Harvard Pilgrim Health Care June 2014 i

Harvard Pilgrim Health Plan HIPAA Transaction Standard Companion Guide (835, 005010X221A1) Refers to the Technical Report Type 3 Based on X12 version 005010 Companion Guide Version Number: 1.03 Harvard Pilgrim Health Care June 2014 i

Preface This Companion Guide to the ASC X12N Technical Report Type 3 guide Guides adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Harvard Pilgrim Health Plan. Transmissions based on this companion guide, used in tandem with the X12N Technical Report Type 3 guide Guides, are compliant with both 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 Technical Report Type 3 guide Guides. Harvard Pilgrim Health Care June 2014 ii

Preface... ii 1. INTRODUCTION... 2 Overview... 2 References... 2 Technical Requirements... 2 Trading Partner Registration and Agreement... 3 2. TESTING AND ACCESS... 3 Live Files... 3 Access... 3 3. CONNECTING and COMMUNICATING... 3 e-channels... 3 Security... 4 4. CONTACT INFORMATION... 5 EDI Services... 5 Provider Service Center... 5 Health Plan Products, Programs, Policies and Procedures... 5 5. HPHC BUSINESS RULES and LIMITATIONS... 5 File-Naming Convention... 5 Envelope Identifiers... 6 Receiver Identification... 6 835 Distribution Schedule... 6 Claim Adjustment Reason Codes and Remittance Advice Codes... 7 835 Structure... 8 9999999999 as NPI... 8 Claim & Service Line Adjustments... 9 Capitated Claim... 9 Member Identification... 9 Denied Claim Lines vs. Denied Claims... 9 The Electronic 835 and the Paper Explanation of Payment... 9 Provider Level Adjustments (PLB)... 9 Matching Process... 11 6. TABLES... 12 APPENDICES... 14 A. Sample 835... 14 B. Revision Control... 17 Harvard Pilgrim Health Care June 2014 1

1. INTRODUCTION Overview The Health Insurance Portability and Accountability Act Administration Simplification (HIPAA-AS) requires Harvard Pilgrim Health Care and all other covered entities to comply with the electronic data interchange standards for health care as established by the Secretary of Health and Human Services. This companion guide has been prepared to help those responsible for testing and setting up electronic Claim Payment Advice transactions. Specifically, it documents and clarifies when situational data elements and segments are to be expected for Claim Payment Advice files. This guide supplements (but does not contradict) any requirements in the ASC X12N 835 (version 005010X221A1) implementation. The information here should be given to the provider s business area to ensure that Claim Payment Advice transactions are interpreted correctly. Within this guide you will find three sections: The first section details the technical requirements necessary to transmit EDI information with Harvard Pilgrim Health Care, and general information on setting up the trading partner relationship. The second section details data requirements specific to Harvard Pilgrim for processing the 835. And the third contains tables showing the segments and elements affected, code listings, and examples of the X12 data for the 835. References The ASC X12N 835 (version 005010X221A1) Technical Report Type 3 Guide for Health Care Claim Payment Advice has been established as the standard for Claim Payment Advice transactions and is available at http://www.wpc-edi.com/hipaa. Harvard Pilgrim Health Care s website, containing documentation on e- transactions for providers, can be found at http://www.harvardpilgrim.org Technical Requirements Harvard Pilgrim supports the 835 ASC X12N version for health care claim payment/advice. Providers wishing to receive the 835 must support this version. For Core HMO, PPO and POS, products Harvard Pilgrim may send one 835/ERA file for each check that has been generated for a payee. Checks and 835/ERA files are generated weekly. A payee may receive up to six checks and ERA files (a medical and hospital check for each Harvard Pilgrim insurance system). The 835 transaction does not include or support pended claims or Negative Balance Reports. For Choice Plus and Options products jointly offered with United Healthcare, Harvard Pilgrim may send one or many checks per 835/ERA file. Checks and 835/ERA files are generated daily. Files are generated by tax ID and are not able to be separated by payee number or site address to deliver to multiple recipients. Recipients who share a tax ID will need to identify one recipient to which the 835 files will be delivered. Harvard Pilgrim Health Care June 2014 2

Trading Partner Registration and Agreement Important documents to setup new EDI partnerships are detailed below: 2. TESTING AND ACCESS EDI Trade Partner Agreement Defines requirements for the secure use, transmission, and storage of protected information exchanged between the payer and trading partners. EDI Enrollment Form A survey of Trading Partner information, identifiers, desired EDI transactions, and requested e-channels. This information is used to set up new Trading Partners for EDI or to edit existing information. Identification of Third Party Representative Form Required for billing services, clearinghouses and intermediaries. This form defines the relationship between provider and third party and gives authorization to send/retrieve data on behalf of provider. Live Files Harvard Pilgrim does not send test or sample 835 transactions in response to a test 837 submission. All 835 transactions are live (i.e., actual production data). The decision to post 835 transactions to the payee s test or production accounts receivable system is solely the responsibility of the recipient. Access The EDI team will assign a user ID, password and mailbox (folder) for file dropoff and retrieval: The user ID allows access to the production environment. Harvard Pilgrim does not set up 835 transactions in the payee s test/development environment. When possible, an existing production user ID, password and mailbox will be used. 3. CONNECTING and COMMUNICATING e-channels Harvard Pilgrim provides 4 options for trading partners to retrieve production 835s. Downloading these transactions directly eliminates the need for an intermediary and is offered to providers at no cost per transaction. Our preferred e-channels are: HPHConnect A provider retrieves the 835 ERA by downloading the file via the HPHConnect File Transfer Agent (FTA). New England Healthcare Exchange Network (NEHEN) Harvard Pilgrim delivers the 835 file to a specified directory on the Harvard Pilgrim gateway. The Harvard Pilgrim gateway will be configured to automatically deliver the 835 file to the receiver s NEHEN gateway. It is the receiver s responsibility to configure their NEHEN gateway to accept the 835 file. Please contact your NEHEN representative to review your gateway software version and configuration. NEHENNet A provider retrieves the 835 ERA by downloading the file from the NEHENNet secure Web site. Harvard Pilgrim Health Care June 2014 3

Secure FTP Harvard Pilgrim delivers the 835 file to the Harvard Pilgrim secure FTP (File Transfer Protocol) server in a specified directory. The provider can retrieve the file using an assigned user ID and password. Security Maintaining the confidentiality of personal health information continues to be one of Harvard Pilgrim s guiding principles. Harvard Pilgrim has a strict confidentiality policy for safeguarding patient, employee, and health plan information. All staff is required to be familiar with, and comply with, Harvard Pilgrim s policy on the confidentiality of member personal and clinical information to ensure that it is treated in a confidential and respectful manner. The policy permits use or disclosure of members medical or personal information only as necessary to conduct required business, care management, approved research or quality assurance or measurement activities, or when authorized to do so by a member or as required by law. To comply with internal policies as well as the provisions of the Health Insurance Portability and Accountability Act (HIPAA), Harvard Pilgrim has outlined specific requirements applicable to the electronic exchange of protected health information (PHI), including provisions for: Maintaining confidentiality of protected information Confidentiality safeguards Security standards Return or destruction of protected information Compliance with state and federal regulatory and statutory requirements Required disclosure Use of business associates These requirements are detailed in the privacy and security agreement presented to Harvard Pilgrim s electronic trading partners during our initial discussions. Harvard Pilgrim offers a variety of solutions to transmit protected health information (PHI) using a public network. In accordance with Harvard Pilgrim Policy and the HIPAA Security Rule, any PHI that is transmitted using a public network must be encrypted. Web-based applications are configured to use secure socket layer security software capabilities, and only a browser with support for 128-bit high encryption is acceptable under this policy Harvard Pilgrim s policy requires the use of any encryption technology for file transmission to be approved by the Harvard Pilgrim information security officer prior to its implementation. NEHEN trading partners transmit transactions using private network frame relay connections, Virtual Private Networks (VPN) or X.509 digital certificates for Web Services connections. Harvard Pilgrim Health Care June 2014 4

4. CONTACT INFORMATION EDI Services If the answers to questions you have are not found in this Companion Guide, contact the Harvard Pilgrim EDI team: Phone: Toll Free: 800-708-4414 (option 1, then option 3) Direct: 617-509-8998 Fax: 866-884-3844 Email: edi_team@harvardpilgrim.org Web site: www.harvardpilgrim.org Provider Service Center If you have questions regarding claim adjudication results, claim status, member eligibility or referral/authorization, contact the Harvard Pilgrim Provider Service Center: Phone: 800-708-4414 (option 1 then option 5) Email: provider_callcenter@harvardpilgrim.org Health Plan Products, Programs, Policies and Procedures The online Provider Manual represents up-to-date information on Harvard Pilgrim Health Care products, programs, policies and procedures. Information found online may differ from your print version. Web site: http://www.harvardpilgrim.org/providers/provider Manual/ 5. HPHC BUSINESS RULES and LIMITATIONS File-Naming Convention Harvard Pilgrim s file-naming convention for the 5010 835 is: TSS_<ISA08>_<GS03>_CCYYMMDD_HHMM_835.txt T = Type of Check ( H for Hospital, M for Medical or C for combined) SS = Insurance system that generated the 835/ERA, specifically: NS = Combined National Product IS = Integrated Commercial MI = Medicare Supplement and Wrap/Miscellaneous Commercial <ISA08> = Assigned Receiver ID <GS03> = Assigned Application Receiver ID CCYYMMDD_HHMM = date and time the ERA file was created by Harvard Pilgrim insurance systems. Harvard Pilgrim Health Care June 2014 5

Examples: MIS_HPHC0001_HPHC0001B_20050119_1134_835.txt HMI_NEHEN003_NEHEN003_20050131_1000_835.txt CNS_HPHC0001_HPHC0001B_20070124_0920_835.txt Harvard Pilgrim has begun transitioning our 835 transactions over to our new Claims Payment system for 5010. 835s created for members in this system will employ a new naming convention in addition to the 835s from the old system. This new report will be generated as a HIPAA version 5010 production file with file name beginning with COH indicating it is a combined medical and institutional 835 file. Additionally, a two-letter code will be added to the naming convention for these 835. For paid claims with an associated check number either PC will be used to indicate the claims within are commercial claims, or PI will be used to indicate indemnity claims. EC will be used to indicate the 835 contains only non-payment or encounter commercial claims, and EI indicates non-payment or encounter indemnity claims. Both EC and EI will have a NOCHK identifier rather than a check number, followed by a 6-digit number to uniquely identify it. 5010_COH_HPHC0001_HPHC0001_20130314_1610_EC_835.txt 5010_COH_HPHC0001_HPHC0001_20130314_0900_EI_835.txt 5010_COH_NEHEN003_NEHEN003_20120314_1200_PC_835.txt 5010_COH_NEHEN003_NEHEN003_20130105_0850_PI_835.txt For all claims adjudicated on the new system, the claim status inquiry in HPHConnect will be reported with the HIPAA 277 claim status codes and descriptions. Envelope Identifiers Harvard Pilgrim Health Care supplies each submitting provider with the Interchange Receiver and Application Receiver Identifiers for the envelope elements as a part of the setup process. These IDs may depend upon which e- Channel is used. For NEHEN and NEHENnet: Both the Interchange Sender ID (ISA06) and Application Submitter ID (GS02) are NEHEN003 For HPHConnect and SFTP: The Interchange Sender ID (ISA06) is HPHC0001 and the Application Receiver ID (GS02) is HPHC0001B Receiver Identification Harvard Pilgrim Health Care may send the REF segment with EV qualifier for receiver identification and include the ISA06 and GS02 from the original claims file as the identifiers. 835 Distribution Schedule For Core HMO, PPO and POS products, Harvard Pilgrim produces checks on a weekly basis. The 835 files are available by close-of-business on Wednesday. The check reported in the 835 is dated Tuesday. Harvard Pilgrim Health Care June 2014 6

For Choice Plus and Options, Harvard Pilgrim produces checks daily. In general, the 835 files are available the next business morning. Currently, for each submitter, there may be up to six checks and six files. This corresponds to a medical check and hospital check for each of Harvard Pilgrim s three claims processing systems. Claim Adjustment Reason Codes and Remittance Advice Codes Harvard Pilgrim Health Care has reviewed all Claim Adjustment Reason Code and Remittance Advice Remark Code (CARC/RARC) Combinations in order to comply with the ACA-mandated CAQH CORE Operating Rule #360 (Uniform Use of CARCs and RARCs (835) Rule). This rule is part of the Phase III CAQH CORE EFT & ERA Operating Rules adopted to fulfill the ACA Section 1104 Federal mandate. A Harvard Pilgrim specific business scenario exists that is not available in the current rule; the code-combination for this scenario is as follows: HPHC-Defined Business Scenarios for 835 Related to Code Combinations for Denied Appeals CARC CARC Description RARC RARC description ASC X12 CAGC 193 Original payment decision is being maintained. Upon review, it was determined that this claim was processed properly. MA46 The new information was considered but additional payment will not be issued. PI Harvard Pilgrim Health Care June 2014 7

835 Structure Harvard Pilgrim sends an 835 file for each type of check generated by each of its insurance systems. There is a difference in the structure of Choice Plus and Options products from those of Legacy HPHC products. See the Appendices in Section 7 for examples of each. Core HMO, PPO and POS product 835s are based on the Harvard Pilgrim Payee number. Each 835 ISA/IEA loop will have one GS/GE loop, and one ST/SE loop per payee for the original submitter. *For remittance accompanying mailed checks, the second Loop 1000B REF Payee Additional Information segment will have the PQ qualifier and the Harvard Pilgrim payee number; EFT payment remittance files do not include the Harvard Pilgrim payee number. A new LX segment will introduce each new Health Care Provider under that payee, and each provider s claims will follow starting with a CLP segment. Choice and Choice Plus 835s are based on the payee s Tax ID. Each 835 ISA/IEA loop will have one GS/GE loop, and one ST/SE loop per check. Each check will have only one provider, but may have multiple claims. 9999999999 as NPI Harvard Pilgrim Health Care June 2014 8

Harvard Pilgrim reports a value of 9999999999 when we are unable to identify the payee or rendering provider NPI to report in the 835 file. Claim & Service Line Adjustments In general, Harvard Pilgrim s claims processing system processes claims at a service line level. A claim is not reported on an 835 until all service lines are in a final state (paid or denied). A pended claim will not be reported on an 835. Capitated Claim Harvard Pilgrim will identify an encounter at the line level. Each claim line that includes an encounter service will be reported with Adjustment Group code CO and Adjustment Reason Code 24 (Charges are covered under a capitation agreement/managed care plan). The value of this claim line will be the fee for service equivalent of the capitated service. Member Identification Core HMO, PPO and POS Member identifiers, including suffix, are 11-character alphanumeric values, (e.g. HP123456700). The last two digits [(e.g., 00)] represent the member suffix. Choice Plus and Options member identifiers consist of a nine-character subscriber ID and six character group numbers. Harvard Pilgrim will return the subscriber ID in Patient Name Loop (2100) where NM108 is MI and NM109 is the subscriber ID number. The group number will be returned in Claim Payment Information Loop (2100) where REF01 is 1L and REF02 is the group number. Denied Claim Lines vs. Denied Claims A claim can have denied lines and still be considered a paid claim, however if a claim has a zero dollar payment and no patient responsibility, it is a denied claim. Harvard Pilgrim will define a Denied Claim as a claim on which the last version of all claim lines is denied. The Electronic 835 and the Paper Explanation of Payment Harvard Pilgrim Health Care sends both the 835 and the paper Explanation of Payment (EOP) to our trading partners. Please note that separate processes generate the 835 and paper EOP which may result in differences between the two. Harvard Pilgrim is migrating to the use of HIPAA standard CARC and RARC codes in the paper EOP to minimize differences between the paper EOP and 835 file. As member claims migrate to the new Harvard Pilgrim processing system, paper EOPs from the new system will report the HIPAA standard CARC and RARC codes. Paper EOPs for claims adjudicated on legacy systems will report Harvard Pilgrim legacy explanation of payments codes, not standard CARCs and RARCs. Provider Level Adjustments (PLB) In order to tie back the provider level adjustments to the claim/service lines, each PLB segment contains the NPI in PLB01, or for atypical providers ineligible for NPI, the Harvard Pilgrim assigned provider number, which corresponds to the appropriate LX/TS3 segment. Harvard Pilgrim Health Care June 2014 9

Non-reconcilable Refund Checks When Harvard Pilgrim receives a refund check that cannot be reconciled to a claim, or an entire amount that cannot be reconciled, we return the unreconcilable amount in a PLB segment with a B2 qualifier and the check number received in the PLB03-2. Harvard Pilgrim Health Care June 2014 10

Matching Process Harvard Pilgrim makes a best effort to match incoming claims information with the data in its claims processing system. The approach is to match adjudicated lines within Harvard Pilgrim s system that are being paid on the 835 with incoming claim data that was stored in a supplemental database. The process evaluates all of the claim s lines in Harvard Pilgrim s system for the best match. The following fields are used to match inpatient institutional claims: Revenue codes - a selected set is used to match accommodations Revenue codes/procedure codes - those codes that are not related to accommodations are used to match ancillary services The following fields are used to match both outpatient and professional claims: Service line adjudication status code Amount charged Date of service Procedure code or revenue code Units Modifiers It is strongly recommended that submitters of paper claims use standard codes. Non-standard codes will not be matched on the 835 to the original claim. In these cases, Harvard Pilgrim will use the data stored in our claims adjudication system to match to the 835. The following fields will be impacted: Submitted Charges (Monetary amount Loop 2100 CLP03) ----Contains the claim total charged/submitted amount as stored in Harvard Pilgrim insurance systems. Bill Type/Place of Service (Facility Code Value CLP08) ----Contains a Harvard Pilgrim location code. Service Date (Loop 2110 DTM) ----Contains the value(s) stored in the Harvard Pilgrim system. Harvard Pilgrim Health Care June 2014 11

6. TABLES Loop ID Segment Type Segment Designator Header ISA Interchange Control Header TRN Reassociation Trace Number 1000A REF Additional Payer Information 1000B REF Payee Additional Information 2000 TS3 Provider Summary Information 2100 CLP Claim Payment Information Element ID 06 08 Data Element 02 Reference Identification 04 Reference Identification 01 Reference Identification Qualifier 02 Reference Identification 01 Reference Identification Qualifier HPHC Business Rule Value will be the check number for payments. For a zero-dollar amount, value will say NOCHK with additional characters to make the value unique. For legacy claims, value will be HPHC, for Choice Plus and Options claims, value will be 000004271 Not used for legacy claims, for Choice Plus and Options claims value will be 2U Not used for legacy claims, for Choice Plus and Options claims value will be 04271 In addition to the Tax ID, Core HMO, PPO and POS product claims value will be PQ for the payee number. 03 Date Set to the last day of the calendar year, e.g. 20111231 01 Claim Submit Identifier 02 Claim Status Code 03 Monetary Amount Patient account number. If value contains an *, ~ or :, the characters will be replaced with a space to prevent conflicts with EDI control characters. Value will be 1, 2, or 22. Total charges submitted. May not be the same as submitted on paper by the provider if the line item totals did not match the claim total. Harvard Pilgrim Health Care June 2014 12

2100 SVC Service Information 2110 REF Service Identification 02 Monetary Amount 01 Reference Identification Qualifier 02 Reference Identification Total charges submitted. May not be the same as submitted on paper by the provider if the line items totals did not match the claim total Value will be BB Authorization Number Harvard Pilgrim Health Care June 2014 13

APPENDICES A. Sample 835 The example below contains a check with three items. REFNUMBER1 is an example of a normal paid claim. REFNUMBER2 is an example of a correction and reversal. REFNUMBER3 is an example of a denied claim. At the time of this publication, an example of version 5010 Choice Plus or Options 835 is not available. ISA*00* *00* *ZZ*NEHEN003 *ZZ*NEHEN00A *110516*1134*^*00501*000006994*0*P*:~ GS*HP*NEHEN003*00000009B*20110314*1100*529*X*005010X221A1~ ST*835*0529~ BPR*I*1132*C*CHK************20110101~ TRN*1*000123456*1999999999*HPHC~ REF*EV*NEHEN00A-00000009B~ N1*PR*HPHC Insurance Company, Inc.~ N3*Claim Services Dept.*1600 CROWN COLONY DRIVE~ N4*QUINCY*MA*02169~ PER*CX**TE*8007084414~ PER*BL*EDI TEAM*TE*8007084414*EM*EDI_TEAM@HARVARDPILGRIM.ORG*FX*8668843844~ N1*PE*GENERAL HOSPITAL*XX*9999999999~ N3*POSTAL ADDRESS*PO BOX 123~ N4*QUINCY*MA*021690001~ REF*TJ*999999999~ REF*PQ*HPHCPAYEENUMBER~ LX*0~ TS3*9999999999*21*20111231*1*8133.31~ CLP*REFNUMBER1*2*8133.31*1132**15*HPCLAIMNUMBER1*11*1**0272~ NM1*QC*1*LASTNAME*FIRSTNAME****MI*HP000000000~ NM1*82*1*HOSPITAL*GENERAL****XX*9999999999~ DTM*050*20110415~ SVC*NU:0120*2589*1132**3~ CAS*CO*94*-3533.31~ CAS*OA*23*4990.31~ REF*6R*1~ AMT*B6*6122.31~ SVC*NU:0240*607.81*0**1*NU:0250*600~ CAS*OA*16*5544.31**94*-4936.5~ REF*6R*2~ AMT*B6*5544.31~ SVC*NU:0240*52.5*0**1*NU:0258*11~ Harvard Pilgrim Health Care June 2014 14

CAS*CO*97*52.5~ REF*6R*3~ SVC*NU:0240*201*0**1*NU:0270*3~ CAS*CO*97*201~ REF*6R*4~ SVC*NU:0240*955*0**1*NU:0300*27~ CAS*CO*97*955~ REF*6R*5~ SVC*NU:0240*277*0**1*NU:0320*600~ CAS*CO*97*277~ REF*6R*6~ SVC*NU:0240*168*0**1*NU:0324*600~ CAS*CO*97*168~ REF*6R*7~ SVC*NU:0240*811*0**1*NU:0341*600~ CAS*CO*97*811~ REF*6R*8~ SVC*NU:0240*301*0**1*NU:0343*2~ CAS*CO*97*301~ REF*6R*9~ SVC*NU:0240*212*0**1*NU:0424*600~ CAS*CO*97*212~ REF*6R*10~ SVC*NU:0240*832*0**1*NU:0450*600~ CAS*CO*97*832~ REF*6R*11~ SVC*NU:0240*632*0**1*NU:0730*7~ CAS*CO*97*632~ REF*6R*12~ SVC*NU:0240*495*0**1*NU:0921*600~ CAS*CO*97*495~ REF*6R*13~ LX*1~ CLP*REFNUMBER2*22*-17315.1*0**15*HPCLAIMNUMBER2*21***0945~ NM1*QC*1*LASTNAME2*FIRSTNAME2****MI*HP900000000~ Harvard Pilgrim Health Care June 2014 15

NM1*82*1*GENERAL HOSPITAL*STATE****XX*9999999999~ DTM*050*20110310~ SVC*NU:0101*-9405*0**-11~ DTM*150*20110113~ DTM*151*20110124~ CAS*CO*94*-3909.29~ CAS*OA*23*-5495.71~ SVC*NU:0240*-7910.1*0**-1~ DTM*150*20110113~ DTM*151*20110124~ CAS*CO*97*-7910.1~ CLP*REFNUMBER2*2*17315.1*0**15*HPCLAIMNUMBER2*21***0945~ NM1*QC*1*LASTNAME2*FIRSTNAME2****MI*HP900000000~ NM1*82*1*FAMILY HOSP*STEWARD****XX*9999999999~ DTM*050*20110310~ SVC*NU:0101*9405*0**11~ DTM*150*20110113~ DTM*151*20110124~ CAS*CO*129*9405~ AMT*B6*5495.71~ SVC*NU:0240*7910.1*0**1~ DTM*150*20110113~ DTM*151*20110124~ CAS*CO*129*7910.1~ AMT*B6*7910.1~ CLP*REFNUMBER3*1*15598.06*0**HM*HPHCCLAIMNUMBER3*11*7**0373~ NM1*QC*1*LASTNAME3*FIRSTNAME3P****MI*HP800000001~ NM1*IL*1*LASTNAME3*FIRSTNAME3S****MI*HP800000000~ NM1*82*1*GENERAL HOSPITAL*STATE****XX*9999999999~ DTM*050*20110311~ SVC*NU:0120*5550*0**3~ DTM*150*20110213~ DTM*151*20110216~ CAS*CO*15*5550~ REF*6R*1~ AMT*B6*5550~ SVC*NU:0240*14.02*0**1*NU:0250*11~ DTM*150*20110213~ DTM*151*20110216~ CAS*CO*129*10048.06~ CAS*OA*94*-10034.04~ REF*6R*2~ AMT*B6*10048.06~ SVC*NU:0240*144*0**1*NU:0300*3~ DTM*150*20110213~ DTM*151*20110216~ CAS*CO*97*144~ REF*6R*3~ SVC*NU:0240*49*0**1*NU:0305*11~ DTM*150*20110213~ DTM*151*20110216~ CAS*CO*97*49~ REF*6R*4~ SVC*NU:0240*568*0**1*NU:0310*11~ DTM*150*20110213~ DTM*151*20110216~ Harvard Pilgrim Health Care June 2014 16

CAS*CO*97*568~ REF*6R*5~ SVC*NU:0240*945*0**1*NU:0370*11~ DTM*150*20110213~ DTM*151*20110216~ CAS*CO*97*945~ REF*6R*6~ SVC*NU:0240*478.04*0**1*NU:0636*10~ DTM*150*20110213~ DTM*151*20110216~ CAS*CO*97*478.04~ REF*6R*7~ SVC*NU:0240*7850*0**1*NU:0722*11~ DTM*150*20110213~ DTM*151*20110216~ CAS*CO*97*7850~ REF*6R*8~ SE*165*0529~ GE*1*529~ IEA*1*000006994~ B. Revision Control Version 1.01 Added comment about Receiver Identifier in section 5 Version 1.02 Added additional naming convention information Version 1.03 Added information about non-reconcilable refunds in section 5 Harvard Pilgrim Health Care June 2014 17