Blue Cross of NE PA. Standard Companion Guide. Instructions related to Transactions based on ASC X12 Implementation Guides, version

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1 Blue Cross of NE PA Standard Companion Guide Instructions related to Transactions based on ASC X12 Implementation Guides, version Companion Guide Version Number: 1.0 December

2 Preface This Companion Guide to the v5010 ASC X12N Implementation Guide and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Blue Cross of Northeastern PA. Transmissions based on this companion guide, used in tandem with the v5010 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. December

3 Table of Contents 1 Introduction... 5 Scope Overview... 6 References.. 7 Additional Information 7 2 Getting Started... 8 Working with Blue Cross of NEPA... 8 Trading Partner Registration... 9 Certification and Testing Overview Testing with the Payer Certification Requirements Connectivity with the Payer/Communications Process flows Transmission Administrative Procedures Re-Transmission Procedure Communication protocol specifications Passwords 13 5 Contact information EDI Customer Service EDI Technical Assistance Provider Service Number Applicable websites / Control Segments / Envelopes ISA/IEA GS/GE 17 ST/SE 17 7 Payer Specific Business Rules and Limitations Acknowledgements and Report 19 December

4 Report Inventory Trading Partner Agreements...19 Trading Partners Transaction Specific Information Appendices Implementation Checklist Business Scenarios Transmission Examples Frequently Asked Questions Change Summary.21 December

5 1 Introduction Scope The Trading Partner Companion Guide addresses how partners conduct HIPAA approved electronic transactions with Blue Cross of Northeastern Pennsylvania (BCNEPA). Transactions include Claims Status Inquiry, Eligibility and Benefit Inquiry and Electronic Remittance Advice. A Trading Partner is defined as a clearinghouse, provider, billing service, employer group, vendor, etc. that transmits or receives HIPAA transactions with BCNEPA. December

6 Overview The Trading Partner Companion Guide includes information needed to commence and maintain connectivity for HIPAA transactions with BCNEPA. The information in this guide is organized based on the following sections. Getting Started This section describes how to contact NEPA for a connection, including the EDI Registration process Trading Partner agreements for a direct connection and Electronic Remittance Advice Request form. Testing with the Payer This section describes the BCNEPA testing expectations and an overview of testing steps. Connectivity with the Payer/Communications This section describes connectivity options, process flows and the security surrounding BCNEPA transactions transmissions. Contact Information This section describes contact information for BCNEPA EDI transmissions, as well as provider and customer service contact numbers. Control Segments/Envelopes This section describes the values to create ISA/IEA, GE/GE and ST/SE control segments for BCNEPA. Payer Specific Business Rules and Limitations This section describes BCNEPA rules for business processes, such as Eligibility and Claim Status Inquiries and Electronic Remittance Advice. Acknowledgements and/or Reports This section describes available reports for trading partners, such as the Functional Acknowledgments (999). December

7 Trading Partner Agreements This section describes the process to obtain and complete the BCNEPA Trading Partner Agreements with BCNEPA. Transaction Specific Information This section contains data element specifics that are over and above the information contained within the Implementation Guide. References Trading Partners must use the HIPAA X12 National Implementation Guides mandated through the Administrative Simplification Electronic Transaction rule in conjunction with the BCNEPA Companion Guide. The BCNEPA Companion Guides can be found: Please refer to the Washington Publishing Company website for the HIPAA X12 National Implementation Guides: Additional Information There is no additional information at the present time. December

8 2 Getting Started Working with BCNEPA BCNEPA is able to accept the 270 and 276 transactions in a real-time mode only. BCNEPA systems are available Monday through Saturday and Sunday midnight through 8pm, in accordance with CORE requirements. BCNEPA produces 835 Electronic Remittance Advice files on a weekly basis. Provider files for all lines of business are available on Wednesday morning. The following characters are exceptions for data elements that are type AN: Character * : < > { ~ ^ These characters are used by BCNEPA as delimiters on the outgoing transactions and are not allowed in the transaction data. As described in the X12 standards, a string data element is a sequence of characters from the basic or extended character sets and contains at least one non-space character. The significant characters shall be left justified. Leading spaces, when they occur, are presumed to be significant characters. In the actual data stream trailing spaces should be suppressed. December

9 Trading Partner Registration The first step in this registration process is to send an requesting connectivity for the 270/271-Health Care Eligibility Benefit Inquiry and Response and/or the 276/277-Health Care Claim Status Request and Response real-time transactions utilizing address: Please include the Trading Partner name, contact name, contact phone number and address. Upon acceptance of the Trading Partner , a Trading Partner Agreement (TPA) will be sent for execution by both parties. Upon execution of the TPA, appropriate connectivity and security information will be exchanged. This includes SenderID, Receiver ID, usernames and passwords. Certification and Testing Overview BCNEPA will meet with the Trading Partner to discuss an agreeable number of test cases, including specified scenarios from the Appendix, Section 2, Business Scenarios. Upon successful connectivity setup by BCNEPA and the Trading Partner, a simple connectivity test between the two entities will occur. Once the connectivity verification is completed and approved by both entities, the Trading Partner will be approved to proceed to the testing phase. For inquiry transactions, the Trading Partner will pitch the request, which will be validated and processed by BCNEPA. A successful response, rejected Functional Acknowledgement (999) or TA1 will be sent back to the Trading Partner. The testing scenarios will be successfully completed and acknowledged by BCNEPA prior to approval to migrate to the production environment. December

10 3 Testing with the Payer Additional scenarios and testing results will be discussed with the Trading Partner and BCNEPA as the project progresses. 4 Connectivity with the Payer/Communications BCNEPA offers three types of connectivity for real-time transactions. IBM WebSphere MQ Series which is Message Oriented Middleware allowing independent communication between distributed applications independent of platform utilizing standard communication protocols (TCP/IP). This software provides assured one-time delivery of messages (transactions) allowing for realtime or batch processing of messages. BCNEPA s connection is through the mainframe. Trading Partners can choose to utilize MQ Series on a variety of platforms. CORE connectivity utilizing SOAP over the internet HTTPS. CORE connective utilizing MIME over the internet HTTPS. For Electronic Remittance Advices, BCNEPA can offer the same type of connectivity outlined above. In addition, we currently offer connectivity in a batch mode through several clearinghouses, direct connections to the provider or via NaviNet. Files are available for pick-up on BCNEPA servers for clearinghouses and direct connections. Providers who opt for NaviNet can log into this system and download the files to a location defined by the provider on their local network. December

11 Process flow for real-time December

12 Transmission Administrative Procedures BCNEPA provides real-time connectivity for the 270/271 and 276/277 HIPAA transactions. Batch processing is currently not supported for these transactions. The Electronic Remittance Advice (835) files are generated in batch on a weekly basis. CORE connectivity or batch delivery options are available for the 835. Re-transmission procedures Trading Partners can re-submit their transaction inquiries at their discretion. Communication Protocols IBM Websphere MQ Series via TCP/IP BCNEPA supports the following X12 based real-time transactions: Health Care Eligibility Request and Response (270/271) Health Care Claim Status Inquiry Request and Response (276/277) Health Care Claim Payment/Advice (835) SOAP over HTTPS BCNEPA supports the following CAQH CORE SOAP based transactions: Health Care Eligibility Request and Response (270/271) Health Care Claim Status Inquiry Request and Response (276/277) Health Care Claim Payment/Advice (835) MIME over HTTPS BCNEPA supports the following CAQH CORE MIME based transactions: Health Care Eligibility Request and Response (270/271) Health Care Claim Status Inquiry Request and Response (276/277) December

13 NaviNet for Report Download BCNEPA supports the Health Care Claim Payment/Advice (835) Secure FTP or FTP with PGP encryption batch delivery BCNEPA supports the Health Care Claim Payment/Advice (835) Passwords User names and passwords will be shared with the Trading Partner upon successful execution of the Trading Partner Agreement. The user names and passwords will be utilized within the MIME and SOAP messages and will be validated against a BCNEPA internal Trading Partner table. User names and passwords will also be assigned for batch retrieval of Electronic Remittance Advices upon successful execution of the Trading Partner Agreement. December

14 5 Contact information EDI Customer Service BlueCare HMO/HMO Plus: BlueCare Traditional: BlueCare PPO: BlueCare EPO: EDI Technical Assistance Contact information for Vendors/Clearinghouses: Phone: All providers are to utilize the contact information in the EDI Customer Service section above. Provider Services Number Inquiries pertaining to Provider Relations should be directed to: Provider Relations: Applicable websites / Provider Information website: December

15 6 Control Segments / Envelopes ISA-IEA According to the Implementation Guide, delimiters are determined by the characters sent in specified, set positions of the ISA header. For transactions submitted to BCNEPA, the following list contains all characters that can be accepted as a delimiter. Character * : < > { ~ ^ December

16 Data Element Summary Loop ID Reference Name Codes Notes/Comments ISA Interchange Control Header ISA01 Authorization Information Qualifier 00 ISA02 Authorization Information ISA03 Security Information Qualifier ISA04 Security Information Interchange ID 30 Trading Partner Federal tax id. ISA05 Qualifier ZZ For 835, send ZZ qualifier. ISA06 Interchange Sender ID For 835, send ISA07 Interchange ID Qualifier 30 ZZ Trading Partner Federal tax id For 835, send ZZ and Trading Partner Federal tax id ISA08 Interchange Receiver Please send ID For 835, please send Trading Partner NPI ISA09 Interchange Date ISA10 Interchange Time ISA11 Repetition Separator { Left Bracket ISA12 Interchange Control Current mandated HIPAA Version Number version. ISA13 Interchange Control Number ISA14 Acknowledgment Requested ISA15 Interchange Usage Indicator P, T December

17 IEA ISA16 IEA01 IEA02 Component Element Separator Interchange Control Trailer Number of Included Functional Groups Interchange Control Number : Colon GS-GE Data Element Summary Loop ID Reference Name Codes Notes/Comments GS Functional Group Header HS or GS01 Functional Identifier HN Use for 270/271 or 276/277 Code HP Use for 835 GS02 GS03 Application Sender s Code Application Receiver s Code Trading Partner Federal tax id. For 835 send Please send For 835 send Trading Partner NPI December

18 GE GS04 GS05 GS06 GS07 GS08 GE01 GE02 Date Time Group Control Number Responsible Agency Code Version/Release/Indu stry Identifier Code Functional Group Trailer Number of Transaction Sets Included Group Control number ST-SE Blue Cross of Northeastern PA has no requirements beyond the National transactional Implementation Guides. 7 Payer Specific Business Rules and Limitations BCNEPA only allows providers within the 13 counties and acceptable contiguous counties to submit transactions to NEPA. Requests from providers outside of our service area must be submitted through their local Blue Cross/Blue Shield company. All inquiries made for members outside of our service area will be pitched to the Home Plan for responses. BCNEPA does not support multiple inquiries per request for the 270. BCNEPA only supports 1 occurrence of the EQ01 on a 270 inquiry transaction. BCNEPA does not support Claim Inquiries by claim line. December

19 8 Acknowledgements AND/OR Reports Report Inventory o TA1 Segment will be sent back to the Trading Partner for Interchange Errors. o 999 Transaction Acknowledgement for Health Care Insurance will be sent for HIPAA errors only. Positive acknowledgements will not be sent for inquiry transactions. o All reports will be sent as real-time responses only when applicable condition exists for the 270/271 and 276/277 transactions. o All reports for the 835 will be sent via batch, unless CORE connectivity is selected.. 9 Trading Partner Agreements Trading Partners A BCNEPA Trading Partner is defined as any BCNEPA customer (provider, clearinghouse, billing service, vendor, etc.) who transmits electronic inquiries and receives responses from BCNEPA. Trading Partner agreements describe the EDI transactions that will be conducted, protocols around transmissions, connectivity and contact information. December

20 10 Transaction Specific Information Blue Cross of Northeastern PA has no specific transaction information at this time. December

21 Appendices 1. Implementation Checklist o BCNEPA does not have an Implementation Checklist at this time. 2. Business Scenarios o BCNEPA does not have Business Scenarios at this time. 3. Transmission Examples o BCNEPA does not have any transmission examples at this time. 4. Frequently Asked Questions o BCNEPA does not have any FAQ s at this time. 5. Change Summary The items below were revised. Page Section Description December

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