and Ethernet routers as appropriate to the line service being provided. A ansceiver and/or cable from the router to the patch panels. The cables must terminate in an RJ45 (CAT 5 UTP recommended). The length of the cable will need to be coordinated with MMS prior to installation. CSU/DSUs and Ethernet router must include rack-mounting hardware for a standard 19 eleconics rack. Note, that the telecommunications DEMARC is located in a separate room approximately 600 feet from the rack housing the CSU/DSU. The connection between the DEMARC and the rack will be provided by MMS. Standard phone wiring will be used unless special arrangements are established prior to installation. 5.3 WAN PROTOCOLS FOR TCP CONNECTIONS MMS uses TCP/IP protocols only. The network vendor is responsible for all IP addressing space up to, but not including the Ethernet interface on the MMS side of the router. The vendor and MMS will provide public routable Ethernet IP addresses unless otherwise negotiated. The vendor s interface will be connected to a non-secure April 11,

15 Ethernet DMZ. Routing protocols such as RIP will not be enabled. Static routes will only be used. Testing with a temporary IP address can be accommodated. 5.4 NUMBER OF TCP CONNECTIONS TO MMS The number of connections to MMS is limited to ensure that all networks are provided equitable service. Normally, network vendors are limited to four (4) connections to each MMS system. A single connection can process ansactions for Point of Sale (POS), Medicaid Eligibility and Verification System (MEVS), and CSI applications. We do not designate connections for any specific application. If additional connections would be beneficial, contact MMS. The specific port number for a network vendor will be assigned by MMS. No other TCP service port should be used. 5.5 TRANSACTION PROCESSING Once a connection is established, it is normally left connected and ansactions are processed when sent. The connection should only be disconnected under error conditions. Each connection can handle multiple simultaneous ansactions. The responses will be returned when processing is completed. Once ansmission of a ansaction has been initiated, all Transmission Conol Protocol (TCP) for those ansactions must be ansmitted before sending packets from any other ansaction. Likewise, MMS will send all packets for a response together. Packets from different responses will not be intermingled. All MMS processing is performed in seam mode. Packets are consucted for convenience in ansmission only. The envelope described in the following section provides an End of Transmission (EOT) flag to identify the end of each ansaction and response. Because of the nature of seams processing, responses will not always be contained in separate packets. The size of the response packet is such that the start of the following response may be in the same packet as the termination of the preceding response. The EOT flag must be scanned to locate properly the end of the responses. 5.6 SINGLE THREADED/MULTI THREADED TRANSACTION PROCESSING MMS supports two types of connections: single-threaded and multi-threaded. These are also called half duplex and full duplex mode, respectively. In a single-threaded connection, once a ansaction is received, MMS will not accept any additional ansactions on that connection until the response has been returned. All ansactions in the single-threaded connections have a timeout response. If for some April 11,

16 reason we are unable to process a ansaction within the timeout period, a timeout response is returned at the end of the timeout period. In a multi-threaded connection, ansactions can be submitted at any time. You do not need to wait until the previous response is returned. However, the order of the responses received may be different than the order of the ansactions that were sent. The returned envelope can be used to associate the response with the ansaction. Timeouts for processing are similar to those for single-threaded except that not all timeouts may result in system unavailable responses. There are conditions where no response will be provided. Should a vendor wish to change their original connection type, a request must be sent to the NAEC Help Desk. The request will be sent to the appropriate technician to make the change. 5.7 TIMEOUTS Timeouts for CSI ansactions are 30 seconds. If the vendor decides to timeout the line earlier than the MMS timeout response and reestablish the connection, they may encounter a situation where MMS will not start up another connection until the first connection has completely dropped. As a result, there may be periods where the vendor will not be able to reestablish the connection immediately. We recommend waiting until the timeout message has been received, or setting the timeout to beyond 30 seconds for CSI ansactions. When a connection is dropped, any ansactions that have been received but not responded to will be effectively lost, because there is no longer any way to return the response, even though these ansactions may have been processed on the MMS system. Network vendors can contact NAEC to have their lines reset. Situations can occur where a connection will come down hard between the network vendor and the MMS system, but the MMS system keeps the connection open. In these situations when the network vendor ies to establish a connection, they will receive a message indicating that they cannot open a new connection because the MMS system believes the network vendor already has the maximum number of connections open. Having the NAEC operators restart a vendor s connection usually takes a second to perform and can be done at the request of the network vendor. 5.8 HEADER INFORMATION CSI ansactions and responses must be placed in envelopes. Transactions submitted by network switches to MMS must be in the following envelope. April 11,

17 A 16 byte header must be prefixed to each ansaction defined by: The first three (3) bytes of the header must be a network switch identifier. The value of the identifier will be assigned by MMS. The next six (6) bytes should contain a ansaction identifier containing any combination of the characters 0-9, A-Z, and a-z, or they must contain all zeros. This ansaction identifier is used by the network switch to match the response with the corresponding request. This is necessary since in multi-threaded mode multiple claims may be processed and the responses are not necessarily returned in the same order the requests were received. If a network switch does not use this ansaction identifier, then the network switch will have to wait for the response to a ansaction before sending the next ansaction. The next seven (7) bytes must be spaces. Each ansaction must be terminated by an EOT flag consisting of a single byte with the binary value 100, which is decimal 04. The response to a ansaction will be returned in the same envelope. The response will be prefixed with the header that was received with the ansaction. If a network switch requires variations in the response header, they must be negotiated with MMS prior to installation. 5.9 DEFAULT RESPONSE FORMATS There are situations where MMS will not be able to process the ansaction. In those situations, a default response will be returned in the received envelope. The format of this response is as follows: ERRORMMISnnnneeeeeee 9 where nnnn is a four-digit message identifier that identifies the reason the claim was not processed; eeeeeee is a seven-digit sequence number that identifies the ansaction within the MMS systems. There are nine spaces after the sequence number. The four-digit message identifiers currently in use are: Application is not currently active April 11,

18 Application is not currently active Application is not currently active Network ID in envelope is not correct Unable to respond within required time limits Application is not authorized Cannot determine the appropriate application Default response not defined for this application COORDINATION WITH MOLINA MEDICAID SOLUTIONS The contact point for coordination of the line parameters and connections is: John Dempsey (805) The contact point for line installation is: Scott Totman (801) The contact point for other communication related issues is: Kermit Patty (225) April 11,

19 6.0 HEALTH CARE CLAIM STATUS TRANSACTION SPECIFICATIONS HEALTH CARE CLAIM STATUS REQUEST The Primary input to the CSI application is the ASC X12 Health Care Claim Status Request (276) version X212 of the X12 telecommunications standards format for Claim Status Inquiry. If the receiver/provider cannot be uniquely identified and cross-walked to a Louisiana Medicaid ID using the National Provider Identifier (NPI) and has not been deemed atypical by Louisiana Medicaid, an error will be returned; A4 35 IP NPI/Provider ID is not found in base. A description of the Format is provided below in Table 1. Symbol R AN ID DT TM Nn Type Decimal Sing Identifier Date Time Numeric Table 1 Claim Status Inquiry (276) Elements ANSI ASC X Transaction Atibutes ISA Interchange Conol Header R ISA01 I01 Authorization Information Qualifier ISA02 I02 Authorization Information 00= No authorization information present (No meaningful information in I02) filled with ten (10) zeroes R ID 2/2 R AN 10/10 April 11,

20 ANSI ASC X Transaction ISA03 I03 Security Information Qualifier ISA04 I04 Security Information ISA05 I05 Interchange ID Qualifier ISA06 I06 Interchange Sender ID ISA07 I05 Interchange ID Qualifier ISA08 I07 Interchange Receiver ID ISA09 I08 Interchange Date (U.S. Cenal Time) ISA10 I09 Interchange Time (U.S. Cenal Time) 00 = No security Information present (No meaningful information in I04) filled with ten (10) zeroes ZZ = Mutually defined as sender s ID in I06 Vendor ID to be used for routing data back to them via ASC X response ZZ = Mutually defined as Receiver s ID Receiver s ID to whom the sender is routing the data: = BIN number for the Molina Medicaid processor. Date of the interchange in YYMMDD format Time in HHMM format Atibutes R ID 2/2 R AN 10/10 R ID 2/2 R AN 15/15 R ID 2/2 R AN 15/15 R DT 6/6 R TM 4/4 April 11,

21 ANSI ASC X Transaction ISA11 I65 Interchange Conol Repetition Separator This field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data sucture; this value must be different than the data element separator, component element separator and the segment terminator. Value is ASCII character 94. Atibutes R 1/1 ISA12 I11 Interchange Conol Version ISA13 I12 Interchange Conol ISA14 I13 Acknowledge ment Requested ISA15 I14 Interchange Usage Indicator ISA16 I15 Sub-element Separator R ID 5/5 that uniquely identifies the interchange data to the sender. The value in ISA13 must match IEA02. R N0 9/9 0 = No R ID 1/1 P = Production data T = Test data. <us> (hexadecimal 1F) R ID 1/1 R 1/1 April 11,

22 ANSI ASC X Transaction Atibutes GS Functional Group Header R GS Functional Header Code GS Application Sender s code GS Application Receiver s Code GS Date (U.S. Cenal Time) GS Time (U.S. Cenal Time) GS06 28 Group Conol GS Responsible Agency Code GS Version/ Release Indusy Identifier Code HR = Health Car e Claim Status Notification (276) Vendor ID Code Identifying party sending ansmission BIN of the Molina Medicaid processor Date in CCYYMMDD format Recommended Time format HHMM. Assigned number originated and maintained by the sender. The value in GS06 must match GE02. X = ASC X12 standard R ID 2/2 R AN 2/15 R AN 2/15 R DT 8/8 R TM 4/8 R N0 1/9 R ID 1/ X212 R AN 1/12 ST Transaction Set Header R April 11,

23 ANSI ASC X Transaction Atibutes ST Transaction Set Identifier Code ST Transaction Set Conol ST Version, Release, or Indusy Identifier Code 276 = Health Care Claim Status Request Identifying conol number that must be unique within ansaction set assigned by originator. Value in ST02 must match SE02. R ID 3/3 R AN 4/ X212 R AN 1/35 BHT Hierarchical Transaction R BHT Hierarchical Sucture Code BHT Transaction Set Purpose Code BHT erence Identification 0010 Information Source, Information Receiver, Provider of Service, Subscriber, dependent R ID 4/4 13 Request R ID 2/2 assigned by the originator to identify the ansaction within the originator s business application system R AN 1/50 April 11,

24 ANSI ASC X Transaction Atibutes BHT Transaction Set Creation Date (U.S. Cenal Time) BHT Transaction Set Creation Time (U.S. Cenal Time) CCYYMMDD R DT 8/8 HHMM R TM 4/8 HL Hierarchical Level Loop R HL Hierarchical ID HL Parent ID HL Hierarchical Level Code HL Hierarchical Child Code 1 R AN 1/12 Null Not Used AN 1/12 20 Information Source 1 Additional Subordinate HL Segment NM1 Information Source Name R NM Entity ID Code NM Entity Type Qualifier NM Organization Name R ID 1/2 R ID 1/1 PR Payer R ID 2/3 2 Non-person R ID 1/1 MOLINA LAMMIS R AN 1/60 NM First Name Null Not used AN 1/35 NM Middle Name Null Not Used AN 1/25 April 11,

25 ANSI ASC X Transaction Atibutes NM Name Prefix Null Not Used AN 1/10 NM Name Suffix Null Not Used AN 1/10 NM Identification Code Qualifier NM Identification Code PI Payer Identification BIN HL Hierarchical Level R HL Hierarchical ID HL Hierarchical Parent ID HL Hierarchical Level Code HL Hierarchical Child Code R ID 1/2 R AN 2/80 2 R AN 1/12 1 R AN 1/12 21 Information Receiver R ID 1/2 1 R ID 1/1 NM1 Information Receiver Name R NM Entity Identifier Code NM Entity Type Qualifier 41 Submitter R ID 2/3 1 Person 2 Non-person R ID 1/1 April 11,

26 ANSI ASC X Transaction Atibutes NM Last Name or Organization Name Last Name, (if the identifier in NM109 is not sufficient to identify the Information Receiver) S AN 1/60 NM First Name (if NM102 is 1) S AN 1/35 NM Middle Name (if NM102 is 1) S AN 1/25 NM Name Prefix Null - Not Used AN 1/10 NM Name Suffix Null Not Used AN 1/10 NM Identification Code Qualifier NM Identification Code 46 ETIN R ID 1/2 Information Receiver Identification HL Service Provider Level R HL Hierarchical ID HL Hierarchical Parent ID HL Hierarchical Level Code HL Hierarchical Child Code R AN 2/80 3 R AN 1/12 2 R AN 1/12 19 Provider of Service R ID 1/2 1 R ID 1/1 NM1 Provider Name R April 11,

27 ANSI ASC X Transaction Atibutes NM Entity Identifier Code NM Entity Type Qualifier NM Last Name or Organization Name 1P Provider R ID 2/3 1 Person 2 Non-person Last name (if the identifier in NM109 is not sufficient to identify the Provider) R ID 1/1 S AN 1/60 NM First Name (if NM102 is 1) S AN 1/35 NM Middle Name (if NM102 is 1) S AN 1/25 NM Name Prefix NULL not used AN 1/10 NM Name Suffix (if NM102 is 1) S AN 1/10 NM Identification Code Qualifier NM Identification Code XX National Provider Identifier (NPI) SV Service Provider (for atypical providers) Provider Identification Code HL Subscriber Level R HL Hierarchical ID R ID 1/2 R AN 2/80 4 R AN 1/12 April 11,

28 ANSI ASC X Transaction Atibutes HL Hierarchical Parent ID HL Hierarchical Level Code HL Hierarchical Child Code DMG DMG Date Time Period Format Qualifier DMG Recipient Date of Birth 3 R AN 1/12 22 Subscriber R ID 1/2 0 No Subordinate HL Segments Subscriber Demographic Information D8 CCYYMMDD Subscriber Birth Date - CCYYMMDD format DMG Gender Code F Female M Male NM1 Subscriber Name R NM Entity Identifier Code NM Entity Type Qualifier IL Insured or Subscriber NM Last Name Subscriber Last Name NM First Name Subscriber First Name if person has first name R ID 1/1 R The subscriber is the patient R ID 2/3 R AN 1/35 S ID 1/1 R ID 2/3 1 Person R ID 1/1 R AN 1/60 S AN 1/35 April 11,

29 ANSI ASC X Transaction Atibutes NM Middle Name Subscriber Middle Name if person has middle name or initial S AN 1/25 NM Name Prefix NULL Not Used AN 1/10 NM Name Suffix if NM102 = 1 (Under most circumstances, this is not sent) NM Identification Code Qualifier NM Identification Code MI Member ID Recipient ID (Subscriber Identifier) TRN Claim Status Tracking R TRN Trace Type Code TRN erence Identification 1 current ansaction ace number Trace from the originator of the ansaction to be returned by the receiver of the ansaction. REF Payer Claim Conol S REF erence ID Qualifier 1K Payor s Claim. S AN 1/10 R ID 1/2 R AN 2/80 Required When The subscriber is the patient R ID 1/2 R AN 1/50 Use if the subscriber is the Patient R ID 2/3 April 11,

30 ANSI ASC X Transaction Atibutes REF erence ID Payer Claim Conol LAMMIS ICN REF REF erence ID Qualifier Institutional Bill Type ID BLT Billing Type. REF erence ID Bill Type Identifier Found on UB92 record Found on 837 CLM-05. Found on UB92 paper form locator 4. Required for Institutional claims Inquires. AMT Claim Submitted Charges R AMT Amount Qualifier Code AMT Monetary Amount T3 Total Submitted Charges Total Claim Charge Amount DTP Claim Service Date S DTP Date/Time Qualifier DTP Date Time Period Format Qualifier R AN 1/50 S Send When Subscriber is the Patient R ID 2/3 R AN 1/50 The subscriber is the patient R ID 1/3 R R 1/18 If not here, then must use Service Line Date below 472 Service Date R ID 3/3 RD8 - range of dates D8 single date R ID 2/3 April 11,

31 ANSI ASC X Transaction Atibutes us us us us DTP Date Time Period SVC01-1 SVC01-2 SVC01-3 SVC01-4 Service Period Date in format CCYYMMDD- CCYYMMDD or CCYYMMDD SVC Service Line Information S 235 Product/ Service ID Qualifier 234 Product/ Service ID 1339 Procedure Modifier 1339 Procedure Modifier AD ADA Code HC HCPCS Code N4 National Drug Code (NDC) in Format NU NUBC Revenue Code WK Advanced Billing Concepts (ABC) codes Service ID Code if SVC01-1 is NU, then this element contains the NUBC Revenue Code and SVC04 is not used Required if submitted on original claim service line Required if submitted on original claim service line R AN 1/35 Use this segment to request status information about a service line. R ID 2/2 R AN 1/48 S AN 2/2 S AN 2/2 April 11,

32 ANSI ASC X Transaction Atibutes us SVC01-5 SVC Procedure Modifier 1339 Procedure Modifier SVC Monetary Amount SVC Monetary Amount SVC Product/ Service ID Required if submitted on original claim service line Required if submitted on original claim service line Line Item Charge Amount S AN 2/2 S AN 2/2 R R 1/18 Null Not Used R 1/18 Revenue Code NUBC revenue code belon in SVC01-2 S AN 1/48 SVC Quantity Null Not Used R 1/15 SVC06 C003 Composite Medical Procedure ID Null Not Used SVC Quantity Units of service count. The default is 1. Use this element for values greater than 1. REF Service Line Item Identification S REF erence ID Qualifier FJ = Line Item Conol REF erence ID Line Item Conol R R 1/15 Required when available from original claim (not used) R ID 2/3 R AN 1/50 April 11,

33 ANSI ASC X Transaction Atibutes DTP Service Line Date S DTP Date/Time Qualifier DTP Date Time Period Format Qualifier DTP Date Time Period If not here, then must use Claim Service Date above 472 Service R ID 3/3 RD8 Range of Dates D8 Single Date Service line date in format CCYYMMDD CCYYMMDD or CCYYMMDD SE Transaction Set Trailer R SE01 96 of Included Segments SE Transaction Set Conol Total number of segments included in the ansaction set, including ST and SE segments. Value in SE02 must match ST02. R ID 2/3 R AN 1/35 R N0 1/10 R AN 4/9 GE Functional Group Trailer R GE01 97 of Transaction Sets Included Will always be one (1). R N0 1/6 GE02 28 Group Conol The value in GE02 must match GS06. IEA Interchange Trailer R R N0 1/9 April 11,

34 ANSI ASC X Transaction IEA01 I16 of Included Functional Groups IEA02 I12 Interchange conol This will always be one (1). The value in IEA02 must match ISA13. Atibutes R N0 1/5 R N0 9/9 April 11,

35 HEALTH CARE CLAIM STATUS RESPONSE (OUTPUT) The Primary from CSI application is the ANSI X12 Health Care Claim Status (277) version X212 of the X12 telecommunications standards format for Claim Status Inquiry (276) request. A description of the format is provided below in Table 2. Symbol R AN ID DT TM Nn Type Decimal Sing Identifier Date Time Numeric Table 2 Claim Status (277) Elements ANSI ASC X Transaction Atibutes ISA Interchange Conol header R ISA01 I01 Authorization Information Qualifier ISA02 I02 Authorization Information ISA03 I03 Security Information Qualifier 00= No authorization information present (No meaningful information in I02) filled with ten (10) zeroes. 00 = No security Information present (No meaningful information in I04) R ID 2/2 R AN 10/10 R ID 2/2 April 11,

36 ANSI ASC X Transaction Atibutes ISA04 I04 Security Information ISA05 I05 Interchange ID Qualifier ISA06 I06 Interchange Sender ID ISA07 I05 Interchange ID Qualifier ISA08 I07 Interchange Receiver ID ISA09 IO8 Interchange Date (U.S. Cenal Time) ISA10 I09 Interchange Time (U.S. Cenal Time) filled with ten (10) zeroes. ZZ = Mutually defined as sender s ID in I Bin. ISA06 must match GS02. ZZ = Mutually defined as Receiver s ID R AN 10/10 R ID 2/2 R AN 15/15 R ID 2/2 Vendor ID R ID 15/15 Date of Interchange in YYMMDD format Time of Interchange in HHMM format R DT 6/6 R TM 4/4 April 11,

37 ANSI ASC X Transaction Atibutes ISA11 I65 Interchange Conol Repetition Separator This field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data sucture; this value must be different than the data element separator, component element separator and the segment terminator. Value is ASCII character 94. R 1/1 ISA12 I11 Interchange Conol Version ISA13 I12 Interchange Conol ISA14 I13 Acknowledge ment Requested R ID 5/5 that uniquely identifies the interchange data to the sender. The value in ISA13 must match IEA02. ISA15 I14 Test Indicator P = Production data T = Test data. ISA16 I15 Sub-element Separator R N0 9/9 0 = No R ID 1/1 <us> (hexadecimal 1F) R ID 1/1 R AN 1/1 April 11,

38 ANSI ASC X Transaction Atibutes GS Functional Group Header R GS Functional Header Code GS Application Sender s code GS Application Receiver s Code GS Date (U.S. Cenal Time) GS Time (U.S. Cenal Time) GS06 28 Group Conol GS Responsible Agency Code GS Version/ Release Indusy Identifier Code HN = Health Care Claim Status Notification (277) Bin. Must match value for ISA06 R ID 2/2 R AN 2/15 Vendor ID R AN 2/15 Date in CCYYMMDD format Time format HHMM. Assigned number originated and maintained by the sender. The value in GS06 must match GE02. X = ASC X12 standard R DT 8/8 R TM 4/8 R N0 1/9 R ID 1/ X212 R AN 1/12 ST Transaction Set Header R April 11,

39 ANSI ASC X Transaction Atibutes ST Transaction Set Identifier Code ST Transaction Set Conol ST Version, Release or Indusy Identifier 277 = Health Care Claim Status Notification Identifying conol number that must be unique within ansaction set assigned by Molina. Value in ST02 must match SE02. R ID 3/3 R AN 4/ X212 R AN 1/35 BHT Hierarchical Transaction R BHT Hierarchical Sucture Code BHT Transaction Set Purpose Code 0010 Information Source, Information Receiver, Provider of Service, Subscriber, dependent R ID 4/4 08 Status R ID 2/2 April 11,

40 ANSI ASC X Transaction Atibutes BHT erence Identification BHT Transaction Set Creation Date (U.S. Cenal Time) BHT Transaction Set Creation Time (U.S. Cenal Time) BHT Transaction Type Code Originator Application Transaction Identifier assigned by the originator will contain the Trace from the associated 276 ansaction s TRN02. R AN 1/50 CCYYMMDD R DT 8/8 HHMM R TM 4/8 DG R ID 2/2 HL Hierarchical Level Loop R HL Hierarchical ID HL Parent ID HL Hierarchical Level Code HL Hierarchical Child Code 1 R AN 1/12 Null Not Used AN 1/12 20 Information Source 1 Additional Subordinate HL Segment R ID 1/2 R ID 1/1 April 11,

41 ANSI ASC X Transaction Atibutes NM1 Information Source Name R NM Entity ID Code NM Entity Type Qualifier NM Organization Name PR Payer R ID 2/3 2 Non-person R ID 1/1 MOLINA LAMMIS R AN 1/60 NM First Name Null Not Used AN 1/35 NM Middle Name Null Not Used AN 1/25 NM Name Prefix Null Not Used AN 1/10 NM Name Suffix Null Not Used AN 1/10 NM Identification Code Qualifier NM Payer Identifier PI Payer Identification BIN PER Payer Contact Information S PER Contact Function Code IC Information Contact R ID 1/2 R AN 2/80 Used When the 507/508 returned values indicate an Error R ID 2/2 PER02 93 Name Null Not Used AN 1/60 PER Comm. Qualifier TE Telephone R ID 2/2 April 11,

42 ANSI ASC X Transaction Atibutes PER Comm. PER Comm. Qualifier PER Comm. Molina Medicaid Solutions POC Telephone format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number EX Telephone Extension Molina Medicaid Solutions POC Telephone Extension If required the extension of the Molina Medicaid Solutions POC telephone number R AN 1/256 S ID 2/2 S AN 1/256 HL Hierarchical Level R HL Hierarchical ID HL Hierarchical Parent ID HL Hierarchical Level Code HL Hierarchical Child Code 2 R AN 1/12 1 R AN 1/12 21 Information Receiver R ID 1/2 1 R ID 1/1 April 11,

43 ANSI ASC X Transaction Atibutes NM1 Information Receiver Name R NM Entity Identifier Code NM Entity Type Qualifier NM Last Name or Organization Name 41 Submitter R ID 2/3 1 Person 2 Non-person Last Name, (if NM102 is 1) Organization name (if NM102 is 2) R ID 1/1 S AN 1/60 NM First Name (if NM102 is 1) S AN 1/35 NM Middle Name (if NM102 is 1) S AN 1/25 NM Name Prefix Null not used AN 1/10 NM Name Suffix Null not used AN 1/10 NM Identification Code Qualifier 46 Eleconic Transmitter Identification (ETIN) R ID 1/2 NM Identification Code Information Receiver Identification R AN 2/80 HL Service Provider Level R HL Hierarchical ID 3 R AN 1/12 April 11,

44 ANSI ASC X Transaction Atibutes HL Hierarchical Parent ID HL Hierarchical Level HL Hierarchical Child Code 2 R AN 1/12 19 Provider of Service R ID 1/2 1 R ID 1/1 NM1 Provider Name R NM Entity Identifier Code NM Entity Type Qualifier NM Last Name or Organization Name 1P Provider R ID 2/3 1 Person 2 Non-person Last name (if NM102 is 1) or Organization name (if NM102 is 2) R ID 1/1 S AN 1/60 NM First Name (if NM102 is 1) S AN 1/35 NM Middle Name (if NM102 is 1) S AN 1/25 NM Name Prefix Null not used AN 1/10 NM Name Suffix (if NM102 is 1) S AN 1/10 NM Identification Code Qualifier XX National Provider Identifier (NPI) SV Service Provider (for atypical providers. ) R ID 1/2 April 11,

45 ANSI ASC X Transaction Atibutes NM Identification Code Provider Identification Code R AN 2/80 HL Subscriber Level R HL Hierarchical ID HL Hierarchical Parent ID HL Hierarchical Level Code HL Hierarchical Child Code 4 R AN 1/12 3 R AN 1/12 22 Subscriber R ID 1/2 0 No Subordinate HL Segments NM1 Subscriber Name R NM Entity Identifier Code NM Entity Type Qualifier NM Last Name or Organization IL Insured or Subscriber 1 Person 2 Non-Person Entity Subscriber Last Name NM First Name Subscriber First Name if person has first name NM Middle Name Subscriber Middle Name if person has middle name or initial R ID 1/1 R ID 2/3 R ID 1/1 R AN 1/60 S AN 1/35 S AN 1/25 April 11,

46 ANSI ASC X Transaction Atibutes us us NM Name Prefix Null not used AN 1/10 NM Name Suffix Only if NM102 = 1 S AN 1/10 NM Identification Code Qualifier NM Identification Code MI Member ID Recipient ID (Subscriber Identifier) TRN Claim Status Tracking R TRN Trace Type Code TRN erence Identification STC01-1 STC01-2 STC erenced ansaction ace number Trace corresponding 276 Trace. STC Claim Level Status Information R R ID 1/2 R AN 2/80 The subscriber is the patient R ID 1/2 R AN 1/ Indusy Code Code source 507 R AN 1/ Indusy Code Code Source 508 R AN 1/30 98 Entity Identifier Code 1P Provider 13 Conacted Service Provider 1I PPO CK Pharmacist 80 Hospital S ID 2/3 April 11,

47 ANSI ASC X Transaction Atibutes STC Date (U.S. Cenal Time) Status information effective date in CCYYMMDD format R DT 8/8 STC Action Code Null Not Used ID 1/2 STC Monetary Amount STC Monetary Amount STC Date (U.S. Cenal Time) STC Payment Method Code STC Date (Us Cenal Time) STC Check Total Claim Charge Amount Claim Payment Amount Adjudication or Payment date in CCYYMMDD format if payment determination is complete. S R 1/18 S R 1/18 S DT 8/8 Null not used ID 3/3 Remittance Date - Check issue or EFT date. Remittance Trace - Check or EFT Trace number (if paid) LA will return the remit number S DT 8/8 S AN 1/16 April 11,

48 ANSI ASC X Transaction Atibutes us us us us STC10 C043 Health Care Claim Status S Used if a second claim status is needed. LA will return multiple explanation of benefits when needed for clarification STC Indusy Code Code Source 507 R AN 1/30 STC10-2 STC Indusy Code Code Source 508 R AN 1/30 98 Entity Identifier Code 1P - Provider 13 Conacted Service Provider 1I PPO CK Pharmacist 80 Hospital S ID 2/3 STC11 C043 Health Care Claim Status S Used if a third claim status is needed. LA will return multiple explanation of benefits when needed for clarification STC Indusy Code Code Source 507 R AN 1/30 STC11-2 STC Indusy Code Code Source 508 R AN 1/30 98 Entity Identifier Code 1P - Provider 13 Conacted Service Provider 1I PPO CK Pharmacist 80 Hospital S ID 2/3 April 11,

49 ANSI ASC X Transaction Atibutes REF Payer Claim Conol S REF erence ID Qualifier 1K Payor s Claim. REF erence ID Payer Claim Conol LAMMIS ICN REF Institutional Bill Type ID S REF erence ID Qualifier REF erence ID If Subscriber is the Patient. R ID 2/3 R AN 1/50 Send When Subscriber is the Patient and data is found in Claim History BLT Billing Type. R ID 2/3 Bill Type Identifier Found on UB92 record Found on 837 CLM-05. Found on UB92 paper form locator 4. Required for Institutional claims Inquires. REF Patient Conol S REF erence ID Qualifier R AN 1/50 When available from original claim (echoes data received in 276) EJ- Patient Account R ID 2/3 April 11,

50 ANSI ASC X Transaction Atibutes REF erence ID Patient Conol REF Pharmacy Prescription S REF erence ID Qualifier REF erence ID REF REF R AN 1/50 When available from original claim (echoes data received in 276) XZ- Pharmacy Prescription R ID 2/3 Pharmacy Prescription Claim Identification for Clearinghouses and Other Transmission Intermediaries erence ID Qualifier REF erence ID R AN 1/50 S When available from original claim (echoes data received in 276) D9 Claim R ID 2/3 Clearinghouse Trace DTP Claim Service Date S DTP Date/Time Qualifier R AN 1/50 If not here, then will be in Service Line Date below 472 Service Date R ID 3/3 April 11,

51 ANSI ASC X Transaction Atibutes us us DTP Date Time Period Format Qualifier DTP Date Time Period SVC01-1 SVC01-2 RD8 if date is a single date of service, then begin date equals the end date. Claim Service Period in format CCYYMMDD- CCYYMMDD SVC Service Line Information S 235 Product/ Service ID Qualifier 234 Product/ Service ID AD ADA Code HC HCPCS Code HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code N4 National Drug Code (NDC) in Format NU NUBC Revenue Code WK Advanced Billing Concepts (ABC) Codes Service ID Code if SVC01-1 is NU, then this element contains the NUBC Revenue Code and SVC04 is not used R ID 2/3 R AN 1/35 This segment is used in response for information about a service line R ID 2/2 R AN 1/48 April 11,

52 ANSI ASC X Transaction Atibutes us us us SVC01-3 SVC01-4 SVC01-5 SVC Procedure Modifier 1339 Procedure Modifier 1339 Procedure Modifier 1339 Procedure Modifier SVC Monetary Amount SVC Monetary Amount SVC Product/ service ID Identifies special circumstances related to the performance of the service Identifies special circumstances related to the performance of the service Identifies special circumstances related to the performance of the service Identifies special circumstances related to the performance of the service Line Item Charge Amount Line Item Provider Payment Amount Revenue Code NUBC revenue code belon in SVC01-2. When SVC01-1 = NU, this element is not used. S AN 2/2 S AN 2/2 S AN 2/2 S AN 2/2 R R 1/18 R R 1/18 S AN 1/48 SVC Quantity Null Not Used R 1/15 April 11,

53 ANSI ASC X Transaction Atibutes SVC06 C003 Composite Medical Procedure Identifier Null Not Used SVC Quantity Units of service count. R R 1/15 us us STC01-1 STC01-2 STC01-3 STC Service Line Status Information S 1271 Indusy Code Code Source 507 R AN 1/ Indusy Code Code Source 508 R AN 1/30 98 Entity Identifier Code STC Date (U.S. Cenal Time) 1P Provider 13 Conacted Service Provider 1I PPO CK Pharmacist 80 Hospital Status information effective date in CCYYMMDD format S ID 2/3 R DT 8/8 STC Action Code Null Not Used ID 1/2 STC Monetary Amount STC Monetary Amount Null Not Used R 1/18 Null Not Used R 1/18 STC Date Null Not Used DT 8/8 STC Payment Method Code Null Not Used ID 3/3 April 11,

54 ANSI ASC X Transaction Atibutes us us us us STC Date Null Not Used DT 8/8 STC Check Null Not Used AN 1/16 STC10 C043 Health Care Claim Status S Used if a second claim status is needed. LA will return multiple explanation of benefits when needed for clarification STC Indusy Code Code Source 507 R AN 1/30 STC10-2 STC10-3 STC11 STC11-1 STC Indusy Code Code Source 508 R AN 1/30 98 Entity Identifier Code 1P = Provider 13 Conacted Service Provider 1I PPO CK Pharmacist 80 Hospital S ID 2/3 C043 Used if a third Health Care Claim Status S claim status is needed. LA will return multiple explanation of benefits when needed for clarification 1271 Indusy Code Code Source 507 R AN 1/ Indusy Code Code Source 508 R AN 1/30 April 11,

55 ANSI ASC X Transaction Atibutes STC Entity Identifier Code 1P = Provider 13 Conacted Service Provider 1I PPO CK Pharmacist 80 Hospital REF Service Line Item Identification S REF erence ID Qualifier REF erence Identification FJ = Line Item Conol Line Item Conol DTP Service Line Date S DTP Date/Time Qualifier DTP Date Time Period Format Qualifier DTP Date Time Period S ID 2/3 Required when available from original claim (echoes data received in 276) R ID 2/3 R AN 1/50 If not here, then will be in Claim Service Date above 472 Service R ID 3/3 RD8 Range of Dates if single date, start date equals end date. Service line date in format CCYYMMDD CCYYMMDD SE Transaction Set Trailer R R ID 2/3 R AN 1/35 April 11,

56 ANSI ASC X Transaction Atibutes SE01 96 if Included Segments SE Transaction Set Conol Total number of segments included in the ansaction set, including ST and SE segments. Value in SE02 must match ST02. R N0 1/10 R AN 4/9 GE Functional Group Trailer R GE01 97 of Transaction Sets Included Will always be one (1). R N0 1/6 GE02 28 Group Conol The value in GE02 must match GS06. IEA Interchange Trailer R IEA01 I16 of Included Functional Groups IEA02 I12 Interchange conol Will always be one (1). The value in IEA02 must match ISA13. R N0 1/9 R N0 1/5 R N0 9/9 April 11,

57 FUNCTIONAL ACKNOWLEDGEMENT (OUTPUT) The Functional Acknowledgment (997) is used to acknowledge the receipt of a Health Care Payer Unsolicited Claim Status. CSI application will use 997 acknowledgements to acknowledge formatting error in Header, Detail and Trailer level. CSI will be able to send up to 25 formatting errors. A description of the format is provided below in Table 3. Symbol AN ID DT TM Nn Type Sing Identifier Date Time Numeric Table 3 Functional Acknowledgment (997) Elements ANSI ASC X Acknowledgment Atibutes ISA Interchange Conol header R ISA01 I01 Authorization Information Qualifier ISA02 I02 Authorization Information ISA03 I03 Security Information Qualifier ISA04 I04 Security Information 00= No authorization information present (No meaningful information in I02) filled with ten (10) zeroes. 00 = No security Information present (No meaningful information in I04) filled with ten (10) zeroes. R ID 2/2 R AN 10/10 R ID 2/2 R AN 10/10 April 11,

58 ANSI ASC X Acknowledgment Atibutes ISA05 I05 Interchange ID Qualifier ISA06 I06 Interchange Sender ID ISA07 I05 Interchange ID Qualifier ISA08 I07 Interchange Receiver ID ISA09 IO8 Interchange Date (U.S. Cenal Time) ISA10 I09 Interchange Time (U.S. Cenal Time) ISA11 I65 Interchange Conol Standards Identifier ZZ = Mutually defined as sender s ID in I Bin. ISA06 must match GS02. ZZ = Mutually defined as Receiver s ID R ID 2/2 R AN 15/15 R ID 2/2 Vendor ID R ID 15/15 Date of Interchange in YYMMDD format Time of Interchange in HHMM format This field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data sucture; this value must be different than the data element separator, component element separator and the segment terminator. Value is ASCII character 94. R DT 6/6 R TM 4/4 R ID 1/1 April 11,

59 ANSI ASC X Acknowledgment Atibutes ISA12 I11 Interchange Conol Version ISA13 I12 Interchange Conol ISA14 I13 Acknowledge ment Requested R ID 5/5 that uniquely identifies the interchange data to the sender. The value in ISA13 must match IEA02. ISA15 I14 Test Indicator P = Production data T = Test data. ISA16 I15 Sub-element Separator R N0 9/9 0 = No R ID 1/1 <us> (hexadecimal 1F) GS Functional Group Header R GS Functional Header Code GS Application Sender s code GS Application Receiver s Code GS Date (U.S. Cenal Time) FA = Functional Acknowledgment (997) Bin. Must match value for ISA06 R ID 1/1 R AN 1/1 R ID 2/2 R AN 2/15 Vendor ID R AN 2/15 Date in CCYYMMDD format R DT 8/8 April 11,