Standard Companion Guide. ASC X12N 276/277: Health Care Claim Status Request and Response CORE Phase II System Companion Guide. Version Number: 1.

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1 Standard Companion Guide ASC X12N 276/277: Health Care Claim Status Request and Response CORE Phase II System Companion Guide Version Number: 1.0 February 2012 Page 1 of 33

2 Page 2 of 33

3 Disclosure Statement The information in this document is subject to change. Changes will be posted via the Network Health website located at: Page 3 of 33

4 Preface This Companion Guide to the ASC X12N Technical Report Type 3 guides adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Network Health Insurance Plan. The following information is intended to serve as a companion document to the HIPAA ASC X12N 276/277 (005010X279A1) Implementation Guide for Health Care Claim Status Request and Response. This companion document supplements, but does not exceed any requirements in the ASC X12N 276/277 (005010X279A1) Implementation Guide. The information describes specific requirements for submitting Health Care Claim Status Request and Response to Network-Health through New England Healthcare Exchange Network (NEHEN) and web services. Page 4 of 33

5 Table of Contents 1. INTRODUCTION Scope s Technical Requirements Trading Partners Registration and Agreements Testing Communication and Connecting E-Channels Security Contact Information Network Health Business Rules and Limitations Envelope Identifiers Member Numbers Claim Header for Each Claim Claim Status and Explanation of Payment (EOP) Information ACKNOWLEDGEMENTS AND REPORTING Tables...12 Page 5 of 33

6 1. INTRODUCTION 1.1. Scope The Health Insurance Portability and Accountability Act Administration Simplification (HIPAA-AS) requires (NETWORK HEALTH 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. The primary focus of this document is to clarify specific segments and data elements that should be submitted to Network Health on the 276 Claim Status Request and certain information that will be included on the 277 Response Transaction. This guide supplements (but does not contradict) requirements in the ASC X12N 276/277 (version X212E2) implementation. This information should be given to the provider s business area to ensure that health care claim status responses are interpreted correctly s 1. The ASC X12N 276/277 (version X212E2) Implementation Guide for Health Care Claim Status Request and Response has been established as the standard for eligibility transactions and is available at 2. Network Health s Web site containing documentation on transactions for providers is located at Technical Requirements Network Health supports the 276/277 ASC X12N version X212 for health care claim status inquiries and responses. Providers wishing to receive the 277 must support this version. We employ real time transactions. Real Time 276 transactions have a single ST/SE loop, one information source, one information receiver, and one subscriber loop. For trading partners using the NEHEN portal, Page 6 of 33

7 the last character of the GS02 element is set to R on the 276. Typical turnaround time is under 10 seconds during which the portal connection is held open. A single 277 is created for each 276 submitted. Up to 99 inquiries can be included per ST/SE loop. For trading partners using the NEHEN portal, the last character of the GS02 is set to B on the 276. Each inquiry file can contain one, and only one, Interchange Control Header and Trailer (ISA/ISE segments) and one, and only one, functional group header and trailer (GS/GE segments). The one, and only one, functional group can contain a maximum of 1,000 ST/SE segments. Each transaction set can contain a maximum of 99 inquiries per ST/SE segments and a maximum of one file per day can be submitted Trading Partners Registration and Agreements Two documents important to the setup of new EDI partnerships are detailed below: 1. VPN Set Up Form To submit via NEHEN, please refer to the NEHEN set up guide. 2. EDI Intake 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. Please contact EDI Team for further information. Page 7 of 33

8 2. Testing Trading Partners need to submit 276 Claim Status Request files via NEHEN or via web services in order to receive a 277 Claim Status response. If a trading partner or a provider submits the 276 Claim Status Request directly to Network Health via web services, the trading partner will receive the 277 Claim Status Response directly. Page 8 of 33

9 3. Communication and Connecting 3.1. E-Channels Network Health provides two options for submission of production 276s.Our preferred channels are: 1. New England Healthcare Exchange Network (NEHEN) 2. Web Services (https) - Trading Partners and Providers will be given detailed information on how to log on to through the web services by the EDI Team. For further information, Please contact the EDI Team. Network Health follows the connectivity rules specified in the CORE Guide ( Security Network Health has a strict confidentiality policy for safeguarding patient, employee, and health plan information. This policy permits use or disclosure of members medical or personal information only when 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. Network Health offers a variety of solutions to transmit protected health information (PHI) using a public network. In accordance with Network Health Policy and the HIPAA Security Rule, any PHI transmitted using a public network must be encrypted. Web-based applications are configured to use secure socket layer (SSL) security software capabilities. Page 9 of 33

10 4. Contact Information Most questions can be answered by referencing the materials posted at Updates to the companion guide will be posted at: health.org/providers/doing-business-and-getting-paid/health-it-resources-and- initiatives/version-5010.aspx EDI Team can be contacted by - edi@network-health.org, Phone / and via Fax from Monday Friday 8 a.m. to 5 p.m. If you have questions regarding claim adjudication results, claim status, member eligibility or referral/authorization, Please contact Provider Services at Provider Services is available Monday Friday 8 a.m. to 5 p.m. in provider s time zone. 5. Network Health Business Rules and Limitations 5.1. Envelope Identifiers Network Health supplies each submitting provider with the Submitter and Sender Identifiers for the envelope elements as a part of the setup process. The Interchange Receiver and Application Receiver IDs depend upon which e-channel is used. 1. For NEHEN: Both the Interchange Receiver ID (ISA08) and Application Receiver ID (GS03) is NEHEN For non-nehen e-channels: The Interchange Receiver ID (ISA08) is A and the Application Receiver ID (GS03) is A 5.2. Member Numbers Complete Network Health member IDs, including suffix, are 11-character alphanumeric values. The last two digits represent the member suffix. If a member ID is sent without the two digit suffix, Network Health will attempt to match members using either the MMIS ID or SSN. If both MMIS ID and SSN are not Page 10 of 33

11 submitted but 9 digit Member ID is submitted, Network Health will try to match the ID to a single Id. If a single 9 digit member id submitted on the claim is not found in the system, Network Health will return the error code Claim Header for Each Claim If a claim number is submitted on the status request, the response is sent for that specific claim. If a range of date of service is sent on the status request, Network Health will return all of the claims within the date of service for the member or provider sent Claim Status and Explanation of Payment (EOP) Information The 276/277 transaction pair is designed to provide information only on the status of a claim. It is not intended to be used as an EOP and does not contain detailed information about payments other than the date and amount paid. The Health Care Payment/Advice transaction (the 835) is used to convey claim payment information such as Copay, Denied amount, Deductible, Risk, etc Validation Checks Performed by Network Health Network Health performs the following validation checks on the 276 status file to warrant a 277 status response: # Validation Description 1. Submitter is authorized to use the 276/277 transaction 2. Provider is related to the Submitter of the 276/277 transactions 3. Member ID is submitted 4. Member Last name is submitted 5. Member First Name is submitted 6. Member Birth Date is submitted 7. Member Gender is submitted 8. Provider NPI is submitted 9. Provider Last Name is submitted 10. Provider First Name is submitted Page 11 of 33

12 11. Member Birth Date is in the future 12. Claim DOS is in the future 13. Claim DOS is missing 6. Acknowledgements And Reporting Network Health uses the following codes to return claim status. Category Code E0 Error on submitted request E1 Response not possible A2 Acceptance into Adjudication system A4 Not found P1 Pending\In Process F1 Finalized\Payment F2 Finalized\Denial Status Code 0 Cannot provide further status 0 Cannot provide further status 20 Accepted for Processing 3 - Claim has been adjudicated and is awaiting payment cycle. 33 Subscriber Not Found 35 Claim Not Found 26 Provider Not Found 0 Cannot provider further status electronically 65 Claim\line has been paid 1 See Remittance Advice 7. Tables Following are the 276 Data Specifications that Network Health requires providers to send in: Element Identifier Description ID Min. Max. Usage Reg. Loop Loop Repea t Values Page 12 of 33

13 ISA ISA01 ISA02 ISA03 ISA04 ISA05 ISA06 ISA07 ISA08 INTERCHANGE CONTROL HEADER 1 R Authorization Information Qualifier ID 2-2 R Authorization Information AN R Security Information Qualifier ID 2-2 R Security Information AN R Interchange ID Qualifier ID 2-2 R Interchange Sender ID AN R Interchange ID Qualifier ID 2-2 R Interchange Receiver ID AN R ISA09 Interchange Date DT 6-6 R T ISA10 Interchange Time M 4-4 R Repetition ISA11 Separator 1-1 R ISA12 Interchange Control Version Number ID 5-5 R 00 Expected Value: 10 Spaces 00 Expected Value: 10 Spaces ZZ ZZ NEHEN041 YYMMDD HHMM Expected Value: ^ (Caret) ISA13 ISA14 ISA15 ISA16 GS Interchange Control Number N0 9-9 R Acknowledgement Requested ID 1-1 R Interchange Usage Indicator ID 1-1 R Component Element Separator 1-1 R FUNCTIONAL GROUP HEADER 1 R 0 P, T (Colon) Page 13 of 33

14 GS01 Functional Identifier Code ID 2-2 R HR GS02 GS03 Application Sender's Code AN 2-15 R Application Receiver's Code AN 2-15 R GS04 Date DT 8-8 R T GS05 Time M 4-8 R NEHEN041 CCYYMMDD HHMMSS GS06 GS07 GS08 ST ST01 ST02 ST03 Group Control Number N0 1-9 R Responsible Agency Code ID 1-2 R Version/ Release/ Industry Identifier Code AN 1-12 R TRANSACTION SET HEADER 1 R Transaction Set Identifier Code ID 3-3 R Transaction Set Control Number AN 4-9 R Implementation Convention AN 1-35 R X X X212 BHT BHT01 BHT02 BHT03 BEGINNING OF HIERARCHICAL TRANSACTION 1 R Hierarchical Structure Code ID 4-4 R Transaction Set Purpose Code ID 2-2 R AN 1-50 R Page 14 of 33

15 BHT04 Date DT 8-8 R T BHT05 Time M 4-8 R CCYYMMDD HL HL01 HL03 HL04 INFORMATION SOURCE LEVEL 1 R 2000A >1 Hierarchical ID Number AN 1-12 R Hierarchical Level Code ID 1-2 R Hierarchical Child Code ID 1-1 R NM1 Payer Name 1 R 2100A 1 NM101 NM102 NM103 NM108 NM109 HL HL01 HL02 HL03 HL04 NM1 NM101 Code ID 2-3 R Entity Type Qualifier ID 1-1 R Name Last or Organization Name AN 1-60 R Code Qualifier ID 1-2 R Code AN 2-80 R INFORMATION RECEIVER LEVEL 1 R 2000B >1 Hierarchical ID Number AN 1-12 R Hierarchical Parent ID Number AN 1-12 R Hierarchical Level Code ID 1-2 R Hierarchical Child Code ID 1-1 R INFORMATION RECEIVER NAME 1 R 2100B 1 Code ID 2-3 R PR 2 PI Page 15 of 33

16 NM102 NM103 Entity Type Qualifier ID 1-1 R Name Last or Organization Name AN 1-60 R 1, 2 NM104 Name First AN 1-35 S NM105 Name Middle AN 1-25 S NM108 NM109 HL HL01 HL02 HL03 HL04 Code Qualifier ID 1-2 R Code AN 2-80 R Service Provider LEVEL 1 R 2000C >1 Hierarchical ID Number AN 1-12 R Hierarchical Parent ID Number AN 1-12 R Hierarchical Level Code ID 1-2 R Hierarchical Child Code ID 1-1 R NM1 Provider Name 1 R 2100C 1 NM101 Code ID 2-3 R Entity Type NM102 Qualifier ID 1-1 R Name Last or Organization NM103 Name AN 1-60 R P 1, 2 NM104 Name First AN 1-35 S NM105 Name Middle AN 1-25 S NM108 Code Qualifier ID 1-2 R NM109 Code AN 2-80 R HL Subscriber Level 1 R 2000D 1 Hierarchical ID HL01 Number AN 1-12 R XX Page 16 of 33

17 HL02 HL03 HL04 DMG DMG01 Hierarchical Parent ID Number AN 1-12 R Hierarchical Level Code ID 1-2 R Hierarchical Child Code ID 1-1 R Subscriber Demographic Information S 2000D Date Time Period Format Qualifier ID 2-3 S D8 DMG02 Date Time Period AN 1-35 S DMG03 Gender Code ID 1-1 S SUBSCRIBER NM1 NAME 1 R 2100D 1 NM101 Code ID 2-3 R Entity Type NM102 Qualifier ID 1-1 R Name Last or Organization NM103 Name AN 1-60 R NM104 Name First AN 1-35 S NM108 Code Qualifier ID 1-2 R NM109 Code AN 2-80 R Claim Status Tracking TRN Number S 2200D 1 TRN01 Trace Type Code ID 1-2 R F,M IL 1 MI Network Health ID MMIS ID 1 TRN02 REF REF01 REF02 REF AN 1-50 R Payer Claim Control Number S 2200D Qualifier ID 2-3 R AN 1-50 R Institutional Bill Type S 2200D 1K Network Health Claim Number Page 17 of 33

18 REF01 REF02 Qualifier ID 2-3 R AN 1-50 R BLT 236 REF REF01 REF02 REF REF01 REF02 Patient Control Number S 2200D 1 Qualifier ID 2-3 R AN 1-50 R Claim Number For Clearinghouses and Other Transmission Intermediaries S 2200D 1 Qualifier ID 2-3 R AN 1-50 R EJ Patient Control Number D9 Patient Control Number AMT Claim Submitted Charges S 2200D T3 AMT01 Amount Qualifier Code ID 1-3 R AMT02 Monetary Amount R 1-18 R DTP DTP01 Claim Service Date S 2100C Date/Time Qualifier ID 3-3 R 472 Page 18 of 33

19 DTP02 Date Time Period Format Qualifier ID 2-3 R D8,RD8 DTP03 Date Time Period AN 1-35 R SE SE01 SE02 GE GE01 TRANSACTION SET TRAILER 1 R Number of Included Segments N R Transaction Set Control Number AN 4-9 R FUNCTIONAL GROUP TRAILER 1 R Number of Transaction Sets Included N0 1-6 R GE02 IEA IEA01 IEA02 Group Control Number N0 1-9 R INTERCHANGE CONTROL TRAILER 1 R Number of Included Functional Groups N0 1-5 R Interchange Control Number N0 9-9 R Following are the 277 Data Specifications Element Identifier Description ID Min. Max. Usage Reg. Loop Loop Repea t Values ISA ISA01 INTERCHANGE CONTROL HEADER 1 R Authorization Information Qualifier ID 2-2 R 00 Page 19 of 33

20 ISA02 ISA03 ISA04 ISA05 ISA06 ISA07 ISA08 Authorization Information AN R Security Information Qualifier ID 2-2 R Security Information AN R Interchange ID Qualifier ID 2-2 R Interchange Sender ID AN R Interchange ID Qualifier ID 2-2 R Interchange Receiver ID AN R ISA09 Interchange Date DT 6-6 R T ISA10 Interchange Time M 4-4 R Repetition ISA11 Separator 1-1 R ISA12 Interchange Control Version Number ID 5-5 R Expected Value: 10 Spaces 00 Expected Value: 10 Spaces ZZ NEHEN041 ZZ YYMMDD HHMM Expected Value: ^ (Caret) ISA13 ISA14 ISA15 ISA16 GS GS01 GS02 GS03 Interchange Control Number N0 9-9 R Acknowledgement Requested ID 1-1 R Interchange Usage Indicator ID 1-1 R Component Element Separator 1-1 R FUNCTIONAL GROUP HEADER 1 R Functional Identifier Code ID 2-2 R Application Sender's Code AN 2-15 R Application Receiver's Code AN 2-15 R 0 P, T (Colon) HN NEHEN041 Page 20 of 33

21 GS04 Date DT 8-8 R T GS05 Time M 4-8 R CCYYMMDD HHMMSS GS06 GS07 GS08 ST ST01 ST02 ST03 Group Control Number N0 1-9 R Responsible Agency Code ID 1-2 R Version/ Release/ Industry Identifier Code AN 1-12 R TRANSACTION SET HEADER 1 R Transaction Set Identifier Code ID 3-3 R Transaction Set Control Number AN 4-9 R Implementation Convention AN 1-35 R X X X214 BHT BHT01 BHT02 BHT03 BEGINNING OF HIERARCHICAL TRANSACTION 1 R Hierarchical Structure Code ID 4-4 R Transaction Set Purpose Code ID 2-2 R AN 1-50 R BHT04 Date DT 8-8 R BHT05 BHT06 Time T M 4-8 R Transaction Type Code ID 2-2 R CCYYMMDD TH Page 21 of 33

22 HL HL01 HL03 HL04 INFORMATION SOURCE LEVEL 1 R 2000A >1 Hierarchical ID Number AN 1-12 R Hierarchical Level Code ID 1-2 R Hierarchical Child Code ID 1-1 R 20 1 NM1 NM101 NM102 NM103 NM108 NM109 TRN Information Source Name 1 R 2100A 1 Code ID 2-3 R Entity Type Qualifier ID 1-1 R Name Last or Organization Name AN 1-60 R Code Qualifier ID 1-2 R Code AN 2-80 R Transmission Receipt Control Identifier S 2200A 1 AY,PR 2 46,FI,PI,XV TRN01 Trace Type Code ID 1-2 R TRN02 DTP DTP01 DTP02 AN 1-50 R Information Source Receipt Date R 2200A Date/Time Qualifier ID 3-3 R Date Time Period Format Qualifier ID 2-3 R 050 D8 Page 22 of 33

23 DTP03 Date Time Period AN 1-35 R DTP DTP01 DTP02 Information Source Process Date R 2200A 1 Date/Time Qualifier ID 3-3 R Date Time Period Format Qualifier ID 2-3 R 009 D8 DTP03 Date Time Period AN 1-35 R HL INFORMATION RECEIVER LEVEL 1 R 2000B >1 HL01 Hierarchical ID Number AN 1-12 R HL02 HL03 HL04 NM1 NM101 NM102 NM103 Hierarchical Parent ID Number AN 1-12 R Hierarchical Level Code ID 1-2 R Hierarchical Child Code ID 1-1 R INFORMATION RECEIVER NAME 1 R 2100B 1 Code ID 2-3 R Entity Type Qualifier ID 1-1 R Name Last or Organization Name AN 1-60 R 21 0, , 2 Page 23 of 33

24 NM104 Name First AN 1-35 S NM105 Name Middle AN 1-25 S NM108 NM109 TRN Code Qualifier ID 1-2 R Code AN 2-80 R Information Receiver Application Trace Identifier S 2200B 1 TRN01 Trace Type Code ID 1-2 R TRN02 AN 1-50 R Information Receiver Status STC Information 2200B >1 Health Care Claim Co STC01 Status mp R STC01-01 Industry code AN 1-30 R STC01-02 Industry Code AN 1-30 R STC01-03 Code ID 2-3 R STC02 Date DT 8-8 R STC03 Action Code ID 1-2 R ,40,41,AY,PR CCYYMMDD U,WQ STC04 Monetary Amount R 1-18 R Health Care Claim Co STC10 Status mp S STC10-01 Industry Code AN 1-30 R STC10-02 Industry Code AN 1-30 R STC10-03 STC11 Code ID 2-3 R Health Care Claim Co Status mp R STC11-01 Industry code AN 1-30 R STC11-02 Industry Code AN 1-30 R ,40,41,AY,PR Page 24 of 33

25 STC11-03 QTY Code ID 2-3 R Total Accepted Quantity S 2200B 1 QTY01 Quantity Qualifier ID 2-2 R QTY02 Quantity R 1-15 R Total Rejected QTY Quantity S 2200B 1 QTY01 Quantity Qualifier ID 2-2 R QTY02 Quantity R 1-15 R Total Accepted AMT Amount 2200B 1 AMT01 Amount Qualifier Code ID 1-3 R AMT02 Monetary Amount R 1-18 R Total Rejected AMT Amount 2200B 1 AMT01 Amount Qualifier Code ID 1-3 R 36,40,41,AY,PR 90 AA YU YY AMT02 Monetary Amount R 1-18 R Billing Provider of Service HL Level 1 R 2000C 1 Hierarchical ID HL01 Number AN 1-12 R HL02 HL03 HL04 NM1 NM101 NM102 NM103 Hierarchical Parent ID Number AN 1-12 R Hierarchical Level Code ID 1-2 R Hierarchical Child Code ID 1-1 R Billing Provider Name 1 R 2100C 1 Code ID 2-3 R Entity Type Qualifier ID 1-1 R Name Last or Organization Name AN 1-60 R 19 0,1 85 1, 2 NM104 Name First AN 1-35 S Page 25 of 33

26 NM105 Name Middle AN 1-25 S NM108 Code Qualifier ID 1-2 R NM109 Code AN 2-80 R TRN Provider of Service Information Trace Identifier S 2200C 1 TRN01 Trace Type Code ID 1-2 R TRN02 AN 1-50 R Billing Provider Status STC Information 2200C >1 Health Care Claim Co STC01 Status mp R STC01-01 Industry code AN 1-30 R STC01-02 Industry Code AN 1-30 R STC01-03 Code ID 2-3 R STC02 Date DT 8-8 R STC03 Action Code ID 1-2 R STC04 Monetary Amount R 1-18 R Health Care Claim Co STC10 Status mp S STC10-01 Industry Code AN 1-30 R STC10-02 Industry Code AN 1-30 R STC10-03 STC11 Code ID 2-3 R Health Care Claim Co Status mp R STC11-01 Industry code AN 1-30 R STC11-02 Industry Code AN 1-30 R STC11-03 Code ID 2-3 R Provider Secondary REF Identifier S 2200C FI,XX ,40,41,77,82,85,8 7,AY,PR CCYYMMDD U,WQ ,40,41,77,82,85,8 7,AY,PR ,40,41,77,82,85,8 7,AY,PR Page 26 of 33

27 REF01 REF02 QTY Qualifier ID 2-3 R AN 1-50 R Total Accepted Quantity S 2200C 1 QTY01 Quantity Qualifier ID 2-2 R QTY02 Quantity R 1-15 R Total Rejected QTY Quantity S 2200C 1 QTY01 Quantity Qualifier ID 2-2 R QTY02 Quantity R 1-15 R Total Accepted AMT Amount S 2200C 1 AMT01 Amount Qualifier Code ID 1-3 R AMT02 Monetary Amount R 1-18 R Total Rejected AMT Amount S 2200B 1 Amount Qualifier AMT01 Code ID 1-3 R 0B,1G,G2,LU<SY< TJ QA QC YU YY AMT02 Monetary Amount R 1-18 R HL Patient Level 1 R 2000D 1 Hierarchical ID HL01 Number AN 1-12 R HL02 Hierarchical Parent ID Number AN 1-12 R HL03 Hierarchical Level Code ID 1-2 R NM1 Patient Name 1 R 2100D 1 NM101 Code ID 2-3 R Entity Type NM102 Qualifier ID 1-1 R Name Last or Organization NM103 Name AN 1-60 R PT QC 1 NM104 Name First AN 1-35 S NM105 Name Middle AN 1-25 S Page 27 of 33

28 NM108 NM109 TRN Code Qualifier ID 1-2 R Code AN 2-80 R Claim status Tracking Number S 2200D 1 TRN01 Trace Type Code ID 1-2 R TRN02 AN 1-50 R Claim Status Level STC Information R 2200D >1 Health Care Claim Co STC01 Status mp R STC01-01 Industry code AN 1-30 R STC01-02 Industry Code AN 1-30 R STC01-03 Code ID 2-3 R STC02 Date DT 8-8 R STC03 Action Code ID 1-2 R II,MI ,1P,1Z,40,41,71,7 2,73,77,8285,87,D K,DN,DQ,FA,GB, HK,IL,LI,PR,QB,Q C,QD,TL,TU,MSC, PRP,SEP,TTP CCYYMMDD U,WQ STC04 Monetary Amount R 1-18 R Health Care Claim Co STC10 Status mp S STC10-01 Industry Code AN 1-30 R STC10-02 Industry Code AN 1-30 R STC10-03 STC11 Code ID 2-3 R Health Care Claim Co Status mp R STC11-01 Industry code AN 1-30 R STC11-02 Industry Code AN 1-30 R STC11-03 Code ID 2-3 R ,1P,1Z,40,41,71,7 2,73,77,8285,87,D K,DN,DQ,FA,GB, HK,IL,LI,PR,QB,Q C,QD,TL,TU,MSC, PRP,SEP,TTP ,1P,1Z,40,41,71,7 2,73,77,8285,87,D Page 28 of 33

29 STC12 REF REF01 REF02 REF REF01 REF02 REF REF01 REF02 DTP DTP01 DTP02 Free-form Message Text AN S Payer Claim Control Number S 2200D Qualifier ID 2-3 R AN 1-50 R Claim Identifier Number For Clearinghouse and Other Transmission Intermediaries S 2200D 1 Qualifier ID 2-3 R AN 1-50 R Institutional Bill Type S 2200D 1 Qualifier ID 2-3 R AN 1-50 R Claim Level Service Date S 2200D Date/Time Qualifier ID 3-3 R Date Time Period Format Qualifier ID 2-3 R K,DN,DQ,FA,GB, HK,IL,LI,PR,QB,Q C,QD,TL,TU,MSC, PRP,SEP,TTP 1K D9 BLT 235, D8,RD8 DTP03 Date Time Period AN 1-35 R Service Line SVC Information S 2220D Composite SVC01 Medical Procedure Identifier Co mp R SVC01-01 Product/Service ID Qualifier ID 2-2 R Product/Service SVC01-02 ID AN 1-18 R AD,ER,HC,HP,IV, NU,WK 843,132,513,716,13 0,576,135 Page 29 of 33

30 SVC01-03 SVC01-04 SVC01-05 SVC01-06 Procedure Modifier AN 2-2 R Procedure Modifier AN 2-2 R Procedure Modifier AN 2-2 R Procedure Modifier AN 2-2 R 843,132,513,716,13 0, ,132,513,716,13 0, ,132,513,716,13 0, ,132,513,716,13 0,576 SVC02 Monetary Amount R 1-18 R SVC04 Product/Service ID AN 1-48 S 132 SVC07 Quantity R 1-15 S Service Line Level Status STC Information R 2200D >1 STC01 Health Care Claim Status Co mp R STC01-01 Industry code AN 1-30 R STC01-02 Industry Code AN 1-30 R STC01-03 Code ID 2-3 R STC02 Date DT 8-8 R STC03 Action Code ID 1-2 R Health Care Claim Co STC10 Status mp S STC10-01 Industry Code AN 1-30 R STC10-02 Industry Code AN 1-30 R STC10-03 STC11 Code ID 2-3 R Health Care Claim Co Status mp R STC11-01 Industry code AN 1-30 R STC11-02 Industry Code AN 1-30 R ,1P,1Z,40,41,71,7 2,73,77,8285,87,D K,DN,DQ,FA,GB, HK,IL,LI,PR,QB,Q C,QD,TL,TU,MSC, PRP,SEP,TTP CCYYMMDD U ,1P,1Z,40,41,71,7 2,73,77,8285,87,D K,DN,DQ,FA,GB, HK,IL,LI,PR,QB,Q C,QD,TL,TU,MSC, PRP,SEP,TTP Page 30 of 33

31 STC11-03 STC12 REF REF01 REF02 REF REF01 REF02 Code ID 2-3 R Free-form Message Text AN S Service Line Item R 2220D 1 Qualifier ID 2-3 R AN 1-50 R Pharmacy Prescription Number S 2220D 1 Qualifier ID 2-3 R AN 1-50 R 03,1P,1Z,40,41,71,7 2,73,77,8285,87,D K,DN,DQ,FA,GB, HK,IL,LI,PR,QB,Q C,QD,TL,TU,MSC, PRP,SEP,TTP FJ Network Health Claim Number XZ DTP Service Line Date S 2220D 1 DTP01 DTP02 Date/Time Qualifier ID 3-3 R Date Time Period Format Qualifier ID 2-3 R 472 D8,RD8 DTP03 Date Time Period AN 1-35 R SE SE01 TRANSACTION SET TRAILER 1 R Number of Included Segments N R SE02 Transaction Set Control Number AN 4-9 R Page 31 of 33

32 GE GE01 GE02 IEA IEA01 IEA02 FUNCTIONAL GROUP TRAILER 1 R Number of Transaction Sets Included N0 1-6 R Group Control Number N0 1-9 R INTERCHANGE CONTROL TRAILER 1 R Number of Included Functional Groups N0 1-5 R Interchange Control Number N0 9-9 R 8. Samples 8.1. Sample 276 ISA*00* *00* *ZZ*NEHEN041 *ZZ*NEHEN *110715*2238* *00501* *0*T*:~ GS*HR*NEHEN041*NEHEN * *2238*212*X*005010X21 2~ ST*276*0208*005010X212~ BHT*0010*13*NWH * *223839~ HL*1*0*20*1~ NM1*PR*2*Network Health*****PI*NEHEN041~ HL*2*1*21*1~ NM1*41*2*Network Health*****46*NEHEN041~ HL*3*2*19*1~ NM1*1P*2*Onepatient Diagnostic*****XX* ~ HL*4*3*22*0~ DMG*D8* *M~ NM1*IL*1*Smith*john****MI*N ~ TRN*1*291114V1672~ AMT*T3*29.00~ DTP*472*RD8* ~ SE*15*0208~ GE*1*212~ IEA*1* ~ Page 32 of 33

33 8.2. Sample 277ACK ISA*00* *00* *ZZ*NEHEN *ZZ*NEHEN041 *130325*1513* *00501* *0*T*:~ GS*HN*NEHEN *NEHEN041* *1513*52826*X*005010X 212~ ST*277*52884~ BHT*0010*08*294554V1672* *151328*DG~ HL*1**20*1~ NM1*PR*2*Network Health*****PI*NEHEN041~ PER*IC*E-Business HL*2*1*21*1~ NM1*41*2*Network Health*****46*NEHEN041~ HL*3*2*19*1~ NM1*1P*2* Onepatient Diagnostic*****XX* ~ HL*4*3*22*0~ NM1*IL*1* Smith*john****MI*N ~ TRN*2*294554V1672~ STC*F1:65* **59*131.02* *CHK* * ~ REF*1K*10000E0000M~ REF*EJ*290000V1000~ DTP*472*RD8* ~ SVC*HC:60*159*131.02****1~ STC*F1:65* **59*31.82~ DTP*472*RD8* ~ SE*20*52884~ GE*1*52826~ IEA*1* ~ Page 33 of 33

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