CLAIM BILLING TRANSACTION

Transcription

1 HCC EZ-DE NCPDP vd.0 Payer Sheet / Claim e-bill GENEAL INFOATION Payer Name: EZ-DE Date: Plan Name/Group Name: EZ-DE BIN: PCN: All See Appendix A for current plans. Processor: Various Effective as of: NCPDP Telecommunication Standard Version/elease #: D.0 NCPDP Data Dictionary Version Date: July 2007 NCPDP External Code List Version Date: arch 2010 Contact/Information Source: [email protected] (888) opt 1 Certification Testing Window: Starting Certification Contact Information: [email protected] (888) opt 1 Provider elations Help Desk Info: [email protected] (888) opt 1 Other versions supported: NDPCP 5.1 discontinuation date is to be determined. OTHE TANSACTIONS SUPPOTED Transaction Code B1 Transaction Name FIELD LEGEND FO COLUNS Payer Value Explanation Column ANDATOY The Field is mandatory for the Segment in the designated Transaction. EQUIED The Field has been designated with the situation of "equired" for the Segment in the designated Transaction. QUALIFIED EQUIEENT W equired when. The situations designated have qualifications for usage CLAI BILLING TANSACTION The following lists the segments and fields in a for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Transaction Header Segment Questions Check Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Clearinghouse Issued Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Switch/VAN issued Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Not used x Software Certification ID will be issued based on successful completion of certification Transaction Header Segment 1Ø1-A1 BIN NUBE Please see Appendix A for valid PCN s Used 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1 1Ø4-A4 POCESSO CONTOL NUBE See complete list at the end of payer sheet 1Ø9-A9 TANSACTION COUNT aximum of 4 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Valid Values 2Ø1-B1 SEVICE POVIDE ID 4Ø1-D1 DATE OF SEVICE 11Ø-AK SOFTWAE VENDO/CETIFICATION ID EZDE0810D Page 1 of 20

2 Insurance Segment Questions Check Insurance Segment Segment Identification (111-A) = Ø4 3Ø2-C2 CADHOLDE ID 312-CC CADHOLDE FIST NAE W Imp Guide: equired if necessary for state/federal/regulatory agency programs when the cardholder has a first name. Payer equirement: equired when claim is submitted for a commercial plan and patient relationship code = 2, 3, or CD CADHOLDE LAST NAE W Imp Guide: equired if necessary for state/federal/regulatory agency programs when the cardholder has a first name. Payer equirement: equired when claim is submitted for a commercial plan and patient relationship code = 2, 3, or 4 3Ø1-C1 GOUP ID W Imp Guide: equired if necessary for state/federal/regulatory agency programs. Payer equirement: equired when claim is submitted for a plan that requires a group number, primarily commercial plans 3Ø6-C6 PATIENT ELATIONSHIP CODE 359-2A EDIGAP ID W Imp Guide: equired, if known, when patient has edigap coverage. Payer equirement equired when a patient has dual coverage, and the primary claim is to automatically generate a secondary claim.. Information was previously reported and may still be reported the group number, or added via the web site 36Ø-2B EDICAID INDICATO W Imp Guide: equired, if known, when patient has edicaid coverage D POVIDE ACCEPT ASSIGNENT INDICATO W Payer equirement: equired when a patient has dual coverage, and the primary claim is to automatically generate a secondary claim. Information was previously reported and may still be reported the group number, or added via the web site Imp Guide: equired if necessary for state/federal/regulatory agency programs. Payer equirement equired if necessary for state/federal/regulatory agency programs. 115-N5 EDICAID ID NUBE W Imp Guide: equired, if known, when patient has edicaid coverage. Payer equirement: equired when a patient has dual coverage, and the primary claim is to automatically generate a secondary claim.. Information was previously reported and may still be reported the group number, or added via the web site Page 2 of 20

3 Patient Segment Questions Check Patient Segment Segment Identification (111-A) = Ø1 Field NCPDP Field Name Value Payer 3Ø4-C4 DATE OF BITH 3Ø5-C5 PATIENT GENDE CODE 31Ø-CA PATIENT FIST NAE 311-CB PATIENT LAST NAE 322-C PATIENT STEET ADDESS 323-CN PATIENT CITY ADDESS 324-CO PATIENT STATE / POVINCE ADDESS 325-CP PATIENT ZIP/POSTAL ZONE 326-CQ PATIENT PHONE NUBE 3Ø7-C7 PLACE OF SEVICE Claim Segment Questions Check This payer supports partial fills This payer does not support partial fills Claim Segment Segment Identification (111-A) = Ø7 455-E PESCIPTION/SEVICE EFEENCE NUBE QUALIFIE 1 = x Billing Imp Guide: For Transaction Code of B1, in the Claim Segment, the Prescription/Service eference Number Qualifier (455-E) is 1 (x Billing). 4Ø2-D2 PESCIPTION/SEVICE EFEENCE NUBE 436-E1 PODUCT/SEVICE ID QUALIFIE 4Ø7-D7 PODUCT/SEVICE ID 458-SE POCEDUE ODIFIE CODE COUNT aximum count of 1Ø. W Imp Guide: equired if Procedure odifier Code (459-E) is used. 459-E POCEDUE ODIFIE CODE W Imp Guide: equired to define a further level of specificity if the Product/Service ID (4Ø7-D7) indicated a Procedure Code was submitted. Payer equirement: equired if destination plan requires odifier codes on transmitted product 442-E7 QUANTITY DISPENSED 4Ø3-D3 FILL NUBE 4Ø5-D5 DAYS SUPPLY 4Ø6-D6 COPOUND CODE 4Ø8-D8 DISPENSE AS WITTEN (DAW)/PODUCT SELECTION CODE 414-DE DATE PESCIPTION WITTEN 354-N SUBISSION CLAIFICATION CODE COUNT aximum count of 3. W Imp Guide: equired if Submission Clarification Code (42Ø-DK) is used. 42Ø-DK SUBISSION CLAIFICATION CODE W Imp Guide: equired if clarification is needed and value submitted is greater than zero (Ø Payer equirement: equired when needed to override specific rejections. Check with EZ- DE for supported values Page 3 of 20

4 Claim Segment Segment Identification (111-A) = Ø7 3Ø8-C8 OTHE COVEAGE CODE W Imp Guide: equired if needed by receiver, to communicate a summation of other coverage information that has been collected from other payers. equired for Coordination of Benefits. Payer equirement: equired when a COB claim is submitted 6ØØ-28 UNIT OF EASUE W Imp Guide: equired if necessary for state/federal/regulatory agency programs. equired if this field could result in different coverage, pricing, or patient financial responsibility. Payer equirement: equired when submitting NDC number in product service id. 461-EU PIO AUTHOIZATION TYPE CODE W Imp Guide: equired if this field could result in different coverage, pricing, or patient financial responsibility. 462-EV PIO AUTHOIZATION NUBE SUBITTED W Payer equirement equired when 462-EV is present Imp Guide: equired if this field could result in different coverage, pricing, or patient financial responsibility. Payer equirement: equired when overriding Level 2 claims 357-NV DELAY EASON CODE W Imp Guide: equired when needed to specify the reason that submission of the transaction has been delayed. Payer equirement: equired when destination plan allows and claim is not submitted within timely filing deadlines 995-E2 OUTE OF ADINISTATION W Imp Guide: equired if specified in trading partner agreement. Pricing Segment Questions Check Payer equirement: equired when submitting a compound claim Pricing Segment Segment Identification (111-A) = 11 4Ø9-D9 INGEDIENT COST SUBITTED 412-DC DISPENSING FEE SUBITTED W Imp Guide: equired if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. 433-D PATIENT PAID AOUNT SUBITTED 43Ø-DU GOSS AOUNT DUE Payer equirement: equired if its value has an effect on the Gross Amount Due (43Ø-DU) calculation. Page 4 of 20

5 Pharmacy Provider Segment Questions Check This segment is not used Prescriber Segment Questions Check Prescriber Segment Segment Identification (111-A) = Ø3 466-EZ PESCIBE ID QUALIFIE 411-DB PESCIBE ID 427-D PESCIBE LAST NAE 364-2J PESCIBE FIST NAE 468-2E PIAY CAE POVIDE ID QUALIFIE W Imp Guide: equired if Primary Care Provider ID (421-DL) is used. Payer equirement: equired when destination plan requires referring prescriber 421-DL PIAY CAE POVIDE ID W Imp Guide: equired if needed for receiver claim/encounter determination, if known and available. equired if this field could result in different coverage or patient financial responsibility. equired if necessary for state/federal/regulatory agency programs. Payer equirement: equired when destination plan requires referring prescriber 47Ø-4E PIAY CAE POVIDE LAST NAE W Imp Guide: equired if this field is used as an alternative for Primary Care Provider ID (421- DL) when ID is not known. Coordination of Benefits/Other Payments Segment Check Questions equired only for secondary claims equired if needed for Primary Care Provider ID (421-DL) validation/clarification. Payer equirement: equired when destination plan requires referring prescriber Scenario 1 - Other Payer Amount Paid epetitions Only Note: COB claim final remittance values may still be completed on line at Scenario 2 - Other Payer-Patient esponsibility Amount epetitions and Benefit Stage epetitions Only Scenario 3 - Other Payer Amount Paid, Other Payer- Patient esponsibility Amount, and Benefit Stage epetitions Present (Government Programs) Coordination of Benefits/Other Payments Segment Segment Identification (111-A) = Ø5 Scenario 1 - Other Payer Amount Paid epetitions Only Page 5 of 20

6 337-4C COODINATION OF BENEFITS/OTHE aximum count of 9. PAYENTS COUNT 338-5C OTHE PAYE COVEAGE TYPE 339-6C OTHE PAYE ID QUALIFIE 34Ø-7C OTHE PAYE ID 443-E8 OTHE PAYE DATE 341-HB OTHE PAYE AOUNT PAID COUNT aximum count of HC OTHE PAYE AOUNT PAID QUALIFIE 431-DV OTHE PAYE AOUNT PAID 471-5E OTHE PAYE EJECT COUNT aximum count of 5. W Imp Guide: equired if Other Payer eject Code (472-6E) is used. Payer equirement: equired if Other Payer eject Code (472-6E) is used E OTHE PAYE EJECT CODE W Imp Guide: equired when the other payer has denied the payment for the billing, designated with Other Coverage Code (3Ø8-C8) = 3 (Other Coverage Billed claim not covered). Payer equirement equired when the other payer has denied the payment for the billing, designated with Other Coverage Code (3Ø8- C8) = 3 (Other Coverage Billed claim not covered). Workers Compensation Segment Questions Check This Segment is not used DU/PPS Segment Questions Check equired when destination plan requires specific information to process claim. DU/PPS Segment Segment Identification (111-A) = Ø E DU/PPS CODE COUNTE aximum of 9 occurrences. 439-E4 EASON FO SEVICE CODE Coupon Segment Questions Check This Segment is not used Compound Segment Questions Check This segment is required when a compounded drug is submitted. Compound Segment Segment Identification (111-A) = 1Ø 45Ø-EF COPOUND DOSAGE FO DESCIPTION CODE Page 6 of 20

7 Compound Segment Segment Identification (111-A) = 1Ø 451-EG COPOUND DISPENSING UNIT FO INDICATO 447-EC COPOUND INGEDIENT COPONENT aximum 25 ingredients COUNT 488-E COPOUND PODUCT ID QUALIFIE 489-TE COPOUND PODUCT ID 448-ED COPOUND INGEDIENT QUANTITY 449-EE COPOUND INGEDIENT DUG COST W Imp Guide: equired if needed for receiver claim determination when multiple products are billed. 49Ø-UE COPOUND INGEDIENT BASIS OF COST DETEINATION W Payer equirement: equired when submitting a compounded drug Imp Guide: equired if needed for receiver claim determination when multiple products are billed. Payer equirement: equired when submitting a compounded drug Clinical Segment Questions Check Clinical Segment Segment Identification (111-A) = VE DIAGNOSIS CODE COUNT aximum count of WE DIAGNOSIS CODE QUALIFIE 424-DO DIAGNOSIS CODE 493-E CLINICAL INFOATION COUNTE aximum 5 occurrences W supported. 496-H2 EASUEENT DIENSION W Imp Guide: equired if easurement Unit (497- H3) and easurement Value (499-H4) are used. equired if necessary when this field could result in different coverage and/or drug utilization review outcome. equired if necessary for patient s weight and height when billing edicare for a claim that includes a Certificate of edical Necessity (CN). Payer equirement: equired if necessary for patient s weight and height when billing edicare for a claim that includes a Certificate of edical Necessity (CN). 497-H3 EASUEENT UNIT W Imp Guide: equired if easurement Dimension (496-H2) and easurement Unit (497-H3) are used. equired if necessary for patient s weight and height when billing edicare for a claim that includes a Certificate of edical Necessity (CN). equired if necessary when this field could result in different coverage and/or drug utilization review outcome. Page 7 of 20

8 Clinical Segment Segment Identification (111-A) = 13 Payer equirement: equired if easurement Dimension (496-H2) and easurement Value (499-H4) are used. 499-H4 EASUEENT VALUE W Imp Guide: equired if easurement Dimension (496-H2) and easurement Unit (497-H3) are used. Additional Documentation Segment Questions Check This Segment is not Used This segment will be implemented at a later time equired if necessary for patient s weight and height when billing edicare for a claim that includes a Certificate of edical Necessity (CN). equired if necessary when this field could result in different coverage and/or drug utilization review outcome. Payer equirement: equired if necessary for patient s weight and height when billing edicare for a claim that includes a Certificate of edical Necessity (CN). Facility Segment Questions Check This segment is required when patient resides in a location other than home. Facility information may still be completed on line at as well as submitted via the B1 transaction. Facility Segment Segment Identification (111-A) = C FACILITY ID 385-3Q FACILITY NAE 386-3U FACILITY STEET ADDESS 388-5J FACILITY CITY ADDESS 387-3V FACILITY STATE/POVINCE ADDESS 389-6D FACILITY ZIP/POSTAL ZONE Narrative Segment Questions Check This segment is required if destination plan requires additional Narrative information. Narrative information may still be completed on line at as well as submitted via the B1 transaction. Narrative Segment Segment Identification (111-A) = 16 39Ø-B NAATIVE ESSAGE Page 8 of 20

9 CLAI BILLING - CAPTUED (O DUPLICATE OF CAPTUED) ESPONSE The following lists the segments and fields in a response (Captured or Duplicate of Captured) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. esponse Transaction Header Segment Questions Check Captured (or Duplicate of Captured) esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1, B3 1Ø9-A9 TANSACTION COUNT Same value as in request 5Ø1-F1 HEADE ESPONSE STATUS A = Accepted 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request 2Ø1-B1 SEVICE POVIDE ID Same value as in request 4Ø1-D1 DATE OF SEVICE Same value as in request Captured (or Duplicate of Captured esponse essage Segment Questions Check Captured (or Duplicate of Captured. esponse essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE Captured (or Duplicate of Captured esponse Insurance Segment Questions Check Captured (or Duplicate of Captured This Segment is not used esponse Patient Segment Questions Check Captured (or Duplicate of Captured This Segment is not used esponse Status Segment Questions Check Captured (or Duplicate of Captured esponse Status Segment Segment Identification (111-A) = AN TANSACTION ESPONSE STATUS C=Captured Q=Duplicate of Captured 5Ø3-F3 AUTHOIZATION NUBE 547-5F APPOVED ESSAGE CODE COUNT aximum count of F APPOVED ESSAGE CODE Captured (or Duplicate of Captured) Page 9 of 20

10 esponse Status Segment Segment Identification (111-A) = 21 13Ø-UF ADDITIONAL ESSAGE INFOATION aximum count of 25. COUNT 132-UH ADDITIONAL ESSAGE INFOATION QUALIFIE 526-FQ ADDITIONAL ESSAGE INFOATION 131-UG ADDITIONAL ESSAGE INFOATION CONTINUITY 549-7F HELP DESK PHONE NUBE QUALIFIE 55Ø-8F HELP DESK PHONE NUBE Captured (or Duplicate of Captured) 987-A UL esponse Claim Segment Questions Check Captured (or Duplicate of Captured) esponse Claim Segment Segment Identification (111-A) = E PESCIPTION/SEVICE EFEENCE 1 = xbilling NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE NUBE Captured (or Duplicate of Captured) esponse Pricing Segment Questions Check Captured (or Duplicate of Captured) Please Note: All claims are captured claims, any values returned in the pricing segment are either: 1. epresentative only, i.e. Best Guess based on published fee schedules from the destination payer. 2. Values sent in the claim billing transaction are mirrored back in response. These values do not represent any guarantee of payment or pricing. esponse Pricing Segment Segment Identification (111-A) = 23 Captured (or Duplicate of Captured) 5Ø5-F5 PATIENT PAY AOUNT 5Ø6-F6 INGEDIENT COST PAID 5Ø7-F7 DISPENSING FEE PAID 566-J5 OTHE PAYE AOUNT ECOGNIZED W Imp Guide: equired if this value is used to arrive at the final reimbursement. equired if Other Payer Amount Paid (431- DV) is greater than zero (Ø) and Coordination of Benefits/Other Payments Segment is supported. 5Ø9-F9 TOTAL AOUNT PAID Payer equirement: equired if this value is used to arrive at the final reimbursement. Page 10 of 20

11 esponse Pricing Segment Segment Identification (111-A) = FH AOUNT APPLIED TO PEIODIC W DEDUCTIBLE 518-FI AOUNT OF COPAY 572-4U AOUNT OF COINSUANCE Captured (or Duplicate of Captured) Imp Guide: equired if Patient Pay Amount (5Ø5-F5) includes deductible Payer equirement: equired if Patient Pay Amount (5Ø5-F5) includes deductible esponse DU/PPS Segment Questions Check Captured (or Duplicate of Captured) This Segment is not used esponse Coordination of Benefits/Other Payers Segment Questions This Segment is not used Check Captured (or Duplicate of Captured) CLAI BILLING ACCEPTED / EJECTED ESPONSE esponse Transaction Header Segment Questions Check Accepted / ejected esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B1 1Ø9-A9 TANSACTION COUNT Same value as in request 5Ø1-F1 HEADE ESPONSE STATUS = ejected 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request 2Ø1-B1 SEVICE POVIDE ID Same value as in request 4Ø1-D1 DATE OF SEVICE Same value as in request ejected/ejected esponse essage Segment Questions Check Accepted / ejected esponse essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE ejected/ejected esponse Status Segment Questions Check Accepted / ejected esponse Status Segment Segment Identification (111-A) = AN TANSACTION ESPONSE STATUS = eject ejected/ejected Page 11 of 20

12 esponse Status Segment Segment Identification (111-A) = 21 5Ø3-F3 AUTHOIZATION NUBE 51Ø-FA EJECT COUNT aximum count of FB EJECT CODE 13Ø-UF ADDITIONAL ESSAGE INFOATION aximum count of 25. COUNT 132-UH ADDITIONAL ESSAGE INFOATION QUALIFIE 526-FQ ADDITIONAL ESSAGE INFOATION 131-UG ADDITIONAL ESSAGE INFOATION W CONTINUITY 549-7F HELP DESK PHONE NUBE QUALIFIE 55Ø-8F HELP DESK PHONE NUBE 987-A UL ejected/ejected Imp Guide: equired if and only if current repetition of Additional essage Information (526-FQ) is used, another populated repetition of Additional essage Information (526-FQ) follows it, and the text of the following message is a continuation of the current. Payer equirement: equired if appropriate Page 12 of 20

13 CLAI EVESAL What is your reversal window? (If transaction is billed today what is the timeframe for reversal to be submitted?) The claim has two reversal windows 1) The claim can be reversed until it has been submitted to the destination payer. 2) The claim can also be reversed if rejected by the destination payer. CLAI EVESAL TANSACTION The following lists the segments and fields in a Claim eversal Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. Transaction Header Segment Questions Check Claim eversal Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Payer Issued Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Switch/VAN issued Source of certification IDs required in Software Vendor/Certification ID (11Ø-AK) is Not used Transaction Header Segment 1Ø1-A1 BIN NUBE 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B2 1Ø4-A4 POCESSO CONTOL NUBE 1Ø9-A9 TANSACTION COUNT aximum count is 1 2Ø2-B2 SEVICE POVIDE ID QUALIFIE 2Ø1-B1 SEVICE POVIDE ID 4Ø1-D1 DATE OF SEVICE 11Ø-AK SOFTWAE VENDO/CETIFICATION ID Claim eversal Insurance Segment Questions Check Claim eversal This Segment is not used Claim Segment Questions Check Claim eversal Claim Segment Segment Identification (111-A) = Ø7 455-E PESCIPTION/SEVICE EFEENCE NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE NUBE 4Ø3-D3 FILL NUBE Claim eversal Imp Guide: For Transaction Code of B2, in the Claim Segment, the Prescription/Service eference Number Qualifier (455-E) is 1 (x Billing). Page 13 of 20

14 Pricing Segment Questions Check Claim eversal This Segment is not used Coordination of Benefits/Other Payments Segment Questions This Segment is not used. Check Claim eversal DU/PPS Segment Questions Check Claim eversal This Segment is not used. CLAI EVESAL ACCEPTED/APPOVED ESPONSE GENEAL INFOATION CLAI EVESAL ACCEPTED/APPOVED ESPONSE The following lists the segments and fields in a Claim eversal response (Approved) Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. esponse Transaction Header Segment Questions Check Claim eversal Accepted/Approved esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B2 1Ø9-A9 TANSACTION COUNT Same value as in request 5Ø1-F1 HEADE ESPONSE STATUS A = Accepted 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request 2Ø1-B1 SEVICE POVIDE ID Same value as in request 4Ø1-D1 DATE OF SEVICE Same value as in request Claim eversal Accepted/Approved esponse essage Segment Questions Check Claim eversal Accepted/Approved esponse essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE Claim eversal Accepted/Approved esponse Status Segment Questions Check Claim eversal Accepted/Approved esponse Status Segment Segment Identification (111-A) = AN TANSACTION ESPONSE STATUS A = Approved 549-7F HELP DESK PHONE NUBE QUALIFIE Claim eversal Accepted/Approved Page 14 of 20

15 esponse Status Segment Segment Identification (111-A) = 21 55Ø-8F HELP DESK PHONE NUBE Claim eversal Accepted/Approved 987-A UL esponse Claim Segment Questions Check Claim eversal Accepted/Approved esponse Claim Segment Claim eversal Accepted/Approved Segment Identification (111-A) = E PESCIPTION/SEVICE EFEENCE NUBE QUALIFIE 1 = xbilling Imp Guide: For Transaction Code of B2, in the esponse Claim Segment, the Prescription/Service eference Number Qualifier (455-E) is 1 (x Billing). 4Ø2-D2 PESCIPTION/SEVICE EFEENCE NUBE esponse Pricing Segment Questions Check Claim eversal Accepted/Approved This Segment is not used CLAI EVESAL ACCEPTED/EJECTED ESPONSE esponse Transaction Header Segment Questions Check Claim eversal - Accepted/ejected esponse Transaction Header Segment 1Ø2-A2 VESION/ELEASE NUBE DØ 1Ø3-A3 TANSACTION CODE B2 1Ø9-A9 TANSACTION COUNT Same value as in request 5Ø1-F1 HEADE ESPONSE STATUS A = Accepted 2Ø2-B2 SEVICE POVIDE ID QUALIFIE Same value as in request 2Ø1-B1 SEVICE POVIDE ID Same value as in request 4Ø1-D1 DATE OF SEVICE Same value as in request Claim eversal Accepted/ejected esponse essage Segment Questions Check Claim eversal - Accepted/ejected esponse essage Segment Segment Identification (111-A) = 2Ø 5Ø4-F4 ESSAGE Claim eversal Accepted/ejected esponse Status Segment Questions Check Claim eversal - Accepted/ejected esponse Status Segment Segment Identification (111-A) = AN TANSACTION ESPONSE STATUS = eject 5Ø3-F3 AUTHOIZATION NUBE Claim eversal Accepted/ejected Page 15 of 20

16 esponse Status Segment Segment Identification (111-A) = 21 51Ø-FA EJECT COUNT aximum count of FB EJECT CODE 549-7F HELP DESK PHONE NUBE QUALIFIE 55Ø-8F HELP DESK PHONE NUBE 987-A UL Claim eversal Accepted/ejected esponse Claim Segment Questions Check Claim eversal - Accepted/ejected esponse Claim Segment Segment Identification (111-A) = E PESCIPTION/SEVICE EFEENCE 1 = xbilling NUBE QUALIFIE 4Ø2-D2 PESCIPTION/SEVICE EFEENCE NUBE Claim eversal Accepted/ejected APPENDI A SUPPOTED PLANS Processor Control Number AAPS ACCLS ACSCS ADVNS ADVHS ADVFS ADHSS AETNS AAAHS ABHTS AEHCS AILS AETS AFFTS ALS ALBSS FLUAL FLUAK ALLHS APPOS ALWIS ALSS ABNSS ANCS ASCS ACCJS ABGS ACBLS AFICS AFIS AGNS ALCS APWUS APS ACHPS Plan Name AAP ACCLAI ACS CONSULTING SEVICES ADVANTA ADVANTA / HEALTH AEICA ADVANTA FEEDO ADVENTIST HEALTH SYSTE WEST AETNA AETNA AFFODABLE HEALTH CHOICES AETNA BETTE HEALTH PA EDICAID AETNA BETTE HEALTH CONNECTICUT EDICAID AETNA ILLINOIS EDICAID AETNA EDICAID AFFINITY HEALTH PLAN AL EDICAID ALABAA BLUE SHIELD ALABAA PAT B FLU SHOTS ALASKA PAT B FLU SHOTS ALLIANCE HEALTHCAE/SPIPA ALLIANCE PPO ALLIANCE HEALTHPLAN OF WISCONSIN ALTA SENIO CAE AEIBEN SOLUTIONS AEICA 1ST CHOICE NC AEICA 1ST CHOICE SC AEICAID COUNITY CAE OF NEW JESEY AEICAN BENEFITS ANAGENT AEICAN COECIAL BAGE LINES AEICAN FAILY INSUANCE COPANY AEICAN FAILY INSUANCE COPANY AEICAN GENEAL AEICAN LIFECAE AEICAN POSTAL WOKES UNION AEICAN EPUBLIC AEICAS CHOICE HLTHPLNS NA Processor Control Number ACNJS ANJPS ACNYS ACYPS APPCS APCS AGFWS AGDLS AGNVS AGVAS AGHS AGNJS AGOHS AGTNS AHADS AHNJS ANJHS ANBSS BSINS AS ACAS FLUAZ ABSS FLUA ASSTS ANWHS ACADS ATHPS AGADS AVHLS BASSS BSAZS BECHS BASLS Plan Name AEICHOICE OF NEW JESEY (EDICAID NJ) AEICHOICE OF NEW JESEY PESOANL CAE PLUS AEICHOICE OF NEW YOK (EDICAID NY) AEICHOICE OF NEW YOK PESONAL CAE PLUS (EDICAE NY) AEICHOICE OF PA PESONAL AEICHOICE PA EDICAISE / CHIPS AEIGOUP FOT WOTH AEIGOUP DALLAS /FOT WOTH AEIGOUP - NV AEIGOUP VIGINIA AEIGOUP HOUSTON AEIGOUP OF NEW JESEY AEIGOUP OHIO AEIGOUP TENNCAE AEIHEALTH ADINISTATOS AEIHEALTH NEW JESEY AEIHEALTH OF NEW JESEY HO ANTHE BCBS ANTHE BCBS INDIANA A EDICAID ACADIAN AIZONA PAT B FLU SHOTS AKANSAS BLUE SHIELD AKANSAS PAT B FLU SHOTS ASSUANT HEALTH ASUIS NOTHWEST HEALTH ATLANTICAE ADINISTATOS ATLANTIS HEALTH PLAN AUTOATED GOUP ADINISTATOS AVEA HEALTH BASS AD BCBS-AIZONA BEECH STEET COPOATION BENEFIT ADINISTATION SEVICES LTD Page 16 of 20

17 Processor Control Number BENCS BGSS BGTS BNPLS BNOHS BTLCS BCOS BCNYS BCCAS COBSS BSOS PABHS BGFS NEBS UTBSS BCHS BSKCS BKCHS CAS CABSS FLUCN FLUCS CNGS CCTS CCHS CIS CSIN CSOHS CCTS CFDCS CKS CPTNS CPHPS CWKS CHPS CSHS CHSLS CCNPS CCS CNYBS CSVS CHPSS CHTCS CHPS CFNS CIGHS CGSS CACPS CLAHS COS COBAS COKPS CWCAS CHAS CHCHS WACHS CCHS CCPS CCS Plan Name BENEFIT CONCEPTS BENEFIT ANAGEENT SEVICES, INC BENEFIT GT SYSTES BENEFIT PLANNES BENEFIT SEVICES INC. (AKON, OH) BENEFIT TUST LIFE CAE BLUE CHOICE O BLUE CHOICE - NY BLUE COSS - CA BLUE SHIELD COLOADO ANTHE BLUE SHIELD O BLUE SHILD PA HIGHAK CLAIS/ENCOUNTES BLUEGASS FAILY HEALTH BLUSE SHIELD NEBASKA BLUE COSS BLUE SHIED OF UTAH BOSTON EDICAL CENTE HEALTH PLAN BS KANSAS CITY BUCKEYE COUNITY HEALTH CA EDICAID CALIFONIA BLUE COSS CALIFONIA PAT B FLU SHOTS NOTH CALIFONIA PAT B FLU SHOTS - SOUTH CANNON COCHAN ANAGEENT SEVICES CANNON COCHAN ANAGEENT SEVICES LA CAE CHOICE CAE IPOVEENT PLUS CAE SOUCE OF INDIANA CAE SOUCE OF OHIO CAECENTI CAEFIST BCBS OF DC/NCA CAEAK CAEPATNES CAEPLUS HEALTH PLANS CAEWOKS CAITEN HEALTH PLAN CAITEN SENIO CAPENTES HTH ST LOUIS CCN CENTECAE CENTAL NY BC CENTAL ESEVE CHAPUS TI-CAE (PGBA) CHAPUS TICAE (PALETTO) CHAPUS VA-HAC CIGNA FLE (NEW EICO ONLY) CIGNA HP CIGNA SENIO CLAI ADINISTATION COP CO ACCESS HO CO EDICAID COLOADO BLUE ADVANTAGE COLOADO KAISE PEANENTE COONWEALTH CAE ALLIANCE COUNITY HEALTH ALLIANCE CO HEALTH CHOICE CO HLTH WA COUNITY CAE ANAGED HEALTH PLANS OF OK COUNITY CAE PLUS COUNITY CAE Processor Control Number CCIS CO1S CHLTS CHCTS CHPS CCGS CTCS CTDS CGPS CGICS CCHPS CCSPS CSILS CSCS COOHS CBSAS CVLAS CVGAS CVKSS CVHCS CTBSS CTCBS CTS FLUCT CSHWS FLUDC FLUDE DELTS DUTS DCHPS EBSLS EDSAS EDPS EPFHS ELHTS EHNS EBSS EBAS EBPLS EBCS EPGPS EISS EHTHS EVCS FALCS FHHVS FHOS FAAS FCEBS FDCS FADS FCCS FTCHS 1STHS FPHS 1STS FHKSS FLS FLWVS FLDDS Plan Name COUNITY CHOICE ICHIGAN COUNITY FIST COUNITY HEALTH COUNITY HEALTH NETWOK OF CONNECTICUT COUNITY HEALTH PLAN COP CAE GT CONNECTICAE CONNECTICAE - EDICAE CONSOCIATE GOUP CONTINENTAL GENEAL LIFE INSUANCE COOK CHILDEN S HEALTH PLAN COOK CHILDEN S STA PLAN COESOUCE IL COESOUCE LITTLE OCK COESOUCE OF OHIO COPOATE BENEFIT SEVICES OF AEICA COVENTY HEALTH LOUISIANA COVENTY HEALTH PLANS GA COVENTY HEALTH PLANS KS COVENTY HEALTHCAE OF THE CAOLINAS CT BCBC ANTHE CT BLUE CAE CT EDICAID CT PAT B FLU SHOTS CTL ST HLTH WE DC PAT B FLU SHOTS DELAWAE PAT B FLU SHOTS DELTA HEALTH SYSTES DESET UTUAL DISCOLL S CHILDEN S HEALTH PLAN EBS OF LA EDS ADIN SEVICES EDUCATOS UTUAL EL PASO 1ST HLTH NETWOK ELDE HEALTHCAE TEAS EEALD HEALTH NETWOK EPIE BLUE SHIELD NEW YOK EPLOYEE BENEFIT ADIN AND GT EPLOYEE BENEFIT PLAN EPLOYEE BENEFITS CONSUL EPOCH GOUP EISA ESSENCE HEALTHCAE EVECAE FALLON COUNITY HEALTH FAILY HEALTH PATNES - HEALTHWAVE FAILY HEALTH PATNES/C ISSOUI FAA FCEB BENEFIT ADINISTATOS FIDELIS CAE NY FIST ADINISTATOS FIST CAOLINA CAE FIST CHOICE FIST HEALTH FIST PIOITY HEALTH FISTCAE STA EDICAID FISEV HEALTH - KANSAS FL EDICAID FL EDICAID WAIVE FL EDICAID WAIVE DEVELOPENTAL Page 17 of 20

18 Processor Control Number FLBCS FHHSS FHCS FHLTS GABSS GAS GWHP GEHAS GEISS FLUGA GHNYS GHIS GILSS GICS GLHPS GWSTS GPADS GPAHS GPHCS GHCWS GHPS GISCS GDNS HHILS HBSIS HPHPS FLUHI HCHAS HFTS HFHPS HPNYS HLTNS HNPLS HPPAS HPIS HCTPS HCUSS HCAZS HLCPS HHOS HPPOS HNNES HPJTS HPNS HPHS HPPHS HSBIS HLTAS HSPCS HSOHS HLSPS HAPS HHNJS HHLPS HUAS HENCS HHOHS HOS Plan Name DISABILITY FLOIDA BLUE SHIELD FLOIDA HOSPITAL HEALTHCAE SYSTES FH COE SOUCE FEEDO HEALTH GA BLUE SHEILD GA EDICAID GATEWAY HEALTH PLAN GEHA GEISINGE HEALTH PLANS GEOGIA PAT B FLU SHOTS GHI NEW YOK GHI HO GILSBA GOLDEN ULE INSUANCE CO GEAT LAKES HEALTH PLAN GEAT WEST GOUP AND PENSION ADINISTATOS GOUP BENEFIT ADINISTATOS GOUP HEALTH COOP GOUP HEALTH COOPEATIVE WEST (GHC OF PUGET SOUND) GOUP HEALTH PN GOUP INSUANCE SEVICE CENTE, INC. GUADIAN HAONY HEALTH PLAN OF ILLINOIS HAINGTON BENEFIT SEVICES HAVAD PILGI HEALTH PLAN HAWAII PAT B FLU SHOTS HCH ADINISTATION - PEOIA HEALTH FIST HEALTH FIST HEALTH PLANS HEALTH INSUANCE PLAN OF NEW YOK (HIP) HEALTH NET HEALTH NET PEAL HEALTH PATNES OF PHILADEPHIA HEALTH PLAN OF ICHIGAN HEALTHCAE TASNACTION POCESSING HEALTHCAE USA HEALTHCHOICE OF AIZONA HEALTHCOP, INC HEALTHLINK HO HEALTHLINK PPO HEALTHNET OF THE NOTHEAST HEALTHPATNES JACKSON TN HEALTHPATNES INNESOTA HEALTHPATNES INNESOTA HEOPHELIA HEALTHPLUS PHSP HEALTHSCOPE BENEFITS INC HEALTHSAT ACCEL HEALTHSAT PEFEED CAE HEALTHSOUCE OHIO HEALTHSPING HO/HEALTHSPING EDICAE+CHOICE HLTH ALLC ED PLANS HOIZON HEALTHCAE OF NEW JESEY HUDSON HEALTH PLAN HUANA HUANA ENCOUNTES ONLY HUANA HEALTH PLANS OHIO HUANA HO Processor Plan Name Control Number IAS IA EDICAID IDS ID EDICAID IDBSS IDAHO BLUE SHIELD FLUID IDAHO PAT B FLU SHOTS ILS IL EDICAID FLUIL IL PAT B FLU SHOTS ILBSS ILLINOIS BLUE SHIELD INS IN EDICAID INDHS INDEPENDENT HEALTH INBSS INDIANA BLUE SHEILD FLUIN INDIANA PAT B FLU SHOTS INSTLS INSTIL HEALTH ITS INSUANCE ANAGEENT SEVICES OF TEAS IHCS INTEOUNTAIN HEALTH CAE FLUIA IOWA PAT B FLU SHOTS JALIS JOHN ALDEN LIFE INSUANCE KPNWS KAISE NW EGION KPCAS KAISE PEANENTE CALIFONIA KPSCS KAISE PEANENTE SOUTHEN CALIFONIA BCKSS KANSAS BCBS KSBSS KANSAS BCBS FEEDO PLANS FLUKS KANSAS PAT B FLU SHOTS KBAAS KBA ASSUANT HEALTH FLUKY KENTUCKY PAT B FLU SHOTS KYSHS KENTUCKY SPIIT HEALTH KFHCS KEN FAILY HEALTH KEYFS KEY FAILY - HIGHAK KEYES KEYSTONE HEALTH PLAN EAST KHPS KEYSTONE ECY HEALTH KLCOS KLAIS AND COPANY KSS KS EDICAID KYS KY EDICAID LABS LA BCBS LAS LA EDICAID ABSS A BLUE SHIELD AS A EDICAID FLUA A PAT BE FLU SHOTS AAGS AEICAN ADINISTATIVE GOUP AAG (FOELY GALLAGHE BENEFITS) AGHS AGNOLIA HEALTH PLAN HINS ANAGED HEALTH SEVICES OF INDIANA / AICAE DBSS AYLAND BLUE SHIELD FLUD AYLAND PAT B FLU SHOTS AYOS AYO ANAGEENT SEVICES DS D EDICAID DCTS EDCOST INC EDAS EDICA EDHS EDICA HEOPHELIA HCPS EDICA HLTH CAE TPPS EDICAID T PEIE PLN BOHS EDICAL BENEFITS COPANY (NEWAD, OH) OHS EDICAL UTUAL OF OHIO DNS EDICAL ESOUCE NETWOK VOHS EDICAL VALUE PLAN - OHIO 001 EDICAE DE CPBS EDICAE PLUS BLUE / EDICAE ADVANTAGE EDIS EDIPACT EGAS EGA LIFE AND HEALTH HPLS ECY HEALTH PLAN OF NEW JESEY Page 18 of 20

19 Processor Plan Name Control Number CPLS ECY HEALTH PN TOS ETO PLUS THPS ETOPOLITAN HEALTH PLAN IBCS I BCBS IBDS I BCBS DIENSION IBNS I BLUE CAE NETWOK IS I EDICAID FLUI ICHIGAN PAT B FLU SHOTS DCHS IDLANDS CHOICE WSCS IDWEST SECUITY SBSS ISSISSIPPI BLUE SHIELD FLUS ISSISSIPPI PAT B FLU SHOTS FLUO ISSOUI PAT B FLU SHOTS OCS ISSOUI CAE NBCS N BCBS NBHS N BCBS HEOPHELIA NS N EDICAID FLUN N PAT B FLU SHOTS OS O EDICAID OLIS OLINA HEALTHCAE OWAS OLINA HEALTHCAE OF WA HUTS OLINA HEALTHCAE OF UTAH OIS OLINA ICHIGAN OOHS OLINA OHIO FLUT ONTANA PAT B FLU SHOTS GINS ONUENTAL GENEAL INS SS S EDICAID PCNS S PHYSICIANS CAE NET TS T EDICAID HBFS UNICIPAL HEALTH BENEFITS FUND UASS UTUAL ASSUANCE OOIS UTUAL OF OAHA VNY VP HEALTH PLAN OF NY NAADS NAA (North America Admin., L.P.) Nashville, TN NALCS NALC HEALTH BENEFITS NLBFS NATIONAL BENEFIT FUND NHINS NATIONAL HEALTH INSUANCE NTCAS NATL TELECO COOP ASS NCBSS NC BLUE SHIELD NCS NC EDICAID NCAFS NCA FAIFA, VA NDS ND EDICAID NDWCS ND WC NES NE EDICAID FLUNE NE PAT B FLU SHOTS NHPTS NEIGHBOHOOD HEALTH PATNESHIP NHHPS NEIGHBOHOOD HEALTH PLAN NWHLS NETWOK HEALTH FLUNV NEVADA PAT B FLU SHOTS NEAS NEW EA NJBSS NEW JESEY BLUE SHIELD FLUNJ NEW JESEY PAT B FLU SHOTS NBSS NEW EICO BLUE SHIELD FLUN NEW EICO PAT B FLU SHOTS FLUNN NEW YOK PAT B FLU SHOTS - DOWNSTATE FLUNQ NEW YOK PAT B FLU SHOTS - QUEENS FLUNU NEW YOK PAT B FLU SHOTS - UPSTATE NYPCS NEW YOK PESBYTEIAN COUNITY HEALTH PLAN NGASS NGS AEICAN, INC NHS NH EDICAID NJS NJ EDICAID Processor Control Number FLUNC NDBSS FLUND NCSS NVS NIPAS NWPHS NYS NYIS OOGBS OHS OHBSS OHCPS FLUOH OKS OKBSS FLUOK OCCVS OCGS OS FLUO OBSS OFDS PABSS PAS FLUPA PACFS PPPOS PAPS PKLDS PSHPS PNHPS PPADS PSADS PPHPS PCTS PECHS PEHPS PABCS PHNTS PPCS PHOES PHLPS PHCHS PHUS PNCS PLADS POCS PPLCS PPOS PFCPS PHSIS PE1S PEHS PLFES PTYS PCGS PHPLS PUDS QUALS Plan Name NOTH CAOLINA PAT B FLU SHOTS NOTH DAKOTA BLUE SHEILD NOTH DAKOTA PAT B FLU SHOTS NOTHEN CALIFONIA SHEET ETAL WOKES INSUANCE NV EDICAID NW SUBUBAN IPA NWP ODS HEALTH PLAN NY EDICAID NYI OFOD OFFICE OF GOUP BENEFITS OH EDICAID OHIO BLUE SHIELD Ohio Health Choice PPO OHIO PAT B FLU SHOTS OK EDICAID OKLAHOA BLUE SHIELD OKLAHOA PAT B FLU SHOTS ONICAE, A CONVENTY HEALTH PLAN ONICAE EDICAL GOUP O EDICAID O PAT B FLU SHOT OEGON BLUE SHIELD OFOD HEALTH PA BCBS INDEPENDENCE PESONAL CHOICE PA EDICAID PA PAT B FLU SHOTS PACIFICAE PACIFICAE PPO PAPE CLAI HCFA 1500 FO PAKLAND COUNITY HEALTH PLAN PAT HEALTH Partners National Health Plan of NC PASSPOT ADVANTAGE PASSPOT ADVANTAGE PASSPOT HLTH PLAN PCA HEALTH PLANS OF TEAS PEACH STATE HEALTH PLAN PEHP UTAH PENNSYLVANIA BCBS PEOPLES HEALTH NETWOK PESONAL PHYSICIAN CAE PHOENI HEALTHCAE PHYSCN HLTH PLAN PHP PHYSICIANS HEALTH CHOICE PHYSICIANS UTUAL PINNACLE CLAIS ANAGEENT PLANNED ADINISTATOS POCO PPO PLUS LLC PPO PEFEED CAE PEFEED HEALTH PEFEED ONE PEFEED ONE HEOPHELIA PINCIPAL LIFE INSUANCE PIOITY HEALTH POFESSIONAL CLAIS ANAGEENT POVIDENCE HEALTH PLAN PUDENTIAL QUALICAE INC Page 19 of 20

20 Processor Plan Name Control Number QCAS QUALITY CHOICE OF AKANSAS BSOS EGENCE BCBS OF O BSWS EGENCY BLUESHIELD OF WA BIDS EGENCY BLUESHIEOD OF ID ESTS ESTAT IS I EDICAID SCS SCO OBSS OCHESTE NEW YOK BLUE SHIELD HOS OCKY OUNTAIN HO SSHSS S & S HEALTHCAE STATEGIES SHNS SAGAOE HEALTH NET SCBCS SC BLUE SHIELD SCS SC EDICAID SDS SD EDICAID FLUSD SD PAT B FLU SHOTS SHPTS SECUE HEALTH PLAN T SHHS SECUE HOIZONS HO SHLPS SECUITY HEALTH PLAN SCES SELECT CAE SHSCS SELECT HEALTH SOUTH CAOLINA SHPS SENTA HEALTH ANAGEENT SIAS SIEA HEALTH SYSTES SADS SITH ADINISTATOS FLUSD SOUTH DAKOTA PAT B FLU SHOTS SHSIS SOUTHEN HEALTH SEVICES, INC. STVNS ST VINCENT S CATHOLIC EDICAL CENTE STAS STA HG STFS STATE FA STL1S STELING OPTION 1 STIDS STUDENT INSUANCE DIVISION SCHPS SUACAE HEALTH PLAN SHPCS SUPEIO CHIPS SHPTS SUPEIO HEALTH PLAN TEAS TBTPS TBT FLUTN TENNESSEE PAT B FLU SHOTS TNBSS TENNESSEE BLUE SHIELD TBSS TEAS BLUE SHIELD TCHPS TEAS CHLDN HLTH FLUT TEAS PAT B FLU SHOTS TTCS TEAS TUE CHOICE LOOS THE LOOIS CO TOPS TODAY S OPTION PYAID TLINS TOWE LINE INSUANCE TALIS TANAEICA LIFE INSUANCE TCLFS TICAE FO LIFE TCNSS TI-CAE NO AND SO TCNS TICAE NOTH TCSS TICAE SOUTH TCWS TICAE WEST THLPS TUFTS HEALTH PLAN TCCS T CO CAE Processor Control Number THOS TS UCES UFCWS UWAS UCOJS UPHS UNHPS UNHCS UHVS UNS UNVS UVHCS USAAS FLUUT UHCOS VAS VAPHS VNTGS VTBSS VTS FLUVA VIVAS VNCS WAS FLUWA WSBA WSBIS WEATS WTPAS WELLS WLPFS WLPFS WLDS WNYBS WSFGS WIS FLUWI WHCNS WIES WIBCS WIS WLDS WYS WYBSS FLUWY Plan Name T HO BLUE SHIELD T EDICAID UCAE UFCW CENTAL OHIO UWA HEALTH AND ETIEENT FUND UNICAE OLD JOHN HANCOCK UNIFO EDICAL PLAN / HAINGTON BENEFIT SEVICES UNISON HEALTH PLAN UNITED HEALTHCAE UNITED HEALTHCAE OF IVE VALLEY UNITED EDICAL ESOUCES UNIVEA HEALTHCAE UNIVESAL HEALTH CAE USAA LIFE/ US AUTO ASSOC UTAH PAT B FLU SHOTS UTD HLTHC OVAT VA EDICAID VA PEIE HEALTH PLAN VANTAGE HEALTH PLAN VEONT BCBS VEONT EDICAID VIGINIA PAT B FLU SHOTS VIVA HEALTH PLAN VNS CHOICE EDICAE WA EDICAID WASHINGTON PAT B FLU SHOTS WATESTONE BENEFIT ADNDTS WAUSAU BENEFITS INC WEA TUST WEB TPA WELLCAE / UNICAE WELLCAE PFFS WELLCAE PFFS WELLED CLAIS WESTEN NY BCBS WESTEN SOUTHEN FINANCIAL GOUP WI EDICAID WI PAT B FLU SHOTS WINDSO H C NET WINDSO EDICAE ETA WISCONSIN BLUE COSS WISCONSIN EDICAID WOLD INSUANCE CO WY EDICAID WYOING BLUE COSS WYOING PAT B FLU SHOTS Page 20 of 20