276/277 Health Care Claim Status Request and
Contents
1. Data Element Description Size Comments Transaction ID Transaction ID 4 Data content will be HETS Transaction m Trace Identification usos Number or ISA13 ui Date Stamp System Date 8 CCYYMMDD Time Stamp System time 9 HHMMSSSSS P Incoming ISA cannot be read Response n REA ISA Formatting Error 2 D Delimiter cannot be identified Error code refer to Table 9 of this Message Code Error Code 8 Companion Guide uum Message Text Description Description Error Descriptions 500 d to Table 9 of this Companion uide Table 11 describes the Proprietary Error Message Codes Table 11 Proprietary Error Message Codes Message Code Message Text Description HTSO00101 Transmission Wrapper SOH hex 01 is invalid or missing HTS00102 Transmission Wrapper STX hex 02 is invalid or missing HTS00103 Transmission Wrapper ETX hex 03 is invalid or missing HTS00104 Transmission Wrapper Length is missing or not numeric Transmission Wrapper Length is greater than the PHOTOS Transmission Length HTS00106 Transmission data is invalid or not ASCII HTS00107 p 276 transaction does not start with ISA Segment HTS00111 Transmission Inbound Message was empty Interchange Error Message specific to the condition will HTS00115 also be included in the error message description Page 19 of 40 276 277 5010 COMPANION GUIDE Message Code Message Text2. Protocol If you wish to download your files in a compressed format check PKZIP or UNIX If not check No Compression Check the preferred communication method If you select the HTTPS channel please follow instructions in the CORE Companion Guide If you select Secure FTP or VPN complete and return the SFTP VPN Customer Parameter Survey and attach your public key ID file to your email If you select TCPIP via VPN complete and return the BlueCross BlueShield of South Carolina Commercial TCPIP via VPN Customer Connectivity Parameter Survey and or the PGBA TCPIP via VPN Customer Connectivity Parameter Survey If you select NDM complete the BlueCross BlueShield of South Carolina Commercial NDM Customer Connectivity Parameter Survey and or the PGBA NDM Customer Connectivity Parameter Survey All Customer Connectivity Parameter Survey forms are in the Appendix of the EDI Gateway Technical Communications User s Manual Please complete and return the form to EDIG SUPPORTGPalmettoGBA com Service Address Enter the trading partner s complete address including street city state and ZIP This address must be the physical location for your business 12 Page 27 of 40 276 277 5010 COMPANION GUIDE Form Field Name Billing Address Instructions for Field Completion If different from the service address enter the trading partner s billing or mailing address including street city st
3. 2100A NM109 Primary TRICARE Identifier Table 19 Information Receiver TR3 X12 Page Implementation Notes P Loop ID Reference mp NS Codes Comments 234 2100B NMios Geulilication xx N A Qualifier 235 21008 NM109 Information XX we rises Fl Federal Ge eae Taxpayer umber Identification Number 34 Social Security Number Service SV Provider Number Page 24 of 40 276 277 5010 COMPANION GUIDE 11 APPENDIX A IMPLEMENTATION CHECKLIST PGBA suggests entities use this information as a checklist of steps to become a submitter Read and review this guide Contact PGBA Technology Support Center at 803 736 5980 or 800 868 2505 with questions if any e Get user ID and password e Send at least one test transaction These tests must be performed for each different transaction type that a trading partner is approved to submit to EDIG Begin submitting transactions 12 APPENDIX B SAMPLE 276 277 This example includes the minimum required data elements for a 276 request Additional data may be provided but will not affect the 277 response Sample 276 ISA 03 7GWZZM2SCS 01 A70LISA3 ZZ 571132733 ZZ 571132733 130318 0935 00501 076575000 0 T GS HR 7GWZZM2SCS 7GWZZM2SCS 20130318 0935 331001 X 005010X212 ST 276 000000001 005010X212 BHT 0010 13 076575000331001000000001 20130318 093522 HL 1 20 1 NM1 PR 2 TRICARE PI 571 132733 HL 2 1 21 1 NM1 41 2 TRICARE EDI 46 5
4. data It is important you follow these instructions and complete all the required information We will return incomplete forms to the applicant which could delay the enrollment process The enrollment form is in the Appendix of the EDI Gateway Technical Communications User s Manual and is also available at the HIPAA Critical Center You should complete enrollment forms electronically and email them to EDIG OPS QPalmettoGBA com Use your TAB key to move forward through the form fields or click your cursor in a desired field or box Be sure to save the file after you have completed the form The Trading Partner Agreement is a legal document All trading partners are required to print complete and return the originally signed hard copy via mail prior to being moved to production status The PGBA Trading Partner Agreements can be found at the HIPAA Critical Center The PGBA Trading Partner Agreement can be found on myTRICARE com in the Electronic Claims Filing section If you are a prospective PGBA LLC trading partner print and mail a hard copy of the completed Trading Partner Agreement to Palmetto GBA Attention EDIG Operations AG 280 2300 Springdale Drive Building One Camden SC 29020 1728 Table 20 will help trading partners complete the enrollment form Page 26 of 40 276 277 5010 COMPANION GUIDE Table 20 Enrollment Form Instructions Form Field Name Date Instructions for Field Completion Enter today s date Req 12
5. ys ext Fax 6 9 e On Call Technical Contact s Information Email a 6 Jas ex Fax o pl i 276 277 5010 COMPANION GUIDE Transaction Volume Estimates Transmission Y N Avg Transt Transmission Y N Avg Transt ASC X12N 270 005010X279A1 O wk ASC X12N 8371 005010X223A2 O wk ASC X12N 271 005010X279A1 O wk ASC X12N 837P 005010X222A1 O wk ASC X12N 276 005010X212 O wk ASC X12N 837D 005010X224A2 O wk ASC X12N 277 005010X212 O wk ASC X12N 835 005010X221A1 O wk ASC X12N 278 005010X217 o Tak ASC X12N 834 005010X220A1 o nei Versions supported as of 01 01 2012 t Average number of transactions per week Yes No For every box you checked Y provide the average of transactions to be submitted weekly Vendor s Information If a vendor s software is used to create ASC X12N transactions submitted to the EDI Gateway please provide the vendor s name and address and list the transactions Vendor s Name Address 1 Address 2 City State ZIP Transactions Customer s Information If your business is authorized to send or receive transactions on behalf of another entity please provide the entity s name federal tax identification number and national provider identifier number This is required for all transactions Name Federal Tax National Provider Identification Number Identifier Number Page 30 of 40 276 277 5010 COMP
6. Description Syntax Error Message specific to the condition will also be HTS00116 included in the error message description Transmission Error Message specific to the condition will HTS00117 also be included in the error message description Common Error Processing for SOAP WSDL and HTTP MIME Multipart The 276 277 application will process SOAP and MIME transactions and return errors as described in this section HTTP Status and Error Codes The processing and error codes for the HTTP layer are defined as part of the HTTP specifications http www w3 org Protocols rfc2616 r c2616 sec10 html The intended use of these status and error codes in processing transactions is specified in Table 4 3 3 1 of the Phase II CORE 276 Connectivity Rule This document is located at http www caqh org pdt CLEAN5010 276 v5010 pdf Envelope Processing Status and Error Codes Table 12 describes envelope processing status and error codes specific to the 276 277 application for SOAP and MIME transactions Table 12 Envelope Processing Status and Errors Error Code Error Message lt FieldName gt lllegal Illegal value provided for lt FieldName gt lt FieldName gt Required The field FieldName is required but was not provided VersionMismatch The version of the envelope sent is not acceptable to the receiver Invalid Payload Payload is invalid or does not start with ISA Suc
7. HTTP WEI NTUIEIDOFEs c edatietoanedohder o edid blot unes a a caida hentai mdedibda tee do hes 13 Su bmissionZRetrieval uim ucERERIuR ERR utes uS 13 HTTP MIME Multipart Header Requirements 0 0 0 c cece eeeeeeeesesesesssesesssesssesesesesesesesesesesesesesesesees 14 HTTP MIME Multipart Body Requirements ccccccccccccecsessssecececceeceesessesecesececeseessseeececeesesensnteaeees 14 Table 4 Required Body Elements for 276 Requests Using MIME esee 14 Table 5 Required Body Elements for 277 Response Using MIME essen 14 HTTP MIME Multipart Examples csssssseeseeeeeenee enne emen nnne n nennen nnne enne n nennt nenne nenas 15 Sell eas taeg 15 CONTACT INEORMATION iei Cee uc oes ados e edet eoe ee aH ve pde adito aee xs 15 CONTROL SEGMENTS ENVELOPES eee mem nennen nenne 16 276 277 5010 COMPANION GUIDE Interchange Control Structure ISA IEA cccccessssccecececsesessssecececcesceesssssseeececeeseeeseeseeeeeeseseeeneaaeas 16 Table 6 276 ISA Segment Rules cccccccccccssssssssccecececsessseaceeceseesensnsseaeeeseceesensseaaeaeeescesenseessaaeess 16 Functional Group Structure GS GE a a a A i e aiaa TEA TETS 17 Table 7 276 GS Segment RUIES cccccccccccscssssssnccececcessnsssaeaecescesensnssseaeesseceesensseaseaeeescesenseesaaeess 17 f PAYER SPECI
8. Systems to ensure the accuracy timeliness completeness and confidentiality of each Data Transmission c Data Transmission Accuracy The Parties will take reasonable care to ensure that Data Transmissions are timely complete accurate and secure Each Party will take reasonable precautions in accordance with Article V of this Agreement to prevent unauthorized access to the other Party s Operating System Data Transmissions or the contents of an Envelope transmitted to or from either Party d Retransmission of Lost or Indecipherable Transmissions A Party will retransmit the original transmission within three 3 business day s of its discovery that a Data Transmission is a lost or indecipherable Transmission 276 277 5010 COMPANION GUIDE e Equipment Cost Each Party will obtain and maintain at its own expense its own Operating System necessary for timely complete accurate and secure Data Transmission pursuant to this Agreement Each Party will pay its own costs related to Data Transmission under this Agreement including without limitation charges for the Party s own Operating System equipment software and services maintaining an electronic mailbox connection time terminals connections telephones modems and applicable minimum use charges Each Party will be responsible for its own expenses incurred for translating formatting and sending or receiving communications over the electronic network to any electronic mailbox of the ot
9. a document containing information pertaining to the disposition of a specific claim for payment of services or supplies rendered to an Individual that a Provider or Supplier files with PGBA on the Individual s behalf The documents include without limitation information such as the Provider or Supplier name and address Individual s name date of service amount billed amount paid whether the claim is approved or denied and if denied the reason for the denial 1 9 Envelope means a control structure in a format required by this Agreement for the electronic interchange of one or more encoded Data Transmissions between PGBA and Trading Partner 1 10 Health Information means any information whether oral or recorded in any form or medium that i is created or received by a Provider health plan public health authority employer life insurer school university or health care clearinghouse and ii relates to the past present or future physical or mental health or condition of an Individual the provision of health care to an Individual or the past present or future payment for the provision of health care to an Individual 1 11 Individual means a person whose claims for services or supplies may be eligible to be paid under the terms of an applicable governmental or private program for which PGBA processes or administers claims and specifically includes without limitation Medicare Eligible Individuals Medicaid Eligible Individuals and Covere
10. connectivity channel Prospective trading partners must complete and submit an EDIG Trading Partner Enrollment Form and the Trading Partner Agreement Please refer to section 5 of this Companion Guide for contact information and to the appendices for the forms Certification and Testing Overview Trading Partners are required to submit test transactions to ensure that their systems are ASC X12 TR3 compliant Each Trading Partner may submit up to 50 test transactions during the testing phase Testing is coordinated as part of the trading partner enrollment process Please refer to section 5 of this Companion Guide for contact information 3 TESTING WITH PGBA Trading Partners must complete basic transaction submission testing with PGBA LLC Tests must be performed for each X12 transaction type EDIG is available to assist with new Trading Partner testing Monday Friday from 9 00 AM to 5 00 PM EST Table 1 Testing Process Testing Steps Test Instructions Test Plan EDIG and the trading partner agree to a predefined set of test data with expected results In addition a plan must be developed for a test to production transition that considers volume testing and transaction acceptance ratios Connectivity EDIG supported connectivity protocols are listed in section 4 of this Companion Guide Security EDIG will validate approved trading partners are submitting transactions allowed per PGBA enrollment applications Dat
11. hospital or professional practitioner duly certified or licensed to provide health care services to Covered Individuals and includes without limitation extended care facilities skilled nursing facilities rehabilitation facilities home health agencies hospices physicians dentists clinical social workers ambulance services and hospitals or professional practitioners specifically certified or approved by HHS to provide reimbursable health care services to Medicare Eligible Individuals 1 17 Security Access Codes mean alphanumeric codes that PGBA assigns to Trading Partner to allow Trading Partner access to PGBA s Operating System for the purpose of successfully executing Data Transmissions or otherwise carrying out this Agreement 1 18 Source Documents mean documents containing Data that are or may be required as part of a Data Transmission concerning a claim for payment of charges for medical services that a Provider furnishes or medical supplies that a Supplier sells to a Covered Individual Source Documents are subject to the security standards of Article V of this Agreement Examples of Data contained within a Source Document include without limitation Individual s name and identification number claim number diagnosis codes for the services rendered dates of service service procedure descriptions applicable charges for the services rendered the Provider s or Supplier s name and or identification number and signature 1 19
12. to configure Trading Partner access to the 276 277 application If the Trading Partner s Digital Certificate has not been approved and properly configured connection to the 276 277 application may be rejected For more information on the Communication Protocol Specifications for connecting to the 276 277 application refer to the EDIG contact information provided in the CONTACT INFORMATION section of this Companion Guide SOAP WSDL The 276 277 application also supports transactions formatted according to SOAP conforming to standards set forth by the WSDL for Extensible Markup Language XML envelope formatting submission and retrieval SOAP XML Schema The XML schema definition used by the 276 277 application is located at http www cagh org SOAP WSDL CORERule2 2 0 xsd WSDL Information The WSDL definition used by the 276 277 application is located at http www cagh org SOAP WSDL CORERule2 2 0 wsdl SOAP Version Requirements The 276 277 application requires that all SOAP transactions conform to SOAP Version 1 2 Submission Retrieval SOAP transactions must be submitted to the 276 277 using the following URL https services pgba com PRODUCTION 9080 CORE ElectronicDatalnterchange Page 11 of 40 276 277 5010 COMPANION GUIDE All X12 payloads defined in the CONNECTIVITY WITH THE PAYER COMMUNICATIONS section of this Companion Guide must be embedded using the Inline method CDATA element for SOAP transactions For mor
13. 276 277 5010 COMPANION GUIDE V PGBA A CELERIAN GROUP COMPANY TRICARE HIPAA Transaction Standard Companion Guide ASC X12N 276 277 005010X212 Health Care Claim Status Request and Response Version 1 1 March 2013 276 277 5010 COMPANION GUIDE DISCLOSURE STATEMENT Please note that the information in this guide is subject to change Any changes will be available at www myTRICARE com This transaction set can be used to inquire about claim status associated with a subscriber or a dependent under the subscriber s policy The use of this document is solely for the purpose of clarification The information describes specific requirements to be used in processing PGBA LLC ASC X12 005010X212 Health Care Claim Status Inquiry 276 277 transactions 276 277 5010 COMPANION GUIDE Preface This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with PGBA LLC 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 Implementati
14. 3 Action Requested New Trading Partner ID Change Cancel Indicate the action to be taken on the enrollment form Note Depending on the requested action different fields of this form are required These are identified in the column at right 1 To apply for a new Trading Partner ID check New Trading Partner ID 2 To change Trading Partner information check Change 3 To cancel your enrollment check Cancel Trading Partner Name Enter the name of the entity that will be submitting receiving electronic transactions with BlueCross BlueShield of South Carolina EDIG 123 Trading Partner ID EDIG assigns the Trading Partner ID to identify trading partners in our system 23 Federal Tax ID Enter the trading partner s federal tax identification number Type of Business Select the type of primary business the trading partner conducts If you check Other indicate the type of business on the line provided Line of Business Check one box per enrollment form indicating if transactions are BlueCross BlueShield of South Carolina Commercial or PGBA Start Date Indicate in mm dd ccyy format the date the trading partner plans to begin transaction testing with BlueCross BlueShield of South Carolina EDIG End Date If you are using this form to cancel an account indicate in mm dd ccyy format the date the trading partner intends to terminate its trading partner account Compression
15. 7 1 132733 HL 3 2 19 1 NM1 1P 2 ST FRANCIS HOSPITAL XX 1919191919 HL 4 3 22 0 DMG D8 19600816 M NM1 IL 1 SMITH BOBBY S MI 796144610 TRN 1 201210090000000873U REF BLT 131 REF 6P 42YT800Q REF EJ LOU 2011 OCT 28 AMT T3 1840 DTP 472 D8 20120912 SE 18 000000001 GE 1 331001 IEA 1 076575000 Sample 277 ISA 00 00 Z2 571132733 ZZ 571132733 130321 1503 00501 076575000 0 T GS HN 7GWZZM2SCS 7GWZZM2SCS 20130321 150303 519 X 005010X212 ST 277 000000010 005010X212 BHT 0010 08 076575000 20130321 1503 DG HL 1 20 1 NM1 PR 2 TRICARE PI 57 1 132733 HL 2 1 21 1 NMI1 41 2 TRICARE EDI 46 57 132733 HL 3 2 19 NM1 1P 2 ST FRANCIS HOSPITAL XX 1919191919 Page 25 of 40 276 277 5010 COMPANION GUIDE HL 4 3 22 0 NMI IL 1 SMITH BOBBY S MI 796144610 TRN 2 201210090000000873U STC F1 gt 1 20121017 1840 670 54 20121017 20121017 0010000156 REF 1K 2285X00510000 REF BLT 131 REF EJ LOU 2011 OCT 28 DTP 472 RD8 20120912 20120912 SE 17 000000010 GE 1 519 IEA 1 076575000 13 APPENDIX C TRADING PARTNER ENROLLMENT Enrollment with the EDI Gateway requires prospective trading partners to complete and submit the PGBA EDIG Trading Partner Enrollment Form and the Trading Partner Agreement The purpose of the PGBA EDIG Trading Partner Enrollment Form is to enroll providers software vendors clearinghouses and billing services as trading partners and recipients of electronic
16. 9 Information RECEIVELS ccccccccccccscssssssncccscececssssssnseaecescesensneseaeesseceesensseaaeaeeeseesenseenaaaeess 24 11 APPENDIX A IMPLEMENTATION CHECKLIST eene 25 12 JAPPENDDGB SAMPEE 276 277 oscar lee cco ie oen On ce E cut ratte Eon 25 13 APPENDIX C TRADING PARTNER ENROLLMENT nmm 26 Table 20 Enrollment Form Instructions esee enneten nnne eese enne 27 14 APPENDIX D CLEARINGHOUSE TRADING PARTNER AGREEMENT 33 15 APPENDIX E REVISION HISTORY 5 aic oae pao der e patte pe acra Sosa c axe ro aenea eu cuve 40 Table 21 Document Revision HIStOLY ccccccecsssssscececececeesessesececececeesesesececesceseeenereseceseeeeseeeneaaeas 40 276 277 5010 COMPANION GUIDE 1 INTRODUCTION Scope Providers billing services and clearinghouses are advised to use the ASC X12N 005010X212 Health Care Claim Status Inquiry 276 Implementation Guide as a basis for their claim status requests This companion document should be used to clarify the business rules for 276 277 data content requirements batch and real time acknowledgment connectivity response time and system availability specifically for submissions through the system This document is intended for use with HTTPS transmissions with CAQH compliant systems Overview The purpose of this document is to introduce and provide information about PGBA s CAQH solution for submitting real time and ba
17. ANION GUIDE Page 31 of 40 276 277 5010 COMPANION GUIDE If you are a clearinghouse or software vendor and would like to be added to the Certified Vendor list on www myTRICARE com please provide this information Website Address URL Salesperson s Name and Telephone If you would like to provide additional contact information please do so here On the description line give a brief explanation or purpose for the additional contact Additional Contact Information 1 Additional Contact Information First Last Name Email Telephone ext Fax 2 Additional Contact Information First Last Name Email Telephone ext Fax 3 Additional Contact Information First Last Name Email Telephone ext Fax 4 Additional Contact Information First Last Name Email Telephone ext Fax Page 32 of 40 276 277 5010 COMPANION GUIDE 14 APPENDIX D CLEARINGHOUSE TRADING PARTNER AGREEMENT CLEARINGHOUSE ELECTRONIC TRADING PARTNER AGREEMENT Agreement No This Electronic Trading Partner Agreement Agreement is entered into as of the day of and 2012 Effective Date by and between PGBA and its subsidiaries Trading Partner RECITALS WHEREAS Trading Partner acts as a Business Associate to certain Providers and submits el
18. AP message or MIME Multipart form data containing the related response Refer to those sections for additional information 9 TRADING PARTNER AGREEMENTS Trading Partner enrollment is required to submit 276 requests to the 276 277 application Refer to the GETTING STARTED section of this Companion Guide under Trading Partner Registration for information regarding enrollment as a Trading Partner The 276 277 application will validate a trading partner s access to our environment prior to Page 21 of 40 276 277 5010 COMPANION GUIDE processing their 276 transaction If the Trading Partner ISA06 cannot be validated an error message is returned Trading Partners may not send transactions to be executed as Usage Indicator ISA15 P until testing has been accomplished and approval to submit production transactions has been given The 276 277 application will return an error 10 TRANSACTION SPECIFIC INFORMATION All references to TR3 in this section assume the ASC X12 TR3 276 277 version referenced in section 1 of this Companion Guide 276 Claim Status Request Transaction This section describes the values required by PGBA in the 276 claim status request transaction Any segments or elements not referenced in Tables 15 or 16 should be sent on the 276 per TR3 Information Source Level Structures Table 15 Information Source TR3 X12 nage Loop ID Reference Implementation Codes CE a gi 2100C NM101
19. C F R Parts 160 and 164 the Privacy Act of 1974 5 U S C 552A or other applicable state and federal statutes and regulations including statutes and regulations protecting the privacy of general medical mental health and substance abuse records collectively Privacy Statutes and Regulations 276 277 5010 COMPANION GUIDE 1 4 Covered Individual means an Individual who is eligible for payment of certain services or supplies rendered or sold to the Individual or to the Individual s eligible dependents under the terms conditions limitations and exclusions of a health benefit program issued or administered by PGBA or a health benefit program issued or administered by another Payor 1 5 Data Transmission means automated transfer or exchange of data pursuant to the terms and conditions of this Agreement between PGBA and Trading Partner by means of their respective Operating Systems which are compatible for that purpose and includes without limitation Electronic Data Interchange EDI Electronic Remittance Advice ERA and Electronic Media Claims EMC transmissions 1 6 Electronic Data Interchange EDI means the automated exchange of business documents from application to application 1 7 Electronic Media Claims EMC means automated methods of submitting claims for payment of medical services or supplies rendered or sold by a Provider or Supplier to an Individual 1 8 Electronic Remittance Advice ERA means
20. FIC BUSINESS RULES AND LIMITATIONS 17 General Structural Notes eesesessseeeeeeeeeee eese ette nennt see ente e ates esse oeste ttt te anas e stet teta te nenne seen 17 Table 8 Preferred 276 Request Delimiters esee eene nnn nnn nnn 18 8 ACKNOWLEDGEMENTS AND ERROR CODES 1 erre 18 uL 18 Pe mM rrr mE e MU 18 Proprietary Error Message e ete nte obe e e Het er o e a er Cn d e ee er Eee dd ees 18 Table 10 Proprietary Error Message ccccccccesssssssecececeeeceeseseeeceecceceeserseaeeeseceeseeessaseceeeceesesesensaaeess 19 Table 11 Proprietary Error Message COCES cc cccccccececeessssecececececeesensesecesececeeeessseeeeeeeeseeeeentaaeess 19 Common Error Processing for SOAP WSDL and HTTP MIME Multipart esseeeen 20 HITP Status aind Error CodeS iiiter veniri cieeniertie ite iie eTis 20 Envelope Processing Status and Error CodeS ap o tenis set on canigia coe Fixed oc uident e UC de dx dei es 20 Table 12 Envelope Processing Status and Errors essssssessseeeeeeeeeenenee eene 20 SOAP Specific Processing Errors c cccccssssssssscccesccscssssssnnccssececssesseaeaeeesecsensseeaeeesecsessesneaaeasseceess 20 Table 13 SOAP Specific Processing Errors ccccccccccccccessessssecececececsesesseseceseceeseeessaseeeeeceeseeessntaaeess 21 MIME Specific Processing EM Ors seh sioe oido sedi pt ic e Uie dida Tote deoa toetucubiad
21. Mode RealTime or Batch Refer to Section 4 4 2 of the Phase Il CORE 276 PayloadID Connectivity Rule for structural guidelines for CORE envelope metadata Page 14 of 40 276 277 5010 COMPANION GUIDE Element Name Description Format is YYYY MM DDTHH MMSSZ Refer to TimeStamp http www w3 org TR xmlschemal 1 2 dateTime for more information SenderID 571132733 ReceiverID This field should be 10 characters in length CORERuleVersion 2 2 0 Payload X12 response HTTP MIME Multipart Examples Examples of a SOAP request and response can be found in Sections 4 2 1 1 and 4 2 1 2 of the CORE Phase II Connectivity Rule at this link http www caqh org pdt CLEAN5010 276 v5010 pdf Security The 276 277 application is located at a secure PGBA data center The HTTPS connection requires a password and features a variety of security measures to protect the integrity of the 276 277 application Trading Partners transmitting with SOAP or MIME must obtain a digital certificate and send the transaction to the 276 277 application via secure internet connection Additionally the 276 277 application authorizes Trading Partners based on either their originating Internet Protocol IP address or digital certificate and their EDIG issued 276 277 Submitter ID All Trading Partners must assume full responsibility for the privacy and security of all beneficiary data PGBA holds Clearinghouse Submitters responsible for the
22. Process Flow To access the 276 277 application potential Trading Partners need to register and obtain a trading partner ID from EDIG Figure 1 illustrates the high level process for successfully registering as a Trading Partner and submitting 276 transactions Figure 1 Process for Submitting 276 Transactions Page 8 of 40 Step 1 Step 2 Step 3 Step 4 Trading P artner Trading P artner Testing Status Production Status Registration Authentication Step 1 Trading Partner Registration Complete and submit the Trading Partner Enrollment Form and the Trading Partner Agreement See the GETTING STARTED section of this Companion Guide Step 2 Trading Partner Authentication EDIG will verify the information on the Trading Partner Agreement Form and approve or deny any Submitter ID requests Step 3 Testing Phase EDIG will coordinate with a Trading Partner to send test transactions and verify that all systems involved can properly submit and receive X12 TR3 compliant transactions 276 277 5010 COMPANION GUIDE Step 4 Production Phase Once testing is complete a Trading Partner can begin to submit 276 transactions and receive 277 transactions in the Production environment Transaction Process Flow A Trading Partner may submit a 276 request to the 276 277 application using Transmission Control Protocol Internet Protocol TCP IP Simple Object Access Protocol SOAP Web Services Description Language WSDL or Hypertext Transfer
23. Protocol HTTP Multipurpose Internet Mail Extensions MIME Multipart communication protocols The Trading Partner is authenticated If the Trading Partner is not authorized then the appropriate error response is returned If the Trading Partner is authorized then the appropriate response is returned Figure 2 illustrates the high level process for communicating with the 276 277 application Figure2 Transaction Process Batc h File gt di uni IM o COMPLIANCE W onis onse Partner System BTTP M IM E PGBA is not doing the file list method but the recommended method of returning the file itself Transmission Administrative Procedures includes Schedule Availability and Downtime Notification EDIG s production environment is available 24 hours a day 7 days a week with the exception of Sundays between 3 00 PM 10 00 PM EST when system maintenance is performed The test environment is accessible Monday through Saturday from 5 00 AM to 10 00 PM EST Notification will be sent via E mail for any unplanned downtime There will be a two day notice for scheduled outages A follow up email will be sent alerting the Trading Partners when the EDIG system becomes available Please refer to section 5 of this Companion Guide for contact information Page 9 of 40 276 277 5010 COMPANION GUIDE Re Transmission Procedure Trading Partners may call 800 868 2505 or E mail EDIG OPS PalmettoGBA com for assistance in researchin
24. Supplier means a person or organization that is a customer of Trading Partner and is engaged in the business of selling or leasing durable medical equipment or supplies to Covered Individuals 1 20 Trade Data Log means the complete written summary of Data and Data Transmissions exchanged between the Parties over the period of time this Agreement is in effect and includes without limitation sender and receiver information and transmission date time and general nature Il TERM AND TERMINATION Page 35 of 40 276 277 5010 COMPANION GUIDE 2 1 2 2 2 3 Term of Agreement This Agreement will remain in effect for an initial period of three 3 year s from the Effective Date and will automatically renew for successive periods of three 3 year s unless terminated pursuant to Section 2 2 or Section 2 3 Voluntary Termination Either Party may terminate this Agreement upon one hundred twenty 120 day s prior written notice to the other Party Termination for Cause PGBA will have the unilateral right to terminate this Agreement immediately by providing Trading Partner with written notice of termination in the event of i a breach by Trading Partner of any section of Article V or of Article VII of this Agreement or ii Trading Partner any of its related business entities or any of its officers directors managing employees Providers or Suppliers is charged with a criminal offense relating to one or more government contracts or gov
25. a Integrity Data integrity is determined by EDIG s TR3 editor Testing cannot progress until a trading partner s data receives no TR3 edit errors EDIG expects there may be an occasional situation in which a trading partner s TR3 edit interpretation differs from PGBA s interpretation EDIG will work with the trading partner to resolve such differences on an individual basis Acknowledgment Trading partners must demonstrate the ability to receive Response acknowledgment and response transactions via the HTTPS channels Transactions Page 7 of 40 276 277 5010 COMPANION GUIDE Testing Steps Test Instructions Results Analysis EDIG and the trading partner will review acknowledgment and response transactions for consistency with the predefined expected results Transition from Test to Production Status When test results have satisfied the test plan and the Trading Partner Agreement has been executed the trading partner s submission status is changed from test to production At this time the trading partner can begin to send production transaction data Please refer to the section 5 of this Companion Guide for EDIG contact information Testing URLs for Real time and Batch SOAP https services pgba com QA 9080 COREElectronicDatalnterchange MIME https services pgba com mimeapi QA 9080 CORE ElectronicDatalnterchange 4 CONNECTIVITY WITH THE PAYER COMMUNICATIONS Trading Partner Registration
26. a enter PR 51 2100C NM102 Entity Type Code 2 51 2100C NM103 Na dd TRICARE 54 2100C Nm108 eae PI E 2100C EE Pu Ld 571132733 Information Receiver Level Structures Page 22 of 40 276 277 5010 COMPANION GUIDE Table 16 Information Receiver TR3 X12 Page Implementation Notes P Loop ID Reference p AA Codes Cominants 77 2100B NM108 Identification Code XX NPI Qualifier FI Federal Taxpayer Identification Number 34 Social Security Number Service Provider SV Number Patient Level Structures Table 17 Patient TR3 X12 Page Implementation Notes P Loop ID Reference p Asl Codes Comments 2100D 57 99 NM108 Member Identification MI Must be the NM109 bscriber s ID TRICARE SaN ers member ID of the insured sponsor 277 Claim Status Response Transaction This section describes the values returned by PGBA in the 277 claim status response transaction The following tables describe the PGBA utilization of segments and elements when there is a type of uniqueness or restriction All other values comply with the TR3 Page 23 of 40 276 277 5010 COMPANION GUIDE Table 18 Information Source TR3 X12 Page Implementation Notes P Loop ID Reference mp eras Codes Coniments 218 2100A NM101 c My denter pm NWA Identification 220 2100A NM108 Code PI N A Qualifier on euon ource 220
27. asada do ra t eds Md Ia RU 21 Table 14 MIME Specific Processing Errors ccccccccccccccssssssssecececececeessnseseceseceesesensaeeeeeceeseeenenteaeess 21 SOAP and MIME Transaction Error Processing ccccsessssccecececeesessnsececececeeeessnseaeeeseeseseserssaeeeseeeens 21 9 TRADING PARTNER AGREEMENTS eene eee nennen nennen nis 21 10 TRANSACTION SPECIFIC INFORMATION errem 22 276 Claim Status Request TranSaction 0 cccccccccccccccccccececececececececececececececececeeececeeeeseeeeeeeeeeeeeess 22 Information Source Level Structures cccccccssssssccececccecsessssecececcesceesessesseseeeeceeesesesseaeeeseeeeseneneaaees 22 Table 15 Information SOULCE L000 ecceccessssccecccecsesssscsecececeeseeesssecececeeeceesenseasecececceseseeesaseceseeseseneneaaees 22 Information Receiver Level Structures cccccssessecececccecsessssecececcceceesesseaseseceseeseseeesseseeeseeeeseneneaaecs 22 Table 16 Information RECEIVELS ccccccccsccccssssssscccscececsenssescaecesecsensnssaaeessececsenssenseaeeeccesenseensaaeess 23 Patient Level Structures naen n ei Eee e ete t e e estote Ee E D eet ie Ede 23 TablezT77 Patient ee e ete ee tete cete tte EH ood tte uci ett eee 23 277 Claim Status Response Transaction esses eene eene eene terne eee enn 23 Table 18 Information SOULE ecceccesssscceccceceesessssecececeeeeeensseeeeeseesesensseasececeseeseeenssaseceseeeesesensaaes 24 Table 1
28. ata Element Description ISA01 Authorization Info 03 Qualifier ISA02 Authorization Information EDIG assigned Trading Partner ID ISA03 Security Information 00 Qualifier ISA04 Security Information None ISA05 Interchange ID Qualifier 01 14 20 22 27 28 29 30 33 ZZ selected by trading partner ISA06 Interchange Sender ID Assigned by trading partner ISA07 Interchange ID Qualifier 30 qualifier indicating U S Federal Tax Identification Number ISA08 Interchange Receiver ID 571132733 ISA09 Interchange Date Populated by trading partner ISA10 Interchange Time Populated by trading partner ISA11 Repetition Separator Assigned by trading partner ISA12 Interchange Control 00501 Version Number ISA13 Interchange Control Assigned by the trading partner must be Number unique for 12 months ISA14 Acknowledgment Assigned by the trading partner Requested ISA15 Usage Indicator P T production or test indicator Page 16 of 40 276 277 5010 COMPANION GUIDE Segment Id Data Element Description ISA16 Component Element Separator Assigned by the trading partner Functional Group Structure GS GE Table 7 describes the values to be populated in the GS segment of the 276 request The GE segment should be populated as instructed by the ASC X12 276 TR3 Table 7 276 GS Segment Rules seamen Data Element Description GS01 Functional Identifi
29. ate and ZIP 12 Primary Business Contact s Information Technical Contact s Information The name email address telephone number and fax number of the trading partner s primary business contact This is the person BlueCross BlueShield of South Carolina EDIG will contact if there are questions regarding the enrollment or future questions about the account The name email address telephone number and fax number of the trading partner s technical contact This is the person BlueCross BlueShield of South Carolina EDIG will contact if there are technical questions or problems 12 12 After Hours Technical Contact s Information The name email address telephone number and fax number of the trading partner s after hours technical contact This is the person BlueCross BlueShield of South Carolina EDIG will contact if there are technical questions or problems after normal business hours 12 On Call Technical Contact s Information The name email address telephone number and fax number of the trading partner s on call technical contact This is the person BlueCross BlueShield of South Carolina EDIG will contact if there are technical questions or problems after normal business hours when it is unable to contact the After Hours Technical Contact 12 Transaction Volume Estimates Mark yes Y or no N for each mode If you mark yes indicate the average number of transactions you anticipa
30. cess Envelope was processed successfully SOAP Specific Processing Errors Table 13 describes examples of SOAP processing errors Page 20 of 40 276 277 5010 COMPANION GUIDE Table 13 SOAP Specific Processing Errors Error Code Error Message nonconforming content No signature in message No signature in the WS Security message for the nonconforming content configured SOAP actor role Unsupported or unrecognized Signature signer format in the message nonconforming content Certificate not found nonconforming content nonconforming content Illegal value provided for ProcessingMode Found lt Fieldnamevalue gt in default namespace but next nonconforming content item should be lt Fieldname gt env Client There was an error in the incoming SOAP request va Processing Mode cannot be empty Value expected is env Client RealTime MIME Specific Processing Errors Table 14 describes examples of MIME processing errors Table 14 MIME Specific Processing Errors Error Code Error Message ProcessingMode value lt FieldValue gt is not a valid instance nonconforming content of type RealTimeMode env Client ProcessingMode of type RealTimeMode may not be empty SOAP and MIME Transaction Error Processing Transaction processing errors described in the ACKNOWLEDGEMENTS AND ERROR CODES section of this Companion Guide will be returned as a SO
31. d Individuals Trading Partner acknowledges and agrees that claim payments made according to this Agreement will be made directly either to Providers on behalf of the Individual or directly to the Individual at PGBA s discretion 1 12 Individually Identifiable Health Information means any Health Information including demographic information collected from an Individual that is created or received by a Provider health plan employer or health care clearinghouse and either i identifies an Page 34 of 40 276 277 5010 COMPANION GUIDE Individual or ii creates a reasonable basis to believe the information can be used to identify the Individual 1 13 Operating System means the equipment software and trained personnel necessary for a successful Data Transmission 1 14 Payor means a business organization that provides benefit payments for certain services or supplies rendered or sold to Covered Individuals or their eligible dependents under the terms conditions limitations and exclusions of a health benefit program issued or administered by the Payor 1 15 Proprietary Information means information used or created by PGBA in the conduct of its business activities that is not normally made available to PGBA s customers competitors or third parties the disclosure of which will or may impair PGBA s competitive position or otherwise prejudice PGBA s ongoing business 1 16 Provider means a customer of Trading Partner that operates as a
32. e information refer to the W3C recommendation on SOAP messaging framework located at http www ws3 org TR soap12 part1 SOAP Header Requirements The SOAP Header should include the timestamp element and should be digitally signed Detailed SOAP WSDL envelope standards for CORE Phase II Connectivity are located at http www cagh org pdf CLEANS5010 276 v5010 pdf SOAP Body Requirements Required PGBA specific body elements for 276 requests using SOAP are defined in Table 2 Table 2 Required Body Elements for 276 Requests Using SOAP Element Name Description PayloadType X12 276 Request 005010X212 ProcessingMode RealTime or Batch Refer to Section 4 4 2 of the Phase II CORE 276 PayloadID Connectivity Rule for structural guidelines for CORE envelope metadata Format is YYYY MM DDTHH MMSSZ Refer to TimeStamp http www w3 org TR xmlschemat1 1 2 dateTime for more information SenderID This field should be 10 characters in length ReceiverID 571132733 CORERuleVersion 2 2 0 X12 request This element must be digitally signed and Payload the entire payload should be enclosed within a CDATA tag Table 3 defines PGBA specific body elements for 277 responses using SOAP Table 3 Required Body Elements for 277 Responses Using SOAP Page 12 of 40 276 277 5010 COMPANION GUIDE Element Name Description PayloadType X12 276 Response 005010X212 ProcessingMode RealTime or Batch R
33. e procuring a certificate Trading Partners are advised to review the information on certificate procurement and platform specific CSR generation at this link http www digicert com csr creation htm e Entrust Entrust provides Advantage SSL Certificates which can be acquired from http www entrust net ssl certificates advantage htm Before acquiring a certificate Trading Partners are advised to review the information on certificate procurement and platform specific CSR generation at this link http www entrust net ssl technical csr_faq cfm e Symantec VeriSign Symantec issues VeriSign Secure Site SSL certificates which can be procured from http www symantec com verisign ssl Page 10 of 40 276 277 5010 COMPANION GUIDE certificates secure site Before acquiring a certificate Trading Partners are advised to review the information on certificate procurement and platform specific CSR generation at this link https knowledge verisign com support ssl certificates support index page content amp actp CROSSLINK amp id AR235 NOTE The certificates listed for each CA are the minimum level required to connect to the 276 277 application Trading Partners may choose to procure a higher level certificate Before accessing the 276 277 application via SOAP or MIME new and existing Trading Partners must provide the Digital Certificate to PGBA by contacting EDIG EDIG will verify the certificate and initiate the process
34. ectronic transactions to PGBA on behalf of such Providers and WHEREAS both Parties are entering into this Agreement to facilitate through transmission via electronic formats consistent with or otherwise allowed by Social Security Act 1173 and the Standards for Electronic Transactions 45 C F R Parts 160 and 162 as may be amended or modified from time to time Transaction Rules the submission and payment of claims for medical services and supplies rendered or sold to Covered Individuals by Providers NOW THEREFORE in consideration for the mutual promises herein the Parties agree as follows I DEFINITIONS The following terms with initial capitals have these meanings Page 33 of 40 1 1 1 2 ANSI means American National Standards Institute an organization whose Accredited Standards Committee develops and approves uniform standards for the electronic interchange of business transactions Business Associate means an entity meeting the definition of 45 C F R Part 160 103 Confidential Health Information means information relating to specific Individuals including Individually Identifiable Health Information and Health Information that is exchanged by and between PGBA and Trading Partner or Providers for various business purposes and that is protected from disclosure to unauthorized persons or entities by Social Security Act 1171 et seq the Standards for Privacy of Individually Identifiable Health Information 45
35. ed by the 276 277 application to communicate the rejection of a 276 request based on errors encountered with X12 compliance formatting or PGBA specific requirements of the ISA IEA Interchange segments A TA1 may be returned if one of the following conditions exists e A276 request is received and the version of the transmission cannot be determined e A276 request is received and the version of the transmission is unsupported by the 276 277 application This includes previously accepted versions that are no longer supported The Trading Partner has not been authorized for the submitted X12 version 277 When the 276 request complies with the X12 TR3 standard syntax requirements and all additional formatting rules as specified by this Companion Guide then a 277 response is returned to the Trading Partner If no error exists the claim status data will be returned within the 277 response Refer to section 10 of this Companion Guide for more information Proprietary Error Message Proprietary error messages will be sent only when the ISA segment of the 276 request cannot be read making it impossible to formulate an ISA segment for a 277 response The proprietary message will return error codes and descriptions Trading Partners may contact EDIG for assistance with Proprietary Errors The format for the proprietary messages is described in Page 18 of 40 276 277 5010 COMPANION GUIDE Table 10 Table 10 Proprietary Error Message
36. efer to Section 4 4 2 of the Phase Il CORE 276 PayloadID Connectivity Rule for structural guidelines for CORE envelope metadata Format is YYYY MM DDTHH MMSSZ Refer to TimeStamp http www w3 org TR xmlschemal 1 2 ztdateTime for more information SenderID 571132733 ReceiverlD This field should be 10 characters in length CORERuleVersion 2 2 0 Payload X12 response SOAP Digital Signature The SOAP communication protocol requires Trading Partners to digitally sign the message body and certain elements i e TimeStamp of the header Refer to http www w3 org TR SOAP dsig for details related to XML signatures SOAP Examples Examples of a SOAP request and response can be found in Sections 4 2 2 3 and 4 2 2 4 of the CORE Phase II Connectivity Rule at this link http www caqh org pdt CLEAN5010 276 v5010 pdf HTTP MIME Multipart The 276 277 application also supports standard HTTP MIME messages The required MIME format is multipart form data Responses to request transactions sent via this protocol will be returned in a MIME multipart form which contains the payload as an X12 document Submission Retrieval MIME transactions must be submitted to the 276 277 using the following URL https services pgba com mimeapi PRODUCTION 9080 COREElectronicDatalnterchange A MIME transaction must be constructed exactly to the multipart form data specifications Refer to http www faqs org rfcs ric2388 html for m
37. ent 4 2 Responsibility for Providers and Suppliers Trading Partner is liable to PGBA for any act failure or omission of any Provider and or Supplier with whom Trading Partner contracts or for whom Trading Partner receives transmits stores or processes data or Data Transmissions or performs related activities as though the act failure or omission were that of Trading Partner 4 3 Notices Regarding Providers Trading Partner will notity PGBA at least fourteen 14 days prior to the addition or deletion of any Provider and or Supplier from the list Page 38 of 40 276 277 5010 COMPANION GUIDE contained in Exhibit A of Providers and Suppliers for whom Trading Partner submits data or Data Transmissions to PGBA Page 39 of 40 276 277 5010 COMPANION GUIDE 15 APPENDIX E REVISION HISTORY Table 21 provides a summary of changes made to this document Table 21 Document Revision History Version Date Description of Changes 1 1 03 26 2013 Edited for format 1 0 12 10 2012 CORE 276 277 Companion Guide Page 40 of 40
38. er Code Populated by trading partner GS02 Application Sender s Code EDIG assigned trading partner ID GS03 Application Receiver s Codd 571132733 GS04 Date Populated by trading partner GS05 Time Populated by trading partner GS06 Group Control Number Pete e Wate rne GS07 Responsible Agency Code X GS08 ebd DE Code populated by trading partner 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS This section describes the business rules and limitations of the 276 277 application All references to the ASC X12 276 277 TR3 assume the version referenced in section 1 of this Companion Guide General Structural Notes Trading Partners should follow the ST SE guidelines outlined in the 276 section of TR3 Trading Partners should follow the ISA IEA and GS GE guidelines for HIPAA in Appendix C of the TR3 and follow the 999 and TA1 guidelines outlined in the Implementation Acknowledgement for Health Care Insurance Trading Partners must follow the character set guidelines as defined in Section B 1 1 2 5 of TR3 Page 17 of 40 276 277 5010 COMPANION GUIDE e PGBA recommends use of the request delimiters in Table 8 Table 8 Preferred 276 Request Delimiters Character Name Delimiter i Asterisk Data Element Separator Component Element gt Greater Than Separator a Tilde Segment Terminator A Carat Repetition Separator 8 ACKNOWLEDGEMENTS AND ERROR CODES TA1 The TA1 Interchange Acknowledgement is us
39. ernment subcontracts or to federal health care programs as defined in Social Security Act 1128B f listed by a federal agency as debarred proposed for debarment or suspended or otherwise excluded from federal program participation including exclusion from participation in a federal health care program as defined in the Social Security Act 1128B f lil OBLIGATIONS OF THE PARTIES 3 1 Page 36 of 40 Mutual Obligations The mutual obligations of PGBA and Trading Partner include the following a Transmission Format All standard transactions as defined by Social Security Act 1173 a and the Transaction Rules conducted between PGBA and Trading Partner will be conducted electronically and will only use code sets data elements and formats specified by the Transaction Rules and the then current version of the PGBA Supplemental Implementation Guides The PGBA Supplemental Implementation Guides and any updates or amendments thereto may be accessed at http www southcarolinablues com and are incorporated herein by reference This section will automatically amend to comply with any final regulation or amendment to a final regulation adopted by HHS concerning the subject matter of this Section upon the effective date of the final regulation or amendment b Testing Prior to the initial Data Transmission each Party will test and cooperate with the other Party in testing the connectivity and interaction of the Parties Operating
40. eseeeeeeee eene eene nnns 8 Transaction Process FOW 2 He i GR RET EGER Tr ERR ERREUR saveddaes ove 9 Figure 2 1 Transaction PIOCBSS esae oncle es p eic MeL aet ta ips aM on rceasas hanes oneeia a 9 Batch File Responsesis ns mee rete obe hielo oec e e EE ate eus is deed vede 9 Transmission Administrative Procedures includes Schedule Availability and Downtime INOUFICOLIOR sate asec rS Sek A dL i a E e AT 9 Re Transmission PLOCECULE cccccesssssscccecececesessscscesceccesensnssseaeceseescnseseaasaaeeescesenseesaaaeesseceesenseasees 10 Communication Protocol Specifications ssssseseseee ee eene nnne nnne enne esee 10 Siem EABee T AT E ossasen A Ia EWS DIDO EEG EOS ROS Te 11 SOAP XML Schema eee oe etre rete teat rete be e d a Ee T ea ST TG 11 WSDLInforiatlomiss see eL M scc 11 SOAP Version Requirements nonini ae nnn nnn nnn a nnn nnn n a n a n nn n nn n nnn nn npe genua 11 Submission Retrleval 3 neis BED deci niei niani 11 SOAP Header Requirements et ene c Re enr eite Lon 12 SOAP Body REGU EO lerfts coe caves da codec cux dd de dese Dedit ens sob dedu lo i PE Sat c Fame Do Ae dece Deed 12 Table 2 Required Body Elements for 276 Requests Using SOAP sesssssesseeeeree 12 Table 3 Required Body Elements for 277 Responses Using SOAP sssssssseeeeeeeenes 12 SOAP Digital Signature pee bt DIE D s 13 SOAP ExampleSz65 itte eth te dirt es Neb trs fra fresu Sas cases estes iier rote da ras eve 13
41. g problems with their transactions EDIG will not edit Trading Partner eligibility data and or resubmit transactions for processing on behalf of a Trading Partner The Trading Partner must correct the transaction and resubmit following the same processes and procedures of the original file Communication Protocol Specifications Trading Partners may connect to the 276 277 application via one of the following communication protocols e SOAP WSDL HTTP MIME Multipart To connect to the 276 277 application via SOAP or MIME Trading Partners will need to authenticate with an X 509 Digital Certificate using the Transport Layer Security TLS 1 0 open standard for client certificate based authentication TLS 1 0 is required for compliance with the federally mandated with Submitter Authentication Standard D in the Conformance Requirements Before a certificate can be procured from a Certificate Authority CA Trading Partners will need to generate a platform specific Certificate Signing Request CSR Trading Partners are requested to review the CA specific CSR process carefully and contact the CAs directly to obtain the certificate The 276 277 application requires a certificate enabled with a minimum 128 bit SSL encryption Trading Partners must use one of the following CAs to procure a Digital Certificate DigiCert DigiCert provides SSL Plus Certificates which can be procured from http www digicert com welcome ssl plus htm Befor
42. her Party f Backup Files Each Party will maintain adequate backup files electronic tapes or other sufficient means to recreate a Data Transmission for at least six 6 years from the Data Transmission s creation date Such backup files tapes or other sufficient means will be subject to the terms of Article V of this Agreement to the same extent as the original Data Transmission g Data and Data Transmission Security PGBA and Trading Partner will employ security measures necessary to protect Data and Data Transmissions between them including authentication encryption password use or other security measures in compliance with Social Security Act 1173 d and any HHS implementing regulations or guidelines and as set forth in Article V of this Agreement Unless PGBA and Trading Partner agree otherwise the recipient of data or Data Transmission will use at least the same level of protection for any subsequent transmission as was used for the original transmission h Security Access Codes The Security Access Codes that PGBA issues to Trading Partner will when affixed to Data Transmissions be legally sufficient to verify the identity of the transmitter and to authenticate the Data Transmission thereby establishing the Data Transmission s validity Data Transmissions having a Security Access Code affixed to them will be deemed to have been written or signed by the sender Computer printouts of the information contained in such corre
43. horized personnel on a need to know basis d Provide PGBA in writing all information requested in Exhibit A to this Agreement not later than Trading Partner s execution of this Agreement While this Agreement is in effect Trading Partner will notify PGBA in writing within one 1 business day of any material change in the information on Exhibit A to this Agreement 3 3 Obligations PGBA will a Make available to Trading Partner via electronic means data and Data Transmissions for which this Agreement grants Trading Partner access or authorization or as provided by law b Provide Trading Partner with at least sixty 60 days prior written notice of any change or addition to the PGBA Supplemental Implementation Guides code sets data elements or formats for Data Transmissions set forth in Section 3 1 a of this Agreement c Provide Trading Partner with Security Access Codes that will allow Trading Partner to exchange Data Transmissions with PGBA s Operating System PGBA reserves the right to change Security Access Codes at any time and in such manner as PGBA in its sole discretion deems necessary IV PROVIDERS AND SUPPLIERS 4 1 Provider and Supplier Obligations Trading Partner will ensure that Providers and Suppliers will be bound by the mutual obligations of the Parties set forth in Section 3 1 and Trading Partner s obligations set forth in Section 3 2 even though Providers and Suppliers are not signatories to this Agreem
44. on Guides 276 277 5010 COMPANION GUIDE 1 2 3 4 5 6 TABLE OF CONTENTS Preface moneen aa e soso Thc a tede a a an os Rv OR eal see EES 3 ISRERODIOG T ON EE E A T AEA O NCE 6 OOO 0 a a a 6 ONAE ists Nit E EA E E E ETE AEE 6 Retererices nete hs a a re a a a Late o Ere Eger Ere deae be ion 6 Additional Informatio M i ertt erre Drev E e repete e e reves ev saath ie ER YR 6 GETTING STARTED isucus drea ouin a qs ioo Dm dntte eS un muita ocu tatum ea nix cer C n ucud 6 Working with PGBA s te tain Sass bs Dae Woda evi et rece Po oet was bas So at E ER e e Soa vive T Rea 6 Trading Partner Registration nenion na a i aaa a araid a NETET 7 Certification and Testing OVErVIEW cccccccsesscececcceceessnsecececececsessssaseceseeceseeenssseceeeeeeseeeneseseeeeeeeeeeees 7 TESTING WIR POBA MR a MUR 7 Table Testing PLOCGSS 5o orte tot retta eese tees i Cesena dure cites estes fasts bine T EE 7 Transition from Test to Production Status ccccccssccccccccecsesesssseceseccceceesssseaeceeceseseeessaeeeeeseesenenentaaeess 8 Testing URLs for Real time and Batch 0 ccccccssccccccccecsessssnsecececeeeesesssseseceeeceesesesssaeeeeeseeseeeneraaeees 8 CONNECTIVITY WITH THE PAYER COMMUNICATIONS nne 8 Trading Partner Registration Process FIOW 0 cccssssccecececeeeesensecececeeeenssesensecececeeecessnaaeceeeeeenseesenaees 8 Figure 1 Process for Submitting 276 Transactions sssssssssss
45. ore information on multipart form header and body specifications Page 13 of 40 276 277 5010 COMPANION GUIDE HTTP MIME Multipart Header Requirements MIME transactions will include standard HTTP header data elements such as POST HOST Content Length and Content Type The supported Content Type is multipart form data HTTP MIME Multipart Body Requirements Since CORE does not specify naming conventions PGBA will implement MIME with the same field names as SOAP Required body elements for MIME transactions are defined in Table 4 Table 4 Required Body Elements for 276 Requests Using MIME Element Name Description PayloadType X12 276 Request 005010X212 ProcessingMode RealTime or Batch Refer to Section 4 4 2 of the Phase II CORE 276 PayloadID Connectivity Rule for structural guidelines for CORE envelope metadata Format is YYYY MM DD THH MMSSZ Refer to TimeStamp http www w3 org TR xmlschemat1 1 2 dateTime for more information SenderID This field should be 10 characters in length ReceiverlD 571132733 CORERuleVersion 2 2 0 X12 request This element must be digitally signed and the entire payload should be enclosed within a CDATA tag Payload Table 5 defines PGBA specific body elements for 277 responses using SOAP or MIME Table 5 Required Body Elements for 277 Response Using MIME Element Name Description PayloadType X12 277 Response 005010X212 Processing
46. privacy and security of eligibility transactions sent directly to them from Providers and requires them to be able to associate each inquiry with a Provider Provider authentication must be established by the Clearinghouse outside of the transaction 5 CONTACT INFORMATION All inquiries and comments regarding Trading Partner registration connectivity set up transaction testing and 276 277 transaction submissions should be directed to EDIG Operations EDIG Operations is available at 800 868 2505 or EDIG OPS PalmettoGBA com Monday through Friday from 8 00 AM to 5 00 PM EST NOTE The EDIG Operations E mail account is monitored during normal business hours E mails are typically answered within 3 business days Page 15 of 40 276 277 5010 COMPANION GUIDE 6 CONTROL SEGMENTS ENVELOPES The following sections describe the 276 277 transaction requirements to be used in conjunction with the requirements outlined in the ASC X12 TR3 Adhering to these requirements will help ensure that transactions received by the 276 277 application will pass the specified business edits All references to the ASC X12 276 277 TR3 assume the version referenced in section 1 of this Companion Guide Interchange Control Structure ISA IEA Table 6 describes the values to be populated in the ISA segment of the 276 request The IEA segment should be populated as instructed by the ASC X12 TR3 Table 6 276 ISA Segment Rules Segment Id D
47. spondence and documents that have been electronically or magnetically recorded and kept in the normal course of the sender s or receiver s business will be considered original business records admissible in any judicial arbitration mediation or administrative proceeding to the same extent and under the same conditions as other business records originated and maintained in documentary form 3 2 Trading Partner Obligations Trading Partner will a Not copy reverse engineer disclose publish distribute alter or use Data Data Transmission or Envelope for any purpose other than for which PGBA has specifically authorized Trading Partner under the terms of this Agreement b Not obtain access by any means to data Data Transmission Envelope or PGBA s Operating System for any purpose other than as PGBA has specifically granted Trading Partner access under this Agreement In the event that Trading Partner Page 37 of 40 276 277 5010 COMPANION GUIDE receives data or Data Transmissions not intended for Trading Partner Trading Partner will immediately notify PGBA and make arrangements to retransmit or otherwise return the data or Data Transmission to PGBA After such retransmission or return Trading Partner will immediately delete the data and Data Transmission from its Operating System c Protect and maintain the confidentiality of Security Access Codes issued to Trading Partner by PGBA and limit disclosure of Security Access Codes to aut
48. tch 276 277 transactions References CAQH CORE Phase l and Il www cagh org benefits php ASC X12 TR3s http store x12 org Trading Partner Enrollment www myTRICARE com Trading Partner Agreement www myTRICARE com Additional Information Submitters must have Internet HTTPS connection capability to submit a 276 request and receive 277 responses The submitter must be associated with at least one provider in the PGBA provider database Both real time and batch 276 inquiries are supported This system supports inquiries for PGBA members only 2 GETTING STARTED Working with PGBA Page 6 of 40 Providers billing services and clearinghouses interested in submitting 276 inquiries and receiving 277 responses via PGBA should contact PGBA by visiting www myTRICARE com and clicking on Contact Us from the EDI page Please note that the information in this guide is subject to change Any changes will be available at www myTRICARE com This transaction set can be used to inquire about the claim status of an associated subscriber or a dependent under the subscriber s policy The use of this document is solely for the purpose of clarification The information describes specific requirements to be used in processing PGBA LLC ASC X12 005010X212 Health Care Claim Status Inquiry 276 transactions 276 277 5010 COMPANION GUIDE Trading Partner Registration Trading partners must enroll with the PGBA EDI Gateway EDIG to use the HTTPS
49. te submitting each week Page 28 of 40 276 277 5010 COMPANION GUIDE Action Requested Check One Trading Partner s Name Trading Partner s ID Federal Tax ID Type of Business Check One Line of Business Check One Date L New Trading Partner ID LI Change LI Cancel Institutional Health Care Provider Clearinghouse Billing Service LI Professional Health Care Provider Health Care Plan Retail Pharmacy LI Pharmacy Benefit Manager L Software Vendor LI Other indicate L BlueCross BlueShield of South Carolina Commercial L PGBA LLC mm dd ccyy End Date mm dd ccyy Start Date Compression Check One Protocol Check One Address 1 Address 2 City State ZIP Address 1 Address 2 City State ZIP First Last Name Telephone First Last Name Telephone First Last Name Telephone First Last Name Telephone Page 29 of 40 Required when canceling an account LI No Compression PKZIP UNIX CO NDM C FTP DIALUP ASYNC DIALUP product Secure FTP VPN CITCPIP via VPN TCPIP via AGNS L HTTPS SOAP L HTTPS MIME Service Address Billing Address If different from the Service Address Primary Business Contact s Information S Email Ha C ext Fax 7 om el Primary Technical Contact s Information ETT Email C y ext Fax e T After Hours Technical Contact s Information Email EI
Download Pdf Manuals
Related Search