Real Time Transactions Companion Guide

Transcription

1 Real Time Transactions Companion Guide Health Care Eligibility Benefit Inquiry and Response ASC X12N X279A1 270/271 Health Care Claim Status Request and Response ASC X12N X212A1 276/277 Capario s Proprietary Health Care Eligibility Benefit Inquiry and Response Capario s ELIG_PIPE_DELIMITED/ELIG_CUSTOM_XML_FORMAT Page 1 of 20

2 Table of Contents Real Time Transactions Companion Guide... 1 Health Care Eligibility Benefit Inquiry and Response... 1 Health Care Claim Status Request and Response... 1 Capario s Proprietary Health Care Eligibility Benefit Inquiry and Response Introduction Capario Real Time Implementation Steps Communications... 5 The following section describes each connectivity option in detail CORE II Complaint Connection... 5 CORE II HTTPS and SOAP Metadata requirement:... 6 CORE II Compliant Production URLs:... 7 CORE II Specific System/Error Messages:... 7 Capario HTTPS POST... 7 Production URL for ANSI X12N Transaction submitters:... 7 Production URL for Capario Proprietary Eligibility Transaction submitters:... 7 Batch Protocol Using Secure File Transfer... 7 Processing Timeframe... 8 Batch Size... 8 Batch Formatting ANSI X12 Real Time Elements... 8 Interchange Control Header (ISA)... 8 Functional Group Header... 9 Beginning of Hierarchical Transaction... 9 Delimiters... 9 Transaction Specific Information - Applicable to All Real Time Transactions Eligibility Benefit Request Claim Status Request and Response Capario Proprietary Eligibility Real Time Parameters Delimiters Transaction Specific Information - Applicable to All Real Time Transactions Capario Proprietary Eligibility Benefit Request Capario Proprietary Eligibility Response Scheduled and Unscheduled Maintenance Downtime Frequently Asked Questions Getting Started Page 2 of 20

3 Troubleshooting Appendix C / 2110D EQ01 Service Type Code List C / 2110D EB01 Code list Request Validation AAA03 Code list D/E and 2220D/E Claim/Service Line Level Status Information code lists (STC01-1 and 01-2) Eligibility 4010 to 5010 Side-By-Side Download: Claim Status Inquiry 4010 to 5010 Side-By-Side Download: Capario s 4010 to 5010 translation business rules for 270/271 and 276/ Page 3 of 20

4 1. Introduction This implementation guide is for users working with Capario for real time and batch transactions. Users of this guide will need to have: A complete understanding of, and experience with, the ANSI ASC X12 Implementation Guides. A detailed knowledge and implementation experience with at least one of the following protocols - HTTPS, CORE II compliant HTTPS multi-part MIME, CORE II compliant SOAP, SFTP, and FTPS protocols. This information in this guide is: Specific to the following transactions A supplement to the transaction implementation guides of these transactions. o ANSI ASC X12N X212A1 276/277 Health Care Claim Status Request/Response o ANSI ASC X12N X279A1 270/271 Health Care Eligibility Benefit Inquiry/Response Capario s implementation guide for Capario s proprietary eligibility request and response. o ELIG_PIPE_DELIMITED Health Care Eligibility Benefit Inquiry o ELIG_CUSTOM_XML_FORMAT Health Care Eligibility Benefit Response Key Implementation Milestones: Select and implement a communications protocol Select and implement a transaction type Review payer list, select payers, and review payer search option documentation Create and test transactions with Capario EDI Implementation Team Production testing Move to Production Status 2. Capario Real Time Implementation Steps You will work with a Capario EDI analyst to complete most of these steps: a) Review this User Guide b) Work with the Capario EDI analyst to determine your communication protocol. Review the communications section of this guide for more information on available communication protocols. Capario will issue a logon and password for transaction testing. c) Identify the payers and transactions Identify transactions: Eligibility (270/271), Claim Status Inquiry (276/277), or both Identify transaction format: ANSI X12 Eligibility (270/271) or Capario Proprietary Eligibility (ELIG_PIPE_DELIMITED/ELIG_CUSTOM_XML_FORMAT) To view and/or download the Capario Real Time Payer Click here Review individual transaction search options documents linked on the payer list Some payers require enrollment for Real Time transactions d) Format test your transactions with the Capario EDI analyst to verify it meets basic transaction and payer requirements For ANSI X12, implement Interchange requirements (ISA, GS, BHT segments) as defined in the ANSI X12 Real Time elements section. For Capario Proprietary Eligibility, implement HTTP POST parameters as defined in the Capario Proprietary Real Time parameters section. Page 4 of 20

5 e) Test Connectivity Create test transaction(s) for connection testing The Capario EDI Team will provide information needed to submit test transactions (URL or FTP information). f) Production Testing Production data is submitted to the selected communication platform and then on to the payer s production system. This allows you to see real responses and get an idea of payer nuances, benefit details returned by a payer, etc. Please limit your test transactions to 100. Transactions submitted over the limit of 100 are subject to billing. Any data content or format issues should be addressed prior to moving to production status. It is recommended that you test all payers/transactions expected to be used g) Production Monitoring Production monitoring begins once you can successfully submit transactions and receive valid responses from the selected payer(s). Monitoring continues for 30 days, The EDI analyst will handle all production issues during this 30-day period. h) EDI Support Services The Capario EDI analyst will provide you with appropriate contact information and escalation procedures for ongoing support. 3. Communications Capario offers following connectivity options: a) ANSI Format Transactions in Real-Time mode, where client submits single eligibility/claim Status Inquiry request and response is returned in the same session: a. CORE II Compliant connection (either HTTPS multi-part MIME or SOAP). b. Capario HTTPS Post b) Capario Proprietary Eligibility Format Transactions in Real-Time mode, where client submits single eligibility/claim Status Inquiry request and response is returned in the same session: a. Capario HTTPS POST c) ANSI Format Transactions in Batch mode, where client submit multiple eligibility/claim Status Inquiry requests in a file and responses are processed offline: a. SFTP (Secure File Transfer Protocol) The following section describes each connectivity option in detail. CORE II Complaint Connection The Council for Affordable Quality Healthcare (CAQH) launched the Committee on Operating Rules for Information Exchange (CORE) with the vision of giving providers access to eligibility and benefits information before or at the time of service using the electronic system of their choice for any patient or health plan. CORE is more than 115 industry stakeholders health plans, providers, vendors, CMS and other government agencies, associations, regional entities, standard-setting organizations and other healthcare entities. CORE participants maintain eligibility and benefits data for more than 130 million commercially insured lives plus Medicare and Medicaid beneficiaries. Working in collaboration they are building consensus on a set of operating rules that will: Enhance interoperability between providers and payers Streamline eligibility, benefits, and claim data transactions Page 5 of 20

6 Reduce the amount of time and resources providers spend on administrative functions time better spent with patients. For more information regarding CORE, please visit Capario offers 2 (two) protocols for CORE compliant communications for ANSI X12 transactions: HTTPS multipart MIME SOAP For both protocols authentication is completed via a logon and password issued by your Capario EDI analyst. CORE II HTTPS and SOAP Metadata requirement: Field Name Description Format Example One of these values: X212A1 for CSI 276/277 Payload Type specifies the type Payload Transactions of payload included within a Type X279A1 for ELG request 270/271 Transactions Processing Mode PayloadID TimeStamp UserName Password Processing Mode indicates Batch or Real Time processing mode. This is an Identifier that you will use to identify the request submitted. Time and Date specifying when a message is created and sent to a receiver. This is the user name to log into the account. A Password will be associated with the User which allows a request to complete. Your User ID will be assigned. This is the password that pairs with the User field to allow access to the Eligibility request system. Your password will be assigned. Value will be: Real Time AlphaNumeric, may contain hyphen. Universal Time (UTC) time /#dateTime 8-10 AlphaNumeric characters. Case sensitive AlphaNumeric characters. Case sensitive. SenderID Capario submitter ID/Client ID 8 AlphaNumeric characters. ReceiverID Capario s Tax ID 9 Numeric CORERuleV ersion Payload The CORE Rule version that this envelope is using. This value can be used to maintain backward compatibility when parsing/processing messages. This contains the file with the X request data HIPAA X Compliant Real Time Capario issued user name Capario issued password. Capario s Tax ID is: Page 6 of 20

7 CORE II Compliant Production URLs: SOAP WSDL (Web Service Description Language) HTTP Multipart Mime CORE II Specific System/Error Messages: The following are the different message responses and error notifications that may be received when submitting CORE II compliant requests. HTTP 200 OK - Returned when authorization is passed and interface is successful with the real time production system. A response with X12 data content will be returned. HTTP 403 Forbidden - If the username and/or password included in the request are not valid an HTTP 403 Forbidden error response with no data will be returned. Server Errors - When the real time production system is not able to process a real-time request due to interface failures or other system unavailability a standard 5xx series error such as HTTP 500 Internal Server Error or HTTP 503 Service will be returned by the application. In this scenario, the submitter will need to resubmit the request once the error has been resolved. Capario HTTPS POST Long before industry adopted CORE compliant communication standards, Capario has supported real-time connectivity using HTTPS Post for ANSI transactions. This method allows for the transfer of data securely over the Internet with 128 bit SSL enabled encryption/decryption. Capario system expects the ANSI ASC X12 request transaction data in the HTTP body. The submitter s system must establish a secure connection with the Capario system before sending data. Capario will supply the necessary server certificate that is needed to establish secure connection from submitter system. Capario utilizes certificates signed by Entrust. Submitters will be issued a user ID and password during the implementation process. For ANSI X12 transactions, the Capario Login ID and password are passed in the Author Information (ISA02) and Security Information (ISA04) elements, respectively. For Capario Proprietary Eligibility transactions, the Capario Login ID and password are passed in the HTTP Post parameters as UserID and Password, respectively. Please note that Capario expects only a single transaction per connection and authentication information in expected in every ISA or Post Parameters. Production URL for ANSI X12N Transaction submitters: Production URL for Capario Proprietary Eligibility Transaction submitters: Batch Protocol Using Secure File Transfer Capario real-time EDI Gateway supports data exchange through Secure file Transfer Protocol (SFTP) with SSH transmission method. This transmission method is more suitable for submitters who would Page 7 of 20

8 prefer to submit large number of transactions in a batch file and expect the processed responses in a batch file. This method is also referred as Batch Mode. Submitters will be issued a user ID and password during the implementation process. The Capario Login ID and password are passed in the Author Information (ISA02) and Security Information (ISA04) elements, respectively. Capario expects authentication information in every Interchange Control Header (ISA). Processing Timeframe Capario allows a 24 hour window to process a batch. However, we return the compiled response report as soon as we receive the last response. Batch Size Although no batch size is enforced, Capario recommends that you process batches in blocks of 200 transactions for efficient processing. There is no limit to the number of batches that can be submitted each day. Batch Formatting Multi-Interchange Control Header (ISA) format This format contains multiple batch requests. Each transaction is formatted to contain a single Interchange Control Header (ISA), a single Functional Group Header (GS), and a single Transaction Set (ST/SE). Single Interchange Control Header (ISA) format This format contains a single batch request. Each request is formatted to contain a single Interchange Control Header (ISA), a single Functional Group Header (GS), and multiple Transaction Sets (ST/SE). 4. ANSI X12 Real Time Elements ANSI X12 real time transactions submitted to Capario must contain the following elements: Interchange Control Header Functional Group Header Transaction Set Header Beginning Of Hierarchical Transaction Information Source Loop Information Receiver Loop Other elements can also be added as needed and as required by the ANSI ASC X12 Implementation Guides. Capario enforces the length, character set, and code set for transactions based on the ANSI ASC X12 Implementation Guides. It is the submitter s responsibility to ensure their system can correctly format and populate the request before submission. The tables below detail the requirements for the Interchange Control Header (ISA), Functional Group Header (GS), and Beginning of Hierarchical Transaction (BHT) segments. Interchange Control Header (ISA) ASC X12 Element Real Time and Batch CORE II ISA Capario Login ID padded out to 10 bytes with trailing 10 Spaces ISA02 spaces ISA Page 8 of 20

9 ISA04 Capario Login ID padded out to 10 bytes with trailing spaces. ISA05 ZZ ISA06 Capario 8 character client ID padded out to 15 bytes using trailing spaces ISA07 ZZ ISA padded out to 15 byes using trailing spaces ISA09 Current date in YYMMDD format ISA10 Current time in HHMM format ISA11 ^ Repetition Separator (U no longer valid in 5010) ISA ISA13 Submitter generated control number, must match value in IEA02 ISA14 0 ISA15 T Test, P Production ISA16 : (Colon) Functional Group Header 10 Spaces ASC X12 GS01 GS02 GS03 GS04 GS05 GS06 GS07 GS08 Element Notes 270 Eligibility HS 276 Claim Status HR Same as value submitted in ISA06 Same as value submitted in ISA08 Current date in CCYYMMDD format Current time in HHMMSSDD format Submitter generated control number, must match value in GE02 X 270/271 Eligibility X279A1 276/277 Claim Status X212A1 Beginning of Hierarchical Transaction ASC X12 Element Notes BHT Eligibility 0022, 276 Claim Status 0010 BHT02 13 Correlation ID set by sender. Capario ensures that this value is present in BHT03 any response documents generated by this request. The requirement is that this identifier is unique within the sending system. BHT04 Current date in CCYYMMDD format BHT05 Current time in HHMM format Delimiters Capario will accept any delimiters compliant with the ASC X12N X212A1 276/277 and ASC X12N X279A1 270/271 implementation guides. Transaction Specific Information - Applicable to All Real Time Transactions Payer Identifier Review and identify the payer from Capario s Real Time payer list. Provider Identifiers - While most payers now require NPI some payers allow for, or require, a Tax ID or legacy provider ID. Refer to the individual payer Search Option Guides to review these requirements Page 9 of 20

10 Member / Subscriber / Patient ID Number - Many payers issue member identifiers that include suffixes or prefixes. For best results be sure to submit the entire member ID including any suffixes or prefixes Eligibility Benefit Request Search Options o Most payers provide more than one search option. Typically, the more data that is submitted the high the probability the payer will make a match. o Some payers do not support dependent searches. For those payers that do not support dependent searches the patient should always be submitted as the subscriber. Eligibility / Service Dates (2100C/D and 2110C/D DTP segments) o Capario will accept a single date (R8) or a date range (RD8). Not all payers accept a date range and will return a response with the from date only. o Transactions submitted without an Eligibility/Service date will default to the current date. o The DTP01 can be submitted with either 102 Service or 291 Eligibility, Capario will modify the value to meet the payer s requirements. Service Type Codes (2110C/D EQ01) o All payers accept Service Type Code 30 - Health Benefit Plan Coverage. If an EQ segment or Service Type Code is not submitted, Capario will insert an EQ segment with a service type code of 30. o Some payer s support Service Type Codes other than 30, refer to the payer Search Option Guides for codes known to be accepted by the payer. o Most payers will respond with Service Type Code 30 if an unsupported Service Type Code is submitted. o A list of Service Type Codes is available in the appendix Claim Status Request and Response Search Options o Most payers provide more than one search option. Typically, the more data submitted the higher the probability the payer will make a match. o Some payers do not support dependent searches. For those payers that do not support dependent searches the patient should always be submitted as the subscriber. 5. Capario Proprietary Eligibility Real Time Parameters Capario proprietary eligibility real time transactions submitted to Capario must contain the following parameters: User ID Password Request Type Response Type Request Data The table below details the requirements for HTTP POST. HTTP Post Parameter Required/Optional UserID Required Capario Assigned Password Required Capario Assigned TrackingID Optional (Max 50 in length) Values Submitter Supplied (will be returned in Response <Tracking> section as Submitter Trace ID) RequestType Required ELIG_PIPE_DELIMITED ResponseType Required ELIG_CUSTOM_XML_FORMAT Page 10 of 20

11 RequestData Required Pipe delimited Eligibility request data Delimiters Capario will only accept pipe delimiter in the Capario proprietary eligibility request. Transaction Specific Information - Applicable to All Real Time Transactions Payer Identifier Review and identify the payer from Capario s Real Time payer list. Provider Identifiers - While most payers now require NPI some payers allow for, or require, a Tax ID or legacy provider ID. Refer to the individual payer Search Option Guides to review these requirements Member / Subscriber / Patient ID Number - Many payers issue member identifiers that include suffixes or prefixes. For best results be sure to submit the entire member ID including any suffixes or prefixes. Capario Proprietary Eligibility Benefit Request Search Options o Most payers provide more than one search option. Typically, the more data that is submitted the high the probability the payer will make a match. Even though there are numerous optional fields in the request, populate as many fields as you can to have a better chance of identifying the Subscriber/Patient at the payer. o Some payers do not support dependent searches. For those payers that do not support dependent searches the patient should always be submitted as the subscriber. o DO NOT POPULATE DEPENDENT INFORMATION WITH THE SAME SUBSCRIBER INFORMATION. Eligibility / Service Dates o Capario will only accept a single date in the proprietary request format. o Transactions submitted without an Eligibility/Service date will default to the current date. Service Type Codes o All payers accept Service Type Code 30 - Health Benefit Plan Coverage. Capario proprietary format does not contain Service Type Code and will default the request to Service Type Code 30. Request Data Payload Field Order Field Content Required/Optional 1 Doctor or Practice Name Required 2 Payer Name Required 3 Subscriber Member ID Optional 4 Relationship Code S-self D-dependent Optional 01-spouse 19-child 5 Current Date (date to check, defaults to today s date) Optional 6 Account Number (Partner s specific Acct ID, to be returned with response) Optional 7 Payer ID (Capario s Payer ID from Payer List) Required 8 EIN Number for practice or provider S required if NPI not present 9 NPI Number for practice or provider S required if EIN not present 10 Subscriber Last Name Optional Page 11 of 20

12 11 Subscriber First Name Optional 12 Subscriber Gender Optional 13 Subscriber Date of Birth Optional 14 Subscriber Policy Number Optional 15 Subscriber Identify Card Number Optional If the relationship code is NOT S (indicates a spouse or dependent/child), then format patient fields. DO NOT populate Patient Information with Subscriber Information both fields have same information) 16 Last Name of Patient Optional 17 First Name of Patient Optional 18 Date of Birth of Patient Optional 19 Social Security Number of Patient Optional Each field is delimited by (tab) even if the field is blank. Example: INTERNALMEDICINE AETNA S 06/22/2012 PRO SMITH J OHN M 04/04/ The RequestType ELIG_PIPE_DELIMITED payload will be converted into the payer's expected format of 4010 or Default service type to '30' for all requests. Subscriber vs Dependent (patient) Logic o If any of the dependent (patient) data elements are supplied, Capario will create a dependent request otherwise Capario will create a subscriber request in the ANSI X (fields 16, 17, 18 or 19 in text delimited request) o If a dependent request is created, relationship code is required. Capario will handle that field as: If dependent data supplied and relationship code is missing -> Capario will create dependent request with relationship code of 34 (other) If dependent data supplied and relationship code S or D -> Capario will create dependent request with relationship code of 34 (other) If dependent data supplied and relationship code is anything other than S or D -> Capario will create dependent request with relationship code from the request o If relationship code is missing and no dependent data supplied, Capario will assume the request is for the subscriber and only create a subscriber request. Relationship code will default to '18' or self. HTTP post parameters and corresponding payload example: UserID=testuser Password=testpass TrackingID= RequestType=ELIG_PIPE_DELIMITED RequestData=PRACTICE NAME INC SERVICES, INC PRINCIPAL MUTUAL INSURANCE CO /08/2012 AAA HPI SMITH JOHN M 06/1 8/ SMITH JOHN 02/12/1973 ResponseType=ELIG_CUSTOM_XML_FORMAT The RequestType ELIG_PIPE_DELIMITED payload will be converted into the payer's expected format of 4010 or Default service type to '30' for all requests. Page 12 of 20

13 Capario Proprietary Eligibility Response Payers ANSI X12 271/999/997 and Capario Errors are converted from 4010 or 5010 into Capario s proprietary 'ELIG_CUSTOM_XML_FORMAT'. The trace id that was submitted in HTTPS Post parameters as TrackingID is included in the response format. The response layout of the ELIG_CUSTOM_XML_FORMAT is broken into 7 sections; <Status>, <Tracking>, <Payer>, <RequestPatientData>, <ResponsePatientData>, <EligibilityBenefitInfo>, where is an Error section that would not be returned if <EligibilityBenefitInfo> section was returned. ELIG_CUSTOMER_XML_FORMAT Payload Section Field Description <Status> Text Description Contains the human readable status that Capario returns. See status column in chart following. <Tracking> Date Time Message date time stamp Submitter Trace ID Submitter tracking number Capario Message ID Capario s internal tracking number <Payer> PayerID Payer id from outbound eligibility request unless transaction fails then payer id is from inbound request (field 7) Payer Name Payer name from outbound eligibility request unless transaction fails then payer name is from inbound request (field 2) Service Date(s) From outbound eligibility request unless transaction fails then from inbound request (field 5) <RequestPatientData> <ResponsePatientData> Practice Name EIN Number NPI Number Member ID Group Number Identity Card Number Member Date of Birth Member Gender Member Last Name Member First Name Provider Inquiry Reference Number Patient Date of Birth Patient Last Name Patient First Name Patient SSN Member ID Member Group Fields from Inbound Eligibility Request (if supplied in request) Fields from Eligibility Response (if returned by payer) Page 13 of 20

14 <EligibilityBenefitInfo> Number Member Date of Birth Member Gender Member Last Name Member First Name Member Address 1 and 2 Member City Member State Member Zip Patient Date of Birth Patient Last Name Patient First Name Plan Begin Date ANSI X EB Info See Error Chart Following (ANSI X N301 + N302) Contains the human readable Eligibility and Benefit Information that the Payer returned. Error responses are returned in human readable plain text when possible. Some responses may contain ANSI X12 language which may be as is in the status section in the error details. Chart Status Message Member Active Member Inactive Review Plan Details Invalid Payer ID sent in the request Payer System Error: Did not get response from payer Error In Provider data or Provider not found Sections Returned In Response 6 sections; <Status>, <Tracking>, <Payer>, <RequestPatientData>, <ResponsePatientData> and <EligibilityBenefitInfo> 6 sections; <Status>, <Tracking>, <Payer>, <RequestPatientData>, <ResponsePatientData> and <EligibilityBenefitInfo> 6 sections; <Status>, <Tracking>, <Payer>, <RequestPatientData>, <ResponsePatientData> and <EligibilityBenefitInfo> <Status>, <Tracking>, <Status>, <Tracking>, <Payer>, <RequestPatientData> and <Status>, <Tracking>, <Payer>, <RequestPatientData>, <ResponsePatientData> and Benefit Information Detail Section Details of Eligibility and Benefit Information received from payer Details of Eligibility and Benefit Information received from payer Details of Eligibility and Benefit Information received from payer No Additional Information No Additional Information No Additional Information. If rejected by Capario then <ResponsePatientData> will not be present ErrorDetails or HTTP Status Code Message N/A N/A N/A Translate 997 to English Payer System Error: Did not get response from payer Translate AAAs to English text Page 14 of 20

15 Error In Subscriber data or Subscriber not found Error In Dependent data or Dependent not found Other Data Error Processing Error at Capario Invalid Request Received Invalid TrackingID Received Processing Error at Capario Authentication Failed Authentication Failed Processing Error at Capario <Status>, <Tracking>, <Payer>, <RequestPatientData>, <ResponsePatientData> and <Status>, <Tracking>, <Payer>, <RequestPatientData>, <ResponsePatientData> and <Status>, <Tracking> and <Status>, <Tracking> and <Status>, <Tracking> and <Status>, <Tracking> and <Status>, <Tracking> and <Status>, <Tracking> and <Status>, <Tracking> and <Status>, <Tracking> and Status Code (400) Status Code (503) Status Code (400) Status Code (400) Status Code (500) No Additional Information. If rejected by Capario then <ResponsePatientData> will not be present No Additional Information. If rejected by Capario then <ResponsePatientData> will not be present Details of the Error based on the error Translate AAAs to English text Translate AAAs to English text Translate AAAs to English text Processing error occurred at Capario Incomplete Pipe Delimited Format TrackingID exceeds max length of 50 Processing error occurred at Capario Invalid username or password Authentication Service unavailable. Please retry later Processing error occurred at Capario Invalid Request Service Unavailable, Please retry later Invalid Request: Failed to identify message format. Invalid Request: Unrecognized Response Type. Internal Server Error Based on the type of error, not all of these sections will be returned in the error details section. For example, if Authentication fails due to login/password then only the <Status>, <Tracking> and Page 15 of 20

16 section with a status of 'Authentication failed. Invalid username or password' would be returned in response. For Example: <?xml version="1.0"?> <Response> <Status>Authentication Failed</Status> <Tracking><![CDATA[Date/Time: 04/02/ :42:00 AM Submitter Trace ID: ]]> </Tracking> <![CDATA[Invalid username or password]]></errordetails> </Response> 6. Scheduled and Unscheduled Maintenance Downtime Capario real time services undergo regularly scheduled in-service maintenance every Saturday from 5am to 7am Eastern Standard Time. During this two hour period we anticipate there will be periods of short, intermittent service outages and/or slow responses. Any maintenance or service interruptions that occur outside of the regularly scheduled window will be preceded by a minimum 1 week notice to be distributed via a Capario Customer Notification and a posting on the Capario Web Portal. Emergency maintenance or service interruptions will be distributed via a Capario Customer notification and a posting on the Capario Web Portal as soon as the interruption is identified. 7. Frequently Asked Questions Getting Started We want to be contracted for real time transactions. Who do we contact? o Contact Capario Inside Sales at: Sales@Capario.com (800) o Or you Sales Representative or Account Manager. Who do I contact for support with real time transactions? o Capario EDI Support team at: EDI@capario.com (800) Where can I obtain the Capario real time payer list? o To download the Capario Real Time Payer Click here When can I obtain payer CSI and eligibility search option documentation? o Search option documentation is accessed via the links found in the Payer Search Options column of the Capario real time payer list. Where can I view which payers require enrollment or prior authorization? o Payers requiring enrollment or prior authorization can be identified by reviewing the Enrollment / Authorization column of the Capario real time payer list. Troubleshooting I ve received a TA1 Interchange Acknowledgement response for my transaction, what does it mean? o A TA1 is returned when there is an issue with the Interchange Header or Trailer (ISA/IEA). This can include invalid User ID and password information in the ISA02 / ISA04 location. The TA1-05 element returns an error code that may be helpful in diagnosing the issue. If the problem persists after checking the validity of the Interchange Header and Trailer please contact the Capario EDI Team for further assistance. Page 16 of 20

17 I ve received a 997/999 Functional Acknowledgment response for my transaction, what does it mean? o A 997/999 is returned when there is a data or formatting issue within the transaction. Typically the issue can be determined with the information returned in the 997/999. A common cause of 997/999 responses is invalid payer ID. If the problem persists after making changes based on the 997/999 or you are unable to interpret the 997/999 please contact the Capario EDI Team for further assistance. What does it mean when my 270 Eligibility inquiry was returned with a AAA*N**15*C~segment. o 270 transactions that do not meet the payer defined minimum search criteria are acknowledged by Capario with a 271. The 271 will include the following AAA and MSG segments: AAA*N**15*C MSG*YOUR SEARCH CRITERIA DOES NOT MATCH PAYER REQUIREMENTS, PLEASE REVIEW TRANSACTION DOCUMENTATION o Please review the Capario Payer Search Option documentation and verify that the required information is submitted. What does it mean when my 276 Claims Status Inquiry was returned with a STC*D0:484***0*0~ segment? o o 276 transactions that do not meet the payer defined minimum search criteria are acknowledged by Capario with a 277. The 277 will include the following STC segment: STC*D0:484***0*0~ Please review the Capario Payer Search Option documentation and verify that required information is submitted. 8. Appendix C / 2110D EQ01 Service Type Code List A list of valid Service Type Codes can be obtained by visiting the Washington Publishing Company s website at: click on the Health Care Service Type Codes link. Please note that not all payers accept all of these codes. Please refer to the individual payer Search Option Companion guides for any known restrictions C / 2110D EB01 Code list Using a single code will not determine coverage. The code must be taken in the context of the entire Active Coverage 2 Active - Full Risk Capitation 3 Active - Services Capitated 4 Active - Services Capitated to Primary Care Physician 5 Active - Pending Investigation 6 Inactive 7 Inactive - Pending Eligibility Update 8 Inactive - Pending Investigation A Co-Insurance B Co-Payment C Deductible CB Coverage Basis D Benefit Description E Exclusions F Limitations G Out of Pocket (Stop Loss) H Unlimited Page 17 of 20

18 I J K L M MC N O P Q R S T U V W X Y Non-Covered Cost Containment Reserve Primary Care Provider Pre-existing Condition Managed Care Coordinator Services Restricted to Following Provider Not Deemed a Medical Necessity Benefit Disclaimer 1321 not recommended; see section Disclaimers within the Transaction. Second Surgical Opinion Required Other or Additional Payer Prior Year(s) History Card(s) Reported Lost/Stolen Contact Following Entity for Eligibility or Benefit Information Cannot Process Other Source of Data Health Care Facility Spend Down 271 Request Validation AAA03 Code list When reviewing AAA segments to determine the payer s response to an eligibility query it is critical to consider the loop and location within the loop in which it appears. Error Code 04 Authorized Quantity Exceeded 10 Administrative Cancellation 15 Required appl. data missing 33 Input Error 35 Out of Network Reason 36 Testing not Included Request Forwarded To and Decision Response Forthcoming From an External 37 Review Organization 41 Authorization/Access Restrictions 42 Unable to Respond at Current Time 43 Invalid/Missing Provider Id 44 Invalid/Missing Provider Name 45 Invalid/Missing Provider Specialty 46 Invalid/Missing Provider Phone 47 Invalid/Missing Provider State 48 Invalid/Missing Referring Provider Id 49 Provider is Not PCP 50 Provider Ineligible for Inquiries 51 Provider Not on File 52 Service Dates Not Within Provider Plan Enrollment 53 Inquired Benefit Inconsistent with Provider Type 54 Inappropriate Product/Service ID Qualifier Page 18 of 20

19 55 Inappropriate Product/Service ID 56 Inappropriate Date 57 Invalid/Missing Date(s) of Service 58 Invalid/Missing Date of Birth 60 Date of Birth Follows Date(s) of Service 61 Date of Death Precedes Date(s) of Service 62 Date of Service Not Within Allowable Inquiry Period 63 Date of Service in Future 64 Invalid/Missing Patient ID 65 Invalid/Missing Patient Name 66 Invalid/Missing Patient Gender 67 Patient Not Found 68 Duplicate Patient ID 69 Inconsistent with Age of Patient 70 Inconsistent with Gender of Patient 71 Patient DOB Does Not Match That for the Patient on the Database 72 Invalid/Missing Subscriber/Insured ID 73 Invalid/Missing Subscriber/Insured Name 74 Invalid/Missing Subscriber/Insured Gender 75 Subscriber/Insured Not Found 76 Duplicate Subscriber/Insured ID 77 Subscriber Found, Patient Not Found 78 Subscriber/Insured Not in Group/Plan Identified 79 Invalid Participant Identification 80 No Response received - Transaction Terminated 82 Not Medically Necessary 83 Level of Care Not Appropriate 84 Certification Not Required for this Service 85 Certification Responsibility of External Review Organization 86 Primary Care Service 87 Exceeds Plan Maximums 88 Non-covered Services 89 No Prior Approval - No Referrals Found 90 Requested Information Not Received 91 Duplicate Request 92 Service Inconsistent with Diagnosis 95 Patient Not Eligible 96 Pre-existing Condition 97 Invalid/Missing Provider Address 98 Experimental Service or Procedure Page 19 of 20

20 E8 T4 T5 Requires Medical Review Payer Name or Identifier Missing Certification Information Missing D/E and 2220D/E Claim/Service Line Level Status Information code lists (STC01-1 and 01-2) A list of codes returned in the STC01-1 and STC01-2 sub elements can be obtained from the Washington Publishing Company s website: The STC01-1 code set is accessed by clicking on the Claim Status Category Codes link. The STC01-2 code set is accessed by clicking on the Claim Status Codes link. Eligibility 4010 to 5010 Side-By-Side Download: Claim Status Inquiry 4010 to 5010 Side-By-Side Download: Capario s 4010 to 5010 translation business rules for 270/271 and 276/277 To view Capario s 4010 to 5010 translation business rules for 270/271 and 276/277 transactions: Click Here Page 20 of 20