Capario_Claims_and_ERA_Payer_List

Capario Payer ID Table

Payer ID Table Column Descriptions:



Updated:

Date added since last publication. N = New Payer, C = Change to payer record.



Participating / Non-Participating / Transitional (Par / Non-par / Trans):

Par - Payers which participate with Capario in efforts to increase EDI volumes by subsidizing all or a significant portion of the cost of electronic transmission.

Non-Par - Payers which do not participate with Capario in programs to increase EDI volumes by subsidizing the cost of electronic transmission.

Trans - Payers which participate with Capario in efforts to increase EDI volume, but do not fully subsidize the cost of the electronic transaction.



Payer ID:

Used to route claims electronically to the payer. Each claim must be associated with a payer ID. If sending directly from your practice management system, speak to your practice management

software vendor about where to store payer IDs.



Commercial / Government / Paper:

Comm = Commercial health plans and those participating Blue Cross/Blue Shield payers.

Govt = Medicare, Medicaid and non participating Blue Cross/Blue Shield payers.

Paper = Payers that can not receive claims electronically. Capario prints to paper and mails to payer address noted on the claim.



State (ST):

State specific payers have state abbreviation, national payers are blank.



Payer Name:

Common name used for payer and/or payer specific plans.



Line of Business:

Professional - Medical claims.

Institutional - Hospital claims.

Dental - Dental claims.

Remittance - Electronic Remittance Advise

Work Comp Prof / Work Comp Inst - Workers Compensation for Professional and Institutional e-Bills.



EDI Version:

This column indicates what version of X12 the payer is receiving/submitting.



NPI Levels:

Legacy_Only - Capario will only deliver legacy Provider ID(s). If the Legacy Provider ID(s) and NPI(s) are sent, the NPI(s) will be stripped. Legacy Provider ID edits apply.

NPI_Or_Legacy - Capario will deliver Legacy Provider ID(s) or NPI(s). If NPI and Legacy ID(s) are submitted, the Legacy ID(s) will be stripped from the outbound payer file. If Legacy Provider ID(s)

only are submitted, Legacy edits apply. If NPI(s) are submitted, Capario will perform an NPI Check digit validation, unless disabled by the Payer.

All_Use - NPI and/or Legacy values accepted. If NPI(s) are present Legacy ID edits will no be performed and Legacy ID(s) will be stripped from the outbound payer files.

NPI_Requireduired - NPI is Required. If Legacy ID(s) are submitted they will be delivered to the payer along with the NPI(s). No Legacy ID edits will be performed. Capario will perform an NPI Check

digit validation, unless disabled by the Payer.

NPI_Primary - NPI is Required in Primary loops only. Capario will perform an NPI Check digit validation, unless disabled by the Payer. If Legacy Provider ID(s) are submitted they will be stripped from

the Primary loops only. NPI and Legacy ID(s) will be submitted in Secondary loops.

- Professional Primary Provider Loops = Billing (2010AA), Pay-to (2010AB), Rendering claim level (2310B) and Rendering line level (2420A).

- Institutional Primary Physician Loops = Billing (2010AA), Pay-to (2010AB), Attending claim level (2310A) and Attending line level (2420A).

NPI_Only - NPI is Required. Only NPI values will be delivered to the payer. Capario will perform an NPI Check digit validation, unless disabled by the Payer. If Legacy Provider ID(s) are submitted they

will be stripped from the outbound payer file.



Enrollment / Authorization:

Payers marked require notification and/or enrollment prior to sending claims and/or receiving remittance. See Capario's searchable Payer List for Enrollment documentation:

http://www.capario.com/services/resource_center/payer/list/default_db.asp



Response Level from Payer:

This column indicates the level of reporting the payer and/or trading partner returns to Capario:



Capario Acknowledgement - Indicates that Capario acknowledges claim, but no response from payer.

File Level Acknowledgement - Indicates a file level response from the payer and/or trading partner.

Batch Level Acknowledgement - Indicates a batch level response from the payer and/or trading partner.

Claim Level Acknowledgement - Indicates a claim level response from the payer and/or trading partner.

Claim Level Rejects Only- Indicates a rejection response only from the payer and/or trading partner but no acceptance acknowledgement. For more information on the status message, please call

the payer.

Claim Level Accept/Rejects - Indicates a claim level acceptance or rejection from the payer and/or trading partner. For more information on the status message, please call the payer.



Payer Accepts COB:

Coordination of Benefits. This column indentifies payers who accept secondary claims electronically.



Notes/Special Instructions:

Notes or special instructions









Revised11/01/2011









11/10/2011 1 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Par 13162 Commercial 1199 National Benefit Fund Institutional 4010A1 Claim Level Accept/Reject

Par 13162 Commercial 1199 National Benefit Fund Professional 4010A1 Claim Level Accept/Reject

Non-Par 13162 Commercial 1199 SEIU National Benefit & Pension Fund Remittance 4010A1 Enrollment

Par 13162 Commercial 1199 SEIU National Benefit & Pension Fund Institutional 4010A1 Claim Level Accept/Reject

Par 13162 Commercial 1199 SEIU National Benefit & Pension Fund Professional 4010A1 Claim Level Accept/Reject

Non-Par 59069 Commercial 21st Century Health and Benefits Institutional 4010A1 No Response From Payer

Non-Par 51028 Commercial 21st Century Insurance and Financial Services Professional 4010A1 File Level Acknowledgement

Non-Par 51028 Commercial 21st Century Insurance and Financial Services Institutional 4010A1 File Level Acknowledgement

Non-Par 31147 Commercial OH 3-Hab (Ohio BWC) Professional 4010A1 Claim Level Accept/Reject

Non-Par 20413 Commercial 3P ADMIN Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 20413 Commercial 3P Administrators Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 74234 Commercial 8th District Electric Professional 4010A1 Claim Level Accept/Reject

Non-Par 93044 Commercial A & I Benefit Plan Administrators Professional 4010A1 Claim Level Accept/Reject

Non-Par 93044 Commercial A & I Benefit Plan Administrators Institutional 4010A1 Claim Level Acknowledgement

Non-Par 95241 Commercial A.G.I.A, Inc Professional 4010A1 Claim Level Acknowledgement

Non-Par 95241 Commercial A.G.I.A, Inc. Institutional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WC188 Commercial AAA Automobile Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC188 Commercial AAA Automobile Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK462 Commercial TX, MN AAA Cooper Transportation Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 75240 Commercial AAG Benefit Plan Administrators, Inc. Institutional 4010A1 No Response From Payer Yes

Par A0701 Commercial CA ABMG - Claims (DOS on or after 07/01/2010) Professional 4010A1 Claim Level Accept/Reject

Par A0701 Commercial CA ABMG - Encounters (DOS on or after 07/01/2010) Professional 4010A1 Claim Level Accept/Reject

Non-Par 03443 Commercial Abraza Advantage Health Plan Professional 4010A1 Claim Level Accept/Reject

Par ABRI1 Commercial WI Abri Healthplan Professional 4010A1 Claim Level Rejects Only

Non-Par 68055 Commercial Absolute Total Care Institutional 4010A1 File Level Acknowledgement

(Prior to submitting claims, call Provider Relations Dept. at 866-475-3129 to verify

your provider info is on file in the Health Plans claim system to avoid any

U: 12/29/2010 Non-Par 68055 Commercial SC Absolute Total Care - Centene Professional 4010A1 Claim Level Accept/Reject rejections)

A: 04/06/2010 Non-Par WC231 Commercial TX, MN Acceptance Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC231 Commercial TX, MN Acceptance Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC231 Commercial TX, MN Acceptance Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par AHS01 Commercial Access Administrators Professional 4010A1 Claim Level Accept/Reject

Non-Par COACC Commercial CO Access Behavioral Care Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WC313 Commercial MN Access Group Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC313 Commercial MN Access Group Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC313 Commercial MN Access Group Auto 4010A1 Claim Level Accept/Reject

Non-Par CM001 Commercial Access IPA Professional 4010A1 Claim Level Accept/Reject

Par AMG01 Commercial CA Access Medical Group Professional 4010A1 Claim Level Rejects Only

Non-Par 64071 Commercial Acclaim Institutional 4010A1 Claim Level Accept/Reject

Non-Par 64071 Commercial Acclaim Professional 4010A1 Claim Level Accept/Reject

Non-Par 21356 Commercial Acclaim Repricing Institutional 4010A1 Claim Level Accept/Reject

Non-Par 21356 Commercial Acclaim Repricing Professional 4010A1 Claim Level Accept/Reject

Trans AMS01 Commercial Accountable Health Plan Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK049 Commercial TX, MN Accuride Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK049 Commercial TX, MN Accuride Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK049 Commercial TX, MN Accuride Corporation Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC343 Commercial Ace American Insuarnce Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC343 Commercial Ace American Insuarnce Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC343 Commercial Ace American Insuarnce Company Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC390 Commercial Ace Fire Underwriters Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC390 Commercial Ace Fire Underwriters Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC390 Commercial Ace Fire Underwriters Insurance Co Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR905 Commercial ACE Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR905 Commercial ACE Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR905 Commercial ACE Insurance Company Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB133 Commercial ACE/ESIS (excludes Sunoco) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC399 Commercial MN Acrometal Companies Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC399 Commercial MN Acrometal Companies Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC399 Commercial MN Acrometal Companies Auto 4010A1 Claim Level Accept/Reject

Non-Par 72467 Commercial ACS Benefit Services Inc. Institutional 4010A1 File Level Acknowledgement

Non-Par 72467 Commercial ACS Consulting Services Inc. Professional 4010A1 No Response From Payer

Non-Par 36112 Commercial ACS Rewards Administration Center Institutional 4010A1 File Level Acknowledgement

Non-Par 36112 Commercial ACS Rewards Administration Center Professional 4010A1 File Level Acknowledgement

Non-Par 38254 Commercial Activa Benefit Services, LLC Institutional 4010A1 Claim Level Accept/Reject

Non-Par 38254 Commercial Activa Benefit Services, LLC Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK474 Commercial Acuity, A Mutual Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC241 Commercial Adams and Brooks, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC241 Commercial Adams and Brooks, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB234 Commercial Administaff Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB234 Commercial Administaff Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 38265 Commercial Administration Systems Research Corporation Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WZ093 Commercial MN Administrative Claim Service, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ093 Commercial MN Administrative Claim Service, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 22384 Commercial Administrative Concepts Inc Professional 4010A1 Claim Level Accept/Reject

Non-Par 22384 Commercial Administrative Concepts Inc. Institutional 4010A1 File Level Acknowledgement

Non-Par 59141 Commercial Administrative Services Inc. Institutional 4010A1 File Level Acknowledgement

Non-Par 59141 Commercial Administrative Services, Inc. Professional 4010A1 No Response From Payer

Non-Par 37278 Commercial AdminOne Institutional 4010A1 No Response From Payer

Non-Par 37278 Commercial AdminOne Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WB229 Commercial ADP Total Source Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB229 Commercial ADP Total Source Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 58202 Commercial Advanced Data Solutions, Inc. Professional 4010A1 Claim Level Accept/Reject

A: 12/21/2010 Non-Par 68056 Commercial Advantage by Buckeye Community Health Plan Institutional 4010A1 Claim Level Accept/Reject

A: 01/10/2011 Non-Par 68056 Commercial Advantage By Managed Health Services Professional 4010A1 Claim Level Accept/Reject

Non-Par 35209 Commercial Advantage Health Solutions Professional 4010A1 Claim Level Acknowledgement

Non-Par 35209 Commercial Advantage Health Solutions Institutional 4010A1 Claim Level Acknowledgement







11/10/2011 2 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 12/06/2010 Non-Par 77070 Commercial Advantage Preferred Plus Professional 4010A1 File Level Acknowledgement

Non-Par 83077 Commercial Advantek Benefit Administrators Professional 4010A1 File Level Acknowledgement

Non-Par 83077 Commercial Advantek Benefit Administrators Institutional 4010A1 File Level Acknowledgement

Non-Par 59374 Commercial MU Advantica Professional 4010A1 Claim Level Acknowledgement

Non-Par 95340 Commercial Adventist Health System West Professional 4010A1 Claim Level Accept/Reject

Non-Par 95340 Commercial Adventist Health System West - Roseville CA Institutional 4010A1 File Level Acknowledgement

10/26/11 Non-Par 36320 Commercial MU Advocate Heaklth Centers Remittance 4010A1 Enrollment No Response From Payer

Non-Par 36320 Commercial Advocate Health Centers Institutional 4010A1 Claim Level Rejects Only

Non-Par 36320 Commercial IL Advocate Health Centers Professional 4010A1 Claim Level Accept/Reject

Non-Par 65093 Commercial IL Advocate Health Partners Institutional 4010A1 Claim Level Accept/Reject

Non-Par 65093 Commercial IL Advocate Health Partners Professional 4010A1 Claim Level Accept/Reject

10/17/11 Non-Par 60054 Commercial Aetna Institutional 5010A1 Claim Level Accept/Reject Yes

9/16/11 Non-Par 60054 Commercial Aetna Professional 5010A1 Claim Level Accept/Reject Yes

Non-Par 60054 Commercial Aetna Remittance 4010A1 Enrollment

10/17/11 Non-Par 57604 Commercial Aetna Affordable Health Choices (SM) - SRC Institutional 5010A1 Claim Level Accept/Reject Yes

10/17/11 Non-Par 57604 Commercial Aetna Affordable Health Choices (SM) - SRC Professional 5010A1 Claim Level Accept/Reject Yes

Non-Par 23228 Commercial PA Aetna Better Health - PA Medicaid Professional 4010A1 Claim Level Accept/Reject

A: 12/21/2010 Non-Par 23228 Commercial Aetna Better Health - PA Medicaid Institutional 4010A1 Claim Level Accept/Reject

Non-Par 23225 Government CT Aetna Better Health Connecticut Medicaid Professional 4010A1 Claim Level Accept/Reject

Non-Par 23225 Government CT Aetna Better Health Connecticut Medicaid Institutional 4010A1 Claim Level Accept/Reject

Non-Par 26337 Commercial MU Aetna IL Medicaid Professional 4010A1 File Level Acknowledgement Yes

Non-Par 38692 Government Aetna Medicaid Professional 4010A1 Claim Level Accept/Reject

Non-Par 38692 Government Aetna TX Medicaid & CHIP Institutional 4010A1 File Level Acknowledgement

Non-Par ADOCS Commercial Affiliated Doctors of Orange County Professional 4010A1 No Response From Payer

Providers must contact Affinity's EDI Coordinator before submitting claims

electronically at EDI@Affinity.org or call (866)247-5678, Opt 1, then 3, then 4, to

Non-Par 13334 Commercial Affinity Health Plan Remittance 4010A1 Enrollment obtain an Affinity provider ID

Providers must contact Affinity's EDI Coordinator before submitting claims

electronically at EDI@Affinity.org or call (866)247-5678, Opt 1, then 3, then 4, to

Non-Par 13334 Commercial Affinity Health Plan Institutional 4010A1 Enrollment Claim Level Accept/Reject obtain an Affinity provider ID

Providers must contact Affinity's EDI Coordinator before submitting claims

electronically at EDI@Affinity.org or call (866)247-5678, Opt 1, then 3, then 4, to

Non-Par 13334 Commercial Affinity Health Plan Professional 4010A1 Enrollment Claim Level Accept/Reject obtain an Affinity provider ID

Non-Par 46594 Commercial Affinity Medical Group Professional 4010A1 File Level Acknowledgement

When submitting to this payer ID please ensure the following: The claim is for a

Medicare Advantage Member, the date of service is equal to or greater than 1/1/10

Non-Par 13333 Commercial Affinity Medicare Advantage Professional 4010A1 File Level Acknowledgement and the subscriber ID you submit is 9 characters in length

Non-Par 95426 Commercial Affordable Benefit Adminidtrators Inc Institutional 4010A1 File Level Acknowledgement

Non-Par 95426 Commercial Affordable Benefit Administrators Inc. Professional 4010A1 File Level Acknowledgement

Non-Par 13346 Commercial AFTRA Health Fund Institutional 4010A1 No Response From Payer

Non-Par 13346 Commercial NY AFTRA Health Fund Professional 4010A1 Claim Level Accept/Reject

Non-Par 37280 Commercial AGA Institutional 4010A1 No Response From Payer

Non-Par 20048 Commercial Agate Resources Inc. (LIPA) Professional 4010A1 Claim Level Accept/Reject

Non-Par 64158 Commercial Agency Services, Inc. Institutional 4010A1 No Response From Payer

Non-Par 64158 Commercial Agency Services, Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par 31138 Commercial AHPO (Cleveland OH) Professional 4010A1 File Level Acknowledgement

Non-Par 31138 Commercial AHPO (Cleveland OH) Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WC312 Commercial AIG Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC312 Commercial AIG Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB108 Commercial AIG Claim Services Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB108 Commercial AIG Claim Services Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 06311 Commercial Alabama Medical Surgical Associates Professional 4010A1 No Response From Payer

U: 01/14/2011 Non-Par 95327 Commercial Alameda Alliance Professional 4010A1 Enrollment

Non-Par 91136 Commercial Alaska Childrens Services, Inc. Institutional 4010A1 No Response From Payer

Non-Par 91136 Commercial Alaska Children's Services, Inc. Grp #P68 Professional 4010A1 Claim Level Accept/Reject

Non-Par 92600 Commercial AK Alaska Electrical Health & Welfare Fund Professional 4010A1 Claim Level Accept/Reject

Non-Par 92600 Commercial Alaska Electrical Health & Welfare Fund Institutional 4010A1 Claim Level Acknowledgement

Non-Par 91136 Commercial Alaska Laborers Construction Industry Trust Institutional 4010A1 No Response From Payer

Non-Par 91136 Commercial Alaska Laborers Construction Industry Trust Grp # F23 Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC331 Commercial Alaska National Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 91136 Commercial Alaska Pipe Trades Local 375 Institutional 4010A1 No Response From Payer

Non-Par 91136 Commercial Alaska Pipe Trades Local Grp # F24 Professional 4010A1 Claim Level Accept/Reject

Non-Par 91136 Commercial Alaska United Food & Commercial Workers Health & Welfare Trust Institutional 4010A1 No Response From Payer

Non-Par 91136 Commercial Alaska United Food & Commercial Workers Health & Welfare Trust Grp # F45 Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC340 Commercial Alcoa Fasteners Systems Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC340 Commercial Alcoa Fasteners Systems Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 13550 Commercial ALICARE Institutional 4010A1 No Response From Payer

Non-Par 13550 Commercial ALICARE Professional 4010A1 Claim Level Acknowledgement

Trans 37602 Commercial All Savers Insurance Co. Institutional 4010A1 No Response From Payer

Trans 37602 Commercial All Savers Insurance Co. Professional 4010A1 No Response From Payer Yes

A: 04/06/2010 Trans WB228 Commercial Allegheny Technologies Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB228 Commercial Allegheny Technologies Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 81040 Commercial Allegiance Benefit Plan Management Professional 4010A1 Claim Level Accept/Reject

Non-Par 81040 Commercial Allegiance Benefit Plan Management Inc. Institutional 4010A1 Claim Level Acknowledgement

Non-Par 13079 Commercial Alliance Healthcare/ SRRIPA Professional 4010A1 No Response From Payer

Non-Par 13079 Commercial MU Alliance Healthcare/SRRIPA Institutional 4010A1 File Level Acknowledgement

Non-Par 23172 Commercial OH Alliance Partners Professional 4010A1 Claim Level Accept/Reject

Non-Par 23172 Commercial OH Alliance Partners Remittance 4010A1 Enrollment

Trans 52149 Commercial Alliance PPO, Inc. Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial Alliance PPO, LLC (Formerly 52148) Institutional 4010A1 No Response From Payer

Trans AMS01 Commercial Alliance Select Professional 4010A1 No Response From Payer



U: 01/14/2011 Non-Par 88461 Commercial Alliance, The (A Wisconsin Provider Network) Institutional 4010A1 No Response From Payer ID cards should show mailing address of PO Box 44365, Madison, WI 53744.

Non-Par 58234 Commercial Alliant Health Plans of Georgia Institutional 4010A1 No Response From Payer

Non-Par 58234 Commercial GA Alliant Health Plans of Georgia Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK050 Commercial TX, MN Allianz Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK050 Commercial TX, MN Allianz Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK050 Commercial TX, MN Allianz Insurance Auto 4010A1 Claim Level Accept/Reject







11/10/2011 3 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 94177 Commercial Allied Administrators Professional 4010A1 Claim Level Acknowledgement

Non-Par 94177 Commercial Allied Administrators (San Francisco, CA) Institutional 4010A1 No Response From Payer

Non-Par 94177 Commercial CA Allied Administrators (San Francisco, CA) Professional 4010A1 Claim Level Accept/Reject

Non-Par 37308 Commercial Allied Benefit Systems, Inc. Institutional 4010A1 No Response From Payer

Non-Par 37308 Commercial Allied Benefit Systems, Inc. Professional 4010A1 No Response From Payer

Non-Par SX156 Commercial Allied Health Systems Chiropractic Professional 4010A1 Claim Level Accept/Reject

10/17/11 Non-Par 75261 Commercial Alpha Data Systems Professional 5010A1 File Level Acknowledgement Yes

A: 04/06/2010 Non-Par WP985 Commercial TX, MN Alpha Review Prof. Work Comp 4010A1 Claim Level Accept/Reject

Par A0701 Commercial CA Alta Bates Medical Group (ABMG) - Claims (DOS on or after 07/01/2010) Professional 4010A1 Claim Level Accept/Reject

Par A0701 Commercial CA Alta Bates Medical Group (ABMG) - Encounters (DOS on or after 07/01/2010) Professional 4010A1 Claim Level Accept/Reject

Non-Par 25133 Commercial Alta Health Strategies Professional 4010A1 Claim Level Accept/Reject Yes

Par IP080 Commercial CA AltaMed Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ216 Commercial MN Altec Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ216 Commercial MN Altec Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ232 Commercial MN Altec Industries Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ232 Commercial MN Altec Industries Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC913 Commercial TX Alternative Service Concepts Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC913 Commercial TX Alternative Service Concepts Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC913 Commercial TX Alternative Service Concepts Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC370 Commercial Alternative Services Concepts Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK051 Commercial TX, MN Alvey Systems (AON Risk) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK051 Commercial TX, MN Alvey Systems (AON Risk) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK051 Commercial TX, MN Alvey Systems (AON Risk) Auto 4010A1 Claim Level Accept/Reject

Non-Par TH071 Commercial AMA Insurance Agency Professional 4010A1 Claim Level Accept/Reject

Non-Par 13550 Commercial Amalgamated Life Institutional 4010A1 No Response From Payer

Non-Par 13550 Commercial Amalgamated Life Professional 4010A1 Claim Level Acknowledgement

Non-Par 13343 Commercial Amalgamated Life - PA / Alicare Professional 4010A1 Claim Level Acknowledgement

Non-Par 13343 Commercial Amalgamated Life - PA / Alicare Institutional 4010A1 Claim Level Acknowledgement

Non-Par 62176 Commercial AMCO Professional 4010A1 Claim Level Acknowledgement

Non-Par 62176 Commercial AMCO Institutional 4010A1 Claim Level Acknowledgement

Trans AMS01 Commercial WI Amer Healthcare Plan Net Professional 4010A1 No Response From Payer

Non-Par 38219 Commercial AmeraPlan Professional 4010A1 Claim Level Accept/Reject

Non-Par 75137 Commercial Ameriben Solutions Professional 4010A1 Claim Level Accept/Reject

Non-Par 75137 Commercial AmeriBen Solutions Inc. Institutional 4010A1 File Level Acknowledgement

Non-Par 75240 Commercial American Administrative Group Institutional 4010A1 No Response From Payer Yes

Non-Par 42112 Commercial American Administrators (West Des Moines Iowa) Professional 4010A1 File Level Acknowledgement

Non-Par 42112 Commercial American Administrators (West Des Moines Iowa) Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WK423 Commercial TX, MN American Alternative Ins Corp Prof. Work Comp 4010A1 Claim Level Accept/Reject

U: 01/10/2011 Non-Par 63103 Commercial American Behavioral Professional 4010A1 No Response From Payer

A: 12/21/2010 Non-Par 63103 Commercial American Behavioral Institutional 4010A1 No Response From Payer

A: 12/17/2010 Non-Par 63106 Commercial American Behavioral FEP/ITS Professional 4010A1 File Level Acknowledgement

Non-Par 95170 Commercial American Benefit Plan Administrators Institutional 4010A1 Claim Level Acknowledgement

Non-Par 34187 Commercial American Benefits Management Institutional 4010A1 No Response From Payer

Non-Par 34187 Commercial American Benefits Management Professional 4010A1 Claim Level Acknowledgement

Non-Par 34187 Commercial American Benefits Management (North Canton, OH) Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK425 Commercial American Casualty Co of Reading PA Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK425 Commercial American Casualty Co of Reading PA Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK425 Commercial American Casualty Co of Reading PA Auto 4010A1 Claim Level Accept/Reject

Trans ACN01 Commercial American Chiropractic Network Group Professional 4010A1 No Response From Payer

Trans ACN01 Commercial NY American Chiropractic Network IPA of NY Professional 4010A1 No Response From Payer

Trans ACN01 Commercial American Chiropractic Network, Inc. Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK052 Commercial TX, MN American Coin Merchandising, Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK052 Commercial TX, MN American Coin Merchandising, Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK052 Commercial TX, MN American Coin Merchandising, Inc Auto 4010A1 Claim Level Accept/Reject

Trans 87726 Commercial American Commercial Lines Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 60305 Commercial MI American Community Mutual Ins. - Livonia, Michigan Professional 4010A1 Claim Level Accept/Reject

Non-Par 60305 Commercial American Community Mutual Insurance Institutional 4010A1 No Response From Payer

Non-Par 60305 Commercial American Community Mutual Insurance Professional 4010A1 Claim Level Accept/Reject

Trans ACN01 Commercial American Complimentary Care Network, Inc. Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK053 Commercial TX, MN American Cyanamid Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK053 Commercial TX, MN American Cyanamid Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK053 Commercial TX, MN American Cyanamid Auto 4010A1 Claim Level Accept/Reject

Non-Par TH095 Commercial American Family Insurance Company Professional 4010A1 Claim Level Accept/Reject

A: 12/17/2010 Non-Par 56071 Commercial American Family PPO Policies Professional 4010A1 File Level Acknowledgement

Non-Par 62030 Commercial American General Institutional 4010A1 No Response From Payer

Non-Par 62030 Commercial American General Professional 4010A1 Claim Level Accept/Reject

Non-Par 62030 Commercial American General Remittance 4010A1 Enrollment

A: 04/06/2010 Non-Par WP065 Commercial American Guarantee Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP065 Commercial American Guarantee Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP065 Commercial American Guarantee Auto 4010A1 Claim Level Accept/Reject

Non-Par 01066 Commercial American Healthcare Alliance Institutional 4010A1 No Response From Payer

Non-Par 01066 Commercial American Healthcare Alliance Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR899 Commercial American Home Assurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR899 Commercial American Home Assurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR899 Commercial American Home Assurance Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC400 Commercial American Home Craft Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC400 Commercial American Home Craft Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC400 Commercial American Home Craft Auto 4010A1 Claim Level Accept/Reject

Non-Par 36369 Commercial American Imaging Management, Inc. Institutional 4010A1 No Response From Payer

Non-Par 36369 Commercial American Imaging Management, Inc. Professional 4010A1 No Response From Payer

Non-Par MAP01 Commercial American Insurance Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WK434 Commercial TX, MN American Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP093 Commercial American Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP093 Commercial American Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP093 Commercial American Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 81949 Commercial American Insurance Company of Texas Professional 4010A1 Claim Level Accept/Reject







11/10/2011 4 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Trans 87726 Commercial American International Group, Inc. (AIG) Institutional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial American International Group, Inc. (AIG) Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WK460 Commercial TX, MN American International South Ins Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 72099 Commercial American LIFECARE Institutional 4010A1 No Response From Payer Yes

Non-Par 72099 Commercial American LIFECARE Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WK453 Commercial American Manufacturers Mutual Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK453 Commercial American Manufacturers Mutual Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK453 Commercial American Manufacturers Mutual Insurance Company Auto 4010A1 Claim Level Accept/Reject

Trans 81400 Commercial American Medical Security Professional 4010A1 Claim Level Accept/Reject

Trans AMS01 Commercial American Medical Security Professional 4010A1 No Response From Payer

Non-Par 81400 Commercial American Medical Security Inc. Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WK438 Commercial American Motorists Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK438 Commercial American Motorists Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK438 Commercial American Motorists Insurance Co Auto 4010A1 Claim Level Accept/Reject

Non-Par 74048 Commercial American National Insurance Company (ANICO) Institutional 4010A1 No Response From Payer

Non-Par 74048 Commercial American National Insurance Company (ANICO) Professional 4010A1 Claim Level Accept/Reject

Non-Par 44444 Commercial American Postal Workers Union Institutional 4010A1 No Response From Payer

Par 44444 Commercial American Postal Workers Union Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WK422 Commercial American Protection Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK422 Commercial American Protection Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK422 Commercial American Protection Insurance Co Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC408 Commercial American Protective Ins. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC408 Commercial American Protective Ins. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC408 Commercial American Protective Ins. Auto 4010A1 Claim Level Accept/Reject

Non-Par 42011 Commercial American Republic Insurance Company (ARIC) Institutional 4010A1 No Response From Payer

Non-Par 42011 Commercial American Republic Insurance Company (ARIC) Professional 4010A1 Claim Level Acknowledgement

Non-Par 42011 Commercial American Republic Insurance Company (ARIC) Remittance 4010A1 Enrollment

A: 04/06/2010 Non-Par WB103 Commercial TX American Risk Services, Inc and all subsidiaries (Amerisafe Insureance Co) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP096 Commercial TX, MN American Rural Work Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP096 Commercial TX, MN American Rural Work Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP096 Commercial TX, MN American Rural Work Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK054 Commercial TX, MN American Specialty Companies Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK054 Commercial TX, MN American Specialty Companies Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK054 Commercial TX, MN American Specialty Companies Auto 4010A1 Claim Level Accept/Reject

Providers should contact Provider Services at 800-972-4226 prior to sending their

U: 08/24/2011 Non-Par ASH01 Commercial American Specialty Health, Inc. Professional 4010A1 Enrollment Claim Level Accept/Reject claims

A: 04/06/2010 Trans WK055 Commercial TX, MN American Specialty Ins. / MIB Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK055 Commercial TX, MN American Specialty Ins. / MIB Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK055 Commercial TX, MN American Specialty Ins. / MIB Auto 4010A1 Claim Level Accept/Reject

Trans 37322 Commercial American Worker Health Plan Professional 4010A1 No Response From Payer

Non-Par 37322 Commercial American Worker Health Plan Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WP103 Commercial American Zurich Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP103 Commercial American Zurich Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP103 Commercial American Zurich Auto 4010A1 Claim Level Accept/Reject

Non-Par 26078 Commercial MU Americas 1st Choice Health Professional 4010A1 No Response From Payer

Non-Par 20553 Commercial Americas 1st Choice Health Plans of South Carolina Inc. Professional 4010A1 File Level Acknowledgement Yes

Non-Par 20553 Commercial Americas 1st Choice Health Plans of South Carolina Inc. Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 20029 Commercial America's Choice Professional 4010A1 Claim Level Accept/Reject

Par 16120 Commercial AMERICAS PPO Institutional 4010A1 No Response From Payer

Par 16120 Commercial America's PPO Professional 4010A1 No Response From Payer

Non-Par 41178 Commercial America's PPO/America's TPA Institutional 4010A1 File Level Acknowledgement

Non-Par 41178 Commercial America's TPA Institutional 4010A1 File Level Acknowledgement

Trans 86047 Commercial NJ Americhoice NJ Medicaid & Family Care Professional 4010A1 Claim Level Acknowledgement

Trans 86047 Commercial NJ Americhoice NJ Medicaid & Family Care Institutional 4010A1 Claim Level Accept/Reject

Non-Par 86047 Commercial NJ Americhoice NJ Medicaid & Family Care Remittance 4010A1 Enrollment

Trans 86001 Commercial AmeriChoice of New Jersey (Medicare) Institutional 4010A1 No Response From Payer

Trans 86001 Commercial NJ AmeriChoice of New Jersey (Medicare) Remittance 4010A1 Enrollment

All claims require your AmeriChoice assigned provider id number. Please call

Trans 86001 Commercial NJ AmeriChoice of New Jersey Personal Care Plus (Medicare) Professional 4010A1 Claim Level Accept/Reject AmeriChoice @ 866-362-3368 for your provider id number

Trans 86048 Commercial NY AmeriChoice of New York (Medicaid) Institutional 4010A1 No Response From Payer

Non-Par 86048 Commercial NY AmeriChoice of New York (Medicaid) Remittance 4010A1 Enrollment

Trans 86002 Commercial NY AmeriChoice of New York (Medicare) Institutional 4010A1 No Response From Payer

Please be aware that Americhoice ERA processing for payer ID 86002 will return

9/14/11 Trans 86002 Commercial NY AmeriChoice of New York (Medicare) Remittance 4010A1 Enrollment ERAs to you under Payer ID 86048.

All claims require your AmeriChoice assigned provider id number. Please call

Trans 86002 Commercial NY AmeriChoice of New York Personal Care Plus (Medicare) Professional 4010A1 Claim Level Acknowledgement AmeriChoice @ 866-362-3368 for your provider id number

Trans 86048 Commercial NY AmeriChoice of New York, Inc. - Medicaid NY Professional 4010A1 Claim Level Acknowledgement

Payer 86049 no longer process claims/ERA for DOS 2011, however, claims can

10/20/11 Trans 86049 Commercial PA AmeriChoice of Pennsylvania (Medicaid) Institutional 4010A1 No Response From Payer still be sent for DOS 2010.

Payer 86049 no longer process claims/ERA for DOS 2011, however, claims can

still be sent for DOS 2010. ERAs will continue to be transmitted for service dates

10/20/11 Non-Par 86049 Commercial PA AmeriChoice of Pennsylvania (Medicaid) Remittance 4010A1 Enrollment prior to 2011 from payer ID 86049

Trans 86003 Commercial PA AmeriChoice of Pennsylvania (Medicare) Institutional 4010A1 No Response From Payer

Trans 86003 Commercial PA AmeriChoice of Pennsylvania (Medicare) Remittance 4010A1 Enrollment

All claims require your AmeriChoice assigned provider id number. Please call

Trans 86003 Commercial PA AmeriChoice of Pennsylvania Personal Care Plus (Medicare) Professional 4010A1 Claim Level Accept/Reject AmeriChoice @ 800-345-3627 for your provider id number

Payer 86049 no longer process claims/ERA for DOS 2011, however, claims can

still be sent for DOS 2010. Payer requires every claim contain the AmeriChoice

10/20/11 Trans 86049 Commercial PA AmeriChoice of Pennsylvania, Inc. - Medicaid PA Professional 4010A1 Claim Level Accept/Reject assigned provider id (including suffix)

Non-Par MSO11 Commercial AmeriChoice of San Diego County Medical Services (CMS) Professional 4010A1 File Level Acknowledgement

Non-Par MSO77 Commercial AmeriChoice of San Diego Coverage Initiative Professional 4010A1 File Level Acknowledgement

Non-Par MSO22 Commercial AmeriChoice of San Diego Physician Emergency Services (PES)/AB75 Professional 4010A1 File Level Acknowledgement

Non-Par WID01 Commercial WI Americhoice of Wisconsin Remittance 4010A1 Enrollment WID01 is for REMITTANCE ONLY

Trans 87726 Commercial WI Americhoice Wisconsin Professional 4010A1 Claim Level Accept/Reject Yes

Par 28809 Commercial FL AMERIGROUP Professional 4010A1 Claim Level Accept/Reject Formerly - AMERIGROUP - Florida

Par 27519 Commercial FL AMERIGROUP Professional 4010A1 Claim Level Accept/Reject Yes Formerly - Amerigroup - Florida

Non-Par 27519 Commercial FL AMERIGROUP Institutional 4010A1 No Response From Payer Yes Formerly - Amerigroup - Florida

Non-Par 27514 Commercial TX AMERIGROUP Institutional 4010A1 No Response From Payer Yes Formerly - AMERIGROUP - Ft Worth









11/10/2011 5 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Par 27514 Commercial TX AMERIGROUP Professional 4010A1 Claim Level Accept/Reject Yes Formerly - AMERIGROUP - Ft Worth

Par 28805 Commercial TX AMERIGROUP Professional 4010A1 Claim Level Accept/Reject Formerly - AMERIGROUP - Houston

Non-Par 27518 Commercial IL AMERIGROUP Institutional 4010A1 No Response From Payer Yes Formerly - Amerigroup - Illinois

Par 27518 Commercial IL AMERIGROUP Professional 4010A1 Claim Level Accept/Reject Yes Formerly - Amerigroup - Illinois

Par 28807 Commercial MD AMERIGROUP Professional 4010A1 Claim Level Accept/Reject Formerly - AMERIGROUP - Maryland/Virginia/District of Columbia

Par 28806 Commercial NJ AMERIGROUP Professional 4010A1 Claim Level Accept/Reject Formerly - AMERIGROUP - New Jersey

Non-Par 27515 Commercial AMERIGROUP Institutional 4010A1 No Response From Payer Yes Formerly - AMERIGROUP - Houston

Par 27515 Commercial MU AMERIGROUP Professional 4010A1 Claim Level Accept/Reject Yes Formerly - AMERIGROUP - Houston

Par 27517 Commercial MD AMERIGROUP Professional 4010A1 Claim Level Accept/Reject Yes Formerly - Americaid Community Care (Maryland)

Non-Par 27517 Commercial MD AMERIGROUP Institutional 4010A1 No Response From Payer Yes Formerly - Americaid Community Care (Maryland)

Par 27516 Commercial AMERIGROUP Professional 4010A1 Claim Level Accept/Reject Yes Formerly - Americaid Community Care (New Jersey)

Non-Par 27516 Commercial AMERIGROUP Institutional 4010A1 No Response From Payer Yes Formerly - Americaid Community Care (New Jersey)

Par 28804 Commercial TX AMERIGROUP Professional 4010A1 Claim Level Accept/Reject Formerly AMERIGROUP - Ft. Worth/Dallas/GA Medicaid

Par 28808 Commercial AMERIGROUP Professional 4010A1 Formerly - AMERIGROUP - IL & OH

Non-Par 93688 Commercial DE AmeriHealth - Delaware (Non HMO) Remittance 4010A1 Enrollment

Non-Par 95044 Commercial AmeriHealth - NaviMedix Remittance 4010A1 Enrollment

Non-Par 60061 Commercial NJ AmeriHealth - New Jersey (Non HMO) Remittance 4010A1 Enrollment

Non-Par 54763 Commercial AmeriHealth / Independence Administrators Remittance 4010A1 Enrollment

U: 12/30/2010 Non-Par 54763 Commercial AmeriHealth /Independence Administrators Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par 23252 Commercial Amerihealth Administrators Professional 4010A1 Claim Level Acknowledgement

U: 12/30/2010 Non-Par 93688 Commercial PA AmeriHealth Delaware (PPO) Professional 4010A1 Enrollment Claim Level Accept/Reject

U: 12/30/2010 Non-Par 95044 Commercial DE AmeriHealth Delaware HMO Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par 22248 Commercial Amerihealth Mercy Health Plan Institutional 4010A1 No Response From Payer Yes

Non-Par 22248 Commercial Amerihealth Mercy Health Plan Remittance 4010A1 Enrollment

Non-Par 22248 Commercial Amerihealth Mercy Health Plan (excluding Texas and North Carolina) Professional 4010A1 Claim Level Accept/Reject Yes

U: 01/05/2011 Non-Par 60061 Commercial PA AmeriHealth New Jersey (PPO) Professional 4010A1 Enrollment Claim Level Accept/Reject

U: 12/30/2010 Non-Par 95044 Commercial NJ AmeriHealth New Jersey HMO Professional 4010A1 Enrollment Claim Level Acknowledgement

A: 04/06/2010 Non-Par WA054 Commercial Ameriprise Auto & Home Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA054 Commercial Ameriprise Auto & Home Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA054 Commercial Ameriprise Auto & Home Insurance Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB226 Commercial AmerisourceBergen Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB226 Commercial AmerisourceBergen Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC422 Commercial TX, MN Amerisure Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC422 Commercial TX, MN Amerisure Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC111 Commercial TX, MN Amerisure Mutual Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC111 Commercial TX, MN Amerisure Mutual Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par PPM01 Commercial CA Ameri-West Health Associates - Claims Only Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA056 Commercial Amica Mutual Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA056 Commercial Amica Mutual Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA056 Commercial Amica Mutual Insurance Company Auto 4010A1 Claim Level Accept/Reject

Trans FAMR1 Commercial SD AMSI Institutional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP113 Commercial TX, MN Amtrust Insurance Co of Kansas Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP113 Commercial TX, MN Amtrust Insurance Co of Kansas Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP113 Commercial TX, MN Amtrust Insurance Co of Kansas Auto 4010A1 Claim Level Accept/Reject

Par IP080 Commercial CA AMVI Professional 4010A1 Claim Level Accept/Reject

Non-Par 53085 Commercial Anchor Benefit Consulting, Inc. Institutional 4010A1 No Response From Payer Yes

Non-Par 53085 Commercial Anchor Benefit Consulting, Inc. Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 86062 Commercial Ancillary Benefit Services (ABS) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 86062 Commercial Ancillary Benefit Systems Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 86062 Commercial Ancillary Benefit Systems/Arizona Foundation For Medical Care (AFMC) Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 03172 Commercial Ancillary Care Management/ACM Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WP119 Commercial MN Anoka Hennepin-Isd 11 Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP119 Commercial MN Anoka Hennepin-Isd 11 Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP119 Commercial MN Anoka Hennepin-Isd 11 Auto 4010A1 Claim Level Accept/Reject

Non-Par 34192 Commercial Antares Management Solutions Remittance 4010A1 Enrollment

Non-Par 34192 Commercial Antares Management Solutions Institutional 4010A1 Claim Level Rejects Only Yes

Non-Par 34192 Commercial OH Antares Management Solutions, OH Professional 4010A1 Claim Level Accept/Reject Yes

Please verify the payer ID appearing on the members ID card, Plans include but

may not be limited to: Right Choice Benefit Administrators and Self Insured Plans

Non-Par 37331 Commercial Anthem OMHS Professional 4010A1 Claim Level Accept/Reject Inc.

Non-Par 34196 Commercial Apex Benefit Services Institutional 4010A1 No Response From Payer Yes

Non-Par 34196 Commercial Apex Benefit Services (located in Akron, OH) Professional 4010A1 Claim Level Acknowledgement Yes Claims must contain the rendering provider id or the claim will reject.

Non-Par MPM11 Commercial Apollo HealthCare IPA Professional 4010A1 File Level Acknowledgement

Non-Par IP116 Commercial Applecare Medical Group (Applecare Medicare Management) Professional 4010A1 No Response From Payer

Non-Par IP116 Commercial Applecare Medical Management (Applecare/St. Francis/Downey) Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WB164 Commercial Prof. Work Indemnity Co.

Applied Risk Services, A subsidiary of Applied Underwriters, California Insurance Co., and Continental Comp 4010A1 Claim Level Accept/Reject

Non-Par 54160 Commercial APS Healthcare, Inc. Institutional 4010A1 No Response From Payer

Non-Par 54160 Commercial APS Healthcare, Inc. Professional 4010A1 Claim Level Acknowledgement

Non-Par 54100 Commercial APS Paper Claim Institutional 4010A1 No Response From Payer

Non-Par 54100 Commercial APS Paper Claim Professional 4010A1 Claim Level Accept/Reject

Par 44444 Commercial APWU/Affordable Network Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WB112 Commercial Aramark (Prof & Inst Only) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB112 Commercial Aramark (Prof & Inst Only) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Par 16120 Commercial ARAZ Group Institutional 4010A1 No Response From Payer

Par 16120 Commercial ARAZ Group Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WC130 Commercial TX, MN Arcadia Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC130 Commercial TX, MN Arcadia Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 77045 Commercial Arcadian Management Services, Inc. Institutional 4010A1 No Response From Payer

Par 77045 Commercial Arcadian Management Services, Inc. Professional 4010A1 Claim Level Acknowledgement

Par AMS11 Commercial Arcadian Management Services, Inc. Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WP125 Commercial MN Archdiocese Of St Paul & Mpls Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP125 Commercial MN Archdiocese Of St Paul & Mpls Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP125 Commercial MN Archdiocese Of St Paul & Mpls Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX852 Commercial TX, MN ARCMI Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX852 Commercial TX, MN ARCMI Inst. Work Comp 4010A1 Claim Level Accept/Reject

Par WK001 Commercial TX AR-CMI Wal-Mart TX Inst. Work Comp 4010A1 Claim Level Acknowledgement







11/10/2011 6 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Par WK001 Commercial TX AR-CMI Wal-Mart TX Prof. Work Comp 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WP126 Commercial MN Arctic Cat Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP126 Commercial MN Arctic Cat Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP126 Commercial MN Arctic Cat Inc Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP127 Commercial MN Arctic Cat Of South Dakota Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP127 Commercial MN Arctic Cat Of South Dakota Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP127 Commercial MN Arctic Cat Of South Dakota Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP129 Commercial MN Arden Foods, Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP129 Commercial MN Arden Foods, Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP129 Commercial MN Arden Foods, Inc Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ233 Commercial MN Argenbright Holdings Limited Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ233 Commercial MN Argenbright Holdings Limited Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 86062 Commercial Arizona Foundation For Medical Care (AFMC) Professional 4010A1 Claim Level Acknowledgement

Non-Par 86062 Commercial Arizona Foundation for Medical Care (AFMC) Institutional 4010A1 Claim Level Accept/Reject

Non-Par 03432 Commercial Arizona Physicians IPA Institutional 4010A1 Claim Level Acknowledgement

Non-Par 03432 Commercial AZ Arizona Physicians IPA / Americhoice Professional 4010A1 Claim Level Acknowledgement

Par WK100 Commercial Arkansas Best Inst. Work Comp 4010A1 Claim Level Acknowledgement

Par WK100 Commercial Arkansas Best Prof. Work Comp 4010A1 Claim Level Acknowledgement

Non-Par 75278 Commercial Arkansas Best Corporation - Choice Benefits Institutional 4010A1 No Response From Payer

Non-Par 75278 Commercial Arkansas Best Corporation - Choice Benefits Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB165 Commercial Arrow Point Capital (Formerly Royal&SunAlliance) Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 33026 Commercial Arrowhead Administrators Professional 4010A1 File Level Acknowledgement

Non-Par 33026 Commercial Arrowhead Administrators Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WC516 Commercial Artistree, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC516 Commercial Artistree, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC520 Commercial ASC Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 38265 Commercial ASR Institutional 4010A1 File Level Acknowledgement

Non-Par 38265 Commercial ASR Corporation Professional 4010A1 Claim Level Acknowledgement

Non-Par 38265 Commercial ASR Corporation Institutional 4010A1 File Level Acknowledgement

Non-Par 38265 Commercial ASR Health Benefits Institutional 4010A1 File Level Acknowledgement

Non-Par ASRM1 Commercial NJ ASRM, CORP. Professional 4010A1 Claim Level Accept/Reject

Non-Par FAABC Commercial Associated Benefits Corporation Institutional 4010A1 No Response From Payer

Non-Par FAABC Commercial Associated Benefits Corporation Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK435 Commercial TX, MN Associated Indemnity Corp Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 36326 Commercial Associates for Healthcare, Inc. (AHC) Institutional 4010A1 No Response From Payer

Non-Par 36326 Commercial Associates for Healthcare, Inc. (AHC) Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Trans WP987 Commercial Association Casualty Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP987 Commercial Association Casualty Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 39065 Commercial Assurant Health Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par 39065 Commercial Assurant Health Institutional 5010A2 No Response From Payer

Non-Par 39065 Commercial Assurant Health Professional 4010A1 Claim Level Accept/Reject

A: 01/07/2011 Par ASNTH Commercial Assurant Health (Repricing for HealthSpan Network Only) Institutional 4010A1 Claim Level Accept/Reject

A: 01/07/2011 Par ASNTH Commercial Assurant Health (Repricing for HealthSpan Network Only) Professional 4010A1 Claim Level Accept/Reject

Non-Par 37313 Commercial Assurant Health Self-Funded (Ft. Mill, SC) Institutional 4010A1 No Response From Payer

Non-Par 88035 Commercial AssureCare Inc. Professional 4010A1 File Level Acknowledgement

Non-Par 88035 Commercial AssureCare Inc. Institutional 4010A1 File Level Acknowledgement

Non-Par 74240 Commercial Assured Benefits Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 74240 Commercial Assured Benefits Administrators Institutional 4010A1 Claim Level Accept/Reject

Non-Par 93221 Commercial Asuris Northwest Health Professional 4010A1 Claim Level Acknowledgement

Please note that ERAs for payer ID 93221 will be returned to providers under

Non-Par 93221 Commercial Asuris Northwest Health Remittance 4010A1 Enrollment payer ID BS021.

A: 12/06/2010 Non-Par 65064 Commercial ATA - FL Professional 4010A1 File Level Acknowledgement

A: 12/21/2010 Non-Par 65064 Commercial ATA-FL Institutional 4010A1 No Response From Payer

Non-Par 95691 Commercial Athens Area Health Plan Select Institutional 4010A1 No Response From Payer

Non-Par 95691 Commercial Athens Area Health Plan Select Professional 4010A1 Claim Level Accept/Reject

Non-Par 22285 Commercial Atlantic Medical Insurance Professional 4010A1 File Level Acknowledgement

Non-Par 22285 Commercial Atlantic Medical Insurance Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WC550 Commercial TX, MN Atlantic Mutual Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC550 Commercial TX, MN Atlantic Mutual Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK157 Commercial Atlantic Mutual Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK157 Commercial Atlantic Mutual Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 22304 Commercial Atlanticare Administrators Institutional 4010A1 No Response From Payer

Non-Par 22304 Commercial AtlantiCare Administrators Professional 4010A1 Claim Level Acknowledgement

Non-Par 13853 Commercial NY Atlantis Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 13853 Commercial MU Atlantis Health Plan Institutional 4010A1 No Response From Payer

Non-Par ATLAD Commercial Atlas Administrators (USA MCO Provider Network) Professional 4010A1 Claim Level Accept/Reject

Payer ID valid only for claims with a

billing submission address of P.O. Box

U: 01/05/2011 Non-Par 37242 Commercial Aultra Administrative Group Institutional 4010A1 No Response From Payer 35276 Canton, OH 44735-5276

Payer ID valid only for claims with a

billing submission address of P.O. Box

U: 01/05/2011 Non-Par 37242 Commercial Aultra Administrative Group Professional 4010A1 No Response From Payer 35276 Canton, OH 44735-5276

A: 04/06/2010 Non-Par WA053 Commercial MN Auto Club Insurance Association Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA053 Commercial MN Auto Club Insurance Association Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA053 Commercial MN Auto Club Insurance Association Auto 4010A1 Claim Level Accept/Reject

Non-Par 38259 Commercial Automated Benefit Services Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 38259 Commercial MI Automated Benefit Services (ABS) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 37280 Commercial Automated Group Administration, Inc. Institutional 4010A1 No Response From Payer



Please send these EDI claims to the Payer ID of the PPO shown on the Members

Non-Par 37280 Commercial IN Automated Group Administration, Inc. Professional 4010A1 No Response From Payer ID Card. If you have any questions, please call 260-489-6447 x703

Non-Par 91136 Commercial Automotive Machinists Local 289 Health & Welfare Trust Grp # F32 Professional 4010A1 Claim Level Accept/Reject

Non-Par 31147 Commercial OH AvatarComp (Ohio BWC) Professional 4010A1 Claim Level Accept/Reject

Non-Par 46045 Commercial Avera Health Plans Institutional 4010A1 No Response From Payer

Non-Par 46045 Commercial Avera Health Plans Professional 4010A1 Claim Level Accept/Reject

Non-Par 87098 Commercial Avesis Third Party Administrators (Vision Claims Only) Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WP930 Commercial Aviation Safeguard Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX601 Commercial TX, MN Avizent Prof. Work Comp 4010A1 Claim Level Accept/Reject





11/10/2011 7 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Trans WX601 Commercial TX, MN Avizent Inst. Work Comp 4010A1 Claim Level Accept/Reject

Par 59275 Commercial FL AvMed Encounters Professional 4010A1 Claim Level Accept/Reject

10/17/11 Par 59274 Commercial FL AvMed Health Plan Professional 4010A1 and 5010A1 Claim Level Accept/Reject Yes

Non-Par 59274 Commercial AvMed Inc. Institutional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Trans WK158 Commercial TX, MN Ayers Trucking Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK158 Commercial TX, MN Ayers Trucking Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK158 Commercial TX, MN Ayers Trucking Auto 4010A1 Claim Level Accept/Reject

Trans FAMR1 Commercial BAAI Institutional 4010A1 Claim Level Accept/Reject

Non-Par BKRFM Commercial Bakersfield Family Medical Center Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB120 Commercial Banana Republic (GAP) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB120 Commercial Banana Republic (GAP) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP132 Commercial Bancinsure, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP132 Commercial Bancinsure, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP132 Commercial Bancinsure, Inc. Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP135 Commercial Bankers Standard Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP135 Commercial Bankers Standard Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP135 Commercial Bankers Standard Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par 12X42 Commercial AZ Banner Health - Arizona Institutional 4010A1 Claim Level Accept/Reject

Non-Par SX145 Commercial AZ Banner Health AZ Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par SX145 Commercial Banner Health Co. Professional 4010A1 Enrollment Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB113 Commercial Barnes Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB113 Commercial Barnes Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 37248 Commercial Bass Administrators, Inc. Institutional 4010A1 No Response From Payer

Non-Par 37248 Commercial Bass Administrators, Inc. Professional 4010A1 No Response From Payer

Non-Par 31478 Commercial BCBS Kansas Freedom Networks Professional 4010A1 Claim Level Accept/Reject

Non-Par 49153 Commercial BCI Administrators, Inc. Institutional 4010A1 No Response From Payer

Non-Par 49153 Commercial BCI Administrators, Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par 43324 Commercial BEACON HEALTH STRATEGIES Professional 4010A1 File Level Acknowledgement

Non-Par 43324 Commercial BEACON HEALTH STRATEGIES Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WC648 Commercial TX, MN Beall's Inc / Midwest Employers Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC648 Commercial TX, MN Beall's Inc / Midwest Employers Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC648 Commercial TX, MN Beall's Inc / Midwest Employers Auto 4010A1 Claim Level Accept/Reject

Non-Par WK056 Commercial Beall's Inc/Midwest Employers Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK056 Commercial Beall's Inc/Midwest Employers Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB114 Commercial Bed Bath and Beyond (WC Only) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB114 Commercial Bed Bath and Beyond (WC Only) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 95377 Commercial Beech Street Corporation Institutional 4010A1 No Response From Payer

Non-Par 95377 Commercial Beech Street Corporation Professional 4010A1 Claim Level Acknowledgement

Non-Par 63100 Commercial Behavioral Health Systems Institutional 4010A1 Claim Level Accept/Reject

Non-Par 63100 Commercial Behavioral Health Systems Professional 4010A1 Claim Level Accept/Reject

Non-Par MPM10 Commercial Bella Vista Medical Group IPA Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WP049 Commercial Benchmark Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP049 Commercial Benchmark Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP049 Commercial Benchmark Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par 33192 Commercial Bencomp National Corporation Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WP139 Commercial MN Benedictine Group Self-Insurance Assoc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP139 Commercial MN Benedictine Group Self-Insurance Assoc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP139 Commercial MN Benedictine Group Self-Insurance Assoc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 36149 Commercial Benefit Administration Professional 4010A1 Claim Level Accept/Reject

Non-Par 36149 Commercial Benefit Administration Institutional 4010A1 File Level Acknowledgement

Non-Par 36149 Commercial Benefit Administration Remittance 4010A1 Enrollment

Non-Par 25145 Commercial Benefit Coordinators Corp (Pittsburgh, PA) Institutional 4010A1 No Response From Payer

Only claims with a mailing address of: 111 Ryan Ct./Suite 300/Pittsburgh, PA

Non-Par 25145 Commercial PA Benefit Coordinators Corp. Professional 4010A1 Claim Level Acknowledgement 15205 should be sent to this payer id

Non-Par 48611 Commercial Benefit Management Inc. of KS Professional 4010A1 File Level Acknowledgement

Non-Par 48611 Commercial Benefit Management Inc. of KS Institutional 4010A1 File Level Acknowledgement

Non-Par 00999 Commercial LA Benefit Management Services Professional 4010A1 Claim Level Rejects Only

Non-Par 37212 Commercial Benefit Management Systems, Inc. Institutional 4010A1 No Response From Payer

Non-Par 37212 Commercial Benefit Management Systems, Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par 43178 Commercial MO Benefit Management, Inc. (Joplin, MO) Professional 4010A1 Claim Level Acknowledgement

Payer ID valid for only claims with a billing submission address of P.O. Box 1128,

Non-Par 39081 Commercial WI Benefit Plan Administrators Co. - Eau Claire, WI Professional 4010A1 Claim Level Accept/Reject Eau Claire, WI 54702-1128.

Non-Par 39081 Commercial Benefit Plan Administrators Co. (Eau Claire, WI) Institutional 4010A1 No Response From Payer

Please call Mary Bender @940-345-2721 to verify if you should be sending

Non-Par 37118 Commercial VA Benefit Plan Administrators Inc. Professional 4010A1 No Response From Payer claims to BPA Roanoake, VA

Non-Par 88027 Commercial NV Benefit Plan Administrators Inc. (BPA) Professional 4010A1 Claim Level Acknowledgement Only providers in the state of Nevada can send claims to 88027

Non-Par 37118 Commercial VA Benefit Plan Administrators Inc. (Roanoke, VA) Institutional 4010A1 No Response From Payer

Non-Par 37286 Commercial Benefit Plan Administrators, Inc - FARGO, NORTH DAKOTA Professional 4010A1 No Response From Payer

Non-Par 34178 Commercial OH Benefit Services, Inc. (Akron, OH) Professional 4010A1 Claim Level Acknowledgement

Non-Par 42148 Commercial Benefit Solutions Professional 4010A1 Claim Level Accept/Reject

Non-Par 36342 Commercial Benefit Systems & Services, Inc. (BSSI) Institutional 4010A1 No Response From Payer

Non-Par 36342 Commercial Benefit Systems & Services, Inc. (BSSI) Professional 4010A1 Claim Level Accept/Reject

Non-Par 42148 Commercial Benefits, Inc DBA Care Provider Network Professional 4010A1 Claim Level Accept/Reject

Non-Par 87265 Commercial Benesight (formerly The TPA) Professional 4010A1 No Response From Payer Yes

Non-Par 87265 Commercial Benesight, Inc. Institutional 4010A1 No Response From Payer Yes

Non-Par 37248 Commercial Benesys - LHP Claims Unit Professional 4010A1 No Response From Payer

Non-Par 37248 Commercial Benesys, Inc. Institutional 4010A1 No Response From Payer

Non-Par 37248 Commercial Benesys, Inc. Professional 4010A1 No Response From Payer

Non-Par 69752 Commercial Benicorp Professional 4010A1 Claim Level Accept/Reject

Non-Par BNMK1 Commercial MS Benmark Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK159 Commercial TX, MN Berkley Specialty Underwriters Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK159 Commercial TX, MN Berkley Specialty Underwriters Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK159 Commercial TX, MN Berkley Specialty Underwriters Auto 4010A1 Claim Level Accept/Reject

Non-Par call Commercial MU Berkshire Health Partners Professional 4010A1 File Level Acknowledgement Before submitting please contact Lori Calpino at (610) 372-8044 ext. 3019.

A: 04/06/2010 Non-Par WP140 Commercial MN Bermo, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP140 Commercial MN Bermo, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP140 Commercial MN Bermo, Inc. Auto 4010A1 Claim Level Accept/Reject







11/10/2011 8 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Trans WK057 Commercial TX, MN Berwind Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK057 Commercial TX, MN Berwind Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK057 Commercial TX, MN Berwind Corporation Auto 4010A1 Claim Level Accept/Reject

Non-Par 95604 Commercial Best Life & Health Insurance Co. Institutional 4010A1 No Response From Payer

Non-Par 95604 Commercial Best Life & Health Insurance Co. Professional 4010A1 Claim Level Accept/Reject

For claim rejections, please contact Better Health of Florida at (800)514-4561 and

U: 12/02/2010 Non-Par 20488 Commercial Better Health Professional 4010A1 File Level Acknowledgement select the provider services option.

Non-Par 32006 Commercial Better Health Plan of South Carolina Institutional 4010A1 No Response From Payer

Non-Par 62183 Commercial Better Health Plans Inc. Remittance 4010A1 Enrollment

Non-Par 62183 Commercial Better Health Plans, Inc. Institutional 4010A1 No Response From Payer

Non-Par 62183 Commercial Better Health Plans, Inc. Professional 4010A1 Claim Level Acknowledgement

Non-Par CX025 Commercial Big Lots Associates Benefit Plan Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP146 Commercial Birmingham Fire Insurance Co PA Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP146 Commercial Birmingham Fire Insurance Co PA Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP146 Commercial Birmingham Fire Insurance Co PA Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP147 Commercial TX, MN Blockbuster Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP147 Commercial TX, MN Blockbuster Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP147 Commercial TX, MN Blockbuster Inc Auto 4010A1 Claim Level Accept/Reject

Non-Par 03036 Commercial Blue Benefit Administrators of MA Professional 4010A1 Claim Level Acknowledgement

Non-Par 03036 Commercial Blue Benefit Administrators of MA Institutional 4010A1 Claim Level Acknowledgement

Non-Par 95610 Commercial MI Blue Care Network (through MI BCBS) Professional 4010A1 Enrollment Claim Level Rejects Only

Non-Par 95610 Government MI Blue Care Network of Michigan Remittance 4010A1 Enrollment

Non-Par BS062 Government MO Blue Choice - Missouri Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 00804 Commercial Blue Choice - NY Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par BS060 Commercial SC Blue Choice / Companion Healthcare Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par 47198 Government CA Blue Cross - California Institutional 4010A1 No Response From Payer

Non-Par BC001 Commercial CA Blue Cross - California Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par BC001 Commercial CA Blue Cross - California Remittance 4010A1 Enrollment

Trans HM006 Commercial CA Blue Cross - California Care - HMO (Encounters ONLY) Professional 4010A1 Claim Level Accept/Reject

Non-Par BC002 Government ID Blue Cross - Idaho Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS010 Government WA Blue Cross - Premera Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par 12B14 Commercial MA Blue Cross Blue Shield of MA Institutional 4010A1 Claim Level Accept/Reject

U: 01/11/2011 Non-Par BS066 Government Blue Cross Blue Shield Utica Watertown Remittance 4010A1 Enrollment

Please call the provider services department at (888) 296-9790; option 1 for

Non-Par CALL Government NC Blue Medicare HMO/PPO - Formerly - Partners National Health Plans of North Carolina Professional 4010A1 Claim Level Acknowledgement electronic claims submission set-up.

9/16/11 Non-Par BS054 Government AL Blue Shield - Alabama Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS054 Government AL Blue Shield - Alabama Remittance 4010A1 Enrollment

Non-Par BS011 Commercial AK Blue Shield - Alaska Remittance 4010A1 Enrollment

Non-Par BS011 Government AK Blue Shield - Alaska Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par 53589 Commercial AZ Blue Shield - Arizona Professional 4010A1 Claim Level Acknowledgement

Non-Par BS046 Commercial AZ Blue Shield - Arizona Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par BS046 Commercial AZ Blue Shield - Arizona Remittance 4010A1 Enrollment

Non-Par BS046 Commercial AZ Blue Shield - Arizona Institutional 4010A1 File Level Acknowledgement

Non-Par BS048 Commercial AR Blue Shield - Arkansas Remittance 4010A1 Enrollment

Non-Par BS048 Commercial AR Blue Shield - Arkansas Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par 94036 Commercial CA Blue Shield - California Institutional 4010A1 Claim Level Accept/Reject

Non-Par BS001 Commercial CA Blue Shield - California Remittance 4010A1 Enrollment

Non-Par BS001 Commercial CA Blue Shield - California / Blue Shield (FEP) Professional 4010A1 Claim Level Accept/Reject

Non-Par BS020 Government CO Blue Shield - Colorado Remittance 4010A1 Enrollment

Non-Par BS020 Government CO Blue Shield - Colorado --- Anthem Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par BS043 Government CT Blue Shield - Connecticut Remittance 4010A1 Enrollment

U: 12/26/2010 Non-Par BS043 Government CT Blue Shield - Connecticut --- Anthem Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Trans SB580 Commercial DC Blue Shield - DC (Carefirst) Institutional 4010A1 No Response From Payer

9/15/11 Trans SB580 Commercial DC Blue Shield - DC, National Capital Area (CareFirst) Professional 4010A1 Claim Level Accept/Reject

9/23/11 Par BS042 Commercial DE Blue Shield - Delaware Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS042 Government DE Blue Shield - Delaware Remittance 4010A1 Enrollment

Non-Par BS022 Government FL Blue Shield - Florida Remittance 4010A1 Enrollment

10/21/11 Non-Par BS022 Government FL Blue Shield - Florida Professional 4010A1 and 5010A1 Claim Level Rejects Only Yes

U: 12/30/2010 Non-Par BS022 Government FL Blue Shield - Florida Health Options Institutional 4010A1 No Response From Payer Yes

Non-Par BS039 Government GA Blue Shield - Georgia Remittance 4010A1 Enrollment

Non-Par BS039 Government GA Blue Shield - Georgia Professional 4010A1 Claim Level Accept/Reject Yes

U: 12/22/2010 Non-Par BS064 Commercial HI Blue Shield - Hawaii (HMSA) Remittance 4010A1 Enrollment

U: 12/22/2010 Non-Par BS064 Government HI Blue Shield - Hawaii (HMSA) Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par BS002 Commercial ID Blue Shield - Idaho Remittance 4010A1 Enrollment

Non-Par BS002 Commercial ID Blue Shield - Idaho Institutional 4010A1 No Response From Payer Yes

Non-Par BS002 Commercial ID Blue Shield - Idaho Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par BS018 Government IL Blue Shield - Illinios Remittance 4010A1 Enrollment

U: 12/30/2010 Non-Par BS018 Government IL Blue Shield - Illinois Institutional 4010A1 Claim Level Accept/Reject Yes

U: 12/30/2010 Non-Par BS018 Government IL Blue Shield - Illinois Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par BS049 Government IN Blue Shield - Indiana Remittance 4010A1 Enrollment To request ERA for BS049 you must enroll under Payer ID BS051.

Non-Par BS049 Government IN Blue Shield - Indiana Institutional 4010A1 Claim Level Accept/Reject

U: 12/30/2010 Non-Par BS049 Government IN Blue Shield - Indiana --- Anthem Professional 4010A1 Claim Level Accept/Reject Yes

U:10/27/2011 Non-Par BS030 Government IA Blue Shield - Iowa Institutional 4010A1 and 5010A2 Enrollment No Response From Payer Yes

U: 09/22/2011 Non-Par BS030 Government IA Blue Shield - Iowa Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS030 Government IA Blue Shield - Iowa Remittance 4010A1 Enrollment

Non-Par BS023 Government KS Blue Shield - Kansas Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par BS023 Government KS Blue Shield - Kansas Remittance 4010A1 Enrollment

Non-Par BS050 Government KY Blue Shield - Kentucky Remittance 4010A1 Enrollment To request ERAs for BS050 you must enroll under Payer ID BS051

U: 12/30/2010 Non-Par BS050 Government KY Blue Shield - Kentucky --- Anthem Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par BS038 Commercial LA Blue Shield - Louisiana Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par BS038 Government LA Blue Shield - Louisiana Remittance 4010A1 Enrollment

Non-Par BS034 Government ME Blue Shield - Maine Remittance 4010A1 Enrollment

U: 12/30/2010 Non-Par BS034 Government ME Blue Shield - Maine --- Anthem Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Trans SB690 Commercial MD Blue Shield - Maryland (Carefirst) Institutional 4010A1 No Response From Payer

9/15/11 Trans SB690 Commercial MD Blue Shield - Maryland (CareFirst) Professional 4010A1 Claim Level Accept/Reject

Non-Par BS059 Government MA Blue Shield - Massachusetts Remittance 4010A1 Enrollment

U: 12/01/2010 Non-Par BS059 Government MA Blue Shield - Massachusetts Professional 4010A1 Enrollment Claim Level Accept/Reject Yes





11/10/2011 9 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par BS017 Government MI Blue Shield - Michigan Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par BS017 Government MI Blue Shield - Michigan Remittance 4010A1 Enrollment

Non-Par BS085 Government MN Blue Shield - Minnesota Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par BS085 Government MN Blue Shield - Minnesota Remittance 4010A1 Enrollment

Non-Par BS085 Government MN Blue Shield - Minnesota Institutional 4010A1 Claim Level Acknowledgement Yes

Non-Par BS047 Government MS Blue Shield - Mississippi Remittance 4010A1 Enrollment

Non-Par BS047 Government MS Blue Shield - Mississippi Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS025 Commercial MO Blue Shield - Missouri Professional 4010A1 No Response From Payer Yes

Non-Par BS025 Government MO Blue Shield - Missouri Remittance 4010A1 Enrollment

Non-Par BS024 Government MO Blue Shield - Missouri --- Kansas City Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par BS024 Government MO Blue Shield - Missouri --- Kansas City Remittance 4010A1 Enrollment

Non-Par BS036 Government MT Blue Shield - Montana Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS036 Commercial MT Blue Shield - Montana Remittance 4010A1 Enrollment

Non-Par BS058 Government NE Blue Shield - Nebraska Remittance 4010A1 Enrollment

10/06/2011 Non-Par BS058 Government NE Blue Shield - Nebraska Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par BS019 Government NV Blue Shield - Nevada Remittance 4010A1 Enrollment

Non-Par BS019 Government NV Blue Shield - Nevada --- Anthem Professional 4010A1 Claim Level Accept/Reject Yes

U: 12/30/2010 Non-Par BS067 Government NH Blue Shield - New Hampshire --- Anthem Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par BS067 Commercial NH Blue Shield - New Hampshire --- Anthem Remittance 4010A1 Enrollment

Non-Par BS031 Government NJ Blue Shield - New Jersey Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS037 Government NM Blue Shield - New Mexico Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS063 Government NY Blue Shield - New York (Central) Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS033 Commercial NY Blue Shield - New York (Empire) Remittance 4010A1 Enrollment

Professional Claims are automatic approval; only Institutional and ERA require

U: 12/30/2010 Non-Par BS033 Commercial NY Blue Shield - New York (Empire) Professional 4010A1 Claim Level Rejects Only Yes enrollment.

Non-Par BS033 Commercial NY Blue Shield - New York (Empire) Institutional 4010A1 Enrollment Claim Level Rejects Only

Non-Par BS086 Government NY Blue Shield - New York (Northeastern) Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS086 Commercial NY Blue Shield - New York (Northeastern) Remittance 4010A1 Enrollment

U: 01/13/2011 Non-Par BS061 Commercial NY Blue Shield - New York (Rochester) Remittance 4010A1 Enrollment

U: 12/07/2010 Non-Par BS061 Commercial NY Blue Shield - New York (Rochester) Professional 4010A1 Enrollment Claim Level Acknowledgement Yes Yes

Non-Par BS066 Government NY Blue Shield - New York (Utica/Watertown) Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS087 Government NY Blue Shield - New York (Western) Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS003 Government NC Blue Shield - North Carolina Remittance 4010A1 Enrollment

Non-Par BS003 Commercial NC Blue Shield - North Carolina Institutional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS003 Commercial NC Blue Shield - North Carolina Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS057 Government ND Blue Shield - North Dakota Remittance 4010A1 Enrollment

Non-Par BS057 Government ND Blue Shield - North Dakota Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par BS057 Government ND Blue Shield - North Dakota Institutional 4010A1 Enrollment No Response From Payer Yes

Non-Par BS051 Government OH Blue Shield - Ohio Remittance 4010A1 Enrollment

U: 12/30/2010 Non-Par BS051 Government OH Blue Shield - Ohio --- Anthem Professional 4010A1 Claim Level Accept/Reject Yes

U: 12/30/2010 Non-Par BS041 Government OK Blue Shield - Oklahoma Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par BS041 Government OK Blue Shield - Oklahoma Remittance 4010A1 Enrollment

Non-Par BS026 Government OR Blue Shield - Oregon Remittance 4010A1 Enrollment

Non-Par BS026 Government OR Blue Shield - Oregon (Includes: OHP/FEP/HMO) Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

9/13/11 Non-Par BS027 Government PA Blue Shield - PA - Highmark Claims/ Encounters Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par 54704 Commercial PA Blue Shield - PA - Independence BC Personal Choice Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par BS027 Government PA Blue Shield - Pennsylvania (Highmark) Remittance 4010A1 Enrollment

Non-Par BS010 Government WA Blue Shield - Premera (formerly MSC) Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS075 Government RI Blue Shield - Rhode Island Remittance 4010A1 Enrollment

Non-Par BS075 Government RI Blue Shield - Rhode Island Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS028 Government SC Blue Shield - South Carolina Remittance 4010A1 Enrollment

Non-Par BS028 Government SC Blue Shield - South Carolina Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS056 Government SD Blue Shield - South Dakota Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par BS056 Government SD Blue Shield - South Dakota Institutional 4010A1 and 5010A2 Enrollment No Response From Payer Yes

9/22/11 Non-Par BS056 Government SD Blue Shield - South Dakota Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS032 Government TN Blue Shield - Tennessee Remittance 4010A1 Enrollment

Non-Par BS032 Government TN Blue Shield - Tennessee Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS021 Government TX Blue Shield - Texas Remittance 4010A1 Enrollment

Non-Par BS021 Government TX Blue Shield - Texas Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par BS088 Government UT Blue Shield - Utah Remittance 4010A1 Enrollment

Non-Par BS088 Government UT Blue Shield - Utah Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par BS188 Commercial UT Blue Shield - Utah Federal Claims Professional 4010A1 Claim Level Rejects Only Yes

Non-Par BS065 Government VT Blue Shield - Vermont Professional 4010A1 Enrollment Yes

Non-Par BS065 Commercial VT Blue Shield - Vermont Remittance 4010A1 Enrollment

Non-Par BS029 Government VA Blue Shield - Virginia Remittance 4010A1 Enrollment

Non-Par BS029 Government VA Blue Shield - Virginia Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par BS006 Government WA Blue Shield - Washington (Regence) Remittance 4010A1 Enrollment

Non-Par BS006 Government WA Blue Shield - Washington (Regence) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par BS055 Government WV Blue Shield - West Virginia Remittance 4010A1 Enrollment

Although there is no enrollment form for this payer; there is an internal enrollment

process that Capario must complete on your behalf. You will receive an approval

9/23/11 Non-Par BS055 Government WV Blue Shield - West Virginia Professional 4010A1 and 5010A1 Enrollment No Response From Payer Yes email once the process is complete.

Non-Par BS053 Government WI Blue Shield - Wisconsin Professional 4010A1 Enrollment Claim Level Accept/Reject Yes Contact (800) 792-5256

Non-Par BS053 Government WI Blue Shield - Wisconsin Remittance 4010A1 Enrollment Contact (800) 792-5256

Non-Par BS074 Government WY Blue Shield - Wyoming Remittance 4010A1 Enrollment

Non-Par BS074 Government WY Blue Shield - Wyoming Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par BS001 Commercial CA Blue Shield California Institutional 4010A1 Claim Level Accept/Reject

Non-Par HM007 Commercial CA Blue Shield California - HMO Professional 4010A1 Claim Level Accept/Reject

Non-Par BS002 Commercial ID Blue Shield Regence - Idaho Institutional 4010A1 Enrollment No Response From Payer Yes

Non-Par BS175 Government RI BlueChip - Rhode Island Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par 00403 Commercial SC BlueChoice Medicaid Professional 4010A1 File Level Acknowledgement

Non-Par 61124 Commercial Bluegrass Family Health Remittance 4010A1 Enrollment

Par 61124 Commercial Bluegrass Family Health Institutional 4010A1 Claim Level Accept/Reject

Par 61124 Commercial Bluegrass Family Health Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB232 Commercial BMW Manufacturing Corp. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB232 Commercial BMW Manufacturing Corp. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP988 Commercial BMW North America Prof. Work Comp 4010A1 Claim Level Accept/Reject





11/10/2011 10 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Trans WP988 Commercial BMW North America Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 36609 Commercial Boilermakers National Health & Welfare Fund Remittance 4010A1 Enrollment

Non-Par 36609 Commercial Boilermakers National Health & Welfare Fund Institutional 4010A1 No Response From Payer

Non-Par 36609 Commercial Boilermakers National Health & Welfare Fund Professional 4010A1 No Response From Payer Yes

A: 04/06/2010 Non-Par WP149 Commercial MN Bois Forte Reservation Tribal Council Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP149 Commercial MN Bois Forte Reservation Tribal Council Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP149 Commercial MN Bois Forte Reservation Tribal Council Auto 4010A1 Claim Level Accept/Reject

Non-Par 74238 Commercial Boon - Chapman Administrators, Inc. Institutional 4010A1 No Response From Payer

Non-Par 74238 Commercial Boon - Chapman Administrators, Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par 13337 Commercial Boston Medical Center Health Plan Institutional 4010A1 No Response From Payer

Par 13337 Commercial MA Boston Medical Center Healthnet Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK431 Commercial TX, MN Boston Old Colony Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 37286 Commercial BPA/Benefit Plan Administrators (North Dakota) Institutional 4010A1 No Response From Payer

Non-Par 52192 Commercial Bravo Health Remittance 4010A1 Enrollment

Non-Par 52192 Commercial MD Bravo Health Professional 4010A1 Claim Level Acknowledgement

Non-Par 52192 Commercial Bravo Health Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WP187 Commercial TX Brickman Group (Dallas) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP187 Commercial TX Brickman Group (Dallas) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP187 Commercial TX Brickman Group (Dallas) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP190 Commercial TX Brickman Group (Houston) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP190 Commercial TX Brickman Group (Houston) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP190 Commercial TX Brickman Group (Houston) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP194 Commercial TX Brickman Group (Plano) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP194 Commercial TX Brickman Group (Plano) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP194 Commercial TX Brickman Group (Plano) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP206 Commercial TX Brickman Group (Roanoke) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP206 Commercial TX Brickman Group (Roanoke) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP206 Commercial TX Brickman Group (Roanoke) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP179 Commercial TX Brickman Group (Woodlands) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP179 Commercial TX Brickman Group (Woodlands) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP179 Commercial TX Brickman Group (Woodlands) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP186 Commercial TX Brickman Groupp (Austin) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP186 Commercial TX Brickman Groupp (Austin) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP186 Commercial TX Brickman Groupp (Austin) Auto 4010A1 Claim Level Accept/Reject

Non-Par SX067 Commercial Brickstreet Mutual Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par 38365 Commercial OH Bridge Benefits Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB147 Commercial Bridgefield Casualty Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB147 Commercial Bridgefield Casualty Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

U: 12/29/2010 Non-Par 68054 Commercial AZ Bridgeway Arizona Remittance 4010A1 Enrollment

Non-Par 68054 Commercial AZ Bridgeway Arizona Institutional 4010A1 Claim Level Accept/Reject

U: 12/29/2010 Non-Par 68054 Commercial AZ Bridgeway Health Solutions - Centene Professional 4010A1 Claim Level Accept/Reject

Non-Par BHP01 Commercial Bright Health Physicians Professional 4010A1 Claim Level Accept/Reject

Non-Par 22286 Commercial BritCay Professional 4010A1 File Level Acknowledgement

Non-Par 22286 Commercial BritCay Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WP745 Commercial British American Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP745 Commercial British American Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP745 Commercial British American Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par WK025 Commercial Broadspire Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK025 Commercial Broadspire Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP222 Commercial TX Broadspire - Dallas Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP222 Commercial TX Broadspire - Dallas Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP222 Commercial TX Broadspire - Dallas Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP233 Commercial TX Broadspire - Lewisville Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP233 Commercial TX Broadspire - Lewisville Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP233 Commercial TX Broadspire - Lewisville Auto 4010A1 Claim Level Accept/Reject

Non-Par 51037 Commercial Brokerage Concepts Institutional 4010A1 No Response From Payer Yes

Non-Par 51037 Commercial Brokerage Concepts Professional 4010A1 No Response From Payer Yes

Non-Par 37314 Commercial Broward Health Institutional 4010A1 File Level Acknowledgement

Non-Par 94316 Commercial Brown & Toland Medical Group Institutional 4010A1 No Response From Payer

Par 94316 Commercial CA Brown & Toland Medical Group Professional 4010A1 Claim Level Accept/Reject Responses could take up to 10 business days

Par BTSS1 Commercial CA Brown & Toland Sutter Select Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK058 Commercial TX, MN Brownyard Group Inc. (Arch Insurance) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK058 Commercial TX, MN Brownyard Group Inc. (Arch Insurance) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK058 Commercial TX, MN Brownyard Group Inc. (Arch Insurance) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK059 Commercial TX, MN Brunswick Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK059 Commercial TX, MN Brunswick Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK059 Commercial TX, MN Brunswick Corporation Auto 4010A1 Claim Level Accept/Reject

Non-Par 32004 Commercial OH Buckeye Community Health Plan - Centene Remittance 4010A1 Enrollment

Non-Par 32004 Commercial OH Buckeye Community Health Plan - Centene Institutional 4010A1 No Response From Payer

(Prior to submitting claims, call Provider Relations Dept. at 866-475-3129 to verify

your provider info is on file in the Health Plans claim system to avoid any

U: 12/29/2010 Par 32004 Commercial OH Buckeye Community Health Plan - Centene Professional 4010A1 Claim Level Accept/Reject rejections)

Non-Par 50240 Commercial Buenaventura Medical Group Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WC812 Commercial Bunch & Assoc. Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC812 Commercial Bunch & Assoc. Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB166 Commercial Bunch & Associates - CostCo Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB166 Commercial Bunch & Associates - CostCo Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB167 Commercial Bunch & Associates - Food Lion Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB167 Commercial Bunch & Associates - Food Lion Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK060 Commercial TX, MN Burlington Coat Factory Wareho Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK060 Commercial TX, MN Burlington Coat Factory Wareho Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK060 Commercial TX, MN Burlington Coat Factory Wareho Auto 4010A1 Claim Level Accept/Reject

Non-Par 42150 Commercial Butler Benefit Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 42150 Commercial IA Butler Benefits Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 23708 Commercial C & O Employees' Hospital Association Professional 4010A1 Claim Level Accept/Reject

Non-Par 73071 Commercial C. L. Frates & Co - OSMA Health Institutional 4010A1 File Level Acknowledgement







11/10/2011 11 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 33192 Commercial Cadent Administrators Institutional 4010A1 Claim Level Accept/Reject

Non-Par 33192 Commercial Cadent Underwriters Institutional 4010A1 File Level Acknowledgement

Non-Par PPM01 Commercial CA Cal Care IPA - Claims Only Professional 4010A1 Claim Level Accept/Reject

Trans PPM02 Commercial CA Cal Care IPA Encounters - Encounters Only Professional 4010A1 Claim Level Accept/Reject

Trans HMBT6 Commercial CA California Care (BC) All_Use Only Professional 4010A1 Claim Level Accept/Reject

Non-Par MC051 Government CA California Children's Services (CCS) Professional 4010A1 Enrollment No Response From Payer

Non-Par CWS99 Commercial CA California Water Services Professional 4010A1 No Response From Payer

Non-Par IP055 Commercial CA Cal-Net Physicians IPA Professional 4010A1 File Level Acknowledgement

Non-Par CALOP Commercial CalOptima Direct Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC898 Commercial Cambridge (Carrolton, TX) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC898 Commercial Cambridge (Carrolton, TX) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR909 Commercial Cambridge (Concord, CA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR909 Commercial Cambridge (Concord, CA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP598 Commercial Cambridge (Glendale, CA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP598 Commercial Cambridge (Glendale, CA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC915 Commercial Cambridge (Los Angeles, CA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC915 Commercial Cambridge (Los Angeles, CA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP472 Commercial Cambridge (Pasedena, CA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP472 Commercial Cambridge (Pasedena, CA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR872 Commercial Cambridge (Portland, OR) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR872 Commercial Cambridge (Portland, OR) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC902 Commercial Cambridge (Rancho Cordova, CA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC902 Commercial Cambridge (Rancho Cordova, CA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC897 Commercial Cambridge (Sacramento, CA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC897 Commercial Cambridge (Sacramento, CA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC900 Commercial Cambridge (San Diego, CA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC900 Commercial Cambridge (San Diego, CA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX163 Commercial Cambridge Integrated Services Group Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX163 Commercial Cambridge Integrated Services Group Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR911 Commercial Cambridge Integrated Services Group (Glendale, CA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR911 Commercial Cambridge Integrated Services Group (Glendale, CA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP123 Commercial Cambridge Integrated Services Group (Modesto, CA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP123 Commercial Cambridge Integrated Services Group (Modesto, CA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR841 Commercial Cambridge Integrated Services Group (now Xchanging) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR841 Commercial Cambridge Integrated Services Group (now Xchanging) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC903 Commercial Cambridge Integrated Services Group (Pasedena, CA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC903 Commercial Cambridge Integrated Services Group (Pasedena, CA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC910 Commercial Cambridge Integrated Services Group (Rancho Cordova, CA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC910 Commercial Cambridge Integrated Services Group (Rancho Cordova, CA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC907 Commercial Cambridge Integrated Services Group (Sacramento, CA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC907 Commercial Cambridge Integrated Services Group (Sacramento, CA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC908 Commercial Cambridge Integrated Services Group (Salt Lake City, UT) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC908 Commercial Cambridge Integrated Services Group (Salt Lake City, UT) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP978 Commercial Cambridge Integrated Services Group, Inc. (Warren, MI) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP978 Commercial Cambridge Integrated Services Group, Inc. (Warren, MI) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 37105 Commercial Cannon Cochran Management Services Institutional 4010A1 No Response From Payer

Non-Par 71057 Commercial Cannon Cochran Management Services Inc. Metairie LA Institutional 4010A1 File Level Acknowledgement

Non-Par 71057 Commercial Cannon Cochran Management Services, Inc. Professional 4010A1 Claim Level Accept/Reject

** 10/27/2011 ** New ERA (835) enrollment will be pended by Capital Blue Cross

U:10/27/2011 Non-Par 54720 Commercial PA Capital Blue Cross Remittance 4010A1 Enrollment pending version 5010 deployment on or about 01/01/12.

U: 08/18/2011 Non-Par 54720 Government PA Capital Blue Cross Professional 4010A1 and 5010A1 Enrollment Claim Level Acknowledgement Yes Yes

A: 04/06/2010 Non-Par WK454 Commercial TX, MN Capital City Insurance Company, Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

Trans 87726 Commercial Capital Community Health Plan Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par SX065 Commercial Capital District Physician's Health Plan Remittance 4010A1 Enrollment

U: 12/02/2010 Non-Par SX065 Commercial Capital District Physician's Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 95112 Commercial Capital Health Plan Professional 4010A1 No Response From Payer

Non-Par 95112 Commercial Capital Health Plan Institutional 4010A1 File Level Acknowledgement

Non-Par 65067 Commercial Capital International Mgmt Professional 4010A1 Claim Level Accept/Reject

Non-Par 68011 Commercial Capitol Administrators Institutional 4010A1 No Response From Payer

Non-Par 68011 Commercial Capitol Administrators Professional 4010A1 Claim Level Acknowledgement

Non-Par 57116 Commercial AZ Care 1st Health Plan of Arizona Professional 4010A1 Claim Level Accept/Reject

Non-Par 57116 Commercial Care 1st Health Plan of Arizona Institutional 4010A1 Claim Level Rejects Only

Non-Par 57115 Commercial CA Care 1st Health Plan of CA Professional 4010A1 File Level Acknowledgement

Non-Par 77082 Commercial Care Improvement Plus Professional 4010A1 No Response From Payer

Non-Par 77082 Commercial Care Improvement Plus Institutional 4010A1 File Level Acknowledgement

Non-Par 00344 Commercial Care Management Resources Professional 4010A1 No Response From Payer

Non-Par 41222 Commercial Care To Care Professional 4010A1 File Level Acknowledgement

Non-Par 41222 Commercial Care To Care Institutional 4010A1 File Level Acknowledgement

U: 12/30/2010 Non-Par 11345 Commercial CareCentrix Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par 14185 Commercial CareCore Professional 4010A1 No Response From Payer

Non-Par 14182 Commercial CareCore National Professional 4010A1 No Response From Payer

Non-Par 14184 Commercial CareCore National - HealthNet Professional 4010A1 Claim Level Acknowledgement

Non-Par 14185 Commercial CareCore National LLC - Health Net New Jersey Institutional 4010A1 File Level Acknowledgement

Non-Par 14179 Commercial CareCore National, LLC (Aetna Radiology Claims) Professional 4010A1 Claim Level Acknowledgement

WellCare New York, POS 11 Radiology Claims Only. Claims for members in the

following counties should be submitted to WellCare: Monroe, Erie, Wayne, and

Non-Par 14188 Commercial MU CareCore/WCNY RAD Professional 4010A1 No Response From Payer Onondaga.

Non-Par 75190 Commercial VA CareFirst Administrators (Now known as NCAS - Fairfax, VA) Professional 4010A1 Claim Level Acknowledgement

9/15/11 Trans SB580 Commercial DC CareFirst BCBS - DC, National Capital Area Professional 4010A1 Claim Level Accept/Reject

9/15/11 Trans SB690 Commercial MD CareFirst BCBS - Maryland Professional 4010A1 Claim Level Accept/Reject

U: 09/13/2011 Non-Par SB580 Commercial DC CareFirst BCBS DC Remittance 4010A1 Enrollment

U: 09/13/2011 Non-Par SB690 Commercial MD CareFirst BCBS Maryland Remittance 4010A1 Enrollment

9/15/11 Trans SB691 Commercial MD CareFirst Delmarva Health Plan Professional 4010A1 Claim Level Acknowledgement

Non-Par 16147 Commercial CareGuide Professional 4010A1 File Level Acknowledgement

Non-Par 91136 Commercial Caremark WPAS, Inc., Grp# P62 Professional 4010A1 Claim Level Accept/Reject

Non-Par IP128 Commercial CA CareMore Professional 4010A1 No Response From Payer

Non-Par 93975 Commercial CareOregon Professional 4010A1 No Response From Payer





11/10/2011 12 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 93975 Commercial CareOregon Inc. Institutional 4010A1 Claim Level Acknowledgement

Non-Par 22248 Commercial MO CarePartners Professional 4010A1 No Response From Payer

Non-Par 95092 Commercial CarePlus Health Plans, Inc. Professional 4010A1 Claim Level Rejects Only

Non-Par 31114 Commercial OH CareSource OH Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 31114 Commercial CareSource OH Institutional 4010A1 Claim Level Rejects Only Yes

Non-Par 35167 Commercial Carewise Professional 4010A1 Claim Level Accept/Reject

Non-Par 10010 Commercial Careworks Professional 4010A1 Claim Level Accept/Reject

Non-Par 10010 Commercial Careworks Institutional 4010A1 Claim Level Accept/Reject

Non-Par 31147 Commercial OH CareWorks (Ohio BWC) Professional 4010A1 Claim Level Accept/Reject

Non-Par 77015 Commercial Carilion Clinic Medicare Health Plan Professional 4010A1 File Level Acknowledgement

Non-Par 77015 Commercial Carilion Clinic Medicare Health Plan Institutional 4010A1 Claim Level Accept/Reject

Trans FAMR1 Commercial Caring Program Institutional 4010A1 Claim Level Accept/Reject

Trans 56215 Commercial Carolina Behavioral Health Alliance CBHA Professional 4010A1 Claim Level Accept/Reject

Non-Par 57105 Commercial Carolina Care Plan, Inc. Institutional 4010A1 No Response From Payer

Non-Par 57105 Commercial Carolina Care Plan, Inc. Professional 4010A1 Claim Level Acknowledgement

This Id is for Dates of Service prior to June 1, 2010. For dates of service after

Non-Par SX191 Commercial Carolina Crescent Health Plan Inc. Professional 4010A1 Enrollment Claim Level Accept/Reject June 1, 2010 please use ID 68055.

Non-Par 56195 Commercial Carolina Summit Healthcare, Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par 56195 Commercial Carolina Summit Healthcare, Inc. Institutional 4010A1 No Response From Payer

Non-Par 25125 Commercial Carpenters Health And Welfare Trust Institutional 4010A1 No Response From Payer

Non-Par 25125 Commercial Carpenters Health and Welfare Trust Fund of St. Louis Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP312 Commercial MN Casella Ins. Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP312 Commercial MN Casella Ins. Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP312 Commercial MN Casella Ins. Co Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ279 Commercial TX, MN Caseys General Stores Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ279 Commercial TX, MN Caseys General Stores Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ279 Commercial TX, MN Caseys General Stores Auto 4010A1 Claim Level Accept/Reject

Non-Par 12X45 Commercial Catholic Healthcare West Institutional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP870 Commercial TX, MN Catholic Mutual Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP870 Commercial TX, MN Catholic Mutual Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 03036 Commercial CBA Blue Institutional 4010A1 Claim Level Acknowledgement

Non-Par 03036 Commercial CBA Blue Professional 4010A1 Claim Level Acknowledgement

Non-Par 55438 Commercial CBCA Administrators Institutional 4010A1 No Response From Payer

Non-Par 55438 Commercial CBCA Administrators Professional 4010A1 Claim Level Acknowledgement

Non-Par 41170 Commercial CBCA Administrators (HRM) Institutional 4010A1 No Response From Payer

Non-Par 41124 Commercial CBSA Professional 4010A1 Claim Level Accept/Reject

Non-Par 41124 Commercial CBSA Institutional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WP290 Commercial MN CCMLBOI Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP290 Commercial MN CCMLBOI Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP290 Commercial MN CCMLBOI Auto 4010A1 Claim Level Accept/Reject

Par WK010 Commercial CCMSI Inst. Work Comp 4010A1 Claim Level Acknowledgement

Par WK010 Commercial CCMSI Prof. Work Comp 4010A1 Claim Level Acknowledgement

Non-Par 83028 Commercial MU CDO Technologies Institutional 4010A1 Claim Level Accept/Reject No

Non-Par 83028 Commercial MU CDO Technologies Professional 4010A1 Claim Level Accept/Reject No

Non-Par 88022 Commercial CDS Group Health Professional 4010A1 File Level Acknowledgement

Non-Par 88022 Commercial CDS Group Health Institutional 4010A1 File Level Acknowledgement

Par 95167 Commercial CA Cedars-Sinai Medical Network (ENCOUNTERS) Professional 4010A1 Claim Level Accept/Reject

Non-Par 95166 Commercial Cedars-Sinai Medical Network Services Institutional 4010A1 Claim Level Acknowledgement

Par 95166 Commercial CA Cedars-Sinai Medical Network Services (CLAIMS) Professional 4010A1 Claim Level Accept/Reject

Non-Par 68060 Commercial CeltiCare Professional 4010A1 Claim Level Accept/Reject

Non-Par 91136 Commercial Cement Masons & Plasterers Health & Welfare Trust Institutional 4010A1 No Response From Payer

Non-Par 91136 Commercial Cement Masons & Plasterers Hlth & Welfare Trust Grp# F16 Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK061 Commercial TX, MN Cendant Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK061 Commercial TX, MN Cendant Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK061 Commercial TX, MN Cendant Corporation Auto 4010A1 Claim Level Accept/Reject

Non-Par 68048 Commercial Cenpatico - Arizona Institutional 4010A1 Claim Level Accept/Reject

Prior to submitting claims, please call Provider Relations Dept at 1-877-647-4848

to verify your provider info is on file in the claim system. This will prevent rejections

A: 09/12/2011 Non-Par 68052 Commercial IN Cenpatico - Indiana Institutional 4010A1 Claim Level Accept/Reject and allow payments to be made in a timely manner

Prior to submitting claims, please call Provider Relations Dept at 1-866-896-7293

to verify your provider info is on file in the claim system. This will prevent rejections

A: 09/12/2011 Non-Par 68047 Commercial KS Cenpatico - Kansas Institutional 4010A1 Claim Level Accept/Reject and allow payments to be made in a timely manner

Non-Par 68048 Commercial AZ Cenpatico Behavioral Health AZ Professional 4010A1 Claim Level Accept/Reject

Prior to submitting claims, please call Provider Relations Dept at 1-877-647-4848

to verify your provider information is on file in the claim system. This will prevent

Non-Par 68052 Commercial Cenpatico Indiana Professional 4010A1 Claim Level Accept/Reject rejections and allow payments to be made in a timely manner.

Non-Par 68047 Commercial KS Cenpatico Kansas Professional 4010A1 No Response From Payer

A: 09/30/2011 Non-Par 68061 Commercial MA Cenpatico Massachusetts Professional 4010A1 File Level Acknowledgement

Non-Par 68051 Commercial Cenpatico Ohio Professional 4010A1 Claim Level Accept/Reject

U: 12/29/2010 Non-Par 68050 Commercial Cenpatico Peach State Health Plan-Centene Remittance 4010A1 Enrollment

(Prior to submitting claims,call Provider Relations Dept at 866-296-8731 to verify

your provider info is on file in the claim system. This will prevent rejections and

U: 12/29/2010 Par 68050 Commercial GA Cenpatico Peach State Health Plan-Centene Professional 4010A1 Claim Level Accept/Reject allow payments to be made in a timely manner)

Non-Par WK160 Commercial Centennial Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK160 Commercial Centennial Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 13357 Commercial CenterCare Professional 4010A1 Claim Level Acknowledgement

Non-Par 13357 Commercial CenterCare Institutional 4010A1 Claim Level Accept/Reject

Par IP080 Commercial CA Centinela Professional 4010A1 Claim Level Accept/Reject

Non-Par MPM03 Commercial Centinella Valley IPA Professional 4010A1 File Level Acknowledgement

Non-Par 31118 Commercial Central Benefits Institutional 4010A1 No Response From Payer Yes

Non-Par 31118 Commercial Central Benefits Remittance 4010A1 Enrollment

Non-Par 31118 Commercial Central Benefits Life Professional 4010A1 No Response From Payer Yes

Non-Par 31118 Commercial Central Benefits Mutual Professional 4010A1 No Response From Payer Yes

Non-Par 31118 Commercial Central Benefits National Professional 4010A1 No Response From Payer Yes

Please call Alliance EDI Support Unit -

831-430-5510 - before submitting claims. When directed to the payers online

U: 01/14/2011 Non-Par SX169 Commercial CA Central California Alliance for Health (formerly Central Coast Alliance for Health) Professional 4010A1 form, select 'Emdeon' as clearinghouse.

A: 04/06/2010 Trans WK062 Commercial TX, MN Central Hockey League Prof. Work Comp 4010A1 Claim Level Accept/Reject







11/10/2011 13 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Trans WK062 Commercial TX, MN Central Hockey League Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK062 Commercial TX, MN Central Hockey League Auto 4010A1 Claim Level Accept/Reject

Non-Par 02041 Commercial Central Mass. Health Care (CMHC) Professional 4010A1 No Response From Payer Yes

Non-Par 34097 Commercial Central Reserve Life Institutional 4010A1 No Response From Payer

Non-Par 34097 Commercial Central Reserve Life Professional 4010A1 Claim Level Acknowledgement

Non-Par 34097 Commercial Central Reserve Life Remittance 4010A1 Enrollment

Non-Par 62218 Commercial Central SeniorCare Professional 4010A1 File Level Acknowledgement

Non-Par 62218 Commercial Central SeniorCare Institutional 4010A1 File Level Acknowledgement

Non-Par 36215 Commercial Central States Health & Welfare Funds Professional 4010A1 Claim Level Accept/Reject

Non-Par 36215 Commercial Central States Health Welfare Fund Institutional 4010A1 No Response From Payer

U: 12/30/2010 Par HM066 Commercial CA Central Valley Medical Group - Encounters Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par 48120 Commercial Century Health Solutions Institutional 4010A1 No Response From Payer Yes

Non-Par 48120 Commercial Century Health Solutions Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WP336 Commercial MN Cerenity Senior Care Large Deductible Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP336 Commercial MN Cerenity Senior Care Large Deductible Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP336 Commercial MN Cerenity Senior Care Large Deductible Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP370 Commercial MN Certified Power Train Specialists, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP370 Commercial MN Certified Power Train Specialists, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP370 Commercial MN Certified Power Train Specialists, Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 23171 Commercial CHA - Commonwealth Health Alliance Institutional 4010A1 No Response From Payer

Non-Par 23171 Commercial CHA - Commonwealth Health Alliance Professional 4010A1 Claim Level Acknowledgement

Non-Par 23171 Commercial CHA - Commonwealth Health Alliance Remittance 4010A1 Enrollment

U: 12/30/2010 Non-Par 84146 Commercial CHAMP VA - HAC Remittance 4010A1 Enrollment

Non-Par 84146 Commercial CHAMPVA - HAC Institutional 4010A1 No Response From Payer Yes

Non-Par 84146 Commercial CHAMPVA - HAC Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Trans WK063 Commercial TX, MN Charming Shoppes, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK063 Commercial TX, MN Charming Shoppes, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK063 Commercial TX, MN Charming Shoppes, Inc. Auto 4010A1 Claim Level Accept/Reject

Trans 95748 Commercial Chartered Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par CHAT1 Commercial Chatwins Healthcare Administrators Professional 4010A1 Claim Level Accept/Reject

Non-Par 16600 Commercial Chautauqua County Healthcare Plan Institutional 4010A1 No Response From Payer

Non-Par 16600 Commercial Chautauqua County Healthcare Plan Professional 4010A1 Claim Level Acknowledgement

Non-Par 16600 Commercial Chautauqua County Healthcare Plan (Mayville, NY) Professional 4010A1 Claim Level Accept/Reject

10/17/11 Non-Par 75261 Commercial CHEC - A subsidiary of Sprint Professional 5010A1 File Level Acknowledgement Yes

Non-Par 59223 Commercial Chesapeake Life Insurance Company Institutional 4010A1 No Response From Payer

Non-Par 59223 Commercial Chesapeake Life Insurance Company Professional 4010A1 Claim Level Accept/Reject

Non-Par 59223 Commercial Chesapeake Life Insurance Company Remittance 4010A1 Enrollment

Non-Par 34154 Commercial Chesterfield Professional 4010A1 Claim Level Accept/Reject

Non-Par 34154 Commercial Chesterfield Resources Inc. Institutional 4010A1 File Level Acknowledgement Yes

A: 04/06/2010 Non-Par WP371 Commercial TX, MN Chesterfield Serv-Uniontown Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP371 Commercial TX, MN Chesterfield Serv-Uniontown Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP371 Commercial TX, MN Chesterfield Serv-Uniontown Auto 4010A1 Claim Level Accept/Reject

Non-Par CLW99 Commercial IL Chicago Laborers Health & Welfare Fund Professional 4010A1 No Response From Payer

9/16/11 Non-Par 60054 Commercial Chickering Benefit Planning Insurance Agency Professional 5010A1 Claim Level Accept/Reject Yes

Trans 86048 Commercial Child Health Plus Professional 4010A1 Claim Level Acknowledgement

Non-Par 80141 Commercial Childhealth Plus by Healthfirst (CHP) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 84146 Commercial Children of Women Vietnam Veterans - VA HAC Institutional 4010A1 No Response From Payer Yes

Par 94321 Commercial Children's First Healthcare Network Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WP406 Commercial MN Children's Hospitals and Clinics of MN Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP406 Commercial MN Children's Hospitals and Clinics of MN Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP406 Commercial MN Children's Hospitals and Clinics of MN Auto 4010A1 Claim Level Accept/Reject

Non-Par 37314 Commercial Children's Medical Services - Broward NORTH Institutional 4010A1 File Level Acknowledgement

Non-Par CSSD2 Commercial CA Children's Physician of San Diego Professional 4010A1 No Response From Payer

Non-Par CPMG1 Commercial CA Children's Physicians Medical Group Professional 4010A1 No Response From Payer

Par 94302 Commercial Chinese Community Healthcare Professional 4010A1 Claim Level Accept/Reject

A: 01/11/2011 Non-Par 94302 Commercial Chinese Community Healthcare Institutional 4010A1 File Level Acknowledgement

Non-Par CCHP1 Commercial CHIPS Professional 4010A1 Claim Level Accept/Reject

Non-Par LNDMK Commercial ChiroCare Professional 4010A1 Claim Level Acknowledgement

Non-Par CASD1 Commercial SD Chiropractic Assoc. of South Dakota - Dakota Care Professional 4010A1 No Response From Payer

Non-Par CASD2 Commercial SD Chiropractic Assoc. of South Dakota - Sanford Health Professional 4010A1 No Response From Payer

Trans ACN01 Commercial MN Chiropractic Care of Minnesota, Inc. Professional 4010A1 No Response From Payer

Trans ACN01 Commercial WI Chiropractic Care of Wisconsin, Inc. Professional 4010A1 No Response From Payer

Non-Par 33065 Commercial CHOC - Children's Hospital of Orange County Professional 4010A1 Claim Level Acknowledgement

Non-Par 33065 Commercial CHOC - Childrens Hospital of Orange County Health Alliance Institutional 4010A1 No Response From Payer

Non-Par SCH01 Commercial CHOC Health Alliance Professional 4010A1 No Response From Payer

Non-Par 76049 Commercial TX Choice One/ UTMB CHIP Health Plan Professional 4010A1 Claim Level Accept/Reject Must call provider relations (281) 652-8700 prior to submitting claims

Non-Par 76049 Commercial Choice One/UTMB CHIP Health Plan Institutional 4010A1 No Response From Payer

Non-Par 90441 Commercial CHP Direct Supermed Institutional 4010A1 Claim Level Accept/Reject

Non-Par 90441 Commercial CHP Direct Supermed Professional 4010A1 Claim Level Accept/Reject

Non-Par 39112 Commercial CHP/RPU (FABOH) Institutional 4010A1 No Response From Payer

Non-Par 39112 Commercial CHP/RPU (FABOH) Professional 4010A1 Claim Level Accept/Reject

Par 61271 Commercial Christian Brothers Services Institutional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK464 Commercial TX, MN Christus Health Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par SPOHN Commercial Christus Spohn Health Plan Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WK411 Commercial TX, MN Chubb National Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP422 Commercial Church (AUTO ONLY) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP424 Commercial Church Mutual Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP424 Commercial Church Mutual Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP424 Commercial Church Mutual Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 62308 Commercial Cigna Remittance 4010A1 Enrollment

Non-Par 62308 Commercial CIGNA Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial CIGNA - ERA Available Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial CIGNA - PPA Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial CIGNA - PPO Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial CIGNA - PPO Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par MCCBV Commercial CIGNA Behavioral Health Institutional 4010A1 Claim Level Accept/Reject







11/10/2011 14 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par MCCBV Commercial CIGNA Behavioral Health Professional 4010A1 Claim Level Accept/Reject

Non-Par 86033 Commercial Cigna for Seniors Professional 4010A1 Claim Level Acknowledgement

Non-Par 62308 Commercial CIGNA Health Plan Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial CIGNA Health Plan - HMO Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 86033 Commercial Cigna Medicare Advantage Institutional 4010A1 No Response From Payer

Non-Par 62308 Commercial CIGNA Premier Plus Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WK412 Commercial Cincinnati Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK412 Commercial Cincinnati Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK412 Commercial Cincinnati Insurance Co Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX067 Commercial Cintas (Ontario) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX067 Commercial Cintas (Ontario) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX063 Commercial Cintas (Pico Rivera) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX063 Commercial Cintas (Pico Rivera) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX064 Commercial Cintas (Sacramento) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX064 Commercial Cintas (Sacramento) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX066 Commercial Cintas (San Diego) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX066 Commercial Cintas (San Diego) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX068 Commercial Cintas (San Fran) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX068 Commercial Cintas (San Fran) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX065 Commercial Cintas (San Jose) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX065 Commercial Cintas (San Jose) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX069 Commercial Cintas (Tustin) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX069 Commercial Cintas (Tustin) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX070 Commercial Cintas (Vista) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX070 Commercial Cintas (Vista) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX060 Commercial Cintas Fire And Safety Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX060 Commercial Cintas Fire And Safety Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR898 Commercial Cirq Wire Works Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR898 Commercial Cirq Wire Works Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 10207 Commercial Citrus Health Care Professional 4010A1 No Response From Payer

Non-Par IP055 Commercial CA Citrus Valley Physician's Group Professional 4010A1 File Level Acknowledgement

Non-Par CVPG1 Commercial Citrus Valley Physicians Medical Group Professional 4010A1 Claim Level Accept/Reject

Non-Par COA01 Commercial City of Amarillo Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX059 Commercial City of Amarillo (Austin) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX059 Commercial City of Amarillo (Austin) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK161 Commercial TX, MN City Of Arlington Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK161 Commercial TX, MN City Of Arlington Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK161 Commercial TX, MN City Of Arlington Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP473 Commercial MN City of Bloomington Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP473 Commercial MN City of Bloomington Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP473 Commercial MN City of Bloomington Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP474 Commercial MN City of Eagan Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP474 Commercial MN City of Eagan Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP474 Commercial MN City of Eagan Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK162 Commercial TX, MN City Of El Paso Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK162 Commercial TX, MN City Of El Paso Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK162 Commercial TX, MN City Of El Paso Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK465 Commercial TX, MN City of Hurst Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB115 Commercial City of Jacksonville Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB115 Commercial City of Jacksonville Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR497 Commercial TX, MN City of Lewisville Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR497 Commercial TX, MN City of Lewisville Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP475 Commercial City of Minneapolis Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP475 Commercial City of Minneapolis Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP475 Commercial City of Minneapolis Auto 4010A1 Claim Level Accept/Reject

Non-Par 75600 Commercial City of Odessa Institutional 4010A1 No Response From Payer

Non-Par 75600 Commercial City of Odessa Professional 4010A1 Claim Level Accept/Reject

Non-Par WK163 Commercial City of Plano Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK163 Commercial City of Plano Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP476 Commercial MN City of Plymouth Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP476 Commercial MN City of Plymouth Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP476 Commercial MN City of Plymouth Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP478 Commercial MN City of Richfield Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP478 Commercial MN City of Richfield Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP478 Commercial MN City of Richfield Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP480 Commercial MN City of Rochester Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP480 Commercial MN City of Rochester Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP480 Commercial MN City of Rochester Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC152 Commercial TX, MN City of San Angelo Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC152 Commercial TX, MN City of San Angelo Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par TTCEC Commercial TX City of San Antonio Professional 4010A1 Claim Level Accept/Reject

Non-Par CLFR2 Commercial CL Frates Professional 4010A1 Claim Level Accept/Reject

Non-Par 39141 Commercial Claim Management Services, Inc. Institutional 4010A1 No Response From Payer

Non-Par 39141 Commercial Claim Management Services, Inc. Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WP492 Commercial TX Claimetrics Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP492 Commercial TX Claimetrics Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP492 Commercial TX Claimetrics Auto 4010A1 Claim Level Accept/Reject

Non-Par 39141 Commercial Claims Management Services, Inc. Professional 4010A1 No Response From Payer

Non-Par 27008 Commercial Claimshop- Employers Coalition on Health Institutional 4010A1 File Level Acknowledgement

Non-Par 57080 Commercial Claimsware, Inc dba ManageMed Institutional 4010A1 No Response From Payer

Non-Par 57080 Commercial Claimsware, Inc., DBA ManageMed Professional 4010A1 Claim Level Acknowledgement

Non-Par 33192 Commercial Claredon's Health Kids Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK430 Commercial TX, MN Clarendon National Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX124 Commercial TX, MN Clarendon National Insurance Co (Santa Ana) Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 33192 Commercial Clarendon's Healthy Kids Institutional 4010A1 File Level Acknowledgement

Non-Par 95444 Commercial Clarian Health Plans Inc. Professional 4010A1 Claim Level Acknowledgement







11/10/2011 15 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 95444 Commercial Clarian Health Plans Inc. Institutional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK064 Commercial TX, MN Classic Residence By Hyatt Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK064 Commercial TX, MN Classic Residence By Hyatt Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK064 Commercial TX, MN Classic Residence By Hyatt Auto 4010A1 Claim Level Accept/Reject

Non-Par CCS99 Commercial Clayton County Health Benefit Plan Professional 4010A1 No Response From Payer

Non-Par 77201 Commercial Clear Choice Professional 4010A1 Claim Level Accept/Reject

A: 01/13/2011 Non-Par 77201 Commercial Clear Choice Institutional 4010A1 File Level Acknowledgement

Non-Par CRGMN Commercial Clinical Research Group Professional 4010A1 File Level Acknowledgement

Non-Par 56211 Commercial CM Administrators Inc Professional 4010A1 File Level Acknowledgement

Non-Par 56211 Commercial CM Administrators Inc Institutional 4010A1 File Level Acknowledgement

Non-Par 02041 Commercial CMHC Institutional 4010A1 No Response From Payer Yes

Non-Par 02041 Commercial CMHC Central Mass Health Care Institutional 4010A1 No Response From Payer Yes

Par WK001 Commercial MN CMI Wal-Mart MN Inst. Work Comp 4010A1 Claim Level Acknowledgement

Par WK001 Commercial MN CMI Wal-Mart MN Prof. Work Comp 4010A1 Claim Level Acknowledgement

Non-Par WK016 Commercial CNA Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK016 Commercial CNA Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 37227 Commercial CNIC Health Solutions Institutional 4010A1 No Response From Payer

Non-Par 37227 Commercial CNIC Health Solutions Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WP497 Commercial Coach USA Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP497 Commercial Coach USA Inst. Work Comp 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA Coachella Valley Physicians PrimeCare Professional 4010A1 Claim Level Accept/Reject

Non-Par 77052 Commercial Coastal Administrative Services Professional 4010A1 Claim Level Accept/Reject

Non-Par 77052 Commercial Coastal Administrative Services Institutional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Trans WK065 Commercial TX, MN Coca-Cola Enterprises Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK065 Commercial TX, MN Coca-Cola Enterprises Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK065 Commercial TX, MN Coca-Cola Enterprises Inc. Auto 4010A1 Claim Level Accept/Reject

Trans PPOM1 Commercial MI COFINITY (AKA PPOM, Inc. (Pref Prov Org Of Michigan) Professional 4010A1 Claim Level Accept/Reject

A: 01/10/2011 Non-Par 37123 Commercial Colonial Healthcare Professional 4010A1 File Level Acknowledgement

Non-Par 22284 Commercial Colonial Medical Professional 4010A1 File Level Acknowledgement

Non-Par 22284 Commercial Colonial Medical Institutional 4010A1 File Level Acknowledgement

Non-Par COACC Commercial CO Colorado Access HMO Professional 4010A1 Claim Level Acknowledgement

Non-Par COHMO Commercial CO Colorado Blue Advantage Professional 4010A1 Claim Level Acknowledgement

Non-Par COKSR Commercial CO Colorado Kaiser Permanente (Colorado plans only **EXCEPT Colorado Springs**) Professional 4010A1 Claim Level Acknowledgement

Non-Par KSRCS Commercial CO Colorado Springs Kaiser Permanente (Colorado Springs plan only) Professional 4010A1 Claim Level Acknowledgement

Non-Par 25351 Commercial Columbia Cornell Care, LLC Institutional 4010A1 No Response From Payer

Non-Par 25351 Commercial Columbia Cornell Care, LLC Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK066 Commercial TX, MN Columbia Sussex Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK066 Commercial TX, MN Columbia Sussex Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK066 Commercial TX, MN Columbia Sussex Corporation Auto 4010A1 Claim Level Accept/Reject

Non-Par 91162 Commercial Columbia United Providers Professional 4010A1 Claim Level Accept/Reject

Non-Par 91162 Commercial Columbia United Providers Institutional 4010A1 File Level Acknowledgement

Non-Par 62308 Commercial CoMed - CIGNA Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WP514 Commercial Commerce & Industry Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP514 Commercial Commerce & Industry Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP514 Commercial Commerce & Industry Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par 34181 Commercial Commerce Benefits Group Professional 4010A1 Claim Level Accept/Reject

Non-Par 34181 Commercial Commerce Benefits Group Institutional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WK432 Commercial TX, MN Commercial Insurance Co of Newark Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 37237 Commercial CommonWealth Administrative Group Institutional 4010A1 No Response From Payer

Non-Par 37237 Commercial Commonwealth Administrative Group Professional 4010A1 Claim Level Accept/Reject

Non-Par 37237 Commercial Commonwealth Administrators, LLC Professional 4010A1 Claim Level Accept/Reject

Non-Par 14315 Commercial Commonwealth Care Alliance Professional 4010A1 No Response From Payer

Non-Par 14315 Commercial Commonwealth Care Alliance Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WB136 Commercial TX, MN Commonwealth Industries Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB136 Commercial TX, MN Commonwealth Industries Inst. Work Comp 4010A1 Claim Level Accept/Reject

10/17/11 Non-Par 23282 Commercial Community Care BHO Professional 5010A1 Claim Level Accept/Reject

U:10/27/2011 Non-Par 23282 Commercial Community Care BHO Institutional 5010A2 Claim Level Acknowledgement

Non-Par 73143 Commercial OK Community Care Managed Health Care Plans of OK Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 73143 Commercial Community Care Managed Health Care Plans of Oklahoma Institutional 4010A1 No Response From Payer Yes

Non-Par 39126 Commercial Community Care Organization Professional 4010A1 Claim Level Accept/Reject

Non-Par 39126 Commercial Community Care Organization Institutional 4010A1 File Level Acknowledgement

Non-Par 38325 Commercial Community Choice Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 38325 Commercial Community Choice of Michigan Institutional 4010A1 File Level Acknowledgement Yes

U: 08/22/2011 Non-Par 26231 Commercial Community Claims Administration - Administered by Employee Benefit Administrators Professional 4010A1 Claim Level Acknowledgement

Par HCOMP Commercial Community First - Star Health Plan Professional 4010A1 Claim Level Acknowledgement

Non-Par COMMF Commercial Community First Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 35193 Commercial Community Health Alliance Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 35193 Commercial Community Health Alliance (CHA) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par CHCN1 Commercial Community Health Center Network Professional 4010A1 Claim Level Accept/Reject

Non-Par 48145 Commercial Community Health Choice Institutional 4010A1 No Response From Payer

Non-Par 48145 Commercial Community Health Choice Professional 4010A1 Claim Level Acknowledgement

10/17/11 Non-Par 75261 Commercial Community Health Electronic Claims (CHEC) Professional 5010A1 File Level Acknowledgement Yes

U:10/27/2011 Non-Par 75261 Commercial Community Health Electronic Claims (CHEC). Professional 5010A1 File Level Acknowledgement Yes

U:10/27/2011 Non-Par 75261 Commercial Community Health Electronic Claims/CHEC/webTPA Institutional 5010A2 No Response From Payer

Please note that this payer cannot accept anesthesia claims electronically. For

information on sending these claims, please contact LeAnn Olson, Director of

Non-Par 62149 Commercial CT Community Health Network of Connecticut Professional 4010A1 Claim Level Acknowledgement Claims at 203-237-4000 x 3136

Non-Par 62149 Commercial Community Health Network of CT Institutional 4010A1 No Response From Payer

U: 01/17/2011 Non-Par 90010 Commercial Professional 4010A1

Community Health Plan (located in St. Joseph, MO. Service Area includes NW Missouri, NE Kansas, SW Iowa, SE Nebraska) File Level Acknowledgement

Non-Par SB613 Commercial Community Health Plan of Washington Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 12T30 Commercial Community Health Plan of Washington Institutional 4010A1 Claim Level Accept/Reject

Par CMGWV Commercial CA Community Medical Group of the West Valley Professional 4010A1 Claim Level Accept/Reject No Payer Response, please contact payer directly at 818-707-9603

Non-Par 32481 Commercial Community Premier Plus (for Neighborhood Health Providers) Professional 4010A1 Claim Level Acknowledgement

Non-Par 32481 Commercial Community Premier Plus for Neighborhood Institutional 4010A1 No Response From Payer

Non-Par 34177 Commercial Comp - Ohio (Austintown, OH) Institutional 4010A1 No Response From Payer

Non-Par 31147 Commercial OH Comp One (Ohio BWC) Professional 4010A1 Claim Level Accept/Reject







11/10/2011 16 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Trans WK067 Commercial TX, MN Compass Group Usa, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK067 Commercial TX, MN Compass Group Usa, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK067 Commercial TX, MN Compass Group Usa, Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 37297 Commercial CompBenefit Corporation Institutional 4010A1 File Level Acknowledgement

Non-Par 34177 Commercial Compensation Programs Of Ohio, Inc. Professional 4010A1 Claim Level Acknowledgement

Non-Par 93101 Commercial OR, WA Complementary HealthCare Plans Professional 4010A1 Claim Level Accept/Reject

Non-Par 31147 Commercial OH CompManagement Health Systems, Inc. (Ohio BWC) Professional 4010A1 Claim Level Accept/Reject

Non-Par 59314 Commercial Comprehensive Behavioral Care Professional 4010A1 Claim Level Accept/Reject

Non-Par 59314 Commercial Comprehensive Behavioral Care Institutional 4010A1 File Level Acknowledgement

Non-Par CCMC1 Commercial NY Comprehensive Care Management Corp Professional 4010A1 Claim Level Accept/Reject

Non-Par 31147 Commercial OH Comprehensive Medical Care (Ohio BWC) Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX753 Commercial TX, MN CompTech Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX753 Commercial TX, MN CompTech Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX753 Commercial TX, MN CompTech Auto 4010A1 Claim Level Accept/Reject

Non-Par 06105 Commercial Connecticare Institutional 4010A1 No Response From Payer

Non-Par 06105 Commercial Connecticare Remittance 4010A1 Enrollment

Non-Par 78375 Commercial Connecticare - Medicare Institutional 4010A1 File Level Acknowledgement

Non-Par 78375 Commercial Connecticare - Medicare Professional 4010A1 Claim Level Accept/Reject

Par 06105 Commercial Connecticare, Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par BS243 Government CT Connecticut BlueCare Family Plan Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 37307 Commercial Connecticut Carpenters Health Fund Institutional 4010A1 File Level Acknowledgement

Non-Par 37307 Commercial Connecticut Carpenters Health Fund Professional 4010A1 File Level Acknowledgement

Non-Par 62308 Commercial Connecticut General (CIGNA) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial Connecticut General Life Insurance Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WP565 Commercial TX, MN Connecticut Indemnity Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP565 Commercial TX, MN Connecticut Indemnity Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP565 Commercial TX, MN Connecticut Indemnity Co Auto 4010A1 Claim Level Accept/Reject

Non-Par 37135 Commercial Consociate Group Institutional 4010A1 No Response From Payer

Non-Par 37135 Commercial Consociate Group Professional 4010A1 Claim Level Accept/Reject

Non-Par 75284 Commercial Consolidated Associates Railroad Institutional 4010A1 No Response From Payer

Non-Par 75284 Commercial Consolidated Associates Railroad Professional 4010A1 Claim Level Accept/Reject

Par 04274 Commercial Consolidated Group/HPS Professional 4010A1 No Response From Payer

Non-Par 87843 Commercial Consolidated Health Plans Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 87843 Commercial Consolidated Health Plans Professional 4010A1 File Level Acknowledgement Yes

A: 04/06/2010 Non-Par WP674 Commercial Constitution State Services Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP674 Commercial Constitution State Services Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB102 Commercial Constitution States (St. Paul Travelers) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB102 Commercial Constitution States (St. Paul Travelers) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP575 Commercial MN Construction Services Group Self Insured Association Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP575 Commercial MN Construction Services Group Self Insured Association Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP575 Commercial MN Construction Services Group Self Insured Association Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX239 Commercial Container Store (San Diego) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX239 Commercial Container Store (San Diego) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK068 Commercial TX, MN Contech Construction Products Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK068 Commercial TX, MN Contech Construction Products Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK068 Commercial TX, MN Contech Construction Products Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK069 Commercial TX, MN Continental Airlines Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK069 Commercial TX, MN Continental Airlines Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK069 Commercial TX, MN Continental Airlines Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK426 Commercial Continental Casualty Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK426 Commercial Continental Casualty Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK426 Commercial Continental Casualty Co Auto 4010A1 Claim Level Accept/Reject

Non-Par 71404 Commercial Continental General Insurance Company Institutional 4010A1 No Response From Payer

U: 01/17/2011 Non-Par 71404 Commercial Continental General Insurance Company Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WK456 Commercial Continental Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK456 Commercial Continental Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK456 Commercial Continental Insurance Co Auto 4010A1 Claim Level Accept/Reject

Non-Par 35315 Commercial Continental Key Family Institutional 4010A1 File Level Acknowledgement

Non-Par 35315 Commercial Continental Key Family Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WP578 Commercial Continental National Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP578 Commercial Continental National Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP578 Commercial Continental National Insurance Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC131 Commercial TX, MN Continental Western Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC131 Commercial TX, MN Continental Western Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP589 Commercial TX, MN Continental Western Ins Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP589 Commercial TX, MN Continental Western Ins Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP589 Commercial TX, MN Continental Western Ins Co Auto 4010A1 Claim Level Accept/Reject

Non-Par 47046 Commercial Contractors Laborers Teamsters & Engineers Institutional 4010A1 File Level Acknowledgement

Non-Par 47046 Commercial Contractors Laborers Teamsters & Engineers Professional 4010A1 File Level Acknowledgement

Non-Par 25133 Commercial Conventry Health Care (Formerly Health America, Inc./Health Assurance/Advantra 25126)Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Conventry Health Care (Formerly Health America, Inc./Health Assurance/Advantra 25126)Remittance 4010A1 Enrollment

A: 04/06/2010 Trans WK070 Commercial TX, MN Convergys Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK070 Commercial TX, MN Convergys Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK070 Commercial TX, MN Convergys Corporation Auto 4010A1 Claim Level Accept/Reject

Non-Par 55544 Commercial Conversion Plan APWU Professional 4010A1 Claim Level Accept/Reject

Non-Par 55544 Commercial Conversion Plan-APWU Institutional 4010A1 No Response From Payer

Non-Par 35149 Commercial Cook Group Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 35149 Commercial Cook Group Health Plan Institutional 4010A1 File Level Acknowledgement

Non-Par CCHP9 Commercial Cooks Children Star Plan Professional 4010A1 Claim Level Rejects Only

U:10/27/2011 Non-Par 52132 Commercial Cooperative Benefit Administrators (CBA) Institutional 5010A2 No Response From Payer Yes

10/17/11 Non-Par 52132 Commercial Cooperative Benefit Administrators (CBA) Professional 5010A1 No Response From Payer Yes

Non-Par 52132 Commercial Cooperative Benefit Administrators (CBA) Remittance 4010A1 Enrollment

Non-Par 35199 Commercial Cooperative Managed Care Services Professional 4010A1 Claim Level Accept/Reject

Non-Par 35199 Commercial COOPERATIVE MANAGED CARE SERVICES Institutional 4010A1 Claim Level Accept/Reject

Non-Par 58204 Commercial Coordinated Medical Specialists Professional 4010A1 Claim Level Accept/Reject

Non-Par 58231 Commercial Core Administrative Services Institutional 4010A1 No Response From Payer







11/10/2011 17 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 58231 Commercial Core Management Resources Group, Inc. (located in Macon, GA) Professional 4010A1 No Response From Payer

Non-Par 75136 Commercial CoreSource Little Rock Institutional 4010A1 File Level Acknowledgement



Only for claims where the "submit claims to" address on the medical ID card is a

U: 01/17/2011 Non-Par 75136 Commercial AR CoreSource Little Rock Professional 4010A1 File Level Acknowledgement CoreSource address in Little Rock, Arkansas. For assistance call (800)689-0106.

Non-Par 35182 Commercial CoreSource of AZ, MN Professional 4010A1 File Level Acknowledgement

Non-Par 35182 Commercial CoreSource of AZ, MN Institutional 4010A1 File Level Acknowledgement

Non-Par 35182 Commercial CoreSource of AZ, MN Remittance 4010A1 Enrollment

Non-Par 35182 Commercial CoreSource of IL, MD, PA Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 35182 Commercial CoreSource of IL, MD, PA Professional 4010A1 File Level Acknowledgement Yes

Non-Par 35182 Commercial CoreSource of IL, MD, PA Remittance 4010A1 Enrollment

Non-Par 35182 Commercial CoreSource of NC, IN Professional 4010A1 File Level Acknowledgement

Non-Par 35182 Commercial CoreSource of NC, IN Remittance 4010A1 Enrollment

Non-Par 35182 Commercial CoreSource of NC, IN Institutional 4010A1 File Level Acknowledgement

Non-Par 35183 Commercial OH CoreSource of Ohio Institutional 4010A1 No Response From Payer Yes

Non-Par 35183 Commercial OH CoreSource of Ohio Remittance 4010A1 Enrollment



Only for claims where the "submit claims to" address on the medical ID card is a

Non-Par 35183 Commercial OH CoreSource Of Ohio Professional 4010A1 Claim Level Accept/Reject Yes CoreSource address in the state of OH. For assistance, call (800) 689-0106.

Non-Par 35187 Commercial CoreSource-Internal Professional 4010A1 File Level Acknowledgement

Non-Par 35187 Commercial CoreSource-Internal Institutional 4010A1 File Level Acknowledgement

Non-Par 35202 Commercial IN CornerStone Benefit Administrators Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 35202 Commercial Cornerstone Benefit Adminstrators Institutional 4010A1 Claim Level Acknowledgement Yes

Non-Par 41124 Commercial Corporate Benefit Services of America Institutional 4010A1 No Response From Payer

Non-Par 41124 Commercial Corporate Benefit Services of America/ CBSA Professional 4010A1 Claim Level Accept/Reject

Non-Par 56116 Commercial Corporate Benefits Service, Inc. (NC) Institutional 4010A1 No Response From Payer

Non-Par 56116 Commercial Corporate Benefits Services, Inc. Professional 4010A1 Claim Level Acknowledgement

Non-Par 37246 Commercial Corporate Systems Administration Institutional 4010A1 No Response From Payer

Non-Par 37246 Commercial Corporate Systems Administration Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK071 Commercial TX, MN Correctional Management Service Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK071 Commercial TX, MN Correctional Management Service Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK071 Commercial TX, MN Correctional Management Service Auto 4010A1 Claim Level Accept/Reject

A: 12/21/2010 Non-Par 43160 Commercial Correctional Medical Services Institutional 4010A1 File Level Acknowledgement

Non-Par 43160 Commercial Correctional Medical Services, Inc. Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Trans WK072 Commercial TX, MN Corrections Corp of America Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK072 Commercial TX, MN Corrections Corp of America Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK072 Commercial TX, MN Corrections Corp of America Auto 4010A1 Claim Level Accept/Reject

Non-Par 31147 Commercial OH Corvel Corporation (Ohio BWC) Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB116 Commercial Costco (Corp) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB116 Commercial Costco (Corp) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 62553 Commercial Country Life Insurance Company Institutional 4010A1 No Response From Payer

Non-Par 62553 Commercial Country Life Insurance Company Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP613 Commercial MN County Of Olmsted Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP613 Commercial MN County Of Olmsted Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP613 Commercial MN County Of Olmsted Auto 4010A1 Claim Level Accept/Reject

Non-Par 58102 Commercial Covenant Administrators, Inc. Professional 4010A1 Claim Level Acknowledgement

Non-Par 58102 Commercial Covenant Administrators, Inc. (Atlanta, GA) Institutional 4010A1 No Response From Payer

Non-Par 25133 Commercial Coventry Health & Life - Oklahoma Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health & Life - Oklahoma Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care Remittance 4010A1 Enrollment

Non-Par 25133 Commercial Coventry Health Care Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Advantra Freedom 25152) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial Coventry Health Care (Formerly Advantra Freedom 25152) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Advantra Freedom 25152) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Carelink Advantra ,WV and OH only 25139) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Carelink Advantra 25139) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial Coventry Health Care (Formerly Carelink Advantra 25139) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Carelink Health Plan 25139) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Carelink Health Plan 25139) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial Coventry Health Care (Formerly Carelink Medicaid 25140) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial Coventry Health Care (Formerly Carelink Medicaid 25140) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Carenet of Virginia 25142) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial Coventry Health Care (Formerly Carenet of Virginia 25142) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Professional

Coventry Health Care (Formerly Claims Administration Corp. ,Payer office ID is required, 62413) 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly CNA ,Mailhandlers Benefit Plan, 62413) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Coventry - Nevada, 25149) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Coventry - Nevada, 25149) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial Coventry Health Care (Formerly Coventry - Nevada, 25149) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Coventry Carelink Medicaid 25140) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Coventry Carenet 25142) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Coventry Diamond Plan 25131) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Coventry Health Care National Network - 87043) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Coventry Health Care National Network - 87043) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial DE Coventry Health Care (Formerly Coventry Health Care of Delaware, Inc. 25130) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial DE Coventry Health Care (Formerly Coventry Health Care of Delaware, Inc. 25130) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial DE Coventry Health Care (Formerly Coventry Health Care of Delaware, Inc. 25130) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial GA Coventry Health Care (Formerly Coventry Health Care of Georgia, Inc. 25127) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial GA Coventry Health Care (Formerly Coventry Health Care of Georgia, Inc. 25127) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial GA Coventry Health Care (Formerly Coventry Health Care of Georgia, Inc. 25127) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial IN Coventry Health Care (Formerly Coventry Health Care of Indiana, Inc. 25131) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial IA Coventry Health Care (Formerly Coventry Health Care of Iowa, Inc. 25132) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial IA Coventry Health Care (Formerly Coventry Health Care of Iowa, Inc. 25132) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial IA Coventry Health Care (Formerly Coventry Health Care of Iowa, Inc. 25132) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial LA Coventry Health Care (Formerly Coventry Health Care of Louisiana, Inc. 25135) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial LA Coventry Health Care (Formerly Coventry Health Care of Louisiana, Inc. 25135) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial LA Coventry Health Care (Formerly Coventry Health Care of Louisiana, Inc. 25135) Institutional 4010A1 Claim Level Accept/Reject Yes







11/10/2011 18 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 25133 Commercial NE Coventry Health Care (Formerly Coventry Health Care of Nebraska, Inc. 25136) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial NE Coventry Health Care (Formerly Coventry Health Care of Nebraska, Inc. 25136) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial NE Coventry Health Care (Formerly Coventry Health Care of Nebraska, Inc. 25136) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial Coventry Health Care (Formerly Coventry Health Care of the Carolinas 25129) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Coventry HealthCare USA 25143) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Coventry OmniCare 25150) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Diamond Plan 25131) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial Coventry Health Care (Formerly GHP ,Group Health Plan, 25141) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial MO Coventry Health Care (Formerly Group Health Plan 25141) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Health America, Inc./Health Assurance/Advantra 25126) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly HealthCare USA 25143) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Mailhandlers Benefit Plan 62413) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Mailhandlers Benefit Plan 62413) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial Coventry Health Care (Formerly Mailhandlers Benefit Plan,CNA ,62413) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly OmniCare, A Coventry Health Plan 25150) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial Coventry Health Care (Formerly OmniCare, A Coventry Health Plan 25150) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Southern Health Services, Inc 25128) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Southern Health Services, Inc 25128) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Southern Health Services, Inc 25128) Remittance 4010A1 Enrollment

Non-Par 25133 Commercial Coventry Health Care (Formerly Vista Health Plan 55248) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly Vista Health Plan 55248) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care (Formerly WellPath 25129) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Care National Network (f.k.a First Health Direct) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Plan (Formerly Personal Physician Care 34173) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Plan (Formerly Personal Physician Care 34173) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial Coventry Health Plan (Formerly Personal Physician Care 34173) Remittance 4010A1 Enrollment

9/27/11 Non-Par 25133 Commercial CoventryCares of Kentucky Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK073 Commercial TX, MN Coworx Staffing, LLC Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK073 Commercial TX, MN Coworx Staffing, LLC Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK073 Commercial TX, MN Coworx Staffing, LLC Auto 4010A1 Claim Level Accept/Reject

Non-Par 00019 Commercial Cox Health System Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WX335 Commercial Crawford Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX335 Commercial Crawford Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX335 Commercial Crawford Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par 64068 Commercial Creative Medical Systems Professional 4010A1 Claim Level Acknowledgement

Non-Par 64068 Commercial Creative Medical Systems Institutional 4010A1 No Response From Payer

Non-Par 37320 Commercial Creative Plan Administrators Professional 4010A1

Non-Par 37320 Commercial Creative Plan Administrators Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WP618 Commercial TX, MN Crestbrook Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP618 Commercial TX, MN Crestbrook Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP618 Commercial TX, MN Crestbrook Insurance Company Auto 4010A1 Claim Level Accept/Reject

Trans PPM02 Commercial CA Crown City Medical Group - Encounters Only Professional 4010A1 Claim Level Accept/Reject

Non-Par PPM01 Commercial CA Crown City Medical Group - Claims Only Professional 4010A1 Claim Level Accept/Reject

Non-Par 37266 Commercial Croy-Hall Mgmt. Inc. Institutional 4010A1 No Response From Payer

Non-Par WK026 Commercial Crum & Forster Indemnity Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK026 Commercial Crum & Forster Indemnity Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC132 Commercial TX, MN Cumis Insurance Society Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC132 Commercial TX, MN Cumis Insurance Society Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 39170 Commercial Custom Benefit Administrators Professional 4010A1 Claim Level Acknowledgement

Non-Par 39170 Commercial Custom Benefit Administrators Institutional 4010A1 Claim Level Acknowledgement

Non-Par 82056 Commercial Custom Design Benefits Inc. Institutional 4010A1 File Level Acknowledgement

Non-Par 82056 Commercial Custom Design Benefits Inc. Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WK074 Commercial TX, MN CVS Pharmacy Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK074 Commercial TX, MN CVS Pharmacy Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK074 Commercial TX, MN CVS Pharmacy Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB117 Commercial CVS Pharmacy / Caremark / Minute Clinic Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB117 Commercial CVS Pharmacy / Caremark / Minute Clinic Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 57080 Commercial CWIBENEFITS, Inc. Institutional 4010A1 No Response From Payer

Non-Par DEW99 Commercial D. Edward Wright Professional 4010A1 No Response From Payer

Non-Par 25172 Commercial D. H. Evans & Associates Professional 4010A1 No Response From Payer Call Jessica Picarde @ 410-349-3222 for payer id

Non-Par DAK01 Commercial SD DakotaCare Institutional 4010A1 Claim Level Acknowledgement

Non-Par DAK01 Commercial SD DakotaCare Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK455 Commercial Dallas National Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK455 Commercial Dallas National Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK075 Commercial TX, MN Danaher Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK075 Commercial TX, MN Danaher Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK075 Commercial TX, MN Danaher Corporation Auto 4010A1 Claim Level Accept/Reject

Non-Par 06172 Commercial Dart Management Corporation Institutional 4010A1 File Level Acknowledgement

Non-Par 06172 Commercial Dart Management Corporation Professional 4010A1 File Level Acknowledgement

Non-Par 33066 Commercial Davita Health Institutional 4010A1 File Level Acknowledgement

Non-Par 33066 Commercial Davita Health Professional 4010A1 File Level Acknowledgement

Non-Par 95740 Commercial DC Chartered Health Plan Inc. (Alliance) Institutional 4010A1 Claim Level Rejects Only

Non-Par 95748 Commercial DC Chartered Health Plan Inc. (Medicaid & Alliance) Institutional 4010A1 Claim Level Accept/Reject

Non-Par 95740 Commercial DC HealthCare Alliance Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP647 Commercial MN DCI, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP647 Commercial MN DCI, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP647 Commercial MN DCI, Inc. Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK076 Commercial TX, MN De Bartolos, Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK076 Commercial TX, MN De Bartolos, Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK076 Commercial TX, MN De Bartolos, Inc Auto 4010A1 Claim Level Accept/Reject

Non-Par 39113 Commercial WI Dean Health Plan Professional 4010A1 Enrollment No Response From Payer

U: 12/30/2010 Non-Par 39113 Commercial Dean Health Plan Institutional 4010A1 Enrollment Claim Level Acknowledgement

Trans 64159 Commercial Definity Health Plan Professional 4010A1 Claim Level Accept/Reject

Trans 64159 Commercial Definity Health Plan Institutional 4010A1 Claim Level Accept/Reject

Non-Par 25137 Commercial Delaware Care Professional 4010A1 Claim Level Acknowledgement

Non-Par 27009 Commercial DE Delaware Physicians Care (Delaware Medicaid Plan) Professional 4010A1 Claim Level Rejects Only







11/10/2011 19 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 27009 Commercial Delaware Physicians Care Inc. Institutional 4010A1 Claim Level Accept/Reject

9/15/11 Trans SB691 Commercial MD Delmarva Health Plan - Carefirst Professional 4010A1 Claim Level Acknowledgement

Par DHS01 Commercial CA Delta Health Systems Professional 4010A1 Claim Level Accept/Reject

Non-Par 94235 Commercial Delta Health Systems Institutional 4010A1 File Level Acknowledgement

Trans AMS01 Commercial MI Dentemax Professional 4010A1 No Response From Payer

Trans AMS01 Commercial MI Dentemax/DPI (MI) Professional 4010A1 No Response From Payer

Non-Par 84134 Commercial Denver Health - Indigent Professional 4010A1 Claim Level Accept/Reject

Non-Par 84134 Commercial Denver Health - Indigent Institutional 4010A1 Claim Level Accept/Reject

Non-Par 84133 Commercial Denver Health and Hospital Auth Professional 4010A1 Claim Level Accept/Reject

Non-Par 84133 Commercial Denver Health and Hospital Authority Institutional 4010A1 No Response From Payer

Non-Par 84135 Commercial Denver Health Medical Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 84135 Commercial Denver Health Medical Plan Institutional 4010A1 No Response From Payer

Non-Par 84131 Commercial Denver Health Medical Plan Inc. - Medicare Choice Institutional 4010A1 File Level Acknowledgement

Non-Par 84131 Commercial Denver Health Medical Plan Inc. - Medicare Choice Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WB105 Commercial Department of Energy Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB105 Commercial Department of Energy Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX444 Commercial Department of Labor and Industries (DOL) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX444 Commercial Department of Labor and Industries (DOL) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB104 Commercial Department of Labor Black Lung Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB104 Commercial Department of Labor Black Lung Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par SX105 Commercial Deseret Mutual Remittance 4010A1 Enrollment

Contact DMBA to enroll and obtain a provider id. Call (800)777-3622, ask for

Non-Par SX105 Commercial Deseret Mutual Professional 4010A1 Enrollment Claim Level Accept/Reject provider maintenance. Once provider receives ID, please notify Capario

Non-Par IP121 Commercial CA Desert Medical Group Professional 4010A1 No Response From Payer

Please contact Desert Medical @ (760) 323-2614 x 1580 and request to be added

U: 01/10/2011 Non-Par IP114 Commercial CA Desert Medical Group - Oasis Professional 4010A1 No Response From Payer to their Provider Eligibility List prior to submitting claims.

Non-Par MDL99 Commercial MI Detroit Laborers (Metropolitan) Professional 4010A1 No Response From Payer

Non-Par 56240 Commercial Detroit Medical Center Institutional 4010A1 File Level Acknowledgement

Non-Par 56240 Commercial Detroit Medical Center Professional 4010A1 File Level Acknowledgement

Non-Par 36439 Commercial DiaTri LLC Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WP652 Commercial TX, MN Dillard Departmen (Little Rock) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP652 Commercial TX, MN Dillard Departmen (Little Rock) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP652 Commercial TX, MN Dillard Departmen (Little Rock) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP675 Commercial MN Diocese of Winona Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP675 Commercial MN Diocese of Winona Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP675 Commercial MN Diocese of Winona Auto 4010A1 Claim Level Accept/Reject

Non-Par 23706 Commercial Director's Guild Of America Institutional 4010A1 No Response From Payer

Non-Par 23706 Commercial Director's Guild of America - Producer Health Plans Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Trans WK077 Commercial TX, MN Directory Distributing Assoc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK077 Commercial TX, MN Directory Distributing Assoc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK077 Commercial TX, MN Directory Distributing Assoc. Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK078 Commercial TX, MN Discover Re (Burger King) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK078 Commercial TX, MN Discover Re (Burger King) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK078 Commercial TX, MN Discover Re (Burger King) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP697 Commercial Discover Reinsurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP697 Commercial Discover Reinsurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP697 Commercial Discover Reinsurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 06102 Commercial Diversified Administration Corporation Institutional 4010A1 No Response From Payer

Non-Par 25160 Commercial Diversified Group Administrators, Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par 06102 Commercial CT Diversified Group Brokerage (Marlb, CT) Professional 4010A1 No Response From Payer

Non-Par 06102 Commercial Diversified Group Brokerage/Healthplan Services Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WP748 Commercial TX, MN Dixie Staffing (Lithia Springs) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP748 Commercial TX, MN Dixie Staffing (Lithia Springs) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP748 Commercial TX, MN Dixie Staffing (Lithia Springs) Auto 4010A1 Claim Level Accept/Reject

U:10/27/2011 Non-Par MR032 Government AL DMERC - Alabama (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government AL DMERC - Alabama (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government AK DMERC - Alaska (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government AK DMERC - Alaska (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government AZ DMERC - Arizona (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government AZ DMERC - Arizona (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government AR DMERC - Arkansas (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government AR DMERC - Arkansas (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government CA DMERC - California (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government CA DMERC - California (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government CO DMERC - Colorado (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government CO DMERC - Colorado (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR030 Government CT DMERC - Connecticut (Jurisdiction A) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR030 Government CT DMERC - Connecticut (Jurisdiction A) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR030 Government DE DMERC - Delaware (Jurisdiction A) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR030 Government DE DMERC - Delaware (Jurisdiction A) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government FL DMERC - Florida (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government FL DMERC - Florida (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government GA DMERC - Georgia (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government GA DMERC - Georgia (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government GU DMERC - Guam (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government GU DMERC - Guam (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government HI DMERC - Hawaii (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government HI DMERC - Hawaii (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government ID DMERC - Idaho (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government ID DMERC - Idaho (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR031 Government IL DMERC - Illinois (Jurisdiction B) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR031 Government IL DMERC - Illinois (Jurisdiction B) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR031 Government IN DMERC - Indiana (Jurisdiction B) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR031 Government IN DMERC - Indiana (Jurisdiction B) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government IA DMERC - Iowa (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government IA DMERC - Iowa (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government KS DMERC - Kansas (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes





11/10/2011 20 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par MR024 Government KS DMERC - Kansas (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR031 Government KY DMERC - Kentucky (Jurisdiction B) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR031 Government KY DMERC - Kentucky (Jurisdiction B) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government LA DMERC - Louisiana (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government LA DMERC - Louisiana (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR030 Government ME DMERC - Maine (Jurisdiction A) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR030 Government ME DMERC - Maine (Jurisdiction A) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR030 Government MD DMERC - Maryland (Jurisdiction A) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR030 Government MD DMERC - Maryland (Jurisdiction A) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR030 Government MA DMERC - Massachusetts (Jurisdiction A) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR030 Government MA DMERC - Massachusetts (Jurisdiction A) Remittance 4010A1 Enrollment

Non-Par MR031 Government MI DMERC - Michigan (Jurisdiction B) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR031 Government MI DMERC - Michigan (Jurisdiction B) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

U:10/27/2011 Non-Par MR031 Government MN DMERC - Minnesota (Jurisdiction B) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR031 Government MN DMERC - Minnesota (Jurisdiction B) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government MS DMERC - Mississippi (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government MS DMERC - Mississippi (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government MO DMERC - Missouri (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government MO DMERC - Missouri (Jurisdiction D) Remittance 4010A1 Enrollment

Non-Par MR024 Government MT DMERC - Montana (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government MT DMERC - Montana (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

U:10/27/2011 Non-Par MR024 Government NE DMERC - Nebraska (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government NE DMERC - Nebraska (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government NV DMERC - Nevada (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government NV DMERC - Nevada (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR030 Government NH DMERC - New Hampshire (Jurisdiction A) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR030 Government NH DMERC - New Hampshire (Jurisdiction A) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR030 Government NJ DMERC - New Jersey (Jurisdiction A) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR030 Government NJ DMERC - New Jersey (Jurisdiction A) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government NM DMERC - New Mexico (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government NM DMERC - New Mexico (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR030 Government NY DMERC - New York (Jurisdiction A) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR030 Government NY DMERC - New York (Jurisdiction A) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government NC DMERC - North Carolina (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government NC DMERC - North Carolina (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government ND DMERC - North Dakota (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government ND DMERC - North Dakota (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR031 Government OH DMERC - Ohio (Jurisdiction B) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR031 Government OH DMERC - Ohio (Jurisdiction B) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government OK DMERC - Oklahoma (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government OK DMERC - Oklahoma (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government OR DMERC - Oregon (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government OR DMERC - Oregon (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR030 Government PA DMERC - Pennsylvania (Jurisdiction A) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR030 Government PA DMERC - Pennsylvania (Jurisdiction A) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government PR DMERC - Puerto Rico (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government PR DMERC - Puerto Rico (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR030 Government RI DMERC - Rhode Island (Jurisdiction A) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR030 Government RI DMERC - Rhode Island (Jurisdiction A) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government SC DMERC - South Carolina (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government SC DMERC - South Carolina (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government SD DMERC - South Dakota (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government SD DMERC - South Dakota (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government TN DMERC - Tennessee (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government TN DMERC - Tennessee (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government TX DMERC - Texas (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government TX DMERC - Texas (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government UT DMERC - Utah (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government UT DMERC - Utah (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR030 Government VT DMERC - Vermont (Jurisdiction A) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR030 Government VT DMERC - Vermont (Jurisdiction A) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government VI DMERC - Virgin Islands (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government VI DMERC - Virgin Islands (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government VA DMERC - Virginia (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government VA DMERC - Virginia (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government WA DMERC - Washington (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government WA DMERC - Washington (Jurisdiction D) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR030 Government DC DMERC - Washington DC (Jurisdiction A) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR030 Government DC DMERC - Washington DC (Jurisdiction A) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR032 Government WV DMERC - West Virginia (Jurisdiction C) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR032 Government WV DMERC - West Virginia (Jurisdiction C) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR031 Government WI DMERC - Wisconsin (Jurisdiction B) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR031 Government WI DMERC - Wisconsin (Jurisdiction B) Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par MR024 Government WY DMERC - Wyoming (Jurisdiction D) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR024 Government WY DMERC - Wyoming (Jurisdiction D) Remittance 4010A1 Enrollment

A: 04/06/2010 Trans WX494 Commercial Dollar Tree Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX494 Commercial Dollar Tree Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par IP116 Commercial CA Downey Select IPA (Applecare Medical Management) Professional 4010A1 No Response From Payer

Non-Par 74284 Commercial Driscoll Children's Health Plan Professional 4010A1 File Level Acknowledgement

Non-Par 74284 Commercial Driscoll Children's Health Plan Institutional 4010A1 File Level Acknowledgement

Non-Par 35186 Commercial Dunn & Associates Professional 4010A1 Claim Level Accept/Reject

Non-Par 35186 Commercial Dunn and Associates Benefits Administrators Inc. Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WK079 Commercial TX, MN Dunn-Edwards Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK079 Commercial TX, MN Dunn-Edwards Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK079 Commercial TX, MN Dunn-Edwards Corporation Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX540 Commercial Durham School Services (Oxnard) Prof. Work Comp 4010A1 Claim Level Accept/Reject







11/10/2011 21 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Non-Par WX540 Commercial Durham School Services (Oxnard) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX541 Commercial Durham School Services (Santa Ana) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX541 Commercial Durham School Services (Santa Ana) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK080 Commercial TX, MN Dustrol Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK080 Commercial TX, MN Dustrol Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK080 Commercial TX, MN Dustrol Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK081 Commercial TX, MN Dynamex, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK081 Commercial TX, MN Dynamex, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK081 Commercial TX, MN Dynamex, Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 34108 Commercial E.S. Beveridge & Associates Professional 4010A1 Claim Level Accept/Reject

Non-Par 75232 Commercial E3 Health Inc. Professional 4010A1 Claim Level Acknowledgement

Non-Par 36434 Commercial Early Intervention Central Billing Office Professional 4010A1 Claim Level Accept/Reject

U: 12/28/2010 Par EMG11 Commercial Eastland Medical Group Professional 4010A1 Claim Level Accept/Reject No Payer Response, please contact payer directly at 818-707-9603

Non-Par 62308 Commercial OH Eaton Benefits, OH Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par TTCEC Commercial TX EBA - City of San Antonio Professional 4010A1 Claim Level Accept/Reject

Non-Par EBC01 Commercial AL EBC ( Buffalo Rock) Birmingham Professional 4010A1 Claim Level Accept/Reject

Non-Par CX025 Commercial EBMC Professional 4010A1 Claim Level Accept/Reject

Non-Par 31074 Commercial EBMC Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 12X44 Commercial EBMS - Employee Benefit Management Services, Inc. Institutional 4010A1 No Response From Payer

Non-Par 81039 Commercial EBMS - Employee Benefit Management Services, Inc. Professional 4010A1 Claim Level Acknowledgement

Non-Par 75277 Commercial eComm PPO Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB021 Commercial EDIC Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB021 Commercial EDIC Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 22521 Commercial EDS Admin Services Institutional 4010A1 Claim Level Accept/Reject

Non-Par 22521 Commercial EDS Admin Services Professional 4010A1 Claim Level Accept/Reject

Non-Par SX110 Commercial Educators Mutual Insurance Assoc. (EMIA) Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP805 Commercial MN EEP Workers Compensation Fund Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP805 Commercial MN EEP Workers Compensation Fund Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP805 Commercial MN EEP Workers Compensation Fund Auto 4010A1 Claim Level Accept/Reject

Non-Par WK003 Commercial EIC Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK003 Commercial EIC Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK164 Commercial TX, MN El Paso Community College (Tx Jur) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK164 Commercial TX, MN El Paso Community College (Tx Jur) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK164 Commercial TX, MN El Paso Community College (Tx Jur) Auto 4010A1 Claim Level Accept/Reject

Non-Par EPF02 Commercial El Paso First Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK165 Commercial TX, MN El Paso Water Util Tx Jur Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK165 Commercial TX, MN El Paso Water Util Tx Jur Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK165 Commercial TX, MN El Paso Water Util Tx Jur Auto 4010A1 Claim Level Accept/Reject

Non-Par MPM04 Commercial El Proyecto del Barrio Professional 4010A1 File Level Acknowledgement

Elderplan no longer requires enrollment

& individual provider testing; However,

Elderplan Provider ID is necessary on all

claim submissions. If you do not know

Non-Par 31625 Commercial MU ElderPlan Inc. Institutional 4010A1 your provider Id, contact (718) 921-7979

Non-Par 31625 Commercial ElderPlan, Inc. Professional 4010A1 Claim Level Accept/Reject

Elderplan no longer requires enrollment

& individual provider testing; However,

Elderplan Provider ID is necessary on all

claim submissions. If you do not know

Non-Par 31625 Commercial ElderPlan, Inc. Remittance 4010A1 Enrollment your provider Id, contact (718) 921-7979

A: 04/06/2010 Non-Par WP807 Commercial MN Elim Care, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP807 Commercial MN Elim Care, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP807 Commercial MN Elim Care, Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 36399 Commercial Elmcare LLC Institutional 4010A1 File Level Acknowledgement

Non-Par 36399 Commercial Elmcare LLC Professional 4010A1 File Level Acknowledgement

Non-Par 37253 Commercial ELMCO Institutional 4010A1 No Response From Payer

Non-Par 37253 Commercial ELMCO Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Trans WC160 Commercial TX, MN EMC Risk Services, LLC Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC160 Commercial TX, MN EMC Risk Services, LLC Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC160 Commercial TX, MN EMC Risk Services, LLC Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK082 Commercial TX, MN EMCASCO Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK082 Commercial TX, MN EMCASCO Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK082 Commercial TX, MN EMCASCO Insurance Co Auto 4010A1 Claim Level Accept/Reject

Non-Par 34167 Commercial Emerald Health Network Professional 4010A1 No Response From Payer

Non-Par 34167 Commercial Emerald Health Network, Inc. (All PPO Business) Institutional 4010A1 No Response From Payer

Par EMSF1 Commercial CA Emergency Medical Services Fund Professional 4010A1 Claim Level Accept/Reject

Non-Par 59299 Commercial EMI-KP Ambulance Claims Professional 4010A1 File Level Acknowledgement

U:09/30/2011 Non-Par 73288 Commercial EMPHESYS Professional 4010A1 and 5010A1 Claim Level Rejects Only

Non-Par IP115 Commercial CA Empire Medical Group Professional 4010A1 No Response From Payer

Trans 87726 Commercial Empire Plan- United Healthcare Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WP818 Commercial TX, MN Employ Bridge (Irving) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP818 Commercial TX, MN Employ Bridge (Irving) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP818 Commercial TX, MN Employ Bridge (Irving) Auto 4010A1 Claim Level Accept/Reject

Non-Par 27008 Commercial Employee Coalition (ECOH) Professional 4010A1 Claim Level Accept/Reject

Non-Par 95288 Commercial Employee Benefit Administrators Professional 4010A1 Claim Level Accept/Reject

Non-Par 38241 Commercial Employee Benefit Concepts Professional 4010A1 Claim Level Accept/Reject

Non-Par 38241 Commercial Employee Benefit Concepts (Farmington Hills, MI) Institutional 4010A1 No Response From Payer

Non-Par 31074 Commercial Employee Benefit Management Corp (EBMC) Institutional 4010A1 File Level Acknowledgement Yes

Non-Par CX025 Commercial Employee Benefit Management Corp. Professional 4010A1 Claim Level Accept/Reject

Non-Par 03036 Commercial Employee Benefit Plan Administration (E.B.P.A.) Institutional 4010A1 Claim Level Acknowledgement

Non-Par 03036 Commercial Employee Benefit Plan Administration (E.B.P.A.) Professional 4010A1 Claim Level Acknowledgement

Trans 37216 Commercial Employee Benefit Services Professional 4010A1 No Response From Payer

Non-Par 37216 Commercial Employee Benefit Services (Ft. Mill, SC) Institutional 4010A1 No Response From Payer

Non-Par 41198 Commercial LA Employee Benefit Services of LA, Inc. (EBS) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 41198 Commercial Employee Benefit Services of Louisiana Inc (EBS) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par EBSSA Commercial Employee Benefit Services of San Antonio Professional 4010A1 Claim Level Accept/Reject

Non-Par 37257 Commercial Employee Benefits Consultants Professional 4010A1 Claim Level Acknowledgement







11/10/2011 22 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 75184 Commercial Employee Claim ADJ Institutional 4010A1 File Level Acknowledgement

Non-Par 75184 Commercial TX Employee Claim Adjudication Services Professional 4010A1 Claim Level Accept/Reject

Non-Par 35112 Commercial Employee Plans, LLC Institutional 4010A1 No Response From Payer

Non-Par 35112 Commercial Employee Plans, LLC Professional 4010A1 Claim Level Accept/Reject

Non-Par 74212 Commercial Employer Plan Services Institutional 4010A1 Claim Level Acknowledgement Yes

Non-Par 74212 Commercial Employer Plan Services, Inc. Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WK417 Commercial TX, MN Employers Compensation Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP853 Commercial Employers Compensation Insurance Fund Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP853 Commercial Employers Compensation Insurance Fund Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP853 Commercial Employers Compensation Insurance Fund Auto 4010A1 Claim Level Accept/Reject

Non-Par 75232 Commercial Employers Direct Health Institutional 4010A1 No Response From Payer

Non-Par 75236 Commercial Employers Direct Health - Employee Plan Institutional 4010A1 No Response From Payer

Non-Par 75236 Commercial Employers Direct Health - Employee Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 75235 Commercial Employers Direct Health - FL Institutional 4010A1 No Response From Payer

Non-Par 75235 Commercial Employers Direct Health - FL Professional 4010A1 Claim Level Accept/Reject

Non-Par 75233 Commercial Employers Direct Health - SF Institutional 4010A1 No Response From Payer

Non-Par 75233 Commercial Employers Direct Health - SF Professional 4010A1 Claim Level Accept/Reject

U:09/30/2011 Non-Par 73288 Commercial Employers Health Insurance Professional 4010A1 and 5010A1 Claim Level Rejects Only

A: 04/06/2010 Trans WK083 Commercial TX, MN Employers Mutual Casualty Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK083 Commercial TX, MN Employers Mutual Casualty Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK083 Commercial TX, MN Employers Mutual Casualty Auto 4010A1 Claim Level Accept/Reject

10/17/11 Non-Par 59298 Commercial FL Employer's Mutual, Inc. (Jacksonville, FL) Professional 5010A1 Claim Level Acknowledgement

U:10/27/2011 Non-Par 59298 Commercial FL Employer's Mutual, Inc. (Jacksonville, FL) Institutional 5010A2 No Response From Payer

A: 04/06/2010 Non-Par WK459 Commercial TX, MN Employers Reinsurance Corp Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 35206 Commercial Encircle PPO Institutional 4010A1 No Response From Payer

Non-Par GTPA1 Commercial Encore Encore Professional 4010A1 Claim Level Accept/Reject

Non-Par 35206 Commercial Encore Health Network Institutional 4010A1 No Response From Payer

Non-Par 36364 Commercial ENH Medical Group IPA Institutional 4010A1 No Response From Payer

Non-Par 36364 Commercial ENH Medical Group IPA Professional 4010A1 Claim Level Acknowledgement

Non-Par 91136 Commercial Enstar Natural Gas Institutional 4010A1 No Response From Payer

Non-Par 91136 Commercial Enstar Natural Gas, Grp P61 Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ258 Commercial MN Enterprise Rent A Car Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ258 Commercial MN Enterprise Rent A Car Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK084 Commercial TX, MN Envirosource Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK084 Commercial TX, MN Envirosource Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK084 Commercial TX, MN Envirosource Auto 4010A1 Claim Level Accept/Reject

Non-Par 62308 Commercial EQUICOR Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial EQUICOR Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial EQUICOR - PPO Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial EQUICOR - PPO Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial Equicor Insurance/ Equitable Insurance Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 73126 Commercial Equitable Plan Services Professional 4010A1 Claim Level Acknowledgement

Non-Par 73126 Commercial OK Equitable Plan Services (Oklahoma City, OK) Institutional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WB169 Commercial Erie Insurance Group Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 23250 Commercial Erin Group Administrators Institutional 4010A1 No Response From Payer

Non-Par 23250 Commercial Erin Group Administrators Professional 4010A1 Claim Level Accept/Reject

Non-Par 23250 Commercial Erin Group Administrators Remittance 4010A1 Enrollment

A: 04/06/2010 Trans WK166 Commercial TX, MN ERMC Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK166 Commercial TX, MN ERMC Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK166 Commercial TX, MN ERMC Auto 4010A1 Claim Level Accept/Reject

Non-Par 34108 Commercial ES Beveridge and Associates Institutional 4010A1 File Level Acknowledgement

Non-Par WK018 Commercial ESIS Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK018 Commercial ESIS Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK085 Commercial TX, MN Esis (First American Insurance Co) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK085 Commercial TX, MN Esis (First American Insurance Co) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK085 Commercial TX, MN Esis (First American Insurance Co) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP766 Commercial TX, MN Esis (Irving) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP766 Commercial TX, MN Esis (Irving) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP766 Commercial TX, MN Esis (Irving) Auto 4010A1 Claim Level Accept/Reject

Non-Par 20818 Commercial ESSENCE HEALTHCARE Institutional 4010A1 File Level Acknowledgement

Non-Par 20818 Commercial ESSENCE HEALTHCARE Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WP854 Commercial MN Essential Health Large Deductible Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP854 Commercial MN Essential Health Large Deductible Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP854 Commercial MN Essential Health Large Deductible Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA057 Commercial Esurance Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA057 Commercial Esurance Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA057 Commercial Esurance Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 34159 Commercial E-V Benefits Management, Inc (Columbus, OH) Institutional 4010A1 No Response From Payer

Trans 87726 Commercial Evercare Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 58233 Commercial Evergreen Health Plan Institutional 4010A1 No Response From Payer

Non-Par 58233 Commercial Evergreen Health Plan Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK086 Commercial TX, MN Evolution Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK086 Commercial TX, MN Evolution Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK086 Commercial TX, MN Evolution Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 59313 Commercial Evolutions Healthcare Professional 4010A1 No Response From Payer

Non-Par 59313 Commercial Evolutions Healthcare Systems (New Port Richey FL) Institutional 4010A1 Claim Level Acknowledgement

Par IP080 Commercial CA Exceptional Care Professional 4010A1 Claim Level Accept/Reject

Par 71412 Commercial ExclusiCare Institutional 4010A1 Claim Level Accept/Reject No

Par 71412 Commercial Exclusicare Professional 4010A1 Claim Level Acknowledgement No

Non-Par BVES1 Commercial AZ Eye Specialists Of Arizona Professional 4010A1 Claim Level Accept/Reject

Non-Par WK027 Commercial F.A. Richard & Associates (FARA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK027 Commercial F.A. Richard & Associates (FARA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 91136 Commercial F40 Alaska Carpenters Trust Institutional 4010A1 No Response From Payer

Non-Par 95432 Commercial Facey Medical Foundation Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC133 Commercial TX, MN Facility Insurance Group Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC133 Commercial TX, MN Facility Insurance Group Inst. Work Comp 4010A1 Claim Level Accept/Reject







11/10/2011 23 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 37300 Commercial FACS Group Institutional 4010A1 No Response From Payer

Non-Par 37300 Commercial FACS Group Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK167 Commercial TX, MN Factory 2 U Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK167 Commercial TX, MN Factory 2 U Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK167 Commercial TX, MN Factory 2 U Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ282 Commercial TX, MN Factory Motor Parts Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ282 Commercial TX, MN Factory Motor Parts Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ282 Commercial TX, MN Factory Motor Parts Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP856 Commercial MN Fairmont Foods Of Minnesota (MN) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP856 Commercial MN Fairmont Foods Of Minnesota (MN) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP856 Commercial MN Fairmont Foods Of Minnesota (MN) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK449 Commercial Fairmont Premier Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK449 Commercial Fairmont Premier Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK449 Commercial Fairmont Premier Insurance Company Auto 4010A1 Claim Level Accept/Reject

Par 22254 Commercial Fallon Community Health Professional 4010A1 No Response From Payer

Non-Par 22254 Commercial Fallon Community Health Plan Institutional 4010A1 Claim Level Accept/Reject

Non-Par 60995 Commercial FAMILY CARE Institutional 4010A1 File Level Acknowledgement

A: 12/17/2010 Non-Par 60995 Commercial Family Care Professional 4010A1 File Level Acknowledgement

Non-Par FCD01 Government Family Care Medicaid Professional 4010A1 Claim Level Acknowledgement

Non-Par FCR01 Government Family Care Medicare Professional 4010A1 Claim Level Acknowledgement

Non-Par FCS01 Commercial Family Care Specialists IPA Professional 4010A1 File Level Acknowledgement

Par IP080 Commercial CA Family Choice Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB118 Commercial Family Dollar Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB118 Commercial Family Dollar Inst. Work Comp 4010A1 Claim Level Accept/Reject

Trans AMS01 Commercial WI Family Health Network Professional 4010A1 No Response From Payer

Non-Par 31472 Commercial Family Health Partners - Healthwave Professional 4010A1 Claim Level Accept/Reject

Non-Par 31472 Commercial Family Health Partners - Healthwave of Kansas Institutional 4010A1 File Level Acknowledgement

9/30/11 Non-Par 31472 Commercial Family Health Partners Healthwave Remittance 4010A1 Enrollment

Non-Par 43173 Commercial Family Health Partners/ MC + Missouri Institutional 4010A1 No Response From Payer

U: 01/17/2011 Non-Par 43173 Commercial MO Family Health Partners/MC + Missouri Professional 4010A1 File Level Acknowledgement

9/30/11 Non-Par 43173 Commercial Family Health Partners/MC+ Missouri Remittance 4010A1 Enrollment

Non-Par 36396 Commercial Family Medical Network Professional 4010A1 No Response From Payer

Non-Par FCM01 Commercial Familyl Care MHO Professional 4010A1 Claim Level Acknowledgement

Non-Par 14140 Commercial NY Farm Family Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WP907 Commercial Farm Family Casualty Insuarnce Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP907 Commercial Farm Family Casualty Insuarnce Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP907 Commercial Farm Family Casualty Insuarnce Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 14140 Commercial Farm Family Life Institutional 4010A1 Claim Level Acknowledgement Yes

A: 04/06/2010 Non-Par WB170 Commercial Farmers Insurance (MedRisk Providers ONLY) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK419 Commercial TX, MN Farmland Mutual Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 59069 Commercial FBMC Professional 4010A1 No Response From Payer

Non-Par 33033 Commercial FCE Benefit Administrators Institutional 4010A1 No Response From Payer

Non-Par 33033 Commercial FCE Benefit Administrators Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK424 Commercial Federal Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK424 Commercial Federal Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK424 Commercial Federal Insurance Co Auto 4010A1 Claim Level Accept/Reject

Non-Par 37300 Commercial Federated Benefits Institutional 4010A1 No Response From Payer

Non-Par 37300 Commercial Federated Benefits Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WZ313 Commercial Federated Claims Service Corp. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ313 Commercial Federated Claims Service Corp. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 37300 Commercial Federated HR Services Institutional 4010A1 No Response From Payer

Non-Par 37300 Commercial Federated HR Services/ FACS Group Professional 4010A1 No Response From Payer

Non-Par 41041 Commercial Federated Mutual Health Insurance Institutional 4010A1 No Response From Payer

Non-Par 41041 Commercial MN Federated Mutual Health Insurance Remittance 4010A1 Enrollment

Non-Par 41041 Commercial MN Federated Mutual Health Insurance Company Professional 4010A1 Claim Level Acknowledgement

Non-Par 41041 Commercial Federated Mutual Insurance Remittance 4010A1 Enrollment

Non-Par WK047 Commercial Federated Mutual Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK047 Commercial Federated Mutual Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK168 Commercial TX, MN Federated Rural Electric (TX) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK168 Commercial TX, MN Federated Rural Electric (TX) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK168 Commercial TX, MN Federated Rural Electric (TX) Auto 4010A1 Claim Level Accept/Reject

Non-Par WK169 Commercial Federated Services Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK169 Commercial Federated Services Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK466 Commercial TX, MN Fedex Ground Package System Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 12/17/2010 Par WK187 Commercial FFVA Mutual Insurance Co Prof. Work Comp 4010A1

Trans AMS01 Commercial FL FHC Super Select (FL) Professional 4010A1 No Response From Payer

Trans COFHP Commercial CO FHP of Colorado - HMO Claims Only Professional 4010A1 Claim Level Acknowledgement

Non-Par 11315 Commercial NY Fidelis Care of New York Institutional 4010A1 No Response From Payer

Non-Par 11315 Commercial NY Fidelis Care of New York Professional 4010A1 Claim Level Accept/Reject

Non-Par 77054 Commercial Fidelis Secure Care Professional 4010A1 Claim Level Accept/Reject

Non-Par 77054 Commercial Fidelis Secure Care Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WP937 Commercial Fidelity & Casualty Company of New York Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP937 Commercial Fidelity & Casualty Company of New York Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP937 Commercial Fidelity & Casualty Company of New York Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP941 Commercial Fidelity & Gurananty Insurance Underwriters Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP941 Commercial Fidelity & Gurananty Insurance Underwriters Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP941 Commercial Fidelity & Gurananty Insurance Underwriters Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP938 Commercial Fidelity and Guaranty Insurance Co. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP938 Commercial Fidelity and Guaranty Insurance Co. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP938 Commercial Fidelity and Guaranty Insurance Co. Auto 4010A1 Claim Level Accept/Reject

Non-Par FBI99 Commercial Fidelity Benefit Administrators Professional 4010A1 No Response From Payer Yes

A: 04/06/2010 Non-Par WP942 Commercial TX, MN Fire & Casualty Insuarnce Company of CT Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP942 Commercial TX, MN Fire & Casualty Insuarnce Company of CT Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP942 Commercial TX, MN Fire & Casualty Insuarnce Company of CT Auto 4010A1 Claim Level Accept/Reject

Non-Par WK028 Commercial Fireman's Fund Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK028 Commercial Fireman's Fund Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject







11/10/2011 24 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Trans FAMR1 Commercial First Administrators, Inc Institutional 4010A1 Claim Level Accept/Reject

Trans FAMR1 Commercial SD First Administrators, Inc Professional 4010A1 No Response From Payer

Trans FAMR1 Commercial First American Institutional 4010A1 Claim Level Accept/Reject

Trans FAMR1 Commercial First AmericanAdministrators Institutional 4010A1 Claim Level Accept/Reject

Non-Par 56196 Commercial First Carolina Care Institutional 4010A1 No Response From Payer

Non-Par 56196 Commercial NC First Carolina Care Professional 4010A1 Claim Level Accept/Reject

Non-Par 14162 Commercial CT First Choice (CT) Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 91131 Commercial First Choice Health Network Institutional 4010A1 No Response From Payer

Non-Par 91131 Commercial First Choice Health Network Professional 4010A1 Claim Level Acknowledgement

Non-Par 75138 Commercial First Choice of The Midwest - PPO Institutional 4010A1 No Response From Payer Yes

Non-Par 75138 Commercial SD First Choice of the Midwest - PPO Professional 4010A1 Claim Level Accept/Reject

Non-Par 25133 Commercial First Health Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25133 Commercial First Health (Alta Health Strategies) Remittance 4010A1 Enrollment

Non-Par 73159 Commercial First Health Network (f.k.a CCN Managed Care Inc. & PPO Oklahoma) Institutional 4010A1 No Response From Payer

10/17/11 Non-Par 23241 Commercial First Priority Health Professional 5010A1 Claim Level Acknowledgement

Non-Par 23241 Commercial First Priority Health Remittance 4010A1 Enrollment

Par 59276 Commercial FL First Service Administrators/Florida 1st Professional 4010A1 Claim Level Accept/Reject

Par 59276 Commercial FL First Service Administrators/Florida 1st Institutional 4010A1 No Response From Payer

Par 59276 Commercial FL First Service Administrators/Florida 1st Dental 4010A1 Claim Level Accept/Reject

Par MC104 Government First Services Medicaid Professional 4010A1 No Response From Payer

Par MC104 Government First Services Medicaid Institutional 4010A1 No Response From Payer Yes

Non-Par 94999 Commercial TX Firstcare "Star" Medicaid Professional 4010A1 Claim Level Accept/Reject Contact (800) 365-1051, ext. 6456 to obtain Provider ID.

Non-Par WK029 Commercial Firstcomp Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK029 Commercial Firstcomp Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 11244 Commercial Fitzharris & Company Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Trans WK087 Commercial TX, MN FKI Industries, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK087 Commercial TX, MN FKI Industries, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK087 Commercial TX, MN FKI Industries, Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 59322 Commercial Florida Health Care Plan Professional 4010A1 File Level Acknowledgement

Trans AMS01 Commercial FL Florida Health Choice (FL) Professional 4010A1 No Response From Payer

Trans AMS01 Commercial FL Florida Health Choice/Select (FL) Professional 4010A1 No Response From Payer

U:10/27/2011 Non-Par 59321 Commercial Florida Hospital Healthcare Systems Institutional 5010A2 No Response From Payer Yes

10/17/11 Non-Par 59321 Commercial FL Florida Hospital Healthcare Systems Professional 5010A1 Claim Level Acknowledgement Yes

Non-Par 48116 Commercial Florida Hospital Waterman Institutional 4010A1 No Response From Payer

Non-Par 48116 Commercial FL Florida Hospital Waterman Employee Benefit Plan Professional 4010A1 Claim Level Acknowledgement

Non-Par 59698 Commercial Florida League of Cities Inc. Institutional 4010A1 File Level Acknowledgement

Non-Par 59698 Commercial Florida League of Cities Inc. Professional 4010A1 File Level Acknowledgement

Non-Par 65063 Government Florida NetPass Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WX842 Commercial Florist Mutual Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX842 Commercial Florist Mutual Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX842 Commercial Florist Mutual Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par 48117 Commercial FMH Benefit Services Inc. Remittance 4010A1 Enrollment

Non-Par 48117 Commercial FMH Benefit Services, Inc. Institutional 4010A1 Claim Level Accept/Reject

Non-Par 48117 Commercial FMH Benefit Services, Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par 48117 Commercial FMH Benefit Services, Inc. Remittance 4010A1 Enrollment

A: 04/06/2010 Non-Par WP944 Commercial MN Fond Du Lac Reservation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP944 Commercial MN Fond Du Lac Reservation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP944 Commercial MN Fond Du Lac Reservation Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB119 Commercial Food Lion / Delhaize Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB119 Commercial Food Lion / Delhaize Inst. Work Comp 4010A1 Claim Level Accept/Reject

Trans 95964 Commercial AZ For payable PacifiCare/Secure Horizons HMO claims only. Not for PPO claims. Professional 4010A1 Claim Level Accept/Reject For further questions, you may inquire via email at edioutreach@phs.com

Non-Par 37305 Commercial Ford Meter Box Company, The Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WX692 Commercial TX, MN Forte, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX692 Commercial TX, MN Forte, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 39065 Commercial Fortis Insurance Company (Now known as Time Insurance Company) Professional 4010A1 Claim Level Accept/Reject

Non-Par BOONG Commercial FOUNDATION BENEFIT ADMINISTRATORS/CONTRACTOR EMPLOYEE BENEFITS ADMIN Institutional 4010A1 Claim Level Accept/Reject

Par FH001 Commercial CA Foundation Health Professional 4010A1 Enrollment Claim Level Accept/Reject

9/9/11 Non-Par 64069 Commercial Fox Everett (previously Everett Ingalls Ship Building) Institutional 4010A1 No Response From Payer

9/9/11 Non-Par 64069 Commercial Fox Everett (previously Everett Ingalls Ship Building) Professional 4010A1 No Response From Payer

Non-Par FVMCH Commercial Fox Valley Medicine Site 199 Professional 4010A1 Claim Level Accept/Reject

Non-Par FVMC1 Commercial Fox Valley Medicine Site 451 Professional 4010A1 Claim Level Accept/Reject

Non-Par 64069 Commercial Fox-Everett, Inc. Institutional 4010A1 No Response From Payer

Non-Par 64069 Commercial Fox-Everett, Inc. Professional 4010A1 No Response From Payer

Non-Par WK030 Commercial Frank Gates Service Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK030 Commercial Frank Gates Service Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB106 Commercial Frankenmuth Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB106 Commercial Frankenmuth Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par BS155 Commercial WV Freedom Blue REmittance 4010A1 Enrollment

9/23/11 Non-Par BS155 Government WV Freedom Blue Professional 4010A1 and 5010A1 Enrollment No Response From Payer Yes

Non-Par 31313 Commercial MU Freedom First Professional 4010A1 File Level Acknowledgement

Non-Par 41212 Commercial Freedom Health Professional 4010A1 File Level Acknowledgement

Non-Par 41212 Commercial Freedom Health Plan Institutional 4010A1 File Level Acknowledgement

Non-Par 62324 Commercial Freedom Life Insurance Co. Professional 4010A1 Claim Level Accept/Reject

Non-Par 23130 Commercial Fresenius Medical Care Professional 4010A1 Claim Level Acknowledgement

Non-Par 23130 Commercial Fresenius Medical Care Institutional 4010A1 File Level Acknowledgement

Non-Par 59204 Commercial Fringe Benefit Coordinators Institutional 4010A1 No Response From Payer Yes

Non-Par 59204 Commercial FL Fringe Benefit Coordinators Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 59069 Commercial Fringe Benefit Management Institutional 4010A1 No Response From Payer

Non-Par 34171 Commercial Frontpath Health Coalition Professional 4010A1 Claim Level Acknowledgement

Non-Par 34171 Commercial FrontPath Health Coalition Institutional 4010A1 File Level Acknowledgement

Par FC101 Commercial CA Future Care Medical Associates Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP949 Commercial TX, MN G A B Business Services Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP949 Commercial TX, MN G A B Business Services Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP949 Commercial TX, MN G A B Business Services Auto 4010A1 Claim Level Accept/Reject

Non-Par WK031 Commercial GAB Robbins, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK031 Commercial GAB Robbins, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject







11/10/2011 25 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par WK032 Commercial GAB Robins (for Van Tuyl Companies ONLY) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK032 Commercial GAB Robins (for Van Tuyl Companies ONLY) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP950 Commercial TX, MN Gainey Corporation-Grand Rapids Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP950 Commercial TX, MN Gainey Corporation-Grand Rapids Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP950 Commercial TX, MN Gainey Corporation-Grand Rapids Auto 4010A1 Claim Level Accept/Reject

Non-Par WK020 Commercial Gallagher Bassett Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK020 Commercial Gallagher Bassett Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 37283 Commercial Gallagher Benefit Administrators, Inc./GBA Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 37283 Commercial Gallagher Benefits Management Institutional 4010A1 No Response From Payer Yes

Non-Par 30005 Commercial Galveston County Indigent Health Professional 4010A1 Claim Level Accept/Reject

Non-Par 30005 Commercial Galveston County Indigent Health Institutional 4010A1 No Response From Payer

A: 04/06/2010 Trans WX929 Commercial Gategourmet #836 Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX929 Commercial Gategourmet #836 Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX929 Commercial Gategourmet #836 Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK088 Commercial TX, MN Gates Corp Dba Gates Rubber Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK088 Commercial TX, MN Gates Corp Dba Gates Rubber Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK088 Commercial TX, MN Gates Corp Dba Gates Rubber Co Auto 4010A1 Claim Level Accept/Reject

Non-Par 25169 Commercial Gateway Health Plan - Medicaid PA Remittance 4010A1 Enrollment

Non-Par 60550 Commercial Gateway Health Plan - Medicare Assured Professional 4010A1 File Level Acknowledgement

Non-Par 60550 Commercial Gateway Health Plan - Medicare Assured Remittance 4010A1 Enrollment

Non-Par 60550 Commercial Gateway Health Plan - Medicare Assured Institutional 4010A1 Claim Level Accept/Reject

Non-Par 25169 Commercial Gateway Health Plan Medicaid PA Remittance 4010A1 Enrollment

Non-Par 25169 Commercial Gateway Health Plan - Medicaid PA Institutional 4010A1 No Response From Payer

Non-Par 25169 Commercial Gateway Health Plan - Medicaid PA Professional 4010A1 No Response From Payer

Non-Par 25169 Commercial Gateway Health Plan - Medicare Assured Professional 4010A1 No Response From Payer

Non-Par 44054 Commercial GEHA Institutional 4010A1 No Response From Payer

Non-Par 44054 Commercial GEHA Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 44054 Commercial GEHA Remittance 4010A1 Enrollment

Non-Par 44054 Commercial GEHA Ins. No. 372 Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WCG01 Commercial Geico Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WCG01 Commercial Geico Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WCG01 Commercial Geico Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par 75273 Commercial Geisinger Health Plans Institutional 4010A1 Enrollment No Response From Payer

Non-Par 75273 Commercial Geisinger Health Plans Remittance 4010A1 Enrollment

Non-Par 75273 Commercial Geisinger Health Plans Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par MCS01 Commercial GEMCare (Golden Empire Managed Care System) Professional 4010A1 File Level Acknowledgement

Non-Par MCS03 Commercial GemCare Health Plan, Kern County EPO Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WP955 Commercial General Accident Corp of America Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP955 Commercial General Accident Corp of America Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP955 Commercial General Accident Corp of America Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP957 Commercial TX, MN General Casualty (Eden Prairie) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP957 Commercial TX, MN General Casualty (Eden Prairie) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP956 Commercial TX, MN General Casualty (Farmers' Union) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP956 Commercial TX, MN General Casualty (Farmers' Union) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP958 Commercial TX, MN General Casualty (Freeport) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP958 Commercial TX, MN General Casualty (Freeport) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP959 Commercial TX, MN General Casualty (Indianapolis) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP959 Commercial TX, MN General Casualty (Indianapolis) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP960 Commercial TX, MN General Casualty (Simsbury) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP960 Commercial TX, MN General Casualty (Simsbury) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP961 Commercial TX, MN General Casualty (Sun Prairie) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP961 Commercial TX, MN General Casualty (Sun Prairie) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP962 Commercial TX, MN General Casualty (West Des Moines) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP962 Commercial TX, MN General Casualty (West Des Moines) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK441 Commercial TX, MN General Casualty Co of Wisconsin Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK441 Commercial TX, MN General Casualty Co of Wisconsin Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 46050 Commercial Generations - OCC Professional 4010A1 Claim Level Accept/Reject

Non-Par 46050 Commercial Generations Healthcare Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 46051 Commercial Generations-Hillcrest Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 46051 Commercial Generations-Hillcrest Professional 4010A1 File Level Acknowledgement Yes

Non-Par IP105 Commercial CA Genesis Healthcare Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WC113 Commercial TX, MN Genex Care for Ohio Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC113 Commercial TX, MN Genex Care for Ohio Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC113 Commercial TX, MN Genex Care for Ohio Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX948 Commercial TX, MN Genex Services (Orange County) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX949 Commercial TX, MN Genex Services (Sacramento) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX946 Commercial TX, MN Genex Services (Schaumburg, IL) Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 75238 Commercial TX GENWORTH ADMINISTRATORS, INC., TEXAS Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WB121 Commercial GEO Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB121 Commercial GEO Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC128 Commercial Georgia Casualty & Surety Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC128 Commercial Georgia Casualty & Surety Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

Par 61271 Commercial GA Georgia Power Med. Benefits Pln (Hlth Care Srvcs) Professional 4010A1 No Response From Payer Yes

Non-Par 23212 Commercial Gettysburg Health Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 23212 Commercial Gettysburg Health Professional 4010A1 File Level Acknowledgement Yes

U: 01/10/2011 Non-Par 22937 Commercial GHI - Medicare Private Fee for Service Institutional 4010A1 Claim Level Accept/Reject

A: 01/10/2011 Non-Par 22937 Commercial GHI - Medicare Private Fee for Service Professional 4010A1 Claim Level Accept/Reject

Non-Par 13551 Commercial NY GHI - New York (Group Health, Inc.) Institutional 4010A1 Claim Level Accept/Reject

Non-Par 13551 Commercial NY GHI - New York (Group Health, Inc.) Professional 4010A1 Claim Level Accept/Reject

Any provider that wishes to receive 835 must be a participating provider with the

Non-Par 13551 Commercial NY GHI - New York (Group Health, Inc.) Remittance 4010A1 Enrollment payer. If they are non-participating they will not receive 835.

Non-Par 25531 Commercial GHI HMO Select Institutional 4010A1 No Response From Payer Yes

Non-Par 25531 Commercial GHI HMO Select Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25531 Commercial GHI HMO Select Remittance 4010A1 Enrollment

Non-Par 58204 Commercial GI Innovative Management Professional 4010A1 Claim Level Accept/Reject

Non-Par 80314 Commercial GIC Indemnity Plan Institutional 4010A1 No Response From Payer Yes







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Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Non-Par WP966 Commercial MN Gillette Children'S Specialty H.C. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP966 Commercial MN Gillette Children'S Specialty H.C. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP966 Commercial MN Gillette Children'S Specialty H.C. Auto 4010A1 Claim Level Accept/Reject

Non-Par 07205 Commercial Gilsbar, Inc. Institutional 4010A1 No Response From Payer

Non-Par 07205 Commercial Gilsbar, Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par 91136 Commercial Glassworkers Hlth & Welfare Fund, Grp F29 Professional 4010A1 Claim Level Accept/Reject .

Non-Par 07689 Commercial GA Global Care Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 07689 Commercial Global Care Inc. Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par MPM05 Commercial Global Care Medical Group IPA Professional 4010A1 File Level Acknowledgement

Non-Par 12X59 Commercial Global Healthcare Alliance Institutional 4010A1 File Level Acknowledgement

Non-Par 23641 Commercial GMP Employers Retiree Trust Professional 4010A1 No Response From Payer

Non-Par 47083 Commercial GMS Inc. Institutional 4010A1 Claim Level Acknowledgement Yes

Non-Par 47083 Commercial GMS, Inc Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Trans WK089 Commercial TX, MN Golden Corral Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK089 Commercial TX, MN Golden Corral Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK089 Commercial TX, MN Golden Corral Corporation Auto 4010A1 Claim Level Accept/Reject

Trans 37602 Commercial Golden Rule Insurance Company Institutional 4010A1 No Response From Payer

Trans 37602 Commercial Golden Rule Insurance Company Professional 4010A1 No Response From Payer Yes

A: 04/06/2010 Trans WX984 Commercial Golden State Supply Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX984 Commercial Golden State Supply Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX984 Commercial Golden State Supply Auto 4010A1 Claim Level Accept/Reject

U: 12/29/2010 Non-Par GTPA1 Commercial Golden Triangle Physician Alliance Professional 4010A1 Claim Level Accept/Reject

Non-Par 72189 Commercial Golden Triangle Physician Alliance/SelectCare of Texas (GTPA) Institutional 4010A1 File Level Acknowledgement

Non-Par 72189 Commercial Golden Triangle Physician Alliance/SelectCare of Texas (GTPA) Professional 4010A1 File Level Acknowledgement

Par IP086 Commercial CA Good Samaritan Medical Practice Association (GSMPA) Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB122 Commercial Goodrich Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB122 Commercial Goodrich Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP968 Commercial MN Gopher Resource Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP968 Commercial MN Gopher Resource Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP968 Commercial MN Gopher Resource Corporation Auto 4010A1 Claim Level Accept/Reject

Non-Par 44054 Commercial Government Employees Hospital Association Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 44054 Commercial Government Employees Hospital Association (GEHA) Institutional 4010A1 No Response From Payer

Non-Par 44054 Commercial Government Employees Hospital Association (GEHA) Remittance 4010A1 Enrollment

A: 04/06/2010 Non-Par WP969 Commercial MN Grand Portage Res. Tribal Council Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP969 Commercial MN Grand Portage Res. Tribal Council Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP969 Commercial MN Grand Portage Res. Tribal Council Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP970 Commercial Grange Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP970 Commercial Grange Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP970 Commercial Grange Insurance Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA058 Commercial Grange Mutual Casualty Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA058 Commercial Grange Mutual Casualty Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA058 Commercial Grange Mutual Casualty Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 37234 Commercial Grant Physicians Practice Association Institutional 4010A1 No Response From Payer

Non-Par 37234 Commercial Grant Physicians Practice Association Professional 4010A1 No Response From Payer

Non-Par WK033 Commercial Graphic Arts Mutual Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK033 Commercial Graphic Arts Mutual Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par GCU99 Commercial Graphic Communications Union Local 8-M & 96B Health & Welfare Fund Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WP747 Commercial TX, MN Graphics Art Mutual Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP747 Commercial TX, MN Graphics Art Mutual Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC134 Commercial TX, MN Gray Insurance Co. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC134 Commercial TX, MN Gray Insurance Co. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK034 Commercial Great American Alliance Ins Co. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK034 Commercial Great American Alliance Ins Co. Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK035 Commercial Great American Assurance Co. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK035 Commercial Great American Assurance Co. Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK036 Commercial Great American Ins Co. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK036 Commercial Great American Ins Co. Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK037 Commercial NY Great American Ins of N.Y. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK037 Commercial NY Great American Ins of N.Y. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP971 Commercial Great Central (Argonaut) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP971 Commercial Great Central (Argonaut) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP971 Commercial Great Central (Argonaut) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK170 Commercial TX, MN Great Divide Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK170 Commercial TX, MN Great Divide Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK170 Commercial TX, MN Great Divide Insurance Auto 4010A1 Claim Level Accept/Reject

Trans 95467 Commercial Great Lakes Health Plan Institutional 4010A1 No Response From Payer

Trans 95467 Commercial Great Lakes Health Plan Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Trans WC154 Commercial TX, MN Great River Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC154 Commercial TX, MN Great River Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 80705 Commercial Great West Remittance 4010A1 Enrollment

U: 08/26/2011 Non-Par 80705 Commercial Great West (Formerly One Health Plan CA) Institutional 4010A1 No Response From Payer

U: 08/26/2011 Non-Par 80705 Commercial Great West (Formerly One Health Plan CO) Institutional 4010A1 No Response From Payer

U: 08/26/2011 Non-Par 80705 Commercial Great West (Formerly One Health Plan GA) Institutional 4010A1 No Response From Payer

U: 08/26/2011 Non-Par 80705 Commercial Great West (Formerly One Health Plan IL) Institutional 4010A1 No Response From Payer

U: 08/26/2011 Non-Par 80705 Commercial Great West (Formerly One Health Plan TX 95415) Institutional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK416 Commercial TX, MN Great West Casualty Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK416 Commercial TX, MN Great West Casualty Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

Par GNPMG Commercial Greater Newport Physician Professional 4010A1 Claim Level Accept/Reject

Non-Par NMM01 Commercial Greater Orange County Medical Group Professional 4010A1 Claim Level Accept/Reject

Non-Par 80705 Commercial Great-West Healthcare Institutional 4010A1 No Response From Payer

Non-Par 80705 Commercial MO Great-West Healthcare (formerly Gencare Health -St. Louis / payer id 63665) Professional 4010A1 No Response From Payer

Non-Par 80705 Commercial MO Great-West Healthcare (formerly Genelco - St. Louis Only / payer id 63665) Professional 4010A1 No Response From Payer

Non-Par 80705 Commercial Great-West Healthcare (formerly General American Life / payer id 63665) Professional 4010A1 No Response From Payer

Non-Par 80705 Commercial MO Professional

Great-West Healthcare (formerly General American Life Ins. Co. - Sanus, St. Louis / payer id 63665) 4010A1 No Response From Payer

Non-Par 80705 Commercial Great-West Healthcare (formerly General American -Sanus - East / payer id 63665) Professional 4010A1 No Response From Payer

Non-Par 80705 Commercial Great-West Healthcare (formerly New England Financial/ payer id 66893) Professional 4010A1 No Response From Payer







11/10/2011 27 of 66

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Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 80705 Commercial Great-West Healthcare (formerly One Health Plan ---- Except CA, CO, GA, IL, or TX) Professional 4010A1 No Response From Payer

Non-Par 80705 Commercial CA Great-West Healthcare (formerly One Health Plan of California, Inc./ payer id 95379) Professional 4010A1 No Response From Payer

Non-Par 80705 Commercial CO Great-West Healthcare (formerly One Health Plan of Colorado, Inc. / payer id 95412) Professional 4010A1 No Response From Payer

Non-Par 80705 Commercial GA Great-West Healthcare (formerly One Health Plan of Georgia, Inc / payer id 95569.) Professional 4010A1 No Response From Payer

Non-Par 80705 Commercial IL Great-West Healthcare (formerly One Health Plan of Illinois, Inc. / payer id 95388) Professional 4010A1 No Response From Payer

Non-Par 80705 Commercial TX Great-West Healthcare (formerly One Health Plan of Texas, Inc./ payer id 95415) Professional 4010A1 No Response From Payer

U: 08/26/2011 Non-Par 80705 Commercial MO Great-West Healthcare (formerly Sanus HMO - St. Louis -General American / payer id 63665)Professional 4010A1 No Response From Payer

U: 08/26/2011 Non-Par 80705 Commercial Professional

Great-West Healthcare (formerly Sanus PPO -General American - Sanus East / payer id 63665) 4010A1 No Response From Payer

Non-Par 80705 Commercial Great-West Healthcare (FormerlyAmerican General 63665) Institutional 4010A1 No Response From Payer

U: 08/26/2011 Non-Par 80705 Commercial Great-West Healthcare/ First Great West Life & Annuity Ins. Co. Professional 4010A1 No Response From Payer

U: 08/26/2011 Non-Par 80705 Commercial Great-West Life Institutional 4010A1 No Response From Payer

Non-Par 78521 Commercial Greentree Administrators Professional 4010A1 Claim Level Accept/Reject

Non-Par GASA1 Commercial Group Admin Self-Funded Alternative Professional 4010A1 Claim Level Accept/Reject

Non-Par 36338 Commercial Group Administrators Ltd. Institutional 4010A1 No Response From Payer

Non-Par 36338 Commercial Group Administrators Ltd. Professional 4010A1 Claim Level Acknowledgement

Non-Par 48143 Commercial Group And Pension Administrators Institutional 4010A1 No Response From Payer

Non-Par 48143 Commercial Group and Pension Administrators {Group # required on all claims} Professional 4010A1 Claim Level Acknowledgement

Non-Par 72087 Commercial LA Group Benefits - Louisiana Professional 4010A1 Claim Level Accept/Reject

Non-Par 91121 Commercial Group Health Cooperative - East Institutional 4010A1 Enrollment No Response From Payer

Non-Par 91121 Commercial WA Professional 4010A1

Group Health Cooperative - East [All GHC products, including Options, Alliant, Medicare +Choice and Healthy Options can be submitted electronically.] Claim Level Acknowledgement

U: 12/30/2010 Non-Par 91051 Commercial Group Health Cooperative - WA State Institutional 4010A1 No Response From Payer Yes

Non-Par 91051 Commercial WA Group Health Cooperative - West Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 95192 Commercial Group Health Cooperative of Eau Claire Professional 4010A1 File Level Acknowledgement

Non-Par 39167 Commercial Group Health Cooperative of South Central Wisconsin Institutional 4010A1 No Response From Payer

Non-Par 39168 Commercial Group Health Cooperative of South Central Wisconsin Institutional 4010A1 No Response From Payer

Non-Par 39167 Commercial WI Group Health Cooperative of South Central Wisconsin (claims) Professional 4010A1 Claim Level Accept/Reject

Non-Par 39168 Commercial WI Group Health Cooperative of South Central Wisconsin (encounters) Professional 4010A1 Claim Level Acknowledgement

U: 01/10/2011 Non-Par 22937 Commercial Group Health Inc. Institutional 4010A1 Claim Level Accept/Reject

U: 12/30/2010 Non-Par 91051 Commercial Group Health Options - WA State Institutional 4010A1 No Response From Payer Yes

Non-Par 13551 Commercial NY Group Health, Inc. (GHI) Professional 4010A1 Claim Level Accept/Reject

Non-Par 37276 Commercial Group Insurance Service Center Inc. Institutional 4010A1 No Response From Payer

Non-Par 37276 Commercial Group Insurance Service Center, Inc. (GISC) Professional 4010A1 No Response From Payer

Non-Par 68046 Commercial Group Practice Affiliates Professional 4010A1 Claim Level Accept/Reject

Non-Par 68046 Commercial Group Practice Affiliates Institutional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK090 Commercial TX, MN Gse Lining Technology, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK090 Commercial TX, MN Gse Lining Technology, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK090 Commercial TX, MN Gse Lining Technology, Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 77010 Commercial Guardian Healthcare INC. (SC) Professional 4010A1 Claim Level Acknowledgement

Non-Par 77010 Commercial Guardian Healthcare INC. (SC) Institutional 4010A1 Claim Level Acknowledgement

Non-Par 64246 Commercial Guardian Life Insurance Company of America Institutional 4010A1 No Response From Payer

Non-Par 64246 Commercial MU Guardian Life Insurance Company of America Remittance 4010A1 Enrollment

Non-Par 64246 Commercial Guardian Life Insurance Company Of America (The Guardian) Professional 4010A1 No Response From Payer

Par 41203 Commercial Gulf Coast Physicians Network Professional 4010A1 Claim Level Accept/Reject

Non-Par 39180 Commercial Gundersen Lutheran Health Plan, Inc. Professional 4010A1 No Response From Payer

Non-Par 39180 Commercial Gundersen Lutheran Health Plan, Inc. Remittance 4010A1 Enrollment

A: 04/06/2010 Trans WZ043 Commercial Guy Evans Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ043 Commercial Guy Evans Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ043 Commercial Guy Evans Inc Auto 4010A1 Claim Level Accept/Reject

Non-Par 37114 Commercial H.E.R.E.I.U. Welfare Pension Plan Funds Institutional 4010A1 No Response From Payer

Non-Par 37114 Commercial H.E.R.E.I.U. Welfare Pension Plan Funds Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WB123 Commercial Hannaford Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB123 Commercial Hannaford Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP927 Commercial TX, MN Hanover Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 38224 Commercial HAP/AHL/Curanet Institutional 4010A1 Claim Level Accept/Reject

Par 38224 Commercial MI HAP/AHL/Curanet Professional 4010A1 Claim Level Rejects Only

A: 04/06/2010 Non-Par WK450 Commercial TX, MN Harco National Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 36406 Commercial Harmony Health Plan of Illinois Professional 4010A1 Claim Level Acknowledgement Yes

ONLY CLAIMS FOR INDIANA HOOSIER HEALTHWISE MEMBERS can be

Non-Par 36405 Commercial IN Harmony Health Plan of Indiana Professional 4010A1 Claim Level Acknowledgement Yes sent to this payer electronically

Non-Par 62061 Commercial Harrington Health - formerly Fiserv/Willis Professional 4010A1 Claim Level Accept/Reject

Non-Par 62061 Commercial Harrington Health - formerly Fiserv/Willis Institutional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WB109 Commercial Hartford / Speciality Risk Services (SRS) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB109 Commercial Hartford / Speciality Risk Services (SRS) Inst. Work Comp 4010A1 Claim Level Accept/Reject

U: 12/30/2010 Non-Par 04271 Commercial MA Harvard Pilgrim Health Plan Institutional 4010A1 No Response From Payer

Non-Par 04271 Commercial MA Harvard Pilgrim Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 04271 Commercial MA Harvard Pilgrim Health Plan Remittance 4010A1 Enrollment

Non-Par 86068 Commercial IA Hawki Professional 4010A1 Claim Level Acknowledgement

Non-Par 37111 Commercial HCH Administration Professional 4010A1 No Response From Payer

Non-Par 37111 Commercial HCH Administration (Illinois) Institutional 4010A1 No Response From Payer

Non-Par 37329 Commercial HCHA Albequerque Self-Funded Institutional 4010A1 No Response From Payer

Non-Par 37329 Commercial HCHA Albequerque Self-Funded Professional 4010A1 No Response From Payer

Non-Par 82018 Commercial HCS - Health Claims Service (Boise, ID) Institutional 4010A1 No Response From Payer

Non-Par 90023 Commercial HDPC - Premier Healthcare Institutional 4010A1 File Level Acknowledgement

Non-Par 90023 Commercial HDPC - Premier Healthcare Professional 4010A1 File Level Acknowledgement

Non-Par 20257 Commercial HDPC/Alliance Physicians Institutional 4010A1 File Level Acknowledgement

Non-Par 20257 Commercial HDPC/Alliance Physicians Professional 4010A1 File Level Acknowledgement

Non-Par 34185 Commercial Health Administration Service Professional 4010A1 Claim Level Acknowledgement

Non-Par 34185 Commercial Health Administration Services Institutional 4010A1 No Response From Payer

Trans 77950 Commercial MU Health Alliance Medical Plan Professional 4010A1 Claim Level Acknowledgement

Trans 77950 Commercial Health Alliance Medical Plans Institutional 4010A1 No Response From Payer

Non-Par 77950 Commercial Health Alliance Medical Plans Remittance 4010A1 Enrollment

Non-Par Call Commercial MU Health care District Palm Beach County Professional 4010A1 Claim Level Accept/Reject Please contact payer to obtain payer # at (866) 930-1002

A: 04/06/2010 Non-Par WR012 Commercial MN Health Care Group Self Insured Association Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR012 Commercial MN Health Care Group Self Insured Association Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR012 Commercial MN Health Care Group Self Insured Association Auto 4010A1 Claim Level Accept/Reject

Non-Par MPM06 Commercial Health Care LA, IPA Professional 4010A1 File Level Acknowledgement







11/10/2011 28 of 66

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Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 42102 Commercial Health Care Network Professional 4010A1 Claim Level Accept/Reject

Non-Par 42102 Commercial Health Care Network of Wisconsin (HCN) Institutional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WR019 Commercial MN Health Care Reciprocal Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR019 Commercial MN Health Care Reciprocal Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR019 Commercial MN Health Care Reciprocal Auto 4010A1 Claim Level Accept/Reject

Par 61271 Commercial GA Health Care Services, Georgia Power Professional 4010A1 No Response From Payer Yes

Non-Par 62179 Commercial AZ Health Choice Arizona Professional 4010A1 File Level Acknowledgement

Non-Par 62179 Commercial AZ Health Choice Arizona Remittance 4010A1 Enrollment

Non-Par 62179 Commercial AZ Health Choice Arizona Institutional 4010A1 File Level Acknowledgement

Non-Par 62180 Commercial Health Choice Generations Professional 4010A1 Claim Level Accept/Reject

Non-Par 62180 Commercial Health Choice Generations Institutional 4010A1 Claim Level Accept/Reject

Non-Par 62180 Commercial Health Choice Generations Remittance 4010A1 Enrollment

Non-Par 62179 Commercial AZ Health Choice of AZ Professional 4010A1 File Level Acknowledgement

Non-Par 62179 Commercial AZ Health Choice of AZ Remittance 4010A1 Enrollment

Non-Par 82018 Commercial Health Claims Service Professional 4010A1 Claim Level Acknowledgement

Non-Par 62111 Commercial Health Cost Solutions Institutional 4010A1 File Level Acknowledgement

Non-Par 34158 Commercial Health Design Plus (Hudson, OH) Institutional 4010A1 No Response From Payer

Non-Par 34158 Commercial OH Health Design Plus (Hudson, OH) Professional 4010A1 No Response From Payer

Par 16120 Commercial Health EZ Professional 4010A1 No Response From Payer

Non-Par 95019 Commercial FL Health First Health Plan Professional 4010A1 Claim Level Accept/Reject

A: 12/17/2010 Non-Par 23274 Commercial Health Group Limited Professional 4010A1 File Level Acknowledgement

Non-Par 59087 Commercial Health Help Network Inc. (HHNI) Professional 4010A1 Claim Level Acknowledgement

Non-Par 95567 Commercial Health Net - California Institutional 4010A1 No Response From Payer

Non-Par 95567 Commercial CA Health Net - California Remittance 4010A1 Enrollment

Non-Par 95568 Commercial Health Net - California (Institutional Encounters ONLY) Institutional 4010A1 No Response From Payer

Par 95567 Commercial CA Health Net (Claims Only) Professional 4010A1 Claim Level Accept/Reject No

Trans HM001 Commercial CA Health Net (Encounters Only) Professional 4010A1 Enrollment Claim Level Accept/Reject

TO REQUEST ERA'S FOR HEALTH NET ARIZONA, YOU MUST ENROLL

A: 01/17/2011 Non-Par 38309 Commercial Health Net Arizona Remittance 4010A1 FOR ERAS UNDER PAYER ID 06108.

Par 38309 Commercial AZ Health Net of Arizona Professional 4010A1 Claim Level Acknowledgement

A: 12/21/2010 Non-Par 38309 Commercial Health Net of Arizona Institutional 4010A1 Claim Level Accept/Reject

10/10/2011 Non-Par 06108 Commercial CT Health Net of the Northeast Remittance 4010A1 Enrollment

U: 01/17/2011 Par 06108 Commercial Health Net of the Northeast Professional 4010A1 Claim Level Accept/Reject Please call the EDI Team at 866-334-4638 to verify Provider ID

Non-Par 06108 Commercial Health Net Of The Northeast, Inc. Institutional 4010A1 No Response From Payer

Non-Par 12X48 Commercial Health Net Pearl Institutional 4010A1 Claim Level Accept/Reject

Trans AMS01 Commercial TN Health Net Plus (TN) Professional 4010A1 No Response From Payer

Non-Par 65062 Commercial Health Network One Professional 4010A1 File Level Acknowledgement

Non-Par 04286 Commercial Health New England Professional 4010A1 Claim Level Accept/Reject

Non-Par 36368 Commercial Health Options of Illinois Institutional 4010A1 File Level Acknowledgement

Non-Par 36368 Commercial Health Options of Illinois Professional 4010A1 File Level Acknowledgement

10/22/11 Non-Par BS022 Government FL Health Options, Inc. Professional 4010A1 and 5010A1 Claim Level Rejects Only Yes

Non-Par 62157 Commercial Health Partners - Jackson, TN Institutional 4010A1 No Response From Payer

Non-Par 62157 Commercial TN Health Partners (Tennessee) Professional 4010A1 Claim Level Accept/Reject

Non-Par 80142 Commercial Health Partners of Philadelphia Institutional 4010A1 No Response From Payer

Non-Par 80142 Commercial PA Health Partners of Philadelphia Professional 4010A1 Claim Level Accept/Reject

Non-Par 20270 Commercial Health Payment Services Professional 4010A1 Claim Level Accept/Reject

Non-Par 20270 Commercial Health Payment Systems Inc. Institutional 4010A1 File Level Acknowledgement

Non-Par 63719 Commercial Health Plan Management Services(HPMS) Professional 4010A1 File Level Acknowledgement

Non-Par 63719 Commercial Health Plan Management Services(HPMS) Institutional 4010A1 File Level Acknowledgement

Non-Par 83253 Commercial Health Plan of Michigan Institutional 4010A1 Claim Level Acknowledgement

Non-Par 83253 Commercial MI Health Plan of Michigan - HMO for Medicaid Professional 4010A1 Claim Level Accept/Reject

Non-Par 83253 Commercial MI Health Plan Of Michigan - HMO Medicaid Remittance 4010A1 Enrollment

Non-Par 68035 Commercial Health Plan of San Joaquin Professional 4010A1 Claim Level Acknowledgement

Non-Par 68035 Commercial Health Plan of San Joaquin Institutional 4010A1 File Level Acknowledgement

Par HPSM1 Commercial Health Plan of San Mateo Professional 4010A1 No Response From Payer

Non-Par 94254 Commercial CA Health Plan of the Redwoods (Mediprime) Professional 4010A1 Claim Level Accept/Reject

Trans HP001 Commercial OH Health Plan of Upper Ohio Valley Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par HP001 Commercial OH Health Plan of Upper Ohio Valley Remittance 4010A1 Enrollment

Par 59140 Commercial Health Plan Services Professional 4010A1 No Response From Payer

Non-Par 44273 Commercial Health Plans, Inc. Institutional 4010A1 No Response From Payer

Non-Par 44273 Commercial Health Plans, Inc. Professional 4010A1 Claim Level Acknowledgement

Non-Par 95435 Commercial Health Pledge HMO Professional 4010A1 Claim Level Acknowledgement

Non-Par 11324 Commercial Health Plus PHSP Institutional 4010A1 No Response From Payer Yes

Non-Par 11324 Commercial Health Plus PHSP Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 41170 Commercial Health Risk Management Professional 4010A1 No Response From Payer

Non-Par 55438 Commercial Health Risk Management Institutional 4010A1 No Response From Payer

Non-Par HSM01 Commercial Health Service Management Professional 4010A1 Claim Level Accept/Reject

Non-Par 20896 Commercial Health Services Consulting Group Inc. Institutional 4010A1 File Level Acknowledgement

Non-Par 20896 Commercial Health Services Consulting Group Inc. Professional 4010A1 File Level Acknowledgement

Non-Par 37290 Commercial Health Services for Children (HSCSN) Institutional 4010A1 No Response From Payer

Non-Par 37290 Commercial Health Services for Children (HSCSN) Professional 4010A1 Claim Level Accept/Reject

Non-Par 34167 Commercial Health Services Preferred (HSP) by Emerald Health Institutional 4010A1 No Response From Payer

Non-Par IP102 Commercial CA Healthcare Partners Professional 4010A1 Claim Level Accept/Reject

Non-Par 11328 Commercial HealthCare Partners IPA Institutional 4010A1 No Response From Payer

Non-Par 11328 Commercial NY HealthCare Partners IPA (Formerly Heritage NY Medical Group) Professional 4010A1 No Response From Payer

Contact payer, provider relationsat 1-877-284-0101 ext 7074

Non-Par 90001 Commercial Healthcare Plan PPO Professional 4010A1 Claim Level Acknowledgement Yes prior to submitting claims.

Trans AMS01 Commercial IA Healthcare Preferred (IA) Professional 4010A1 No Response From Payer

Non-Par 82468 Commercial Healthcare Resource Group (HRG) Institutional 4010A1 No Response From Payer

Non-Par 56731 Commercial Healthcare Resources NW Institutional 4010A1 File Level Acknowledgement

Non-Par 56731 Commercial Healthcare Resources NW Professional 4010A1 File Level Acknowledgement

Non-Par 88028 Commercial Healthcare Resources, Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par 73147 Commercial HealthCare Solutions Group Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 73147 Commercial Healthcare Solutions Group Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 31147 Commercial OH Healthcare Transaction Processing, Inc (HTP) Professional 4010A1 Claim Level Accept/Reject

U: 01/11/2011 Trans 25143 Commercial Healthcare USA Remittance 4010A1 Enrollment

Par 36335 Commercial Healthcare's Finest Network Professional 4010A1 Claim Level Accept/Reject





11/10/2011 29 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Par HCOMP Commercial CA HealthComp Professional 4010A1 Claim Level Acknowledgement

Par HCOMP Commercial CA HealthComp Institutional 4010A1 Claim Level Acknowledgement

Non-Par 59608 Commercial FL Healthease Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 41178 Commercial HealthEZ Institutional 4010A1 File Level Acknowledgement

Non-Par 75234 Commercial Healthfirst - TPA (Tyler, TX) Institutional 4010A1 No Response From Payer

Non-Par 80141 Commercial Healthfirst 65 Plus Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 80141 Commercial Healthfirst Family Health Plus (FHP) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 95019 Commercial FL HealthFirst Health Plan Remittance 4010A1 Enrollment

Non-Par 80141 Commercial Healthfirst Health Plan of New Jersey Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 80141 Commercial Healthfirst Inc. (New York) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 80141 Commercial Healthfirst New York (COMMERCIAL) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 80141 Commercial Healthfirst PHSP Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 75234 Commercial TX Healthfirst Tyler, TX Professional 4010A1 Claim Level Acknowledgement

Non-Par 80141 Commercial NY Healthfirst, Inc. Remittance 4010A1 Enrollment



Non-Par 80141 Commercial NY Healthfirst, Inc. Professional 4010A1 Claim Level Acknowledgement Yes Contact the payer prior to submitting claims to verify provider id. (212)801-6078)

Non-Par 23226 Commercial HealthGuard of Lancaster Professional 4010A1 Claim Level Acknowledgement

Non-Par 96475 Commercial Healthlink HMO Institutional 4010A1 No Response From Payer

Non-Par 96475 Commercial Healthlink HMO Professional 4010A1 Claim Level Acknowledgement Contact payer at 800-624-2356 prior to submitting claims.

Please call provider relations dept at 1-877-284-0101 ext 7074

Non-Par 90001 Commercial Healthlink PPO Professional 4010A1 Claim Level Acknowledgement Yes prior to submitting claims for unique provider id

Contact payer, provider relationsat 1-877-284-0101 ext 7074

U:10/27/2011 Non-Par 90001 Commercial Healthlink PPO Institutional 5010A2 Claim Level Acknowledgement Yes prior to submitting claims.

Non-Par 55204 Commercial NY HealthNow New York Professional 4010A1 Enrollment Claim Level Acknowledgement Yes

Non-Par 55204 Commercial NY HealthNow New York Remittance 4010A1 Enrollment

Non-Par 94267 Commercial MN HealthPartners Institutional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par 94267 Commercial MN HealthPartners Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par 94267 Commercial MN HealthPartners Remittance 4010A1 Enrollment

Non-Par 59140 Commercial HealthPlan Services Institutional 4010A1 Claim Level Accept/Reject

U: 12/30/2010 Non-Par 95009 Commercial LA HealthPlus of Louisiana Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par 95009 Commercial LA HealthPlus of Louisiana Remittance 4010A1 Enrollment

Non-Par 38216 Commercial MI HealthPlus of Michigan Professional 4010A1 File Level Acknowledgement

Non-Par 68195 Commercial Healthpoint Corp. Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 71063 Commercial HealthSCOPE Benefits Inc. Remittance 4010A1 Enrollment

Non-Par 71063 Commercial HealthSCOPE Benefits, Inc Professional 4010A1 Yes

Non-Par 71063 Commercial HealthSCOPE Benefits, Inc. Institutional 4010A1 No Response From Payer

Non-Par 75237 Commercial Healthsmart Accel Institutional 4010A1 File Level Acknowledgement Yes

Non-Par HSPC1 Commercial HealthSmart Preferred Care Professional 4010A1 Claim Level Accept/Reject

Non-Par 75250 Commercial Healthsmart Preferred Care, Inc. Institutional 4010A1 No Response From Payer Yes

Non-Par 75250 Commercial Healthsmart Preferred Care, Inc. Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 62308 Commercial AR Healthsource - AR Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial AR Healthsource - AR (Medicare HMO) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 71075 Commercial Healthsource - Arkansas (Med) (CIGNA) Institutional 4010A1 No Response From Payer Yes

Non-Par 58210 Commercial Healthsource - Georgia Institutional 4010A1 No Response From Payer Yes

Non-Par 62308 Commercial IN Healthsource - IN Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 35167 Commercial Healthsource - Indiana Institutional 4010A1 No Response From Payer

Non-Par 61127 Commercial Healthsource - Kentucky Institutional 4010A1 No Response From Payer Yes

Non-Par 62308 Commercial KY Healthsource - KY Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial MA Healthsource - MA Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 01041 Commercial ME Healthsource - Maine Professional 4010A1 No Response From Payer

Non-Par 01041 Commercial ME Healthsource - Maine Institutional 4010A1 No Response From Payer

Non-Par 62308 Commercial ME Healthsource - ME Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial NC Healthsource - NC Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 02038 Commercial NH Healthsource - New Hampshire Institutional 4010A1 No Response From Payer Yes

Non-Par 62308 Commercial NH Healthsource - NH Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 56147 Commercial Healthsource - North Carolina (CIGNA) Institutional 4010A1 No Response From Payer Yes

Non-Par 75255 Commercial Healthsource - North Texas Institutional 4010A1 No Response From Payer Yes

Non-Par 62308 Commercial TX Healthsource - North TX Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial OH Healthsource - OH Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 31141 Commercial Healthsource - Ohio Institutional 4010A1 No Response From Payer Yes

Non-Par 06119 Commercial SC Healthsource - SC Professional 4010A1 No Response From Payer

Non-Par 06119 Commercial SC Healthsource - SC Institutional 4010A1 No Response From Payer Yes

Non-Par 62308 Commercial SC Healthsource - SC Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 06119 Commercial SC Healthsource - South Carolina Institutional 4010A1 No Response From Payer

Non-Par 62129 Commercial Healthsource - Tennessee Institutional 4010A1 No Response From Payer Yes

Non-Par 62308 Commercial TN Healthsource - Tennessee Professional 4010A1 Claim Level Accept/Reject Yes

U: 12/30/2010 Non-Par 13335 Commercial HealthSource / Hudson Health Plan Professional 4010A1 Enrollment Claim Level Acknowledgement

Non-Par 02041 Commercial Healthsource CMHC Institutional 4010A1 No Response From Payer Yes

Non-Par 02041 Commercial Healthsource Massachusetts, Inc. Institutional 4010A1 No Response From Payer Yes

Non-Par 31141 Commercial Healthsource of Ohio Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 68195 Commercial Healthsource Provident Institutional 4010A1 No Response From Payer Yes

Non-Par 62308 Commercial Healthsource Provident Administrators Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial Healthsource Provident Ins. Co. Professional 4010A1 Claim Level Accept/Reject Yes

U: 01/11/2011 Par HSPAN Commercial HealthSpan Network Repricing Institutional 4010A1 File Level Acknowledgement

U: 01/06/2011 Par HSPAN Commercial HealthSpan Network Repricing Professional 4010A1 File Level Acknowledgement

Par HT001 Commercial TN HealthSpring Professional 4010A1 Claim Level Accept/Reject

Par 63092 Commercial HealthSpring HMO/HealthSpring Medicare+Choice Professional 4010A1 Claim Level Accept/Reject

Non-Par 63092 Commercial HealthSpring HMO/HealthSpring Medicare+Choice Institutional 4010A1 Claim Level Accept/Reject

Non-Par 36332 Commercial Healthstar, Inc. Institutional 4010A1 No Response From Payer Yes

Non-Par 36332 Commercial Healthstar, Inc. (Preferred Care Network/PCN) Professional 4010A1 No Response From Payer Yes

Non-Par 58213 Commercial Healthways WholeHealth Network Professional 4010A1 Claim Level Acknowledgement

Non-Par CALL Commercial MU Healthy Kids Professional 4010A1 Claim Level Accept/Reject Providers must CALL (866) 703-1444 to obtain Payer ID.

Trans CALL Commercial Healthy Palm Beaches Professional 4010A1 Claim Level Accept/Reject Please contact (866)930-1002 to enroll.

Non-Par HGL99 Commercial Heavy & General Laborers Welfare Fund Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WZ649 Commercial Helmsman Mgmt. Services Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ649 Commercial Helmsman Mgmt. Services Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ649 Commercial Helmsman Mgmt. Services Auto 4010A1 Claim Level Accept/Reject







11/10/2011 30 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 59230 Commercial Heritage Consultants Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK091 Commercial TX, MN Heritage Group Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK091 Commercial TX, MN Heritage Group Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK091 Commercial TX, MN Heritage Group Auto 4010A1 Claim Level Accept/Reject

Providers must email provider relations (pr@hhsi.com) to get their unique 5 digit

Non-Par HPN11 Commercial Heritage Physician Network (HPN) Professional 4010A1 Claim Level Accept/Reject provider id. This provider id is required on all claims

A: 04/06/2010 Trans WZ140 Commercial Hertz Rent A Car Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ140 Commercial Hertz Rent A Car Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 36335 Commercial HFN, Inc. Institutional 4010A1 No Response From Payer

Par 36335 Commercial HFN, Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par IP125 Commercial CA High Desert Medical Group (Regal Medical Group) Professional 4010A1 No Response From Payer

Non-Par 33069 Commercial High Desert Primary Care Institutional 4010A1 No Response From Payer

Non-Par 33069 Commercial High Desert Primary Care Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WK436 Commercial TX, MN Highlands Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 91164 Government Highline Medical Service Organization - Molina Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 91164 Government Highline Medical Service Organization - Molina Professional 4010A1 File Level Acknowledgement Yes

Non-Par 91161 Government Highline Medical Service Organization - PSHP Professional 4010A1 File Level Acknowledgement Yes

9/13/11 Non-Par 54771 Government Highmark Professional 4010A1 and 5010A1 Enrollment

Non-Par 54771 Government Highmark Remittance 4010A1 Enrollment

Trans 35145 Commercial Highmark - Key Family Professional 4010A1 Claim Level Accept/Reject

Non-Par 35145 Commercial Highmark- Key Family Institutional 4010A1 File Level Acknowledgement



Providers should call the Hill Physicians representative at (925) 362-6259 for

Par CALL Commercial CA Hill Physicians - San Joaquin Delta IPA Provider ONLY Professional 4010A1 Enrollment Claim Level Accept/Reject information to get setup to submit EDI claims and to obtain the payer ID.

Par HIL01 Commercial CA Hill Physicians Medical Group Professional 4010A1 Claim Level Accept/Reject

Non-Par 59347 Commercial Hillcrest Benefit Administrators Institutional 4010A1 No Response From Payer

Non-Par 59347 Commercial Hillcrest Benefit Administrators Professional 4010A1 Claim Level Accept/Reject

Non-Par 36385 Commercial Hinsdale Physician Healthcare Professional 4010A1 Claim Level Acknowledgement

Non-Par 36385 Commercial Hinsdale Physician Healthcare Institutional 4010A1 File Level Acknowledgement

Non-Par 55247 Commercial NY HIP - Health Insurance Plan of Greater New York Remittance 4010A1 Enrollment

Non-Par 55247 Commercial HIP - Health Insurance Plan of Greater New York Institutional 4010A1 Claim Level Acknowledgement Yes

Non-Par 55247 Commercial NY HIP - Health Insurance Plan of Greater New York Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par HMA01 Commercial HMA - Health Management Administrators Professional 4010A1 Claim Level Accept/Reject

Non-Par 39044 Commercial HMA Administrators LLC Professional 4010A1 File Level Acknowledgement

Non-Par 39044 Commercial HMA Administrators LLC Institutional 4010A1 File Level Acknowledgement

Non-Par 86066 Commercial AZ, HI, NV HMA Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par 48330 Commercial HI HMAA - (Hawaii Management Alliance Associate) Professional 4010A1 Claim Level Accept/Reject

Non-Par HM033 Commercial TX HMO Blue - MediCaid Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par 84980 Commercial TX HMO Blue Shield (non-MediCaid) Professional 4010A1 Claim Level Accept/Reject

Non-Par COHMO Commercial CO HMO of Colorado (HMOC) Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WR179 Commercial MN Ho Chunk Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR179 Commercial MN Ho Chunk Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR179 Commercial MN Ho Chunk Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK092 Commercial TX, MN Holly Farms Corp. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK092 Commercial TX, MN Holly Farms Corp. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK092 Commercial TX, MN Holly Farms Corp. Auto 4010A1 Claim Level Accept/Reject

Non-Par 36412 Commercial Holy Cross Health Partners Institutional 4010A1 File Level Acknowledgement

Non-Par 36412 Commercial Holy Cross Health Partners Professional 4010A1 File Level Acknowledgement

Trans AMS01 Commercial WI Homestead CHP/S Professional 4010A1 No Response From Payer

Non-Par 88023 Commercial Hometown Health Plan Nevada Institutional 4010A1 Claim Level Acknowledgement

Non-Par 88023 Commercial Hometown Health Plan of Nevada Professional 4010A1 Claim Level Acknowledgement

Non-Par 88537 Commercial Hometown Health Providers Institutional 4010A1 File Level Acknowledgement

Non-Par 88537 Commercial Hometown Health Providers Professional 4010A1 File Level Acknowledgement

Non-Par BS031 Government NJ Horizon Blue Cross Blue Shield of New Jersey Remittance 4010A1 Enrollment

Non-Par BS031 Government NJ Horizon Blue Cross Blue Shield of New Jersey Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par 22304 Commercial Horizon HealthCare Admin. (HHA) Institutional 4010A1 No Response From Payer

Non-Par 22304 Commercial Horizon Healthcare Admin. (HHA) Professional 4010A1 Claim Level Acknowledgement

Non-Par 22326 Commercial NJ Horizon Mercy Professional 4010A1 Claim Level Acknowledgement Yes

A: 04/06/2010 Trans WK172 Commercial TX, MN Hortica Florist Mutual Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK172 Commercial TX, MN Hortica Florist Mutual Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK172 Commercial TX, MN Hortica Florist Mutual Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par 37274 Commercial Hospital Benefits, Inc Professional 4010A1 File Level Acknowledgement

Non-Par 91136 Commercial Hotel Employees & restaurant Employees Health Trust Institutional 4010A1 No Response From Payer

Non-Par 91136 Commercial Hotel Employees & Restaurant Employees Hlth Trust, Grp# F19 Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK093 Commercial TX, MN Household Merch Nni Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK093 Commercial TX, MN Household Merch Nni Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK093 Commercial TX, MN Household Merch Nni Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK173 Commercial TX, MN Housing Authority El Paso (TX) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK173 Commercial TX, MN Housing Authority El Paso (TX) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK173 Commercial TX, MN Housing Authority El Paso (TX) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK174 Commercial TX, MN Houston Hunters Patrol, Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK174 Commercial TX, MN Houston Hunters Patrol, Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK174 Commercial TX, MN Houston Hunters Patrol, Inc Auto 4010A1 Claim Level Accept/Reject

Non-Par 94254 Commercial HPR Professional 4010A1 Claim Level Accept/Reject

Non-Par 58227 Commercial HPS Paradigm, Inc. Institutional 4010A1 No Response From Payer

Non-Par 58227 Commercial HPS Paradigm, Inc. Professional 4010A1 No Response From Payer

Non-Par 41170 Commercial HRM Claim Management Professional 4010A1 No Response From Payer

Non-Par 82018 Commercial ID HSC - Health Claim Service (Boise ID) Professional 4010A1 Claim Level Acknowledgement

Non-Par 13335 Commercial Hudson Health Plan Institutional 4010A1 Enrollment File Level Acknowledgement

A: 04/06/2010 Trans WK094 Commercial TX, MN Hughes Tool Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK094 Commercial TX, MN Hughes Tool Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK094 Commercial TX, MN Hughes Tool Company Auto 4010A1 Claim Level Accept/Reject

U:09/30/2011 Non-Par 61102 Commercial Humana - Encounters only Professional 4010A1 and 5010A1 Claim Level Rejects Only

U:09/30/2011 Non-Par 61101 Commercial Humana (Formerly Cariten HealthCare, 62073) Professional 4010A1 and 5010A1

Non-Par 61101 Commercial Humana (Formerly Cariten HealthCare, 62073) Remittance 4010A1 Enrollment

U:09/30/2011 Non-Par 61101 Commercial Humana (Formerly Cariten Senior Health, 62071) Professional 4010A1 and 5010A1

Non-Par 61101 Commercial Humana (Formerly Cariten Senior Health, 62072) Remittance 4010A1 Enrollment





11/10/2011 31 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 61101 Commercial Humana (Formerly Cariten Senior Health, 62072) Institutional 4010A1 Claim Level Acknowledgement

Non-Par 61101 Commercial Humana Emphesys Institutional 4010A1 Claim Level Acknowledgement Yes

Non-Par 61101 Commercial Humana Employer Health Insurance Institutional 4010A1 Claim Level Acknowledgement Yes

U:09/30/2011 Non-Par 95348 Commercial Humana Health Plans Of Ohio (formerly Choice Care) Professional 4010A1 and 5010A1 Claim Level Rejects Only

Non-Par 61101 Commercial Humana Insurance Company Choice Care Network Institutional 4010A1 Claim Level Acknowledgement Yes

U: 12/16/2010 Non-Par 61125 Commercial Humana Military Remittance 4010A1 Enrollment

Non-Par 61125 Commercial Humana Military - Tricare South Institutional 4010A1 Claim Level Acknowledgement

Non-Par 61125 Commercial Humana Military - Tricare South Professional 4010A1 Claim Level Acknowledgement

9/15/11 Non-Par 61160 Commercial Humana Veterans (VA Heroes) Professional 4010A1 Claim Level Rejects Only Yes

9/15/11 Non-Par 61160 Commercial Humana Veterans Healthcare Services Institutional 4010A1 File Level Acknowledgement Yes

U:09/30/2011 Non-Par 61101 Commercial Humana, Inc Professional 4010A1 and 5010A1 Claim Level Rejects Only Yes

U:09/30/2011 Non-Par 61101 Commercial Humana, Inc ERA Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par 61101 Commercial Humana, Inc. Institutional 4010A1 Claim Level Acknowledgement Yes

Non-Par 61101 Commercial Humana, Inc. Remittance 4010A1 Enrollment

Ochsner Providers please use payer id 61101 if you have Claims with Dates of

U:09/30/2011 Non-Par 61101 Commercial Humana-Louisiana Professional 4010A1 and 5010A1 Claim Level Rejects Only Yes Service On or After 1/1/2005

Par IP059 Commercial CA Humboldt-Del Norte Foundation/IPA Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WR210 Commercial MN Hutchinson Area Healthcare Center Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR210 Commercial MN Hutchinson Area Healthcare Center Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR210 Commercial MN Hutchinson Area Healthcare Center Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ283 Commercial TX, MN Hy-Vee, Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ283 Commercial TX, MN Hy-Vee, Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ283 Commercial TX, MN Hy-Vee, Inc Auto 4010A1 Claim Level Accept/Reject

Non-Par 22175 Commercial I.E. Shaffer Professional 4010A1 Claim Level Acknowledgement

Non-Par 22175 Commercial I.E. Shaffer Institutional 4010A1 No Response From Payer

Non-Par 37279 Commercial IAA Institutional 4010A1 No Response From Payer

Non-Par IAT99 Commercial IATSE Atlanta Health & Welfare Fund Professional 4010A1 No Response From Payer

Non-Par 54704 Commercial IBC Personal Choice Remittance 4010A1 Enrollment

Non-Par 54704 Commercial PA IBC Personal Choice Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par IBE98 Commercial IBEW Local 38 Professional 4010A1 No Response From Payer

Non-Par IBE97 Commercial IBEW Local 481 Professional 4010A1 No Response From Payer

Non-Par 41124 Commercial IBI Institutional 4010A1 No Response From Payer

Non-Par 41124 Commercial IBI Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR281 Commercial MN IBOCO Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR281 Commercial MN IBOCO Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR281 Commercial MN IBOCO Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 11695 Commercial WI iCARE (Independent Care Health Plan) Professional 4010A1 Claim Level Accept/Reject

Non-Par 26054 Commercial FL ICare Health Options (FL Optometric Phys) Professional 4010A1 Claim Level Accept/Reject

Non-Par 75185 Commercial ICON Benefits Administrators Institutional 4010A1 No Response From Payer Yes

Non-Par 75185 Commercial ICON Benefits Administrators Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA055 Commercial IDS Property Casualty Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA055 Commercial IDS Property Casualty Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA055 Commercial IDS Property Casualty Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 33070 Commercial IEHP Professional 4010A1 Claim Level Accept/Reject

Non-Par 75274 Commercial IHG Direct Professional 4010A1 Claim Level Acknowledgement

Non-Par 75274 Commercial IHG Direct Institutional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Trans WZ250 Commercial IL Fornaio (America) Corp Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ250 Commercial IL Fornaio (America) Corp Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ250 Commercial IL Fornaio (America) Corp Auto 4010A1 Claim Level Accept/Reject

Par 68065 Commercial Illinicare Behavioral Health Professional 4010A1 Claim Level Accept/Reject

Par 68065 Commercial Illinicare Behavioral Health Institutional 4010A1 Claim Level Accept/Reject

Par 68066 Commercial Illinicare Group Health Professional 4010A1 Claim Level Accept/Reject

Par 68066 Commercial Illinicare Group Health Institutional 4010A1 Claim Level Accept/Reject

Non-Par 86069 Commercial IL Illinois Health Solutions Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR315 Commercial Illinois National Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR315 Commercial Illinois National Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR315 Commercial Illinois National Insurance Co Auto 4010A1 Claim Level Accept/Reject

Non-Par 41600 Commercial IMCARE Institutional 4010A1 No Response From Payer

Non-Par 41600 Commercial IMCARE Professional 4010A1 Claim Level Acknowledgement

Non-Par 86070 Commercial NV IMX EZ Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR319 Commercial MN Incstar Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR319 Commercial MN Incstar Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR319 Commercial MN Incstar Corporation Auto 4010A1 Claim Level Accept/Reject

Non-Par 40585 Commercial INDECS Corporation Professional 4010A1 Claim Level Accept/Reject

Non-Par 40585 Commercial INDECS Corporation Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WR323 Commercial Indemnity Insuarnce North America Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR323 Commercial Indemnity Insuarnce North America Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR323 Commercial Indemnity Insuarnce North America Auto 4010A1 Claim Level Accept/Reject

Non-Par TA720 Commercial Independence Administrators Professional 4010A1 Claim Level Accept/Reject

Non-Par 12X26 Commercial MU Independence BluCross&BluChoice-IBC Institutional 4010A1 Claim Level Accept/Reject

Non-Par MHM01 Commercial Independence Medical Group Professional 4010A1 No Response From Payer

Non-Par 26274 Commercial CA Independence Medical Group - Tulare Professional 4010A1 File Level Acknowledgement

U: 12/30/2010 Non-Par 95308 Commercial Independent Health Remittance 4010A1 Enrollment

Non-Par 95308 Commercial NY Independent Health Professional 4010A1 Enrollment Claim Level Acknowledgement Yes

A: 04/06/2010 Trans WR375 Commercial Indiana Lumbermen (Indianapolis) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR375 Commercial Indiana Lumbermen (Indianapolis) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK420 Commercial TX, MN Indiana Lumbermens Mutual Insurnace Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 35161 Commercial IN Indiana ProHealth Professional 4010A1 No Response From Payer

Non-Par 35161 Commercial Indiana ProHealth Network Institutional 4010A1 Claim Level Accept/Reject

Non-Par 31053 Commercial Individual Health Insurance Companies Institutional 4010A1 No Response From Payer

Non-Par 31053 Commercial Individual Health Insurance Companies Professional 4010A1 Claim Level Accept/Reject

A: 09/09/2011 Non-Par 50946 Commercial MU Informed UHC Institutional 4010A1 No Response From Payer

A: 09/09/2011 Non-Par 50946 Commercial MU Informed UHC Professional 4010A1 No Response From Payer

Non-Par 52196 Commercial Informed, LLC Institutional 4010A1 No Response From Payer

Non-Par 52196 Commercial Informed, LLC Professional 4010A1 No Response From Payer

Non-Par 36348 Commercial Ingalls Provider Group Professional 4010A1 Claim Level Acknowledgement







11/10/2011 32 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 36348 Commercial Ingalls Provider Group Institutional 4010A1 File Level Acknowledgement

Non-Par 52212 Commercial Injured Workers Insurance Fund Professional 4010A1 No Response From Payer

Non-Par 33070 Commercial Inland Empire Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 31172 Commercial MU Innovante Benefit Administrator Professional 4010A1 No Response From Payer

Non-Par 04320 Commercial Innovative Healthware Services Network - Plan B Institutional 4010A1 No Response From Payer

Non-Par 04320 Commercial Innovative Healthware Services, Inc. Institutional 4010A1 No Response From Payer

Non-Par 04320 Commercial Innovative Healthware Solutions Professional 4010A1 Claim Level Accept/Reject

Non-Par VAICE Commercial DC INS Health Services Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK095 Commercial TX, MN Insilco Corp Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK095 Commercial TX, MN Insilco Corp Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK095 Commercial TX, MN Insilco Corp Auto 4010A1 Claim Level Accept/Reject

Non-Par 37279 Commercial Insurance Administrator of America, Inc. Institutional 4010A1 No Response From Payer

Non-Par 37279 Commercial Insurance Administrator of America, Inc. (IAA) Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WK437 Commercial TX, MN Insurance Co of North America Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR376 Commercial Insurance Company State of Pennsylvania Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR376 Commercial Insurance Company State of Pennsylvania Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR376 Commercial Insurance Company State of Pennsylvania Auto 4010A1 Claim Level Accept/Reject

Non-Par 13315 Commercial Insurance Design Administrators Institutional 4010A1 No Response From Payer

Non-Par 13315 Commercial Insurance Design Administrators Professional 4010A1 Claim Level Acknowledgement

Non-Par 15688 Commercial Insurance Management Services (Amarillo TX) Institutional 4010A1 File Level Acknowledgement

Non-Par IMSMS Commercial TX Insurance Management Services (IMS) of TX Professional 4010A1 Claim Level Accept/Reject

Non-Par ISL11 Commercial Insurance Service Of Lubbock Professional 4010A1 Claim Level Accept/Reject

U: 08/22/2011 Non-Par 39182 Commercial Insurance TPA Institutional 4010A1 File Level Acknowledgement

U: 08/22/2011 Non-Par 39182 Commercial Insurance TPA Professional 4010A1 File Level Acknowledgement



Non-Par 86304 Commercial Insurers Administrative Corp Professional 4010A1 Claim Level Acknowledgement Please visit this website before submitting claims: http://edihelp.iacusa.com/

Non-Par 86304 Commercial Insurers Administrative Corp. Institutional 4010A1 File Level Acknowledgement

Non-Par 51020 Commercial Integra Administrative Group (Seaford, DE) Institutional 4010A1 No Response From Payer

Non-Par 51020 Commercial INTEGRA Administrative Group, Inc. Professional 4010A1 Claim Level Acknowledgement

Non-Par 31127 Commercial Integra Group Institutional 4010A1 Enrollment No Response From Payer

Non-Par 31127 Commercial Integra Group Professional 4010A1 Claim Level Acknowledgement

Non-Par 31129 Commercial Integra Group - CHA Professional 4010A1 Claim Level Accept/Reject

Non-Par 31128 Commercial INTEGRA GROUP/HOME Institutional 4010A1 File Level Acknowledgement

Non-Par 23229 Commercial Integral Quality Care Professional 4010A1 Claim Level Accept/Reject

A: 12/21/2010 Non-Par 23229 Commercial Integral Quality Care Institutional 4010A1 Claim Level Accept/Reject

Non-Par 74314 Commercial Integrant /SelectCare of Texas Institutional 4010A1 File Level Acknowledgement

Non-Par 74314 Commercial Integrant /SelectCare of Texas Professional 4010A1 File Level Acknowledgement

Non-Par 37124 Commercial IL Integrated Benefit Services, IL Professional 4010A1 No Response From Payer

Non-Par 34167 Commercial Integrated Care Network (ICN) by Emerald Health Institutional 4010A1 No Response From Payer

A: 04/06/2010 Trans WR379 Commercial Integrity (Auto ONLY) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR377 Commercial Integrity (Work Comp ONLY) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR377 Commercial Integrity (Work Comp ONLY) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA059 Commercial Integrity Mutual Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA059 Commercial Integrity Mutual Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA059 Commercial Integrity Mutual Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 37227 Commercial InterCare Health Plans Inc. Professional 4010A1 No Response From Payer

Non-Par 37227 Commercial InterCare Health Plans Inc. Institutional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WX602 Commercial Intercare Insurance Services (Orange) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX602 Commercial Intercare Insurance Services (Orange) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX602 Commercial Intercare Insurance Services (Orange) Auto 4010A1 Claim Level Accept/Reject

Non-Par 60280 Commercial Interface EAP (IEAP) Institutional 4010A1 No Response From Payer Yes

Non-Par 60280 Commercial Interface EAP (IEAP) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 23287 Commercial InterGroup Services Corporation Institutional 4010A1 No Response From Payer

Non-Par 23287 Commercial InterGroup Services PPO Professional 4010A1 Claim Level Accept/Reject



Non-Par SX107 Commercial Intermountain Health Care Professional 4010A1 Enrollment Claim Level Accept/Reject Please contact Intermountain to enroll and obtain a provider id 801-442-5442)

Non-Par IAT99 Commercial GA Fund

International Association of Theatrical Stage Employees (IATSE) Atlanta Health & Welfare Professional 4010A1 No Response From Payer

Non-Par 36609 Commercial International Brotherhodd of Boilermakers Institutional 4010A1 No Response From Payer No

Non-Par 36609 Commercial International Brotherhood of Boilermakers Remittance 4010A1 Enrollment

Non-Par 16158 Commercial International Educational Exchange Services Inc. (IEES) Institutional 4010A1 File Level Acknowledgement

Non-Par 16158 Commercial International Educational Exchange Services Inc. (IEES) Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WR388 Commercial TX, MN International Paper Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR388 Commercial TX, MN International Paper Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR388 Commercial TX, MN International Paper Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 37269 Commercial International Union Of Operating Engineers Local 15, 15A, 15C, & 15D Institutional 4010A1 No Response From Payer

Non-Par 84137 Commercial MT InterWest Health - PPO Professional 4010A1 Claim Level Accept/Reject

Non-Par 41124 Commercial Iowa Benefits Inc. Institutional 4010A1 No Response From Payer

Non-Par 41124 Commercial Iowa Benefits Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par 86068 Commercial IA Iowa Health Solutions Professional 4010A1 Claim Level Accept/Reject

Trans AMS01 Commercial Iowa, Envoy Platinum Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK096 Commercial TX, MN Irex Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK096 Commercial TX, MN Irex Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK096 Commercial TX, MN Irex Corporation Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK097 Commercial TX, MN Ironworking Contract I.P. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK097 Commercial TX, MN Ironworking Contract I.P. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK097 Commercial TX, MN Ironworking Contract I.P. Auto 4010A1 Claim Level Accept/Reject

Non-Par SX172 Commercial IU Medical Group Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK175 Commercial TX, MN J B Hunt Transport Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK175 Commercial TX, MN J B Hunt Transport Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK175 Commercial TX, MN J B Hunt Transport Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 37272 Commercial J. Smith Lanier & Co. Admin Professional 4010A1 No Response From Payer

Non-Par 37272 Commercial J. Smith Lanier & Co. Administrators Institutional 4010A1 No Response From Payer

Par 61271 Commercial J.F. Molloy & Associates, Inc. Professional 4010A1 No Response From Payer Yes

Par 61271 Commercial J.F. Molloy & Associates, Inc. Institutional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ362 Commercial Jack In The Box Corp. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ362 Commercial Jack In The Box Corp. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK467 Commercial TX, MN Jeld Wen Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject





11/10/2011 33 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par JEN99 Commercial GA Jenkins & Associates Professional 4010A1 No Response From Payer 1299 Battlecreek Rd., Ste. 200 & PO Box 607, Jonesboro, GA 30237-0607

Par WK006 Commercial JI Specialty Services Inst. Work Comp 4010A1 Claim Level Acknowledgement

Par WK006 Commercial JI Specialty Services Prof. Work Comp 4010A1 Claim Level Acknowledgement

A: 12/21/2010 Non-Par 09822 Commercial JMH - SFCCN PHT (PSN CMSN) (Jackson Memorial Health Plan) Institutional 4010A1 Claim Level Rejects Only

Non-Par 09822 Commercial JMH - SFCCN PHT (PSN, CMSN) (Jackson Memorial Health Plan) Professional 4010A1 Claim Level Rejects Only

A: 12/20/2010 Non-Par 05014 Commercial JMH HEALTHPLAN COMMERCIAL HMO (Jackson Memorial Health Plan) Institutional 4010A1 File Level Acknowledgement

Non-Par 05014 Commercial JMH HEALTHPLAN COMMERCIAL HMO (Jackson Memorial Health Plan) Professional 4010A1 Claim Level Accept/Reject

Non-Par 16001 Commercial JMH HEALTHPLAN MEDICAID HMO (Jackson Memorial Health Plan) Professional 4010A1 Claim Level Accept/Reject

A: 01/10/2011 Non-Par 59171 Commercial JMH Medicare Advantage (Jackson Memorial Health Plan) Professional 4010A1 File Level Acknowledgement

Non-Par 41099 Commercial John Alden Life Insurance Co. Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par 41099 Commercial John Alden Life Insurance Co. Institutional 5010A2 No Response From Payer

U:10/27/2011 Non-Par 41099 Commercial John Alden Life Insurance Co. Professional 5010A1 Claim Level Accept/Reject

Non-Par 38310 Commercial JOHN MORRELL COMPANY CO. - AHPBA Institutional 4010A1 File Level Acknowledgement

Non-Par 38310 Commercial JOHN MORRELL COMPANY CO. - AHPBA Professional 4010A1 File Level Acknowledgement

Par JMH01 Commercial CA John Muir Health Network Professional 4010A1 Claim Level Rejects Only

Non-Par 37215 Commercial John P Pearl & Associates, Ltd Institutional 4010A1 No Response From Payer

Non-Par 37215 Commercial John P. Pearl & Associates, LTD Professional 4010A1 Claim Level Accept/Reject

Non-Par 52189 Commercial Johns Hopkins Healthcare (EHP/PP) Professional 4010A1 File Level Acknowledgement

Non-Par 52189 Commercial Johns Hopkins Healthcare (EHP/PP) Institutional 4010A1 File Level Acknowledgement

U: 12/30/2010 Non-Par 52123 Commercial Johns Hopkins Healthcare (USFHP) Remittance 4010A1 Enrollment

Non-Par 52123 Commercial Johns Hopkins Healthcare (USFHP) Institutional 4010A1 Claim Level Accept/Reject

Non-Par 52123 Commercial Johns Hopkins Healthcare (USFHP) Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK098 Commercial TX, MN Jones Truck Lines, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK098 Commercial TX, MN Jones Truck Lines, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK098 Commercial TX, MN Jones Truck Lines, Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 43178 Commercial Joplin Claims Institutional 4010A1 No Response From Payer

Non-Par 34136 Commercial JP Farley Corporation Institutional 4010A1 No Response From Payer

Non-Par 34136 Commercial JP Farley Corporation Professional 4010A1 Claim Level Acknowledgement

Non-Par 37272 Commercial JSL Administrators Institutional 4010A1 No Response From Payer

Non-Par 37272 Commercial JSL Administrators Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK099 Commercial TX, MN Juvenile Jail Facility Managem Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK099 Commercial TX, MN Juvenile Jail Facility Managem Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK099 Commercial TX, MN Juvenile Jail Facility Managem Auto 4010A1 Claim Level Accept/Reject

Par KS006 Commercial MU Kaiser - HDHP Professional 4010A1 File Level Acknowledgement

Non-Par KS006 Commercial MU Kaiser - HDHP Remittance 4010A1 Enrollment File Level Acknowledgement

A: 01/10/2011 Non-Par 94320 Commercial Kaiser CSI-California Select for Individuals (Formerly Kaiser PPO) Professional 4010A1 File Level Acknowledgement

A: 12/21/2010 Non-Par 94320 Commercial Kaiser CSI-California Select for Individuals (Formerly Kaiser PPO) Institutional 4010A1 File Level Acknowledgement

Non-Par 21313 Commercial GA Kaiser Foundation Health Plan of Georgia Professional 4010A1 Claim Level Accept/Reject

Non-Par KS007 Commercial Kaiser Foundation Hospitals - North West Region Institutional 4010A1 No Response From Payer

U: 01/17/2011 Par KS008 Commercial Kaiser Health Plan - Mid Atlantic States Institutional 4010A1 Claim Level Rejects Only

A: 01/17/2011 Par KS008 Commercial Kaiser Health Plan - Mid Atlantic States Professional 4010A1 Claim Level Rejects Only

Please call (510) 987-4639 for approval prior to submitting Northern California

Par KS003 Commercial CA Kaiser Health Plan Nothern California Institutional 4010A1 Enrollment Claim Level Accept/Reject referral claims

Non-Par 21313 Commercial GA Kaiser Health Plan of Georgia Institutional 4010A1 No Response From Payer

Non-Par 21313 Commercial GA Kaiser Health Plan of Georgia Remittance 4010A1 Enrollment

U: 12/30/2010 Non-Par KS008 Commercial Kaiser Hlth Plans - Mid Atlantic States Remittance 4010A1 Enrollment

U: 09/07/2011 Non-Par KS007 Commercial WA, OR Kaiser NW Region Remittance 4010A1 Enrollment

Par KS007 Commercial WA, OR Kaiser NW Region Professional 4010A1 Claim Level Accept/Reject

Par KS005 Commercial OH Kaiser Ohio Region Professional 4010A1 Claim Level Accept/Reject

Non-Par KS001 Commercial CA Kaiser Permanente Remittance 4010A1 Enrollment

U: 12/30/2010 Non-Par KS003 Commercial CA Kaiser Permanente (Northern California) Remittance 4010A1 Enrollment

Par KS003 Commercial CA call (866) 285-0362. Referral Claims: Please call (510) 987-4639 or (510) 987-3889Accept/Reject

Kaiser Permanente (Northern California) Emergency claims: For more information, pleaseProfessional 4010A1 Claim Level prior to submitting claims

Par KS001 Commercial CA Kaiser Permanente (Southern California) Professional 4010A1 Claim Level Accept/Reject

Par KS001 Commercial CA Kaiser Permanente (Southern California) Institutional 4010A1 Claim Level Accept/Reject

Non-Par 57038 Commercial Kanawha Healthcare Solutions, Inc. Institutional 4010A1 No Response From Payer

Non-Par 57038 Commercial Kanawha Healthcare Solutions, Inc. Professional 4010A1 Claim Level Acknowledgement

Non-Par 57038 Commercial Kanawha Healthcare Solutions, Inc. Remittance 4010A1 Enrollment

Non-Par 57038 Commercial Kanawha Insurance Co. Remittance 4010A1 Enrollment

Non-Par 57038 Commercial Kanawha Insurance Company Professional 4010A1 Claim Level Acknowledgement

Non-Par 57038 Commercial Kanawha Insurance Company Institutional 4010A1 No Response From Payer

Non-Par 81812 Commercial Katy Medical Claims Institutional 4010A1 File Level Acknowledgement

Non-Par 81812 Commercial Katy Medical Claims Professional 4010A1 File Level Acknowledgement

Trans 37313 Commercial KBA Assurant Health Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK106 Commercial TX, MN KCI Holdings USA Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK106 Commercial TX, MN KCI Holdings USA Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK106 Commercial TX, MN KCI Holdings USA Auto 4010A1 Claim Level Accept/Reject

A: 01/11/2011 Non-Par KELSE Commercial Kelsey Sebold Professional 4010A1 Claim Level Acknowledgement

Non-Par 73100 Commercial Kempton Company Institutional 4010A1 No Response From Payer

Non-Par 73100 Commercial Kempton Company Professional 4010A1 Claim Level Acknowledgement

Non-Par 73100 Commercial Kempton Group Administrators Institutional 4010A1 No Response From Payer

Non-Par 73100 Commercial Kempton Group Administrators Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Trans WK107 Commercial TX, MN Ken Davis Industries Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK107 Commercial TX, MN Ken Davis Industries Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK107 Commercial TX, MN Ken Davis Industries Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 37124 Commercial IL Kepple & Co. (Formerly Integrated Benefit Svcs.) Professional 4010A1 No Response From Payer

Non-Par MCS03 Commercial Kern County EPO, (GemCare Health Plan) Professional 4010A1 File Level Acknowledgement

Non-Par 77039 Commercial CA Kern Family Health Professional 4010A1 No Response From Payer

Non-Par 77039 Commercial Kern Health Systems Institutional 4010A1 Claim Level Accept/Reject

Non-Par 37217 Commercial Key Benefit Administrators Institutional 4010A1 No Response From Payer

Trans 37217 Commercial Key Benefit Administrators Professional 4010A1 No Response From Payer

Non-Par 35317 Commercial KEY GAP Institutional 4010A1 File Level Acknowledgement

Non-Par 35317 Commercial KEY GAP Professional 4010A1 File Level Acknowledgement

Non-Par IP082 Commercial CA Key Medical Group Professional 4010A1 No Response From Payer

Non-Par 37321 Commercial Key Select Institutional 4010A1 File Level Acknowledgement

Trans 37321 Commercial Key Select Professional 4010A1 No Response From Payer

Non-Par 95056 Government PA Keystone Health Plan East Remittance 4010A1 Enrollment







11/10/2011 34 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



U: 12/30/2010 Non-Par 95056 Government PA Keystone Health Plan East Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par 23284 Commercial Keystone Mercy Health Plan Institutional 4010A1 No Response From Payer Yes

Non-Par 23284 Commercial PA Keystone Mercy Health Plan Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 23284 Commercial Keystone Mercy Health Plan Remittance 4010A1 Enrollment

U: 08/18/11 Non-Par 54720 Commercial PA KHP Central Professional 4010A1 and 5010A1 Enrollment Claim Level Acknowledgement Yes Yes

Payer 86049 no longer process claims/ERA for DOS 2011, however, claims can

still be sent for DOS 2010. Payer requires every claim contain the AmeriChoice

10/20/11 Trans 86049 Commercial PA KidsChoice CHIP. - Medicaid PA Professional 4010A1 Claim Level Accept/Reject assigned provider id (including suffix)

Payer 86049 no longer process claims/ERA for DOS 2011, however, claims can

still be sent for DOS 2010. Payer requires every claim contain the AmeriChoice

10/20/11 Trans 86049 Commercial PA KidsChoice via Information Network Corp Professional 4010A1 Claim Level Accept/Reject assigned provider id (including suffix)

Non-Par KPS01 Commercial Kitsap Physicians Services Professional 4010A1 Claim Level Accept/Reject

Non-Par 34145 Commercial KLAIS & Company Institutional 4010A1 No Response From Payer Yes

Non-Par 34145 Commercial KLAIS & Company Professional 4010A1 Claim Level Accept/Reject Yes

Par 3414A Commercial Klais & Company (Repricing for HealthSpan Network Only) Professional 4010A1 Claim Level Acknowledgement

Par 3414A Commercial Klais & Company (Repricing for HealthSpan Network Only) Institutional 4010A1 Claim Level Acknowledgement

U: 12/13/2010 Non-Par KAMG1 Commercial Korean American Medical Group Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WR643 Commercial Kroger Co. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR643 Commercial Kroger Co. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par LACAR Commercial LA Care Heath Plan Professional 4010A1 No Response From Payer

Non-Par WC001 Commercial Labor and Industry Remittance 4010A1 Enrollment

U: 12/15/2010 Non-Par WC001 Commercial WA Labor and Industry Professional 4010A1 Enrollment No Response From Payer

A: 04/06/2010 Non-Par WR647 Commercial TX, MN Laidlaw International, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR647 Commercial TX, MN Laidlaw International, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR647 Commercial TX, MN Laidlaw International, Inc. Auto 4010A1 Claim Level Accept/Reject

Responses could take up to 30-45 business days.

Please contact the payer for further claim inquiry

U: 12/28/2010 Par LCHC1 Commercial Lakeside Comprehensive Healthcare Institutional 4010A1 Claim Level Accept/Reject @ (818) 707-9603, ext. 6014

Responses could take up to 30-45 business days.

Please contact the payer for further claim inquiry

U: 12/28/2010 Par LCHC1 Commercial Lakeside Comprehensive Healthcare Professional 4010A1 Claim Level Accept/Reject @ (818) 707-9603, ext. 6014

Par LMG11 Commercial Lakeside Medical Group Institutional 4010A1 No Response From Payer No Payer Response, please contact payer directly at 818-707-9603

Par LMG11 Commercial Lakeside Medical Group Professional 4010A1 No Response From Payer No Payer Response, please contact payer directly at 818-707-9603

Non-Par LNDMK Commercial Landmark Healthcare, Inc. Remittance 4010A1 Enrollment

Non-Par LNDMK Commercial Landmark Healthcare, Inc. Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WR648 Commercial TX, MN Landmark Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR648 Commercial TX, MN Landmark Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR648 Commercial TX, MN Landmark Insurance Company Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK108 Commercial TX, MN Landstar Bco Wc Program Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK108 Commercial TX, MN Landstar Bco Wc Program Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK108 Commercial TX, MN Landstar Bco Wc Program Auto 4010A1 Claim Level Accept/Reject

Non-Par 36333 Commercial Lawndale Christian Health Center Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 36333 Commercial Lawndale Christian Health Center Professional 4010A1 File Level Acknowledgement Yes

Non-Par 52193 Commercial LBA Health Plans Professional 4010A1 Claim Level Acknowledgement

Non-Par 52193 Commercial LBA Health Plans Institutional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WZ602 Commercial LDI Mechanical Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ602 Commercial LDI Mechanical Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR675 Commercial MN Leech Lake Band Of Ojibwe Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR675 Commercial MN Leech Lake Band Of Ojibwe Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR675 Commercial MN Leech Lake Band Of Ojibwe Auto 4010A1 Claim Level Accept/Reject

Non-Par 37316 Commercial Leon Medical Center Health Plan Institutional 4010A1 File Level Acknowledgement

Non-Par 37316 Commercial Leon Medical Center Health Plan Professional 4010A1 No Response From Payer

Non-Par 37248 Commercial LHP Claims Unit Institutional 4010A1 No Response From Payer

Non-Par 87071 Commercial Liberty Health Advantage Professional 4010A1 Claim Level Accept/Reject

Non-Par 87071 Commercial Liberty Health Advantage Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WZ626 Commercial Liberty Mutual Fire Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ626 Commercial Liberty Mutual Fire Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ626 Commercial Liberty Mutual Fire Insurance Co Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ635 Commercial Liberty Mutual Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ635 Commercial Liberty Mutual Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ635 Commercial Liberty Mutual Insurance Co Auto 4010A1 Claim Level Accept/Reject

Non-Par 37281 Commercial Liberty Union Institutional 4010A1 No Response From Payer

Non-Par 37281 Commercial Liberty Union Life Assurance Co. Professional 4010A1 No Response From Payer

Non-Par 37281 Commercial Life Assurance Company Institutional 4010A1 No Response From Payer

Non-Par 37281 Commercial Life Assurance Company Professional 4010A1 No Response From Payer

Non-Par 41136 Commercial Life Trac Professional 4010A1 Claim Level Accept/Reject

Non-Par 41136 Commercial Life Trac Institutional 4010A1 No Response From Payer

Non-Par LIFE1 Commercial Lifeprint Professional 4010A1 File Level Acknowledgement

Non-Par 93093 Commercial LifeWise Health Plan of Oregon Professional 4010A1 Enrollment Claim Level Acknowledgement Yes

Non-Par LINAE Commercial Linkia for Aetna Professional 4010A1 Claim Level Rejects Only

Non-Par LINAM Commercial Linkia for Americhoice Professional 4010A1 Claim Level Rejects Only

Non-Par LINCI Commercial Linkia for Cigna Professional 4010A1 Claim Level Rejects Only

Non-Par LINMO Commercial Linkia for Mutual of Omaha Professional 4010A1 Claim Level Rejects Only

Non-Par LINPR Commercial Linkia for Principal Professional 4010A1 Claim Level Rejects Only

Non-Par LINTR Commercial Linkia for Triwest Professional 4010A1 Claim Level Rejects Only

Non-Par LINUH Commercial Linkia for UHC National Professional 4010A1 Claim Level Rejects Only

Non-Par LINUN Commercial Linkia for United National Professional 4010A1 Claim Level Rejects Only

Non-Par 75283 Commercial Linn County Institutional 4010A1 No Response From Payer

Non-Par 75283 Commercial Linn County Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR678 Commercial TX LKQ Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR678 Commercial TX LKQ Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 35107 Commercial IN Local 135 Health Benefits (Indianapolis, IN) Professional 4010A1 Claim Level Accept/Reject

Non-Par 35107 Commercial Local 135 Health Benefits Fund (Indianapolis, IN) Institutional 4010A1 No Response From Payer

Non-Par IBT99 Commercial Local 295/851 I.B.T. Employer Group Welfare Fund Professional 4010A1 No Response From Payer

Non-Par 37267 Commercial Loma Linda University Professional 4010A1 No Response From Payer

Non-Par 37267 Commercial Loma Linda University Adventist Health Institutional 4010A1 No Response From Payer

Non-Par 37267 Commercial Loma Linda University Behavioral Medicine Institutional 4010A1 No Response From Payer

Non-Par 37267 Commercial Loma Linda University Employee Health Plan Institutional 4010A1 No Response From Payer





11/10/2011 35 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 37267 Commercial Loma Linda University Health Care Employee Health Plan Institutional 4010A1 No Response From Payer

Non-Par 33036 Commercial Loma Linda University Healthcare - ManagedCare Claims Professional 4010A1 Claim Level Acknowledgement

Non-Par 37267 Commercial Loma Linda University Student Health Plan Institutional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WK413 Commercial TX, MN Lone Star National Ins. Co. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR679 Commercial Longhorn Linen Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR679 Commercial Longhorn Linen Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR679 Commercial Longhorn Linen Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB124 Commercial Longs Drugs Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB124 Commercial Longs Drugs Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par LAF99 Commercial CA Los Angeles Fireman's Relief Fund (LAFRA) Professional 4010A1 No Response From Payer

Trans PPM02 Commercial CA Los Angeles Medical Center - Encounters Only Professional 4010A1 Claim Level Accept/Reject

Non-Par PPM01 Commercial CA Los Angeles Medical Center IPA (LAMC) - Claims Only Professional 4010A1 Claim Level Accept/Reject

Non-Par SX159 Commercial Lovelace Salud Professional 4010A1 No Response From Payer Yes

A: 01/11/2011 Non-Par SX159 Commercial Lovelace Salud Institutional 4010A1 File Level Acknowledgement

Non-Par 90328 Commercial Lovelace Sandia Health Plan Institutional 4010A1 No Response From Payer Yes

Non-Par 90328 Commercial NM Lovelace Sandia Health Plan Professional 4010A1 No Response From Payer Yes

A: 04/06/2010 Non-Par WR680 Commercial MN Lower Sioux Indian Community Jacpot Junction Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR680 Commercial MN Lower Sioux Indian Community Jacpot Junction Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR680 Commercial MN Lower Sioux Indian Community Jacpot Junction Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB126 Commercial Lowe's Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB126 Commercial Lowe's Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 37248 Commercial LPH Claims Unit Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK109 Commercial TX, MN Lsg Sky Chefs International Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK109 Commercial TX, MN Lsg Sky Chefs International Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK109 Commercial TX, MN Lsg Sky Chefs International Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK468 Commercial TX, MN Lubbock ISD Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK439 Commercial TX, MN Lumbermens Mutual Casualty Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR681 Commercial TX, MN Lumbermens Mutual Casualty Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR681 Commercial TX, MN Lumbermens Mutual Casualty Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR681 Commercial TX, MN Lumbermens Mutual Casualty Company Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR682 Commercial TX, MN Lumbermens Under-Carrollton Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR682 Commercial TX, MN Lumbermens Under-Carrollton Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 36334 Commercial MacNeal Health Providers (CHS) Professional 4010A1 Claim Level Accept/Reject

Non-Par 36334 Commercial MacNeal Health Providers- CHS Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WZ721 Commercial Macys (Daly City) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ721 Commercial Macys (Daly City) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ727 Commercial Macys (Newport Beach) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ727 Commercial Macys (Newport Beach) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ310 Commercial Macys Corporate Services Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ310 Commercial Macys Corporate Services Inst. Work Comp 4010A1 Claim Level Accept/Reject

Par 01260 Commercial Magellan Behavioral Health Institutional 4010A1 Claim Level Acknowledgement

Par 01260 Commercial Magellan Behavioral Health Professional 4010A1 Claim Level Accept/Reject

Non-Par 01260 Commercial MD Magellan Behavioral Health Remittance 4010A1 Enrollment

Par MBHCR Commercial Magellan Behavioral Health - Case Rate Professional 4010A1 Claim Level Accept/Reject

Non-Par 11303 Commercial Magnacare Institutional 4010A1 No Response From Payer

Non-Par 11303 Commercial Magnacare Professional 4010A1 Claim Level Accept/Reject

Non-Par 68062 Commercial MS Magnolia Health Plan Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WR686 Commercial TX, MN Major League Baseball Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR686 Commercial TX, MN Major League Baseball Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR686 Commercial TX, MN Major League Baseball Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK110 Commercial TX, MN Major League Baseball 8 Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK110 Commercial TX, MN Major League Baseball 8 Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK110 Commercial TX, MN Major League Baseball 8 Auto 4010A1 Claim Level Accept/Reject

Non-Par 22195 Commercial Maksin Management Corporation Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 22195 Commercial Maksin Management Corporation Professional 4010A1 File Level Acknowledgement Yes

Trans 87726 Commercial MAMSI Life & Health Ins.Co (MLH))HCFA 1500 only(Formerly 52148) Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial MAMSI Life And Health CO. (MLH) (Formerly 52148) Institutional 4010A1 No Response From Payer Yes

Non-Par 87726 Commercial MD MAMSI Life and Health Ins (Formerly 52148) Remittance 4010A1 Enrollment

Non-Par 35162 Commercial Managed Care Services Professional 4010A1 Claim Level Acknowledgement

Non-Par 35162 Commercial Managed Care Services, LLC Institutional 4010A1 No Response From Payer

Non-Par MCS02 Commercial Managed Care Systems (Delano Regional Med. Grp.) Professional 4010A1 File Level Acknowledgement

Non-Par 22771 Commercial Managed Health Network Professional 4010A1 Claim Level Accept/Reject

Non-Par 22771 Commercial Managed Health Network Institutional 4010A1 Claim Level Accept/Reject

Non-Par 39187 Commercial WI Managed Health Services - Centene Institutional 4010A1 No Response From Payer

U: 12/29/2010 Non-Par 39187 Commercial WI Managed Health Services - Centene Remittance 4010A1 Enrollment

(Prior to submitting claims, call Provider Relations Dept. at 800-225-2573, x25525,

to verify your provider info is on file in the Health Plans claim system to avoid any

U: 12/29/2010 Par 39187 Commercial WI Managed Health Services - Centene Professional 4010A1 Claim Level Accept/Reject rejections)

Par 39186 Commercial IN Managed Health Services Indiana (Medicaid HMO) Professional 4010A1 Claim Level Accept/Reject

U: 01/14/2011 Non-Par 39186 Commercial IN Managed Health Services Indiana (Medicaid HMO) Remittance 4010A1 Enrollment

(Prior to submitting claims, call Provider Relations Dept. at 866-475-3129 to verify

your provider info is on file in the Health Plans claim system to avoid any

U: 01/14/2011 Non-Par 39186 Commercial IN Managed Health Services Indiana (Medicaid HMO) Institutional 4010A1 Enrollment Claim Level Accept/Reject rejections)

Non-Par 41555 Commercial Manatee Service Center (Bradenton FL) Institutional 4010A1 File Level Acknowledgement

Non-Par 41555 Commercial Manatee Service Center (Bradenton FL) Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WR691 Commercial TX, MN Manpower Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR691 Commercial TX, MN Manpower Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR691 Commercial TX, MN Manpower Auto 4010A1 Claim Level Accept/Reject

Non-Par 75258 Commercial Mapco, Inc. Professional 4010A1 Claim Level Acknowledgement

Par IP097 Commercial CA Marin IPA Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR726 Commercial TX, MN Marriott Claims-Plano Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR726 Commercial TX, MN Marriott Claims-Plano Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR726 Commercial TX, MN Marriott Claims-Plano Auto 4010A1 Claim Level Accept/Reject

Non-Par MPHC1 Commercial Martins Point Health Care Professional 4010A1 File Level Acknowledgement

Non-Par 22347 Commercial MD Maryland Health Insurance Plan / MHIP Professional 4010A1 Claim Level Accept/Reject

Non-Par 22348 Commercial Maryland Physicians Care Institutional 4010A1 Claim Level Accept/Reject

Non-Par 00247 Commercial MD Maryland Physician's Care Institutional 4010A1 No Response From Payer







11/10/2011 36 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 00247 Commercial MD Maryland Physician's Care Professional 4010A1 Claim Level Accept/Reject

Non-Par 22322 Commercial MD Maryland Public Mental Health Institutional 4010A1 No Response From Payer

Non-Par SX069 Government MD Maryland Public Mental Health System (PMHS) Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par 37121 Commercial Mashantucket Pequot Tribal Nation Institutional 4010A1 No Response From Payer

Non-Par 37121 Commercial Mashantucket Pequot Tribal Nation Professional 4010A1 No Response From Payer

For claims rejections, please contact e-support.Services@valueoptions.com or

A: 08/22/2011 Non-Par 43307 Commercial MA Massachusetts Behavioral Health Plan Professional 4010A1 Enrollment No Response From Payer 888-247-9311 (8am-6pm, M-F

Non-Par WK004 Commercial Matrix Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK004 Commercial Matrix Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK111 Commercial Maxim Crane Works Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK111 Commercial Maxim Crane Works Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR749 Commercial Mayo Clinic Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR749 Commercial Mayo Clinic Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR749 Commercial Mayo Clinic Auto 4010A1 Claim Level Accept/Reject

Non-Par 41154 Commercial MN Mayo Management Services, Inc. Professional 4010A1 File Level Acknowledgement Yes

Non-Par 41154 Commercial MN Mayo Management Services, Inc. Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 83028 Commercial MU MBA Benefit Administrators Professional 4010A1 Claim Level Accept/Reject No

Non-Par 83028 Commercial MU MBA Benefit Administrators Institutional 4010A1 Claim Level Accept/Reject No

Non-Par 87065 Commercial MBA of Wyoming Professional 4010A1 Claim Level Accept/Reject

Non-Par 87065 Commercial MBA of Wyoming (Worland WY) Institutional 4010A1 File Level Acknowledgement

Non-Par 56205 Commercial MBS - MedCost Benefit Services Institutional 4010A1 No Response From Payer Yes

Non-Par 56205 Commercial MBS - MedCost Benefit Services Professional 4010A1 Claim Level Acknowledgement Yes

A: 04/06/2010 Trans WK112 Commercial TX, MN Mc Donald'S-Mcopco Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK112 Commercial TX, MN Mc Donald'S-Mcopco Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK112 Commercial TX, MN Mc Donald'S-Mcopco Auto 4010A1 Claim Level Accept/Reject

Non-Par 25160 Commercial MCA ADMINISTRATORS Institutional 4010A1 File Level Acknowledgement

U:10/27/2011 Non-Par 59331 Commercial McCreary Corporation Institutional 5010A2 No Response From Payer

For plan and claim requirements please contact the payer @ 561-287-7650 ext

10/17/11 Non-Par 59331 Commercial McCreary Corporation Professional 5010A1 Claim Level Acknowledgement 4052

A: 04/06/2010 Non-Par WR751 Commercial TX McGraw-Hill Companies Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR751 Commercial TX McGraw-Hill Companies Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR751 Commercial TX McGraw-Hill Companies Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR760 Commercial MCIT Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR760 Commercial MCIT Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR760 Commercial MCIT Auto 4010A1 Claim Level Accept/Reject

Non-Par MHM02 Commercial McKinley Medical Group Professional 4010A1 No Response From Payer

Non-Par 38232 Commercial McLaren (claims destined for the following address only: POB 30275/Lansing MI) Professional 4010A1 Claim Level Acknowledgement

Non-Par 38338 Commercial McLaren Health Institutional 4010A1 No Response From Payer

Non-Par 38338 Commercial McLaren Health Professional 4010A1 Claim Level Acknowledgement

Non-Par WX776 Commercial MCMC, LLC Prof. Work Comp 4010A1 Claim Level Accept/Reject

Trans 87726 Commercial MD-Individual Practice Assoc. (MD-IPA)(HCFA 1500 only) (Formerly 52148) Professional 4010A1 Claim Level Accept/Reject

Trans 87726 Commercial MD-Individual Practice Association, Inc. (MD.IPA) (Formerly 52148) Institutional 4010A1 No Response From Payer

Non-Par 20475 Commercial MDWise - Hoosier Alliance Remittance 4010A1 Enrollment

Non-Par 20475 Commercial MDWise - Hoosier Alliance Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 20475 Commercial MDWise Hoosier Alliance Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par MDWIS Commercial Mdwis-HIP Institutional 4010A1 File Level Acknowledgement

Non-Par MDWIS Commercial Mdwis-HIP Professional 4010A1 File Level Acknowledgement

Non-Par M3FL9 Commercial MU MED3000 Healthsprings Professional 4010A1 File Level Acknowledgement

Non-Par M3FL2 Commercial MU Med3000 Vista Professional 4010A1 File Level Acknowledgement Enrollment Contact: (866) 703-1444

Non-Par 58202 Commercial MedAdmin Solutions Institutional 4010A1 No Response From Payer

Non-Par 58204 Commercial MedAdmin Solutions Institutional 4010A1 No Response From Payer

Non-Par 58204 Commercial MedAdmin Solutions Professional 4010A1 Claim Level Accept/Reject

U:10/27/2011 Non-Par 74323 Commercial MedBen (Newark, OH) Institutional 5010A2 No Response From Payer

Non-Par 59231 Commercial MedCom (e-MedCom) Institutional 4010A1 No Response From Payer Yes

Non-Par 59231 Commercial MedCom (e-MedCom) Professional 4010A1 Claim Level Accept/Reject Yes

For questions on claim submission, please contact Customer Service (800)824-

Non-Par 56162 Commercial Medcost, Inc. Institutional 4010A1 Enrollment Yes 7406

For questions on claim submission, please contact Customer Service (800)824-

Non-Par 56162 Commercial Medcost, Inc. Professional 4010A1 Claim Level Accept/Reject Yes 7406

Non-Par 38353 Commercial MedDirect Professional 4010A1 File Level Acknowledgement

Non-Par 95321 Commercial Medfocus Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WR833 Commercial TX, MN Media General, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR833 Commercial TX, MN Media General, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR833 Commercial TX, MN Media General, Inc. Auto 4010A1 Claim Level Accept/Reject

Trans 94265 Commercial Medica Remittance 4010A1 Enrollment

Trans 94265 Commercial MN Medica - United Healthcare Institutional 4010A1 No Response From Payer Yes

Trans 94265 Commercial MN Medica - United Healthcare Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 78857 Commercial MEDICA HEALTH CARE PLAN INC. Professional 4010A1 Claim Level Accept/Reject

U:10/07/2011 Non-Par MC018 Government AL Medicaid - Alabama Professional 4010A1 File Level Acknowledgement Yes

Non-Par MC018 Government AL Medicaid - Alabama Remittance 4010A1 Enrollment

Non-Par MC093 Government AK Medicaid - Alaska Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC093 Government AK Medicaid - Alaska Remittance 4010A1 Enrollment

Non-Par SKAZ0 Government AZ Medicaid - Arizona Professional 4010A1 File Level Acknowledgement Yes

Non-Par MC029 Government AR Medicaid - Arkansas Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MC029 Government AR Medicaid - Arkansas Remittance 4010A1 Enrollment

Non-Par MC004 Government CO Medicaid - Colorado Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC004 Government CO Medicaid - Colorado Remittance 4010A1 Enrollment

Non-Par MC004 Government CO Medicaid - Colorado Institutional 4010A1 Enrollment File Level Acknowledgement

Non-Par MC039 Government CT Medicaid - Connecticut Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC039 Government CT Medicaid - Connecticut Remittance 4010A1 Enrollment

Non-Par SKDE0 Government DE Medicaid - Delaware (EDS) Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par SKDE0 Government DE Medicaid - Delaware (EDS) Remittance 4010A1 Enrollment

Non-Par MC010 Government FL Medicaid - Florida Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC010 Government FL Medicaid - Florida Remittance 4010A1 Enrollment

U: 08/26/2011 Non-Par MC020 Government GA Medicaid - Georgia Professional 4010A1 and 5010A1 Enrollment Rejection Only Yes

Non-Par MC020 Government GA Medicaid - Georgia Remittance 4010A1 Enrollment

Non-Par MC103 Government HI Medicaid - Hawaii Professional 4010A1 Enrollment No Response From Payer Yes







11/10/2011 37 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par SKID0 Government ID Medicaid - Idaho Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par SKID0 Government ID Medicaid - Idaho Remittance 4010A1 Enrollment

U:09/30/2011 Non-Par MC009 Government IL Medicaid - Illinois Professional 4010A1 and 5010A1 Claim Level Accept/Reject Yes

Non-Par MC009 Government IL Medicaid - Illinois Remittance 4010A1 Enrollment

Non-Par MC022 Government IN Medicaid - Indiana Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MC022 Government IN Medicaid - Indiana Remittance 4010A1 Enrollment

Non-Par IC026 Government IA Medicaid - Iowa Institutional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC026 Government IA Medicaid - Iowa Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC026 Government IA Medicaid - Iowa Remittance 4010A1 Enrollment

Non-Par MC012 Government KS Medicaid - Kansas Professional 4010A1 No Response From Payer Yes

Non-Par MC012 Government KS Medicaid - Kansas Remittance 4010A1 Enrollment

Non-Par MC032 Government KY Medicaid - Kentucky Remittance 4010A1 Enrollment

Non-Par MC032 Government KY Medicaid - Kentucky Professional 4010A1 Enrollment No Response From Payer Yes

ERA for Payer ID MC089 and MC128 are combined under Payer ID MC089. If

enrolling for Louisiana Medicaid and/or Louisiana Medicaid DME, complete

Non-Par MC089 Government LA Medicaid - Louisiana Remittance 4010A1 Enrollment agreement located under Payer ID MC089.

Non-Par MC089 Government LA Medicaid - Louisiana Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MC128 Government LA Medicaid - Louisiana - DME Professional 4010A1 Enrollment Claim Level Rejects Only Yes

ERA for Payer ID MC089 and MC128 are combined under Payer ID MC089. If

enrolling for Louisiana Medicaid and/or Louisiana Medicaid DME, complete

Non-Par MC128 Government LA Medicaid - Lousisiana - DME Remittance 4010A1 Enrollment agreement located under Payer ID MC089.

Non-Par MC036 Government ME Medicaid - Maine Remittance 4010A1 Enrollment

Claims with dates of service after 09/01/10. For questions filing claims with dates

of service prior to 09/01/2010, Call Maine Medicaid Provider Services 1-866-690-

U: 12/30/2010 Non-Par MC036 Government ME Medicaid - Maine Professional 4010A1 Enrollment Claim Level Rejects Only 5585.

Non-Par IC091 Government MD Medicaid - Maryland Institutional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC091 Government MD Medicaid - Maryland Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC091 Government MD Medicaid - Maryland Remittance 4010A1 Enrollment

Non-Par MC054 Government MA Medicaid - Massachusetts Remittance 4010A1 Enrollment

Non-Par MC054 Government MA Medicaid - Massachusetts Professional 4010A1 Enrollment File Level Acknowledgement Yes

Non-Par MC035 Government MI Medicaid - Michigan Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MC035 Government MI Medicaid - Michigan (PLEASE ENROLL FOR BS017) Remittance 4010A1 Enrollment To receive ERAs for MC035, providers must enroll under Payer ID BS017.

Non-Par IC053 Government MN Medicaid - Minnesota Institutional 4010A1 No Response From Payer Yes

Non-Par MC053 Government MN Medicaid - Minnesota Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC053 Government MN Medicaid - Minnesota Remittance 4010A1 Enrollment

Non-Par MC019 Government MS Medicaid - Mississippi Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC019 Government MS Medicaid - Mississippi Remittance 4010A1 Enrollment

U: 12/30/2010 Non-Par MC011 Government MO Medicaid - Missouri Professional 4010A1 No Response From Payer Yes

Non-Par MC011 Government MO Medicaid - Missouri Remittance 4010A1 Enrollment

Non-Par MC033 Government MT Medicaid - Montana Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC033 Government MT Medicaid - Montana Remittance 4010A1 Enrollment

5010 enrollment required. Nebraska Medicaid requires all providers to complete

new enrollment forms as part of the mandated 5010 migration. Failure to enroll will

U: 09/27/2011 Non-Par MC007 Government NE Medicaid - Nebraska Professional 4010A1 Enrollment Claim Level Rejects Only Yes result in rejected claims and halt ERA delivery.

5010 enrollment required. Nebraska Medicaid requires all providers to complete

new enrollment forms as part of the mandated 5010 migration. Failure to enroll will

U: 09/27/2011 Non-Par MC007 Government NE Medicaid - Nebraska Remittance 4010A1 Enrollment result in rejected claims and halt ERA delivery.

Non-Par MC008 Government NV Medicaid - Nevada Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC008 Government NV Medicaid - Nevada Remittance 4010A1 Enrollment

Non-Par MC059 Government NH Medicaid - New Hampshire Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MC059 Government NH Medicaid - New Hampshire Remittance 4010A1 Enrollment

Non-Par MC087 Government NJ Medicaid - New Jersey Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC087 Government NJ Medicaid - New Jersey Remittance 4010A1 Enrollment

Non-Par MC034 Government NM Medicaid - New Mexico Professional 4010A1 No Response From Payer Yes

Non-Par IC066 Government NY Medicaid - New York Institutional 4010A1 Enrollment Claim Level Rejects Only

U:09/30/2011 Non-Par MC066 Government NY Medicaid - New York Professional 4010A1 and 5010A1 Enrollment File Level Acknowledgement Yes

U: 12/30/2010 Non-Par MC066 Government NY Medicaid - New York Remittance 4010A1 Enrollment

Non-Par MC021 Government NC Medicaid - North Carolina Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MC021 Government NC Medicaid - North Carolina Remittance 4010A1 Enrollment

Non-Par MC121 Government NC Medicaid - North Carolina - Mental Health ONLY Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par IC101 Government ND Medicaid - North Dakota Institutional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC101 Government ND Medicaid - North Dakota Professional 4010A1 File Level Acknowledgement Yes

Non-Par MC046 Government OH Medicaid - Ohio Remittance 4010A1 Enrollment

Non-Par MC046 Government OH Medicaid - Ohio Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MC030 Government OK Medicaid - Oklahoma Remittance 4010A1 Enrollment

Non-Par MC030 Government OK Medicaid - Oklahoma Professional 4010A1 No Response From Payer Yes

Non-Par MC015 Government OR Medicaid - Oregon Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC015 Government OR Medicaid - Oregon Remittance 4010A1 Enrollment

Non-Par MC016 Government PA Medicaid - Pennsylvania Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par MC016 Government PA Medicaid - Pennsylvania Remittance 4010A1 Enrollment

Non-Par MC097 Government RI Medicaid - Rhode Island Professional 4010A1 Enrollment Claim Level Acknowledgement Yes

Non-Par MC097 Government RI Medicaid - Rhode Island Remittance 4010A1 Enrollment

Non-Par SDDHS Government SD Medicaid - SD Department of Human Services Division Professional 4010A1 Claim Level Acknowledgement

Non-Par MC024 Government SC Medicaid - South Carolina Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC024 Government SC Medicaid - South Carolina Remittance 4010A1 Enrollment

U: 12/30/2010 Non-Par IC102 Government SD Medicaid - South Dakota Institutional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC102 Government SD Medicaid - South Dakota Professional 4010A1 Enrollment File Level Acknowledgement Yes

Non-Par MC102 Government SD Medicaid - South Dakota Remittance 4010A1 Enrollment

Non-Par MC092 Government TN Medicaid - Tennessee (TennCare through Tennessee Blue Shield) Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MC092 Government TN Remittance

Medicaid - Tennessee (TennCare through Tennessee Blue Shield) (For Remittance, enroll under BS032) 4010A1 Enrollment

Non-Par MC005 Government TX Medicaid - Texas Remittance 4010A1 Enrollment

Non-Par MC005 Government TX Medicaid - Texas Professional 4010A1 No Response From Payer Yes

Non-Par MC044 Government UT Medicaid - Utah Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC044 Government UT Medicaid - Utah Remittance 4010A1 Enrollment

Non-Par MC081 Government VT Medicaid - Vermont Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MC081 Government VT Medicaid - Vermont Remittance 4010A1 Enrollment

Non-Par MC017 Government VA Medicaid - Virginia Professional 4010A1 No Response From Payer Yes

Non-Par MC017 Government VA Medicaid - Virginia Remittance 4010A1 Enrollment







11/10/2011 38 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par MC006 Government WA Medicaid - Washington (DSHS) Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MC006 Government WA Medicaid - Washington (DSHS) Remittance 4010A1 Enrollment

Non-Par MC088 Government DC Medicaid - Washington DC Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC088 Government DC Medicaid - Washington DC Remittance 4010A1 Enrollment

Non-Par MC048 Government WV Medicaid - West Virginia Professional 4010A1 Claim Level Rejects Only Yes

Non-Par MC048 Government WV Medicaid - West Virginia Remittance 4010A1 Enrollment

Non-Par MC049 Government WI Medicaid - Wisconsin Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC049 Government WI Medicaid - Wisconsin Remittance 4010A1 Enrollment

Non-Par MC055 Government WI Medicaid - Wisconsin HIRSP Only Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC042 Government WY Medicaid - Wyoming Remittance 4010A1 Enrollment

Non-Par MC042 Government WY Medicaid - Wyoming Professional 4010A1 Enrollment No Response From Payer Yes

A: 01/11/2011 Non-Par MC037 Government AZ Medicaid Arizona (AHCCCS) Remittance 4010A1 Enrollment

Non-Par MC051 Government CA Medi-Cal - California Professional 4010A1 Enrollment No Response From Payer Yes

Non-Par MC051 Government CA Medi-Cal - California Remittance 4010A1 Enrollment

Non-Par 57016 Government CA Medi-Cal - California (Institutional) Institutional 4010A1 Enrollment No Response From Payer

Par WK021 Commercial Medical Audit Consultants Inst. Work Comp 4010A1 Claim Level Acknowledgement

Par WK021 Commercial Medical Audit Consultants Prof. Work Comp 4010A1 Claim Level Acknowledgement

Non-Par 37298 Commercial Medical Benefit Administrators Inc/dba MBA of MD Inc Institutional 4010A1 File Level Acknowledgement

Par 68041 Commercial Medical Benefits Administration Professional 4010A1 Claim Level Accept/Reject

Non-Par 37298 Commercial MD Medical Benefits Administrators of MD Professional 4010A1 No Response From Payer

U:10/27/2011 Non-Par 74323 Commercial Medical Benefits Administrators, Inc. (Newark, OH) Institutional 5010A2 No Response From Payer

U:10/27/2011 Non-Par 74323 Commercial Medical Benefits Companies (Newark, OH) Institutional 5010A2 No Response From Payer

U:10/27/2011 Non-Par 74323 Commercial Medical Benefits Mutual (Newark, OH) Institutional 5010A2 No Response From Payer

10/17/11 Non-Par 74323 Commercial Medical Benefits Mutual (Newark, OH) Professional 5010A1 Claim Level Accept/Reject

U:10/27/2011 Non-Par 74323 Commercial Medical Benefits Mutual Life Insurance Co. Institutional 5010A2 No Response From Payer

Non-Par 74323 Commercial Medical Benefits Mutual Life Insurance Co. Remittance 4010A1 Enrollment

Non-Par 75229 Commercial Medical Control Inc. Institutional 4010A1 File Level Acknowledgement

Non-Par 75229 Commercial Medical Control Inc. Professional 4010A1 File Level Acknowledgement

Non-Par 52181 Commercial Medical Development International Institutional 4010A1 No Response From Payer

Non-Par 52181 Commercial Medical Development International Professional 4010A1 Claim Level Accept/Reject

U:10/27/11 Non-Par 29076 Commercial Medical Mutual of Ohio Institutional 5010A2 No Response From Payer Yes

10/17/11 Non-Par BC004 Commercial OH Medical Mutual of Ohio Professional 5010A1 Claim Level Accept/Reject Yes

Non-Par BC004 Commercial OH Medical Mutual of Ohio Remittance 4010A1 Enrollment

Non-Par CSMED Commercial CO Medical Network of Colorado Springs Professional 4010A1 Claim Level Acknowledgement

Non-Par 80026 Commercial Medical Partners of America Institutional 4010A1 File Level Acknowledgement

Non-Par 80026 Commercial Medical Partners of America Professional 4010A1 File Level Acknowledgement

Non-Par 33029 Commercial Medical Pathways Professional 4010A1 Claim Level Acknowledgement

Non-Par 62177 Commercial Medical Reimbursements of America Institutional 4010A1 No Response From Payer

Non-Par 58203 Commercial Medical Resource Network (MRN) Institutional 4010A1 No Response From Payer

Non-Par 58203 Commercial Medical Resource Network (MRN) Professional 4010A1 Claim Level Accept/Reject

Par IP186 Commercial CA Medical Services Initiative Professional 4010A1 Claim Level Accept/Reject

Non-Par 38224 Commercial Medical Value Plan - Ohio (MVP) Institutional 4010A1 Claim Level Accept/Reject

Par 38224 Commercial OH Medical Value Plan-MVP-OH Professional 4010A1 Claim Level Rejects Only

U:09/30/2011 Non-Par MR054 Government AL Medicare - Alabama Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR054 Government AL Medicare - Alabama Remittance 4010A1 Enrollment

Non-Par MR010 Government AK Medicare - Alaska Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR010 Government AK Medicare - Alaska Remittance 4010A1 Enrollment

Non-Par MR008 Government AZ Medicare - Arizona Remittance 4010A1 Enrollment

Non-Par MR008 Government AZ Medicare - Arizona Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR055 Government AR Medicare - Arkansas Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR055 Government AR Medicare - Arkansas Remittance 4010A1 Enrollment

Non-Par MR002 Government CA Medicare - California - Northern Region Remittance 4010A1 Enrollment

Non-Par IR002 Government CA Medicare - California - Northern Region Institutional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR002 Government CA Medicare - California - Northern Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par IR001 Government CA Medicare - California - Southern Region Institutional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR001 Government CA Medicare - California - Southern Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR001 Government CA Medicare - California - Southern Region Remittance 4010A1 Enrollment

Non-Par MR004 Government CO Medicare - Colorado Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR004 Government CO Medicare - Colorado Remittance 4010A1 Enrollment

U:09/30/2011 Non-Par MR049 Government CT Medicare - Connecticut Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR049 Government CT Medicare - Connecticut Remittance 4010A1 Enrollment

U: 09/22/2011 Non-Par MR039 Government DE Medicare - Delaware Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

U: 12/08/2010 Non-Par MR039 Government DE Medicare - Delaware Remittance 4010A1 Enrollment

Non-Par MR025 Government FL Medicare - Florida Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR025 Government FL Medicare - Florida Remittance 4010A1 Enrollment

U:09/30/2011 Non-Par MR015 Government GA Medicare - Georgia Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR015 Government GA Medicare - Georgia Remittance 4010A1 Enrollment

Non-Par MR057 Government HI Medicare - Hawaii Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR057 Government HI Medicare - Hawaii Remittance 4010A1 Enrollment

U:09/30/2011 Non-Par MR003 Government ID Medicare - Idaho Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR003 Government ID Medicare - Idaho Remittance 4010A1 Enrollment

9/22/11 Non-Par MR023 Government IL Medicare - Illinois Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

U: 08/30/2011 Non-Par MR023 Government IL Medicare - Illinois Remittance 4010A1 Enrollment

U:09/30/2011 Non-Par MR041 Government IN Medicare - Indiana Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR041 Government IN Medicare - Indiana Remittance 4010A1 Enrollment

Non-Par IR036 Government IA Medicare - Iowa Institutional 4010A1 Enrollment Claim Level Acknowledgement Yes

U: 09/22/2011 Non-Par MR036 Government IA Medicare - Iowa Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR036 Government IA Medicare - Iowa Remittance 4010A1 Enrollment

U: 09/22/2011 Non-Par MR060 Government KS Medicare - Kansas Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR060 Government KS Medicare - Kansas Remittance 4010A1 Enrollment

Non-Par MR052 Government KY Medicare - Kentucky Remittance 4010A1 Enrollment

U: 09/30/2011 Non-Par MR052 Government KY Medicare - Kentucky Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR048 Government LA Medicare - Louisiana Remittance 4010A1 Enrollment

U:09/30/2011 Non-Par MR048 Government LA Medicare - Louisiana Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR043 Government ME Medicare - Maine Remittance 4010A1 Enrollment

U: 08/26/2011 Non-Par MR043 Government ME Medicare - Maine Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes







11/10/2011 39 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par MR038 Government MD Medicare - Maryland Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par IR038 Government MD Medicare - Maryland Institutional 4010A1 and 5010A2 Enrollment Claim Level Acknowledgement Yes

U: 09/22/2011 Non-Par MR038 Government MD Medicare - Maryland Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR061 Government MA Medicare - Massachusetts Remittance 4010A1 Enrollment

U: 08/26/2011 Non-Par MR061 Government MA Medicare - Massachusetts Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR017 Government MI Medicare - Michigan Remittance 4010A1 Enrollment

9/20/11 Non-Par MR017 Government MI Medicare - Michigan Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR019 Government MN Medicare - Minnesota Remittance 4010A1 Enrollment

Non-Par IR019 Government MN Medicare - Minnesota Institutional 4010A1 Enrollment No Response From Payer Yes

9/23/11 Non-Par MR019 Government MN Medicare - Minnesota Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR050 Government MS Medicare - Mississippi Remittance 4010A1 Enrollment

U:09/30/2011 Non-Par MR050 Government MS Medicare - Mississippi Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

A: 12/07/2010 Non-Par MR094 Government Medicare - Missouri - Eastern Remittance 4010A1 Enrollment

U: 09/22/2011 Non-Par MR094 Government MO Medicare - Missouri - Eastern (WPS) Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR044 Government MO Medicare - Missouri - Western (WPS) Remittance 4010A1 Enrollment

U: 09/22/2011 Non-Par MR044 Government MO Medicare - Missouri - Western (WPS) Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR047 Government MT Medicare - Montana Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR047 Government MT Medicare - Montana Remittance 4010A1 Enrollment

Non-Par MR092 Government NE Medicare - Nebraska Remittance 4010A1 Enrollment

U: 09/22/2011 Non-Par MR092 Government NE Medicare - Nebraska Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR007 Government NV Medicare - Nevada Remittance 4010A1 Enrollment

Non-Par MR007 Government NV Medicare - Nevada Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR051 Government NH Medicare - New Hampshire Remittance 4010A1 Enrollment

U: 08/26/2011 Non-Par MR051 Government NH Medicare - New Hampshire Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR035 Government NJ Medicare - New Jersey Remittance 4010A1 Enrollment

U: 09/22/2011 Non-Par MR035 Government NJ Medicare - New Jersey Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR076 Government NM Medicare - New Mexico Remittance 4010A1 Enrollment

Non-Par MR076 Government NM Medicare - New Mexico Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR042 Government NY Medicare - New York (Empire) Remittance 4010A1 Enrollment

U:09/30/2011 Non-Par MR042 Government NY Medicare - New York (Empire) Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

U:09/30/2011 Non-Par MR045 Government NY Medicare - New York (GHI Queens County Only) Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR045 Government NY Medicare - New York (GHI Queens County Only) Remittance 4010A1 Enrollment

U:09/30/2011 Non-Par MR059 Government NY Medicare - New York (Upstate/Albany) Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR059 Government NY Medicare - New York (Upstate/Albany) Remittance 4010A1 Enrollment

Non-Par MR020 Government NC Medicare - North Carolina Remittance 4010A1 Enrollment

Non-Par MR020 Government NC Medicare - North Carolina Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR083 Government ND Medicare - North Dakota Remittance 4010A1 Enrollment

Non-Par IR083 Government ND Medicare - North Dakota Institutional 4010A1 Enrollment No Response From Payer Yes

Non-Par MR083 Government ND Medicare - North Dakota Professional 4010A1 Enrollment Claim Level Rejects Only Yes

U: 08/25/2011 Non-Par MR033 Government OH Medicare - Ohio Remittance 4010A1 Enrollment

U:09/30/2011 Non-Par MR033 Government OH Medicare - Ohio Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR013 Government OK Medicare - Oklahoma Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR013 Government OK Medicare - Oklahoma Remittance 4010A1 Enrollment

Non-Par MR011 Government OR Medicare - Oregon Remittance 4010A1 Enrollment

Non-Par MR011 Government OR Medicare - Oregon Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR027 Government PA Medicare - Pennsylvania Remittance 4010A1 Enrollment

9/23/11 Non-Par MR027 Government PA Medicare - Pennsylvania Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par SMPR0 Government PR Medicare - Puerto Rico Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR075 Government RI Medicare - Rhode Island Remittance 4010A1 Enrollment

U: 08/26/2011 Non-Par MR075 Government RI Medicare - Rhode Island Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR028 Government SC Medicare - South Carolina Remittance 4010A1 Enrollment

Non-Par MR028 Government SC Medicare - South Carolina Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR084 Government SD Medicare - South Dakota Remittance 4010A1 Enrollment

Non-Par IR084 Government SD Medicare - South Dakota Institutional 4010A1 Enrollment Claim Level Acknowledgement Yes

Non-Par MR084 Government SD Medicare - South Dakota Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par IR184 Government SD Medicare - South Dakota Home Health & Hospice Institutional 4010A1 Enrollment Claim Level Acknowledgement Yes

Non-Par MR034 Government TN Medicare - Tennessee Remittance 4010A1 Enrollment

U:09/30/2011 Non-Par MR034 Government TN Medicare - Tennessee Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

U: 01/05/2011 Non-Par IR034 Government TN Medicare - Tennessee (Part A) Institutional 4010A1 Enrollment Claim Level Acknowledgement Yes

Non-Par MR005 Government TX Medicare - Texas Remittance 4010A1 Enrollment

Non-Par IR005 Government TX Medicare - Texas Institutional 4010A1 Enrollment Claim Level Acknowledgement Yes

Non-Par MR005 Government TX Medicare - Texas Professional 4010A1 Enrollment Claim Level Rejects Only Yes

U: 01/11/2011 Non-Par IR005 Government Medicare - Texas Remittance 4010A1 Enrollment

Non-Par MR046 Government UT Medicare - Utah Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR046 Government UT Medicare - Utah Remittance 4010A1 Enrollment

Non-Par MR062 Government VT Medicare - Vermont Remittance 4010A1 Enrollment

U: 08/26/2011 Non-Par MR062 Government VT Medicare - Vermont Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par SMVI0 Commercial VI Medicare - Virgin Island (Part B) Remittance 4010A1 Enrollment

U: 12/30/2010 Non-Par SMVI0 Government VI Medicare - Virgin Island (Part B) Professional 5010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par MR022 Government VA Medicare - Virginia - All Other Areas Remittance 4010A1 Enrollment

Non-Par MR022 Government VA Medicare - Virginia --- All Other Areas Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR006 Government WA Medicare - Washington Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR006 Government WA Medicare - Washington Remittance 4010A1 Enrollment

U: 12/08/2010 Non-Par MR040 Government DC Medicare - Washington DC Remittance 4010A1 Enrollment

U: 09/22/2011 Non-Par MR040 Government DC Medicare - Washington DC (Includes Counties of Arlington & Fairfax / Cities of Alexandria,Professional & Fairfax) 4010A1 and 5010A1

Falls Church, - ERA Now available Enrollment Claim Level Rejects Only Yes

Non-Par MR056 Government WV Medicare - West Virginia Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR056 Government WV Medicare - West Virginia Remittance 4010A1 Enrollment

Non-Par IR053 Government WI Medicare - Wisconsin Institutional 4010A1 Enrollment Claim Level Acknowledgement Yes

U: 09/22/2011 Non-Par MR053 Government WI Medicare - Wisconsin Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR053 Government WI Medicare - Wisconsin Remittance 4010A1 Enrollment

Non-Par MR074 Government WY Medicare - Wyoming Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR074 Government WY Medicare - Wyoming Remittance 4010A1 Enrollment

Non-Par MR117 Government MI Medicare Plus Blue / Medicare Advantage Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR117 Government MI Medicare Plus Blue / Medicare Advantage Remittance 4010A1 Enrollment

U: 12/30/2010 Non-Par MR118 Government MI Medicare PlusBlue-Medicare Advantage DME Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par IR034 Government TN Medicare Tennessee (Part A) Remittance 4010A1 Enrollment







11/10/2011 40 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 95655 Commercial MediGold Professional 4010A1 Claim Level Accept/Reject

Non-Par 94254 Commercial MediPrime Professional 4010A1 Claim Level Accept/Reject

Non-Par 35205 Commercial MedPartners Professional 4010A1 File Level Acknowledgement Yes

Non-Par 62160 Commercial MedSolutions, Inc. Institutional 4010A1 No Response From Payer

Non-Par 62160 Commercial GA MedSolutions, Inc. of Georgia Professional 4010A1 Claim Level Acknowledgement

Par 00243 Commercial MedStar Family Choice Professional 4010A1 Claim Level Accept/Reject

Non-Par 59221 Commercial MEGA Life & Health Insurance Co. Institutional 4010A1 No Response From Payer

Trans 87726 Commercial Meica Institutional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Trans WR843 Commercial Member Insurance Agency Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR843 Commercial Member Insurance Agency Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR843 Commercial Member Insurance Agency Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 01047 Commercial MEMIC Professional 4010A1 Claim Level Acknowledgement

Non-Par 01047 Commercial MEMIC Institutional 4010A1 Claim Level Acknowledgement

Non-Par 62181 Commercial Memorial Clinical Associates/ SelectCare of Texas (MCA) Professional 4010A1 Claim Level Acknowledgement

Non-Par 62181 Commercial Memorial Clinical Associates/ SelectCare of Texas (MCA) Institutional 4010A1 Claim Level Acknowledgement

Non-Par MHHNP Commercial Memorial Hermann Health Professional 4010A1 File Level Acknowledgement

Non-Par 59065 Commercial Memorial Integrated Healthcare Professional 4010A1 File Level Acknowledgement

Non-Par CALL Commercial Memorial Integrated Healthcare Professional 4010A1 File Level Acknowledgement For the Payer ID please email Tracy Harswick at THARSWICK@MHS.NET

Non-Par 36193 Commercial Memphis Managed Care/TLC Institutional 4010A1 No Response From Payer

Non-Par 36193 Commercial Memphis Managed Care/TLC Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA062 Commercial Mendota Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA062 Commercial Mendota Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA062 Commercial Mendota Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par MNM99 Commercial Mennonite Mutual Aid Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WR847 Commercial Menominee Ind. Tribe of WI Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR847 Commercial Menominee Ind. Tribe of WI Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR847 Commercial Menominee Ind. Tribe of WI Auto 4010A1 Claim Level Accept/Reject

Non-Par MRC01 Government AZ Mercy Care (Arizona) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 86052 Commercial AZ Mercy Care Plan (AHCCCS) Professional 4010A1 Claim Level Accept/Reject

Non-Par 86052 Commercial AZ Mercy Care Plan (AHCCCS) Institutional 4010A1 Claim Level Accept/Reject

Non-Par 22326 Commercial NJ Mercy Health Plan of NJ Remittance 4010A1 Enrollment

Non-Par 22326 Commercial NJ Mercy Health Plan of NJ (Horizon Mercy) Institutional 4010A1 No Response From Payer Yes

Non-Par 22326 Commercial NJ Mercy Health Plan of NJ (Horizon Mercy) Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 43166 Commercial Mercy Health Plans Institutional 4010A1 No Response From Payer

Non-Par 43166 Commercial Mercy Health Plans Professional 4010A1 No Response From Payer

Trans IP079 Commercial CA Mercy Physicians Medical Group - San Diego - MPMG Professional 4010A1 Claim Level Accept/Reject

Non-Par 39114 Commercial Mercycare Institutional 4010A1 No Response From Payer

Non-Par 39114 Commercial Mercycare Professional 4010A1 Claim Level Accept/Reject

Non-Par 13189 Commercial Meridian Health Plan Institutional 4010A1 File Level Acknowledgement

Non-Par 13189 Commercial Meridian Health Plan Professional 4010A1 File Level Acknowledgement

Non-Par 41124 Commercial MI Meritain Health Professional 4010A1 No Response From Payer

Non-Par 41124 Commercial MI Meritain Health Institutional 4010A1 No Response From Payer

Non-Par 64157 Commercial Meritain Health / North American Administrators Professional 4010A1 Claim Level Accept/Reject

Non-Par 64157 Commercial Meritain Health / North American Administrators Institutional 4010A1 Claim Level Accept/Reject

Non-Par 34159 Commercial Meritan Health Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WA060 Commercial Met Life (Metropolitan Property and Casualty) Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA060 Commercial Met Life (Metropolitan Property and Casualty) Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA060 Commercial Met Life (Metropolitan Property and Casualty) Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 23550 Commercial IL Methodist First Choice Professional 4010A1 Claim Level Accept/Reject

Trans AMS01 Commercial Methodist SW Prv Org Professional 4010A1 No Response From Payer

Trans 87726 Commercial Metrahealth Network (HMO & Care Option:A United HealthCare Co.) Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial Metrahealth Plan Administrators (A United HealthCare Co.) Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial Metrahealth/Metrahealth Railroad (A United HealthCare Co.) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 13265 Commercial Metro Plus Health Plan Professional 4010A1 Claim Level Acknowledgement

U: 01/11/2011 Non-Par 13265 Commercial Metro Plus Health Plan Institutional 4010A1 File Level Acknowledgement

U: 01/11/2011 Par 13265 Commercial Metro Plus Health Plan Remittance 4010A1 Enrollment

A: 04/06/2010 Non-Par WR890 Commercial TX, MN Metropolitan Council Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR890 Commercial TX, MN Metropolitan Council Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR890 Commercial TX, MN Metropolitan Council Auto 4010A1 Claim Level Accept/Reject

Non-Par MDL99 Commercial MI Metropolitan Detroit Laborers Professional 4010A1 No Response From Payer

Non-Par 10850 Commercial MN Metropolitan Health Plan Professional 4010A1 File Level Acknowledgement

Non-Par 10850 Commercial MN Metropolitan Health Plan Institutional 4010A1 File Level Acknowledgement

Providers must first contact provider services at (877)620-9090 for

Non-Par 10850 Commercial MN Metropolitan Health Plan Remittance 4010A1 Enrollment credential/contracting

Non-Par MWP01 Commercial Metrowest Health Plan - Preferred Care Professional 4010A1 Claim Level Accept/Reject

Non-Par 23550 Commercial MFC & HealthPlus Peoria Institutional 4010A1 Claim Level Acknowledgement

Non-Par 74289 Commercial MHNET Professional 4010A1 No Response From Payer

Non-Par 74289 Commercial MHNET Institutional 4010A1 File Level Acknowledgement

Trans 87726 Commercial Mid Atlantic Psychiatric Services, Inc (MAPS)(Formerly 52148) Institutional 4010A1 No Response From Payer

Non-Par 37281 Commercial Mid-America Associates, Inc Institutional 4010A1 No Response From Payer

Non-Par 37281 Commercial Mid-America Associates, Inc. Professional 4010A1 No Response From Payer

Non-Par MCI01 Commercial Midcoast Care IPA Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WB137 Commercial TX, MN Middlesex Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB137 Commercial TX, MN Middlesex Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 47080 Commercial Midlands Choice, Inc. Institutional 4010A1 No Response From Payer

Non-Par 47080 Commercial Midlands Choice, Inc. Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK113 Commercial TX, MN Midwest Drywall Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK113 Commercial TX, MN Midwest Drywall Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK113 Commercial TX, MN Midwest Drywall Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR892 Commercial TX, MN Midwest Employers Casualty Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR892 Commercial TX, MN Midwest Employers Casualty Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR892 Commercial TX, MN Midwest Employers Casualty Company Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR907 Commercial MN Midwest Family Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR907 Commercial MN Midwest Family Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 61146 Commercial Midwest Group Benefits Professional 4010A1 Claim Level Accept/Reject

Non-Par 76079 Commercial Midwest Health Partners Institutional 4010A1 File Level Acknowledgement







11/10/2011 41 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par MHP77 Commercial Midwest Health Plans Professional 4010A1 Claim Level Accept/Reject

Non-Par WK038 Commercial Midwest Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK038 Commercial Midwest Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 59224 Commercial Mid-West National Life Ins. Co. of Tennessee Institutional 4010A1 No Response From Payer

Non-Par 59224 Commercial Mid-West National Life Insurance Co. of Tennessee - Insurance Center Remittance 4010A1 Enrollment

Trans 74227 Commercial Mid-West National Life Insurance Co. of Tennessee - Student Insurance Institutional 4010A1 No Response From Payer Yes

Non-Par 59224 Commercial Mid-West National Life Insurance Company of Tennessee - Insurance Center Professional 4010A1 Claim Level Accept/Reject

Trans 74227 Commercial Mid-West National Life Insurance Company of TN - Student Insurance Professional 4010A1 Claim Level Acknowledgement Yes

Trans MSI01 Commercial Midwest Security Administration (MSA) Professional 4010A1 Claim Level Acknowledgement

Trans MSI01 Commercial Midwest Security Insurance Company (MSIC) Professional 4010A1 Claim Level Acknowledgement

Trans MSI01 Commercial Midwester Preferred Professional 4010A1 Claim Level Acknowledgement

Par MPMG1 Commercial CA Mills Peninsula Medical Group Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR912 Commercial MN Minneapolis Park & Recreation Board Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR912 Commercial MN Minneapolis Park & Recreation Board Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR912 Commercial MN Minneapolis Park & Recreation Board Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR913 Commercial TX, MN Minneapolis Public Schools Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR913 Commercial TX, MN Minneapolis Public Schools Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR913 Commercial TX, MN Minneapolis Public Schools Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR914 Commercial MN Minnesota Grp 4 Assigned Risk Plan Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR914 Commercial MN Minnesota Grp 4 Assigned Risk Plan Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR914 Commercial MN Minnesota Grp 4 Assigned Risk Plan Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR917 Commercial MN Minnesota Grp 68 Assigned Risk Plan Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR917 Commercial MN Minnesota Grp 68 Assigned Risk Plan Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR917 Commercial MN Minnesota Grp 68 Assigned Risk Plan Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR919 Commercial MN Minnesota Grp 78 Assigned Risk Plan Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR919 Commercial MN Minnesota Grp 78 Assigned Risk Plan Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR919 Commercial MN Minnesota Grp 78 Assigned Risk Plan Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR923 Commercial MN Minnesota Manufacturers Group Self-Insured Association Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR923 Commercial MN Minnesota Manufacturers Group Self-Insured Association Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR923 Commercial MN Minnesota Manufacturers Group Self-Insured Association Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR924 Commercial MN Minnesota Masonic Homes Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR924 Commercial MN Minnesota Masonic Homes Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR924 Commercial MN Minnesota Masonic Homes Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR925 Commercial MN Minnesota Nonprofits Employers Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR925 Commercial MN Minnesota Nonprofits Employers Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR925 Commercial MN Minnesota Nonprofits Employers Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR927 Commercial MN Minnesota Soft Drink Assoc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR927 Commercial MN Minnesota Soft Drink Assoc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR927 Commercial MN Minnesota Soft Drink Assoc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 05018 Commercial MIPS Professional 4010A1 File Level Acknowledgement

A: 10/19/2011 Non-Par PHM10 Commercial CA Mission Community IPA Professional 4010A1 File Level Acknowledgement

Non-Par MPM07 Commercial Mission Community IPA Medical Group Professional 4010A1 File Level Acknowledgement

Non-Par IP106 Commercial CA Mission Hospital Affiliated Physicians Professional 4010A1 No Response From Payer

Non-Par 64084 Commercial Mississippi Physicians Care Network Professional 4010A1 File Level Acknowledgement

Non-Par 37233 Commercial MS Mississippi Public Employee Benefit Trust Professional 4010A1 No Response From Payer

Non-Par 37233 Commercial Mississippi Public Entity Employee Benefit Trust Institutional 4010A1 No Response From Payer

Non-Par 64088 Commercial Mississippi Select Health Care Institutional 4010A1 No Response From Payer

Non-Par 64088 Commercial MS Mississippi Select Health Care (Gulfport, MS) Professional 4010A1 No Response From Payer

Non-Par 37275 Commercial Missoula County Medical Benefits Plan Professional 4010A1 No Response From Payer

Non-Par 37275 Commercial Missoula County Medical Benefits Plan Institutional 4010A1 No Response From Payer

Non-Par 43179 Commercial Missouri Care/MC Institutional 4010A1 No Response From Payer

Non-Par 43179 Commercial MO Missouri Care/MC Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK114 Commercial TX, MN Mitchell Energy & Devel Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK114 Commercial TX, MN Mitchell Energy & Devel Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK114 Commercial TX, MN Mitchell Energy & Devel Auto 4010A1 Claim Level Accept/Reject

Non-Par 37265 Commercial MLink Professional 4010A1 Claim Level Acknowledgement

Non-Par 35316 Commercial MMA Institutional 4010A1 File Level Acknowledgement

Non-Par 35316 Commercial MMA Professional 4010A1 File Level Acknowledgement

Non-Par 62178 Commercial MMS, LLC. Professional 4010A1 Claim Level Accept/Reject

Non-Par 41154 Commercial MN MMSI Remittance 4010A1 Enrollment

Non-Par 41154 Commercial MN MMSI Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 41154 Commercial MN MMSI Professional 4010A1 File Level Acknowledgement Yes

A: 04/06/2010 Non-Par WB127 Commercial Modern Fibers Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB127 Commercial Modern Fibers Inst. Work Comp 4010A1 Claim Level Accept/Reject

U: 12/30/2010 Non-Par 14165 Commercial NY Mohawk Valley Health Plan of NY (MVP) Remittance 4010A1 Enrollment

Non-Par SX109 Commercial UT Molina Health (UT) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par NM505 Commercial NM Molina Health Care of New Mexico Professional 4010A1 Claim Level Accept/Reject

Non-Par 20554 Commercial TX Molina Health Care of Texas Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 38336 Commercial WA Molina Health Care of Washington Institutional 4010A1 No Response From Payer Yes

U: 08/26/2011 Non-Par 38333 Commercial CA Molina Healthcare of California Remittance 4010A1 Enrollment

Non-Par 38333 Commercial CA Molina Healthcare of California Institutional 4010A1 No Response From Payer Yes

Non-Par 38333 Commercial CA Molina Healthcare of California Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 51062 Commercial FL Molina Healthcare of Florida Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 51062 Commercial FL Molina Healthcare of Florida Professional 4010A1 File Level Acknowledgement Yes

Non-Par 00076 Commercial IN Molina Healthcare of Indiana Professional 4010A1 No Response From Payer

Non-Par 00076 Commercial IN Molina Healthcare Of Indiana Institutional 4010A1 No Response From Payer

U: 08/26/2011 Non-Par 38334 Commercial MI Molina Healthcare of Michigan Remittance 4010A1 Enrollment

Non-Par 38334 Commercial MI Molina Healthcare of Michigan Institutional 4010A1 No Response From Payer Yes

Non-Par 38334 Commercial MI Molina Healthcare of Michigan Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 71079 Commercial MO Molina Healthcare of Missouri Institutional 4010A1 No Response From Payer

Non-Par 71079 Commercial MO Molina Healthcare of Missouri Professional 4010A1 Claim Level Acknowledgement

Non-Par 20676 Commercial NV Molina Healthcare of Nevada Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 20676 Commercial NV Molina Healthcare of Nevada Professional 4010A1 File Level Acknowledgement Yes

U: 08/26/2011 Non-Par NM505 Commercial NM Molina Healthcare of New Mexico Remittance 4010A1 Enrollment

Non-Par 04423 Commercial NM Molina Healthcare of New Mexico -SCI Institutional 4010A1 File Level Acknowledgement Yes

U: 08/26/2011 Non-Par 20149 Commercial OH Molina Healthcare of Ohio Remittance 4010A1 Enrollment







11/10/2011 42 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 20149 Commercial OH Molina Healthcare of Ohio Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 20149 Commercial OH Molina Healthcare of Ohio Institutional 4010A1 File Level Acknowledgement Yes

U: 08/26/2011 Non-Par 20554 Commercial TX Molina Healthcare of Texas Remittance 4010A1 Enrollment

Non-Par 38336 Commercial WA Molina Healthcare of WA (formerly Qualmed WA) Professional 4010A1 Claim Level Accept/Reject Yes

U: 08/26/2011 Non-Par 38336 Commercial WA Molina Healthcare of Washington Remittance 4010A1 Enrollment

Par IP095 Commercial CA Monarch Healthcare IPA Professional 4010A1 Enrollment Claim Level Accept/Reject Monarch assigned rendering provider id required on all claims.

A: 04/06/2010 Non-Par WR928 Commercial TX, MN Monsanto Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR928 Commercial TX, MN Monsanto Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR928 Commercial TX, MN Monsanto Company Auto 4010A1 Claim Level Accept/Reject

U: 12/29/2010 Non-Par 13174 Commercial Montefiore Contract Management Organization Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 13174 Commercial Montefiore Contract Management Organization Institutional 4010A1 No Response From Payer Yes

A: 04/06/2010 Trans WK176 Commercial TX, MN Montgomery County Texas Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK176 Commercial TX, MN Montgomery County Texas Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK176 Commercial TX, MN Montgomery County Texas Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB172 Commercial Montgomery Insurance (Liberty RAM) Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par TH094 Commercial Monumental Life Insurance Company Professional 4010A1 Claim Level Accept/Reject

Non-Par 35092 Commercial MORRIS ASSOCIATES Professional 4010A1 Claim Level Acknowledgement

Non-Par 35092 Commercial MORRIS ASSOCIATES Institutional 4010A1 Claim Level Acknowledgement

Non-Par 35092 Commercial MORRIS ASSOCIATES Remittance 4010A1 Enrollment

A: 04/06/2010 Trans WK115 Commercial TX, MN Morris Material Handling Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK115 Commercial TX, MN Morris Material Handling Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK115 Commercial TX, MN Morris Material Handling Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK116 Commercial TX, MN Morrison Health Care, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK116 Commercial TX, MN Morrison Health Care, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK116 Commercial TX, MN Morrison Health Care, Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par IP083 Commercial CA Mosaic IPA Medical Group Professional 4010A1 No Response From Payer

Par MPI01 Commercial CA Motion Picture Industry Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 95655 Commercial Mount Carmel Services Services Professional 4010A1 Claim Level Accept/Reject

Non-Par 86040 Commercial Mountain States Administrative Services (Tucson, AZ) Institutional 4010A1 No Response From Payer

Non-Par 86040 Commercial Mountain States Administrative Services (Tucson, AZ) Professional 4010A1 Claim Level Accept/Reject

Non-Par 80900 Commercial MPA-Custom Provider Network Institutional 4010A1 File Level Acknowledgement

Non-Par 80900 Commercial MPA-Custom Provider Network Professional 4010A1 File Level Acknowledgement

Non-Par 37233 Commercial MS MPE Employee Benefit Services Professional 4010A1 No Response From Payer

Non-Par 37233 Commercial MPE Employee Benefit Services Institutional 4010A1 No Response From Payer

Non-Par 37233 Commercial MPEEBT Institutional 4010A1 No Response From Payer

Non-Par 37233 Commercial MS MPEEBT Professional 4010A1 No Response From Payer

Non-Par 35177 Government IN MPlan (Medicaid) Institutional 4010A1 File Level Acknowledgement

Non-Par 35177 Government IN MPlan (Medicaid) Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WR932 Commercial TX, MN MSI Risk Manage (Richardson) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR932 Commercial TX, MN MSI Risk Manage (Richardson) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR933 Commercial TX, MN Mueller Water Products, Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR933 Commercial TX, MN Mueller Water Products, Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR933 Commercial TX, MN Mueller Water Products, Inc Auto 4010A1 Claim Level Accept/Reject

Non-Par 34080 Commercial Multiplan Wisconsin Preferred Provider Network Institutional 4010A1 No Response From Payer

Non-Par 34080 Commercial Multiplan Wisconsin Preferred Provider Network Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK117 Commercial TX, MN Munford, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK117 Commercial TX, MN Munford, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK117 Commercial TX, MN Munford, Inc. Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR934 Commercial MN Munich Re - Aaic-Britt/Paulk Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR934 Commercial MN Munich Re - Aaic-Britt/Paulk Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR934 Commercial MN Munich Re - Aaic-Britt/Paulk Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR938 Commercial MN Munich Re -Britt/Paulk Peslic Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR938 Commercial MN Munich Re -Britt/Paulk Peslic Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR938 Commercial MN Munich Re -Britt/Paulk Peslic Auto 4010A1 Claim Level Accept/Reject

Non-Par 81883 Commercial Municipal Health Benefit Fund Institutional 4010A1 File Level Acknowledgement

Non-Par 81883 Commercial Municipal Health Benefit Fund Professional 4010A1 File Level Acknowledgement

Non-Par 37256 Commercial OK Mutual Assurance Professional 4010A1 No Response From Payer

Non-Par 37256 Commercial Mutual Assurance Administrators Institutional 4010A1 No Response From Payer

Non-Par 71412 Commercial NE Mutual of Omaha Remittance 4010A1 Enrollment

Par 71412 Commercial Mutual of Omaha Insurance Company Institutional 4010A1 Claim Level Accept/Reject No

Par 71412 Commercial Mutual of Omaha Insurance Company Professional 4010A1 Claim Level Acknowledgement No

Non-Par 52280 Government NE Mutual Of Omaha Nebraska Medicare Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Par 71412 Commercial Mutually Preferred Institutional 4010A1 Claim Level Accept/Reject No

Par 71412 Commercial Mutually Preferred Professional 4010A1 Claim Level Acknowledgement No

Non-Par 38224 Commercial MVP - Ohio Institutional 4010A1 Claim Level Accept/Reject

Par 14165 Commercial MVP Health Plan (Mohawk Valley) Institutional 4010A1 Claim Level Accept/Reject Yes

U: 08/26/2011 Par 14165 Commercial NY MVP Health Plan (Mohawk Valley) Professional 4010A1 and 5010A1 Claim Level Accept/Reject Yes

U: 12/30/2010 Non-Par SX089 Commercial MVP Health Rochester (Formerly Preferred Care NY) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par SX089 Commercial MVP Health Rochester (Formerly Preferred Care NY) Remittance 4010A1 Enrollment

Non-Par 91136 Commercial N.W. Ironworkers Health & Security Trust Fund Institutional 4010A1 No Response From Payer

Non-Par 91136 Commercial N.W. Ironworkers Hlth & Security Trust Fund, Grp# F16 Professional 4010A1 Claim Level Accept/Reject

Non-Par 91136 Commercial N.W. Roofers & Employers Health & Security Trust Fund Institutional 4010A1 No Response From Payer

Non-Par 91136 Commercial N.W. Roofers & Employers Hlth & Security Trust Fund, Grp# F26 Professional 4010A1 Claim Level Accept/Reject

Non-Par 91136 Commercial N.W. Textile Processors Institutional 4010A1 No Response From Payer

Non-Par 91136 Commercial N.W. Textile Processors Grp# F14 Professional 4010A1 Claim Level Accept/Reject

Non-Par 65085 Commercial NAA (North America Admin., L.P.) Nashville, TN Professional 4010A1 Claim Level Acknowledgement

Non-Par 65085 Commercial NAA (North America Administrators, L.P.) (Nashville, TN) Institutional 4010A1 No Response From Payer

Non-Par 34159 Commercial NABN (Cleveland, OH) Institutional 4010A1 No Response From Payer

NALC claims with DOS on or after 01/01/08 must be submitted with payer id

62308. Claims with DOS prior to 01/01/08 should be submitted using payer id

Non-Par 53011 Commercial NALC Health Benefits Professional 4010A1 Claim Level Accept/Reject Yes 53011

NALC claims with DOS on or after 01/01/08 must be submitted with payer id

62308. Claims with DOS prior to 01/01/08 should be submitted using payer id

Non-Par 62308 Commercial NALC Health Benefits Professional 4010A1 Claim Level Accept/Reject Yes 53011

Non-Par 53011 Commercial NALC/Affordable Institutional 4010A1 No Response From Payer Yes

A: 04/06/2010 Trans WK118 Commercial TX, MN Nap Tools Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK118 Commercial TX, MN Nap Tools Inst. Work Comp 4010A1 Claim Level Accept/Reject







11/10/2011 43 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Trans WK118 Commercial TX, MN Nap Tools Auto 4010A1 Claim Level Accept/Reject

Non-Par NHCA1 Commercial Naperville Health Care Associates Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR940 Commercial TX, MN Nash Finch Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR940 Commercial TX, MN Nash Finch Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR940 Commercial TX, MN Nash Finch Company Auto 4010A1 Claim Level Accept/Reject

Trans AMS01 Commercial TX National Assoc Preferred Prv TX Professional 4010A1 No Response From Payer

Non-Par 53011 Commercial National Association of Letter Carriers Institutional 4010A1 No Response From Payer Yes

Non-Par 53011 Commercial National Association of Letter Carriers Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 53011 Commercial National Association of Letter Carriers / NALC Institutional 4010A1 No Response From Payer Yes

Non-Par 56175 Commercial National Benefit Administrators - New Jersey Institutional 4010A1 No Response From Payer

Non-Par 56176 Commercial National Benefit Administrators - North Carolina Institutional 4010A1 No Response From Payer

Non-Par 56175 Commercial National Benefit Administrators Of New Jersey Professional 4010A1 Claim Level Accept/Reject

Non-Par 56176 Commercial National Benefit Administrators Of North Carolina Professional 4010A1 Claim Level Accept/Reject

Contact payer, provider relationsat 1-877-284-0101 ext 7074

U:10/27/2011 Non-Par 90001 Commercial National Capital Preferred Provider Organization (NCPPO) Institutional 5010A2 Claim Level Acknowledgement Yes prior to submitting claims.

Non-Par 37126 Commercial National Claim Administration, Inc Institutional 4010A1 No Response From Payer

Non-Par 90956 Commercial National Financial Insurance Co. Professional 4010A1 Claim Level Accept/Reject

Non-Par 98205 Commercial National Foundation Life Insurance Co. Professional 4010A1 Claim Level Accept/Reject

Non-Par 75275 Commercial National Health Insurance Company Professional 4010A1 Claim Level Accept/Reject

Non-Par 12X27 Commercial National Imaging Assoc Inc / Magellan Health Services Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par SX190 Commercial National Imaging Associates Professional 4010A1 File Level Acknowledgement Yes

Non-Par SX190 Commercial National Imaging Associates Remittance 4010A1 Enrollment

A: 04/06/2010 Trans WK177 Commercial TX, MN National Interstate (TX) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK177 Commercial TX, MN National Interstate (TX) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK177 Commercial TX, MN National Interstate (TX) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK178 Commercial TX, MN National Loss Prevention, Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK178 Commercial TX, MN National Loss Prevention, Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK178 Commercial TX, MN National Loss Prevention, Inc Auto 4010A1 Claim Level Accept/Reject

10/17/11 Non-Par 52132 Commercial National Rural Electric Cooperative Assoc. Professional 5010A1 No Response From Payer Yes

Par 71412 Commercial National Rural Letter Carrier Association Institutional 4010A1 Claim Level Accept/Reject No

Par 71412 Commercial National Rural Letter Carrier Association Professional 4010A1 Claim Level Acknowledgement No

Non-Par NTA11 Commercial National Teachers Association (NTA) Professional 4010A1 Claim Level Accept/Reject

Non-Par 52103 Commercial National Telecommunications Cooperative Association Institutional 4010A1 No Response From Payer

Non-Par 52103 Commercial National Telecommunications Cooperative Association Professional 4010A1 No Response From Payer

Non-Par 52104 Commercial National Telecommunications Cooperative Association (NTCA - Staff) Institutional 4010A1 File Level Acknowledgement

Non-Par 52104 Commercial National Telecommunications Cooperative Association (NTCA - Staff) Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WR957 Commercial TX, MN National Union Fire Insuarnce Company of Pittsburgh (PA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR957 Commercial TX, MN National Union Fire Insuarnce Company of Pittsburgh (PA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR957 Commercial TX, MN National Union Fire Insuarnce Company of Pittsburgh (PA) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR988 Commercial TX, MN Nationwide Agribusine (Des Moines) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR988 Commercial TX, MN Nationwide Agribusine (Des Moines) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK452 Commercial TX, MN Nationwide Agribusiness Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR988 Commercial MN Nationwide Assurance Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR988 Commercial MN Nationwide General Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 31417 Commercial Nationwide Health Plans Institutional 4010A1 No Response From Payer Yes

Non-Par 31417 Commercial Nationwide Health Plans Remittance 4010A1 Enrollment

A: 04/06/2010 Non-Par WR988 Commercial MN Nationwide Indemnity Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 31417 Commercial Nationwide Insurance Professional 4010A1 No Response From Payer Yes

Non-Par 31417 Commercial Nationwide Insurance Remittance 4010A1 Enrollment

A: 04/06/2010 Non-Par WS038 Commercial TX, MN Nationwide Insurance (G)ainesville Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS038 Commercial TX, MN Nationwide Insurance (G)ainesville Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS039 Commercial TX, MN Nationwide Insurance (Harrisburg) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS039 Commercial TX, MN Nationwide Insurance (Harrisburg) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB233 Commercial NBC Universal Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB233 Commercial NBC Universal Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 75191 Commercial NCAS - Charlotte Institutional 4010A1 No Response From Payer

Non-Par 75191 Commercial NC NCAS - Charlotte Professional 4010A1 Claim Level Acknowledgement

Non-Par 75190 Commercial NCAS - Fairfax, VA Institutional 4010A1 No Response From Payer

Non-Par 75190 Commercial VA NCAS - Virginia Professional 4010A1 Claim Level Acknowledgement

Non-Par 95123 Commercial Neighborhood Health Partnership Professional 4010A1 Claim Level Accept/Reject

Non-Par 96107 Commercial FL Neighborhood Health Partnership of Florida Institutional 4010A1 Claim Level Accept/Reject

Non-Par 96107 Commercial FL Neighborhood Health Partnership of Florida Professional 4010A1 Claim Level Accept/Reject Payer ID is valid for claims submission

Par 04293 Commercial MA Neighborhood Health Plan (Boston, MA) Professional 4010A1 Claim Level Acknowledgement

Non-Par 04293 Commercial MA Neighborhood Health Plan (Boston, MA) Remittance 4010A1 Enrollment

Non-Par 04293 Commercial MA Neighborhood Health Plan (Boston, MA) Institutional 4010A1 No Response From Payer

Non-Par 37255 Commercial Nesika Health Group Institutional 4010A1 No Response From Payer

Non-Par 37255 Commercial Nesika Health Group Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WS045 Commercial Nestle USA Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS045 Commercial Nestle USA Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS045 Commercial Nestle USA Auto 4010A1 Claim Level Accept/Reject

Non-Par 66055 Commercial Netcare Life & Health Insurance (Hagatna, Guam) Institutional 4010A1 No Response From Payer

Non-Par 66055 Commercial Netcare Life & Health Insurance (Hagatna, Guam) Professional 4010A1 Claim Level Acknowledgement

U: 09/21/2011 Non-Par 04332 Commercial Network Health Remittance 4010A1 Enrollment

Before initiating submissions, please contact Provider Relations at (888) 257-

Non-Par CALL Commercial Network Health Professional 4010A1 Enrollment Claim Level Acknowledgement 1985 or edi@network-health.org

Before initiating submissions, please contact Provider Relations at (888) 257-

Non-Par CALL Commercial Network Health Institutional 4010A1 Enrollment No Response From Payer 1985 or edi@network-health.org

Non-Par 77076 Commercial Network Health Insurance Corp-Medicare Institutional 4010A1 File Level Acknowledgement

Non-Par 39111 Commercial Network Health Plan of Wiscon Institutional 4010A1 No Response From Payer

Non-Par 39144 Commercial WI Network Health Plan of Wiscon Professional 4010A1 No Response From Payer

Trans AMS01 Commercial WI Network Health PPO Professional 4010A1 No Response From Payer

Non-Par 77076 Commercial Network Platinum Plus Professional 4010A1 Claim Level Rejects Only

Non-Par 86067 Commercial NV Nevada Health Solutions Professional 4010A1 Claim Level Accept/Reject

Non-Par 86067 Commercial NV NevadaCare Professional 4010A1 Claim Level Accept/Reject

Non-Par 86067 Commercial NV NevadaCare Kids Professional 4010A1 Claim Level Accept/Reject

Non-Par NCH09 Commercial New Century Health - Vista Cardiology Professional 4010A1 File Level Acknowledgement

Non-Par 76031 Commercial New Era Employee Welfare Benefit Plan Trust Institutional 4010A1 File Level Acknowledgement







11/10/2011 44 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 76031 Commercial New Era Employee Welfare Benefit Plan Trust Professional 4010A1 File Level Acknowledgement

Non-Par 75281 Commercial New Era Life Insurance Company Institutional 4010A1 No Response From Payer

Non-Par 75281 Commercial New Era Life Insurance Company Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS047 Commercial New Hampshire Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS047 Commercial New Hampshire Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS047 Commercial New Hampshire Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 22603 Commercial New Jersey Carpenters Health Fund Institutional 4010A1 No Response From Payer Yes

Non-Par 22603 Commercial New Jersey Carpenters Health Fund Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 65056 Commercial New Market Dimensions Institutional 4010A1 No Response From Payer

Non-Par 65056 Commercial New Market Dimensions Professional 4010A1 Claim Level Accept/Reject

Non-Par 84141 Commercial New West Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par TH122 Commercial New York Life Professional 4010A1 Claim Level Accept/Reject

Non-Par 11334 Commercial NY New York Network Management, LLC Professional 4010A1 Claim Level Acknowledgement Claim must contain group plan or policy number and group name

Non-Par 38225 Commercial NGS American, Inc. Institutional 4010A1 No Response From Payer

U:10/21/2011 Par 38225 Commercial NGS American, Inc. Professional 4010A1 No Response From Payer

Non-Par 62124 Commercial NHC Health Benefit Plan Institutional 4010A1 No Response From Payer

Non-Par 11325 Commercial NHP/SHP (Neighborhood Health Providers & Suffolk Health Plan) Institutional 4010A1 No Response From Payer Yes

Non-Par 11325 Commercial NHP/SHP (Neighborhood Health Providers & Suffolk Health Plan) Professional 4010A1 No Response From Payer Yes

Please call NHPRI at (401)459-6020 to obtain or confirm your provider and

Non-Par 05047 Commercial RI NHPRI (Neighborhood Health Plan of Rhode Island) Professional 4010A1 Claim Level Accept/Reject vendor number prior to your initial claims submission.

Par NIA11 Commercial NIA - Magellan Health Services Professional 4010A1 Claim Level Acknowledgement

Non-Par 81264 Commercial Nippon Life Insurance Co. Institutional 4010A1 Claim Level Accept/Reject

Non-Par 81264 Commercial Nippon Life Insurance Co. Professional 4010A1 Claim Level Accept/Reject

Trans 81264 Commercial Nippon Life Insurance Co. Dental 4010A1 No Response From Payer

Non-Par PDT01 Commercial Noble AMA Select IPA Professional 4010A1 Claim Level Accept/Reject

Par IP080 Commercial CA Noble Community Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ939 Commercial Nordstrom, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ939 Commercial Nordstrom, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 64157 Commercial North American Administrators, Inc. Institutional 4010A1 Claim Level Accept/Reject

Non-Par 64157 Commercial North American Administrators, Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par 34159 Commercial North American Benefits Network (Cleveland, OH) Institutional 4010A1 No Response From Payer

Non-Par 64157 Commercial North American Health Plan Professional 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA North American Medical Management - So. California Professional 4010A1 Claim Level Accept/Reject

Non-Par 93100 Commercial TX North American Medical Management - Texas (NAMM) B50 Professional 4010A1 Claim Level Acknowledgement

Non-Par 64157 Commercial North American Preferred Institutional 4010A1 Claim Level Accept/Reject

Non-Par 64157 Commercial North American Preferred Professional 4010A1 Claim Level Accept/Reject

Par WK188 Commercial FL North American Risk Services, Inc (NARS) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS049 Commercial North American Specialty Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS049 Commercial North American Specialty Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS049 Commercial North American Specialty Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par 37314 Commercial FL North Broward Hospital District Professional 4010A1 Claim Level Accept/Reject

Non-Par 37314 Commercial North Broward Hospital District Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WC136 Commercial TX, MN North River Insurance Co of NJ Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC136 Commercial TX, MN North River Insurance Co of NJ Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par NTX11 Commercial TX North Texas Healthcare Professional 4010A1 Claim Level Accept/Reject

Non-Par 35212 Commercial North Texas Healthcare Network Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par PH018 Commercial North West Life Professional 4010A1 No Response From Payer

Non-Par 36347 Commercial Northern Illinois Health Plan Institutional 4010A1 No Response From Payer

Non-Par 36347 Commercial IL Northern Illinois Health Plan Professional 4010A1 No Response From Payer

Non-Par 88027 Commercial Northern Nevada Trust Fund Institutional 4010A1 No Response From Payer

Non-Par NMG01 Commercial Northridge Medical Group Professional 4010A1

Non-Par 60058 Commercial Northstar Advantage Institutional 4010A1 File Level Acknowledgement

Non-Par 60058 Commercial Northstar Advantage Professional 4010A1 File Level Acknowledgement

Non-Par 36234 Commercial NORTHWEST COMMUNITY HEALTH PARTNERS Institutional 4010A1 File Level Acknowledgement

Non-Par 36234 Commercial NORTHWEST COMMUNITY HEALTH PARTNERS Professional 4010A1 File Level Acknowledgement

Non-Par 62119 Commercial Northwest Diagnostic Clinic/SelectCare of Texas (NWDC) Institutional 4010A1 File Level Acknowledgement

Non-Par 62119 Commercial Northwest Diagnostic Clinic/SelectCare of Texas (NWDC) Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WZ646 Commercial Northwest Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ646 Commercial Northwest Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ646 Commercial Northwest Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par 36346 Commercial Northwest Suburban IPA (Illinois) Institutional 4010A1 No Response From Payer

Non-Par 36346 Commercial IL Northwest Suburban IPA (Illinois) Professional 4010A1 Claim Level Accept/Reject

Non-Par PH018 Commercial Northwestern National Life (Reliastar Emp Ben) Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK119 Commercial TX, MN Norwood Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK119 Commercial TX, MN Norwood Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK119 Commercial TX, MN Norwood Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS052 Commercial TX, MN NOV01 Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS052 Commercial TX, MN NOV01 Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS052 Commercial TX, MN NOV01 Auto 4010A1 Claim Level Accept/Reject

Non-Par 16114 Commercial NOVA CASUALITY COMPANY Institutional 4010A1 File Level Acknowledgement

Non-Par 16114 Commercial NOVA CASUALITY COMPANY Professional 4010A1 File Level Acknowledgement

Non-Par 16644 Commercial Nova Healthcare Administrators Institutional 4010A1 No Response From Payer

Non-Par 16644 Commercial Nova Healthcare Administrators Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Trans WK179 Commercial TX, MN Nova Pro Risk Solutions Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK179 Commercial TX, MN Nova Pro Risk Solutions Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK179 Commercial TX, MN Nova Pro Risk Solutions Auto 4010A1 Claim Level Accept/Reject

Non-Par 06226 Commercial Novanet Professional 4010A1 Claim Level Acknowledgement

U: 12/21/2010 Non-Par 06226 Commercial Novanet Institutional 4010A1 No Response From Payer

Non-Par 71080 Commercial Novasys Health Network Institutional 4010A1 No Response From Payer

Non-Par 71080 Commercial Novasys Health Network Professional 4010A1 Claim Level Acknowledgement

Non-Par 24819 Commercial NY Presbyterian System Select Institutional 4010A1 No Response From Payer

Non-Par 24819 Commercial NY NY Presbyterian System Select Professional 4010A1 Claim Level Accept/Reject

Non-Par 14142 Commercial NY NYC Department of Health Professional 4010A1 File Level Acknowledgement

Non-Par 14142 Commercial NY NYC Department of Health Institutional 4010A1 File Level Acknowledgement

Non-Par 37299 Commercial Nyhart Institutional 4010A1 No Response From Payer

Non-Par 37299 Commercial IN Nyhart Professional 4010A1 No Response From Payer







11/10/2011 45 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 14180 Commercial NYMI Oxford Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WB107 Commercial NYSIF Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 36402 Commercial OAK WEST PRIMARY PHYSICIAN ASSOCIATION Institutional 4010A1 File Level Acknowledgement

Non-Par 36402 Commercial OAK WEST PRIMARY PHYSICIAN ASSOCIATION Professional 4010A1 File Level Acknowledgement

Non-Par DESRT Commercial Oasis IPA Professional 4010A1 Claim Level Accept/Reject

Non-Par 13350 Commercial ODS Health Plan Institutional 4010A1 No Response From Payer

Non-Par 13350 Commercial ODS Heath Plan Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS053 Commercial TX, MN Office Depot Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS053 Commercial TX, MN Office Depot Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 72087 Commercial LA Office of Group Benefits - Louisiana Institutional 4010A1 No Response From Payer

Non-Par 72087 Commercial LA Office of Group Benefits - Louisiana Professional 4010A1 Claim Level Accept/Reject

Non-Par OAC99 Commercial OH Ohio AFSCME Care Plan Professional 4010A1 No Response From Payer

Non-Par 31147 Commercial OH Ohio BWC Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS054 Commercial TX, MN Ohio Casualty Insurance (Cincinnati) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS054 Commercial TX, MN Ohio Casualty Insurance (Cincinnati) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS055 Commercial TX, MN Ohio Casualty Insurance (Fairfield) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS055 Commercial TX, MN Ohio Casualty Insurance (Fairfield) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS055 Commercial TX, MN Ohio Casualty Insurance (Fairfield) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS057 Commercial TX, MN Ohio Casualty Insurance (Voorhees) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS057 Commercial TX, MN Ohio Casualty Insurance (Voorhees) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK375 Commercial Ohio Farmers Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK375 Commercial Ohio Farmers Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Trans AMS01 Commercial OH Ohio Health Choice Plan (OH) Professional 4010A1 No Response From Payer

ONLY for claims with a billing submission address of PO Box 3619, Akron, OH

Non-Par 34189 Commercial Ohio Health Choice PPO Institutional 4010A1 No Response From Payer 44309-3619 or PO Box 93538

ONLY for claims with a billing submission address of PO Box 3619, Akron, OH

Non-Par 34189 Commercial OH Ohio Health Choice PPO Professional 4010A1 No Response From Payer 44309-3619 or PO Box 93538

Non-Par SVIPA Commercial CA Ojai Valley Community Med. Group now known as SeaView IPA Professional 4010A1 File Level Acknowledgement

Non-Par CLFR2 Commercial Oklahoma State Medical Association Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS059 Commercial MN Old Home Foods, Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS059 Commercial MN Old Home Foods, Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS059 Commercial MN Old Home Foods, Inc Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX285 Commercial TX, MN Old Republic Insurance Co (PA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX285 Commercial TX, MN Old Republic Insurance Co (PA) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX285 Commercial TX, MN Old Republic Insurance Co (PA) Auto 4010A1 Claim Level Accept/Reject

Non-Par MDCOR Commercial Omni IPA / Medicare HP Professional 4010A1 Claim Level Accept/Reject

Non-Par 68037 Commercial OMNI/Medicore HP Institutional 4010A1 File Level Acknowledgement

Non-Par 68037 Commercial OMNI/Medicore HP Professional 4010A1 File Level Acknowledgement

Par IP088 Commercial CA Omnicare Medical Group (OMNI) Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB173 Commercial One Beacon (formerly CGU) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK121 Commercial TX, MN One Beacon Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK121 Commercial TX, MN One Beacon Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK121 Commercial TX, MN One Beacon Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par 22321 Commercial One Call Medical Institutional 4010A1 File Level Acknowledgement

Non-Par 22321 Commercial One Call Medical (OCM) Professional 4010A1 Claim Level Accept/Reject

Trans 52149 Commercial OneNet PPO, LLC. Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 91136 Commercial Operating Engineers Locals 302 & 612 Health & Security Fund Institutional 4010A1 No Response From Payer

Non-Par 91136 Commercial Operating Engineers Locals 302 & 612 Hlth & Security Fund, Grp# F12 Professional 4010A1 Claim Level Accept/Reject

Non-Par 54154 Commercial Optima Health Insurance Company Professional 4010A1 No Response From Payer

Non-Par 54154 Commercial Optima Health Plan Institutional 4010A1 No Response From Payer

Rendering provider id is required. ID will be 5-7 characters. Positions 1-5 must be

numeric, positions 6 and 7 (if applicable) must be alpha. Please contact Ydsia

Non-Par 54154 Commercial Optima Health Plan Professional 4010A1 No Response From Payer Slagle with provider relations @ 757-552-7477

Non-Par 54154 Commercial Optima Health Plan/Sentara Remittance 4010A1 Enrollment

Non-Par 54154 Commercial Optima Insurance Company Institutional 4010A1 No Response From Payer

Trans 87726 Commercial Optimum choice of the Carolinas, Inc (OCCI) (Formerly 52148) Institutional 4010A1 No Response From Payer

Trans 87726 Commercial Optimum Choice, Inc (OCI)(Formerly 52148) Institutional 4010A1 No Response From Payer

Trans 87726 Commercial Optimum Choice, Inc(OCI)(Formerly 52148) Professional 4010A1 Claim Level Accept/Reject

Non-Par 20133 Commercial Optimum Healthcare Inc. Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 20133 Commercial Optimum Healthcare Inc. Professional 4010A1 File Level Acknowledgement Yes

Par PHP01 Commercial Oregon Educators Benefits Board (OEBB) Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Trans WK122 Commercial TX, MN Orica, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK122 Commercial TX, MN Orica, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK122 Commercial TX, MN Orica, Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 25133 Commercial ORNDA Health D296Corp (First Health)+D312 Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 13383 Commercial Orthonet - Aetna Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 25681 Commercial Orthonet - Health Net Professional 4010A1 No Response From Payer

Non-Par 13382 Commercial Orthonet - Uniformed Service Family Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 13383 Commercial Orthonet- Aetna Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 13381 Commercial Orthonet Corporation Institutional 4010A1 No Response From Payer

Non-Par 13381 Commercial Orthonet Corporation Professional 4010A1 Claim Level Accept/Reject

Non-Par 62171 Commercial OSF Health Plans Institutional 4010A1 File Level Acknowledgement

Non-Par 62171 Commercial IL OSF Healthplans Professional 4010A1 Claim Level Accept/Reject

Non-Par 73071 Commercial OSMA Health - C. L. Frates Institutional 4010A1 File Level Acknowledgement

Non-Par 73071 Commercial OSMA Health - C. L. Frates Professional 4010A1 File Level Acknowledgement

Non-Par 36365 Commercial Our Lady of the Resurrection Physician Association Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WS062 Commercial Owner Operator Services, Inc. (McDonald's) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS062 Commercial Owner Operator Services, Inc. (McDonald's) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Trans 06111 Commercial Oxford Health Plan Institutional 4010A1 Claim Level Accept/Reject

Trans 06111 Commercial Oxford Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 06111 Commercial Oxford Health Plan Remittance 4010A1 Enrollment

Non-Par 87068 Commercial P5 Health Plan Solution of Utah Institutional 4010A1 No Response From Payer

Non-Par 87068 Commercial UT P5 Health Plan Solution of Utah Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK469 Commercial TX, MN Paccar Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par PCFCI Commercial Pacific IPA Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ121 Commercial Pacific Motor Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ121 Commercial Pacific Motor Company Inst. Work Comp 4010A1 Claim Level Accept/Reject







11/10/2011 46 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Trans WZ121 Commercial Pacific Motor Company Auto 4010A1 Claim Level Accept/Reject

Trans 95959 Commercial PacifiCare Professional 4010A1 No Response From Payer

Trans 33053 Commercial Pacificare Behavioral Health Professional 4010A1 No Response From Payer

Trans 95958 Commercial Pacificare Encounters Institutional 4010A1 No Response From Payer

Trans 95959 Commercial PacifiCare ERA Professional 4010A1 No Response From Payer

Non-Par 95959 Commercial CA Pacificare Health Systems Remittance 4010A1 Enrollment

Trans 95959 Commercial Pacificare Health Systems, Inc. (TX/CA) Institutional 4010A1 Claim Level Acknowledgement

Trans HM012 Commercial CA Pacificare HMO / Encounters Professional 4010A1 Enrollment Claim Level Accept/Reject



Trans CALL Commercial AZ PacifiCare of Arizona - Encounters Professional 4010A1 Claim Level Accept/Reject Please email Encountercollection@phs.com to be setup to submit Encounters



For payable PacifiCare/Secure Horizons HMO claims only. Not for PPO claims.

Trans 95959 Commercial CA PacifiCare of California - Claims Professional 4010A1 No Response From Payer For further questions, you may inquire via email at edioutreach@phs.com



Trans CALL Commercial CA PacifiCare of California - Encounters Professional 4010A1 No Response From Payer Please email Encountercollection@phs.com to be setup to submit Encounters



For payable PacifiCare/Secure Horizons HMO claims only. Not for PPO claims.

Trans 95959 Commercial OK PacifiCare of Oklahoma - Claims Professional 4010A1 No Response From Payer For further questions, you may inquire via email at edioutreach@phs.com

Trans CALL Commercial OK PacifiCare of Oklahoma - Encounters Professional 4010A1 No Response From Payer Please contact Barbara Pisano (714)825-5989



For payable PacifiCare/Secure Horizons HMO claims only. Not for PPO claims.

Trans 95959 Commercial OR PacifiCare of Oregon - Claims Professional 4010A1 No Response From Payer For further questions, you may inquire via email at edioutreach@phs.com



Trans CALL Commercial OR PacifiCare of Oregon - Encounters Professional 4010A1 No Response From Payer Please email Encountercollection@phs.com to be setup to submit Encounters

For payable PacifiCare/Secure Horizons HMO claims only. For further questions,

Trans 95959 Commercial TX PacifiCare of Texas - Claims Professional 4010A1 No Response From Payer you may inquire via email at edihmoinfo@phs.com

Trans CALL Commercial TX PacifiCare of Texas - Encounters Professional 4010A1 Claim Level Accept/Reject Please contact Barbara Pisano (714)825-5989

For payable PacifiCare/Secure Horizons HMO claims only. For further questions,

Trans 95959 Commercial WA PacifiCare of Washington - Claims Professional 4010A1 No Response From Payer you may inquire via email at edioutreach@phs.com



Trans CALL Commercial WA Pacificare of Washington - Encounters Professional 4010A1 Claim Level Accept/Reject Please email Encountercollection@phs.com to be setup to submit Encounters

Trans 95999 Commercial Pacificare PPO - All States Institutional 4010A1 Claim Level Acknowledgement

Pacificare (95999) ERA are available under Payer ID 95959. ERA enrollment and

09/02/2011 Trans 95999 Commercial PacifiCare PPO - All States (For payable PPO claims only. NOT for PacifiCare/Secure Horizons HMO claims. For further questions, you may inquire via email at edioutreach@phs.com)

Professional 4010A1 No Response From Payer file delivery appear under payer ID 95959.

Trans COFHP Commercial CO Pacificare/ FHP - Colorado Professional 4010A1 Claim Level Acknowledgement

A: 12/15/2010 Non-Par 93029 Commercial PacificSource Health Plan Remittance 4010A1 Enrollment

Non-Par 93029 Commercial PacificSource Health Plan Institutional 4010A1 No Response From Payer

Non-Par 93029 Commercial PacificSource Health Plan Professional 4010A1 Claim Level Acknowledgement

Non-Par 37287 Commercial PAI Institutional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK123 Commercial TX, MN Papa John's International Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK123 Commercial TX, MN Papa John's International Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK123 Commercial TX, MN Papa John's International Inc Auto 4010A1 Claim Level Accept/Reject

Non-Par PAPER Paper Paper Claims (CMS 1500) Professional 4010A1 Claim Level Acknowledgement

Non-Par PAPER Paper Paper Claims (UB04) Institutional 4010A1 No Response From Payer

Non-Par WK039 Commercial Paradigm Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK039 Commercial Paradigm Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 58174 Commercial Paragon Benefits Inc. Professional 4010A1 File Level Acknowledgement

Non-Par 58174 Commercial Paragon Benefits Inc. Institutional 4010A1 Claim Level Acknowledgement

Non-Par PARHC Commercial Paramount Health Care Professional 4010A1 No Response From Payer

Non-Par PARHC Commercial Paramount Health Care Remittance 4010A1 Enrollment

Non-Par 58204 Commercial Parity Healthcare, LLC Professional 4010A1 Claim Level Accept/Reject

Non-Par 66917 Commercial Parkland Community Health Plan Institutional 4010A1 No Response From Payer

Non-Par 66917 Commercial Parkland Community Health Plan Professional 4010A1 Claim Level Accept/Reject

Trans AMS01 Commercial TX Partners in Practice (TX) Professional 4010A1 No Response From Payer

U: 12/30/2010 Non-Par PHP02 Commercial Partnership Health Plan Professional 4010A1 Enrollment No Response From Payer Yes

U: 12/07/2010 Non-Par PHP02 Commercial Partnership Health Plan Remittance 4010A1 Enrollment

Non-Par 22248 Commercial KY Passport Professional 4010A1 No Response From Payer

Non-Par 76569 Commercial Passport Advantage Professional 4010A1 File Level Acknowledgement Yes

A: 12/21/2010 Non-Par 76569 Commercial Passport Advantage Institutional 4010A1 File Level Acknowledgement

Non-Par 61129 Commercial Passport Health Plan Institutional 4010A1 No Response From Payer Yes

Non-Par 61129 Commercial Passport Health Plan Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 61129 Commercial Passport Health Plan Remittance 4010A1 Enrollment

A: 04/06/2010 Non-Par WB128 Commercial Pathmark Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB128 Commercial Pathmark Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 10525 Commercial Patient Advocates LLC Institutional 4010A1 File Level Acknowledgement

Non-Par 10525 Commercial Patient Advocates, LLC Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB138 Commercial TX, MN Patriot General Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB138 Commercial TX, MN Patriot General Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par PRW99 Commercial Pavers & Road Builders Welfare Fund Professional 4010A1 No Response From Payer

U: 12/20/2010 Non-Par 68049 Commercial GA Peach State Health Plan - Centene Remittance 4010A1 Enrollment

(Prior to submitting claims, call Provider Relations Dept. at 866-475-3129 to verify

your provider info is on file in the Health Plans claim system to avoid any

U: 12/29/2010 Par 68049 Commercial GA Peach State Health Plan - Centene Professional 4010A1 Claim Level Accept/Reject rejections)

A: 04/06/2010 Non-Par WB174 Commercial Peerless Insurance (Liberty RAM) Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK124 Commercial Peg Discover Re Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK124 Commercial Peg Discover Re Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK125 Commercial Peg Discover Re(Food Merchant) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK125 Commercial Peg Discover Re(Food Merchant) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK126 Commercial TX, MN Pegi-Family Dining Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK126 Commercial TX, MN Pegi-Family Dining Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK126 Commercial TX, MN Pegi-Family Dining Auto 4010A1 Claim Level Accept/Reject

To obtain payer id you MUST first call Jessica Picarde, Manager of PPHN Claims

Non-Par CALL Commercial MD Pennsylvania Preferred Health Network (PPHN) Professional 4010A1 No Response From Payer Operations at (410)349-3222

A: 04/06/2010 Non-Par WB129 Commercial People 2.0 Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB129 Commercial People 2.0 Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 72126 Commercial Peoples Health Network Professional 4010A1 Claim Level Accept/Reject

Non-Par 72126 Commercial Peoples Health Network Remittance 4010A1 Enrollment

Non-Par 41124 Commercial Performax, Inc. Institutional 4010A1 Claim Level Accept/Reject

Non-Par 41124 Commercial Performax, Inc. Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS068 Commercial TX, MN PESTSURE ASSOCIATION Prof. Work Comp 4010A1 Claim Level Accept/Reject







11/10/2011 47 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Non-Par WS068 Commercial TX, MN PESTSURE ASSOCIATION Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS068 Commercial TX, MN PESTSURE ASSOCIATION Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS069 Commercial PetSmart Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS069 Commercial PetSmart Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS069 Commercial PetSmart Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 13306 Commercial PHCS Savility Payers Institutional 4010A1 File Level Acknowledgement

Non-Par 13306 Commercial PHCS Savility Payers Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WK127 Commercial TX, MN Phh Fleetamerica Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK127 Commercial TX, MN Phh Fleetamerica Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK127 Commercial TX, MN Phh Fleetamerica Auto 4010A1 Claim Level Accept/Reject

Non-Par 67814 Commercial Phoenix American Life (PAL) Professional 4010A1 No Response From Payer

Non-Par 03440 Commercial Phoenix Health Plan Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 03440 Commercial Phoenix Health Plan Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 67814 Commercial Phoenix Home Life (Phoenix Mutual Life) Professional 4010A1 No Response From Payer

Non-Par 67814 Commercial Phoenix Mutual Life (Phoenix Home Life) Professional 4010A1 No Response From Payer

Non-Par 12399 Commercial PHP - Physicians Health Plan of Northern Indiana (Fort Wayne IN) Institutional 4010A1 Claim Level Accept/Reject

Non-Par 00036 Commercial PHP of Kansas City Professional 4010A1 Claim Level Accept/Reject

Trans 87726 Commercial PHP of South Michigan Institutional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial PHP of Southwest Michigan Institutional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial PHP of West Michigan Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62155 Commercial PHP Tenncare Institutional 4010A1 No Response From Payer

Non-Par 62155 Commercial PHP TennCare Professional 4010A1 Claim Level Acknowledgement

Non-Par 37330 Commercial Phyicians Health Plan (PHP) Mid-Michigan Institutional 4010A1 File Level Acknowledgement

Non-Par 58204 Commercial Physician Associates of Louisiana Professional 4010A1 Claim Level Accept/Reject

U: 01/11/2011 Non-Par 37330 Commercial MI Physician Health Plan South & Mid Michigan Professional 4010A1 No Response From Payer Insured Group/Policy number required

A:10/19/2011 Non-Par PHIPA Commercial CA Physician Healthways IPA Professional 4010A1 File Level Acknowledgement

Non-Par 15749 Commercial Physicians Alliance/Stones River Regional IPA Professional 4010A1 Claim Level Acknowledgement

Non-Par 15749 Commercial Physicians Alliance/Stones River Regional IPA Institutional 4010A1 Claim Level Acknowledgement

Non-Par 38265 Commercial Physicians Care (ASR Corporation) Institutional 4010A1 File Level Acknowledgement

Non-Par 38265 Commercial Physicians Care Health Plans (ASR Corporation) Institutional 4010A1 File Level Acknowledgement

Non-Par 36345 Commercial IL Physicians Care Network (Address Rockford, IL ONLY) Professional 4010A1 Claim Level Acknowledgement

Non-Par 38265 Commercial Physicians Care Network (ASR Corporation) Institutional 4010A1 File Level Acknowledgement

Non-Par 36345 Commercial Physicians Care Network (Rockford, IL only) Institutional 4010A1 No Response From Payer

Non-Par 37136 Commercial Physicians Health Assoc of Illinois Institutional 4010A1 No Response From Payer

Non-Par 37136 Commercial Physicians Health Association of Illinois Professional 4010A1 Claim Level Acknowledgement

Non-Par 12T51 Commercial Physicians Health Choice Institutional 4010A1 Claim Level Accept/Reject

Non-Par PHCS1 Commercial Physicians Health Choice Professional 4010A1 Claim Level Accept/Reject

Non-Par 20398 Commercial Physicians Health Collaborative Institutional 4010A1 File Level Acknowledgement

Non-Par 20398 Commercial Physicians Health Collaborative Professional 4010A1 File Level Acknowledgement

A: 01/10/2011 Non-Par 09173 Commercial Physicians Health Plan Professional 4010A1 No Response From Payer

Trans 87726 Commercial MO Physicians Health Plan (PHP) - Missouri (Greater St. Louis) Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial NC Physicians Health Plan (PHP) - North Carolina Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial SC Physicians Health Plan (PHP) - South Carolina Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 12399 Commercial Physicians Health Plan Of Northern Indiana Professional 4010A1 Claim Level Accept/Reject

Non-Par 37330 Commercial Physicians Health Plan PHP South Michigan Institutional 4010A1 File Level Acknowledgement

10/17/11 Non-Par 65031 Commercial Physicians Healthcare Plans Professional 5010A1 Claim Level Acknowledgement Yes

Non-Par IP118 Commercial CA Physicians Medical Group of San Jose Professional 4010A1 No Response From Payer

Non-Par 47027 Commercial Physicians Mutual Insurance Company Institutional 4010A1 No Response From Payer

Non-Par 47027 Commercial Physicians Mutual Insurance Company Professional 4010A1 Claim Level Accept/Reject

Non-Par 47027 Commercial Physicians Mutual Insurance Company Remittance 4010A1 Enrollment

Non-Par 39156 Commercial Physician's Plus Insurance Corporation Institutional 4010A1 No Response From Payer

Non-Par 39156 Commercial Physician's Plus Insurance Corporation Professional 4010A1 Claim Level Acknowledgement

Non-Par 10775 Commercial Physicians United Plan Professional 4010A1 No Response From Payer

Non-Par 06607 Commercial Piedmont Behavioral Health Institutional 4010A1 File Level Acknowledgement

Non-Par 06607 Commercial Piedmont Behavioral Health Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WB230 Commercial Pier 1 Inc. USA Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB230 Commercial Pier 1 Inc. USA Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 09861 Commercial Pima Health Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par PGLTC Commercial Pinal/Gila Long Term Care Professional 4010A1 Claim Level Accept/Reject

Non-Par 24735 Commercial Pinnacle Claims Management, Inc. Institutional 4010A1 No Response From Payer

Par 24735 Commercial Pinnacle Claims Management, Inc. Professional 4010A1 No Response From Payer

Non-Par 45985 Commercial Pinnacle Physician Management ORG Institutional 4010A1 File Level Acknowledgement

Non-Par 45985 Commercial Pinnacle Physician Management ORG Professional 4010A1 File Level Acknowledgement

U: 01/10/2011 Non-Par 84109 Commercial Pinnacol Assurance Institutional 4010A1 Claim Level Accept/Reject

A: 01/10/2011 Non-Par 84109 Commercial Pinnacol Assurance Professional 4010A1 Claim Level Accept/Reject



U: 12/30/2010 Non-Par CCIA1 Commercial CO Pinnacol Assurance Professional 4010A1 Claim Level Acknowledgement (Contact Sandy Logstrom at 303-361-4822 prior to submission of first claims)

Non-Par PIP98 Commercial IL Pipefitters 597 (45 N. Ogden Ave., Chicago, IL 60607) Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WS073 Commercial TX, MN Pitney Bowes Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS073 Commercial TX, MN Pitney Bowes Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 37224 Commercial Pittman & Associates Remittance 4010A1 Enrollment

Non-Par 37224 Commercial Pittman and Associates Institutional 4010A1 No Response From Payer

Non-Par 37224 Commercial Pittman and Associates Professional 4010A1 Claim Level Acknowledgement

Non-Par 64160 Commercial Pivotal Plan Institutional 4010A1 File Level Acknowledgement

Non-Par 64160 Commercial Pivotal Plan Professional 4010A1 File Level Acknowledgement

Trans AMS01 Commercial IA Plaines (IA) Professional 4010A1 No Response From Payer

Trans AMS01 Commercial FL Plaines Advisor (FL) Professional 4010A1 No Response From Payer

Trans AMS01 Commercial WI Plaines Advisor (WI) Professional 4010A1 No Response From Payer

Trans AMS01 Commercial Plaines Networks - Envoy Professional 4010A1 No Response From Payer

Non-Par 37287 Commercial Planned Administrators, Inc. Institutional 4010A1 No Response From Payer

PAI Providers submitting claims as a Preferred Blue provider should not submit

Non-Par 37287 Commercial Planned Administrators, Inc. Professional 4010A1 No Response From Payer claims using payer ID 37287

Non-Par PCM99 Commercial Plasterers' & Cement Masons' Health & Welfare Fund Professional 4010A1 No Response From Payer

Non-Par CLFR2 Commercial PLICO Professional 4010A1 Claim Level Accept/Reject

Non-Par 00333 Commercial Plumbers & Steamfitters Local 33 Health & Welfare Professional 4010A1 Claim Level Accept/Reject

Non-Par 72054 Commercial Plumbers and Steamfitters Local 106 Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR441 Commercial PMA - Pennsylvania Manufacturing Associates Prof. Work Comp 4010A1 Claim Level Accept/Reject





11/10/2011 48 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Non-Par WR441 Commercial PMA - Pennsylvania Manufacturing Associates Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB175 Commercial PMA Insurance Group & PMA Management Corp Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB175 Commercial PMA Insurance Group & PMA Management Corp Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par PMGSJ Commercial CA PMG of San Jose Professional 4010A1 Claim Level Rejects Only

Non-Par 58204 Commercial Podi Care Managed Care Professional 4010A1 Claim Level Accept/Reject

Non-Par PODST Commercial Podiatry First Network of Florida Professional 4010A1 Claim Level Accept/Reject

Non-Par 59324 Commercial PODIATRY NETWORK FL Professional 4010A1 Claim Level Acknowledgement

Non-Par 59324 Commercial PODIATRY NETWORK FL Institutional 4010A1 Claim Level Acknowledgement

Non-Par 59069 Commercial Poe & Brown Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WC137 Commercial TX, MN Poly America LP Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC137 Commercial TX, MN Poly America LP Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 32680 Commercial Poly America Medical & Dental Benefits Institutional 4010A1 No Response From Payer

Non-Par 32680 Commercial Poly America Medical & Dental Benefits Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 16111 Commercial POMCO Institutional 4010A1 No Response From Payer

Non-Par 16111 Commercial POMCO Professional 4010A1 Claim Level Acknowledgement

U: 01/11/2011 Par 16111 Commercial POMCO Remittance 4010A1 Enrollment

A: 04/06/2010 Non-Par WB139 Commercial TX, MN Ppg Industries Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB139 Commercial TX, MN Ppg Industries Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 73159 Commercial PPO Oklahoma Professional 4010A1 Claim Level Acknowledgement

Non-Par 72148 Commercial PPO Plus, LLC Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 38335 Commercial MI PPOM, Inc. (Pref Prov Org Of Michigan) Institutional 4010A1 No Response From Payer

Non-Par 72148 Commercial PPOPlus, LLC Institutional 4010A1 No Response From Payer Yes

A: 04/06/2010 Non-Par WS075 Commercial MN Prairie Island Ind. Comm. Dba Treasure Island Resort & Casino Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS075 Commercial MN Prairie Island Ind. Comm. Dba Treasure Island Resort & Casino Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS075 Commercial MN Prairie Island Ind. Comm. Dba Treasure Island Resort & Casino Auto 4010A1 Claim Level Accept/Reject

Non-Par 36373 Commercial Prairie States Enterprises, Inc. Professional 4010A1 Claim Level Accept/Reject

Non-Par 36373 Commercial Prairie States Enterprises, Inc. Institutional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WS076 Commercial TX, MN Precision Cast Parts Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS076 Commercial TX, MN Precision Cast Parts Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS076 Commercial TX, MN Precision Cast Parts Auto 4010A1 Claim Level Accept/Reject

Non-Par 53476 Commercial Preferred Benefit Administrators Professional 4010A1 Claim Level Accept/Reject

Non-Par 61665 Commercial Preferred Benefits Administrator Institutional 4010A1 No Response From Payer

Non-Par 61665 Commercial Preferred Benefits Administrator Professional 4010A1 Claim Level Accept/Reject

Non-Par 56178 Commercial Preferred Care NC Professional 4010A1 File Level Acknowledgement

Non-Par 65088 Commercial FL Preferred Care Partners (Miami , FL) Institutional 4010A1 No Response From Payer

Non-Par 65088 Commercial FL Preferred Care Partners (Miami , FL) Professional 4010A1 Claim Level Accept/Reject

Non-Par 73145 Commercial Preferred Community Choice Institutional 4010A1 No Response From Payer Yes

Non-Par 73145 Commercial Preferred Community Choice Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Trans WK128 Commercial TX, MN Preferred Employers Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK128 Commercial TX, MN Preferred Employers Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK128 Commercial TX, MN Preferred Employers Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK129 Commercial TX, MN Preferred Employers Group Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK129 Commercial TX, MN Preferred Employers Group Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK129 Commercial TX, MN Preferred Employers Group Auto 4010A1 Claim Level Accept/Reject

Non-Par 33898 Commercial PA Preferred Health Care PPO Professional 4010A1 Claim Level Accept/Reject

Non-Par 61106 Commercial KY Preferred Health Plan, Inc. (Louisville, KY) Institutional 4010A1 No Response From Payer

Non-Par 61106 Commercial KY Preferred Health Plan, Inc. (Louisville, KY) Professional 4010A1 Claim Level Acknowledgement

Non-Par 31478 Commercial Preferred Health Professionals Institutional 4010A1 File Level Acknowledgement Yes

Providers who are interested in receiving ERAs from Preferred Health Systems

Non-Par 60110 Commercial Preferred Health Systems Insurance Co. Remittance 4010A1 Enrollment need to call 316-609-2434.

Non-Par 60110 Commercial Preferred Health Systems Insurance Co. Professional 4010A1 Claim Level Accept/Reject

Non-Par 60110 Commercial Preferred Health Systems Insurance Co. (PHSIC) Professional 4010A1 Claim Level Accept/Reject

Non-Par 60110 Commercial Preferred Health Systems Insurance Company Institutional 4010A1 No Response From Payer

Non-Par 04320 Commercial Preferred Healthcare System (PPO), The Professional 4010A1 Claim Level Accept/Reject

Non-Par PFIPA Commercial Preferred IPA Professional 4010A1 Claim Level Accept/Reject

Non-Par 36401 Commercial Preferred Network Access Professional 4010A1 Claim Level Acknowledgement

Non-Par 36401 Commercial Preferred Network Access Inc. Institutional 4010A1 Claim Level Acknowledgement

Trans 41147 Commercial Preferred One Institutional 4010A1 No Response From Payer Yes

Non-Par 41147 Commercial Preferred One Remittance 4010A1 Enrollment

Non-Par 14162 Commercial CT Preferred One (CT), a Division of First Choice Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 60110 Commercial Preferred Plus of Kansas Professional 4010A1 Claim Level Accept/Reject

Trans 41147 Commercial MN PreferredOne Professional 4010A1 No Response From Payer Yes

Non-Par BS010 Government WA Premera Blue Cross Remittance 4010A1 Enrollment

Non-Par BS010 Government WA Premera Blue Cross (formerly Medical Services Corp) Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par 43166 Commercial Premier Benefits, Inc. Institutional 4010A1 No Response From Payer

Non-Par 90440 Commercial Premier Health Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 43166 Commercial Premier Health Plans Institutional 4010A1 No Response From Payer

Non-Par 90440 Commercial Premier Health Systems Inc Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 05003 Commercial Presbyterian (NM) Professional 4010A1 Claim Level Acknowledgement



Please add provider number in 2010AA REF02 "or" 2310B REF02. Provider

Non-Par PREHP Commercial Presbyterian Health Plan Professional 4010A1 Claim Level Accept/Reject number is 11 digits or less. Contact (888) 923-5757, #6 then #2 to obtain id.

A: 04/06/2010 Non-Par WS077 Commercial MN Presbyterian Homes & Services Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS077 Commercial MN Presbyterian Homes & Services Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS077 Commercial MN Presbyterian Homes & Services Auto 4010A1 Claim Level Accept/Reject



Please add provider number in 2010AA REF02 "or" 2310B REF02. Provider

Non-Par PRESA Commercial Presbyterian Salud - Receiver type "D" Professional 4010A1 Claim Level Accept/Reject number is 11 digits or less. Contact (888) 923-5757, #6 then #2 to obtain id.

Non-Par 45056 Commercial Prestige Health Choice Institutional 4010A1 File Level Acknowledgement

Non-Par 45056 Commercial Prestige Health Choice Professional 4010A1 File Level Acknowledgement

Non-Par 39185 Commercial Prevea Health Insurance Plan Institutional 4010A1 No Response From Payer

Non-Par 39185 Commercial Prevea Health Insurance Plan Professional 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA Primary Care Associates Medical Group (PCA) Professional 4010A1 Claim Level Accept/Reject

Par IP080 Commercial CA Primary Care Physicians Professional 4010A1 Claim Level Accept/Reject

Non-Par 82048 Commercial Primary Health Network Professional 4010A1 Claim Level Accept/Reject

Non-Par 82048 Commercial Primary Health Network Institutional 4010A1 File Level Acknowledgement

Non-Par 56144 Commercial Primary Physician Care Inc. Professional 4010A1 Claim Level Acknowledgement







11/10/2011 49 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 56144 Commercial Primary PhysicianCare, Inc. Institutional 4010A1 No Response From Payer

Non-Par PPM01 Commercial CA Primary Provider Management - Claims Only Professional 4010A1 Claim Level Accept/Reject

Trans PPM02 Commercial CA Primary Provider Management - Encounters Only Professional 4010A1 Claim Level Accept/Reject

Non-Par 56190 Commercial Prime Vision Health Professional 4010A1 Claim Level Accept/Reject

Non-Par 11678 Commercial MN Prime West Remittance 4010A1 Enrollment

Non-Par 11678 Commercial MN Prime West Professional 4010A1 File Level Acknowledgement Yes

Non-Par 61604 Commercial Prime West Health Plan Institutional 4010A1 No Response From Payer

Non-Par 61604 Commercial Prime West Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 61604 Commercial Prime West Health Plan Remittance 4010A1 Enrollment

Trans IP079 Commercial CA PrimeCare Medical Network - Chino Professional 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA PrimeCare Medical Network - Citrus Valley Professional 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA PrimeCare Medical Network - Corona Professional 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA PrimeCare Medical Network - Hemet Professional 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA PrimeCare Medical Network - Inland Valley Professional 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA PrimeCare Medical Network - Moreno Professional 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA PrimeCare Medical Network - NAMM Institutional 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA PrimeCare Medical Network - Redlands Professional 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA PrimeCare Medical Network - Riverside Professional 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA PrimeCare Medical Network - San Bernardino Professional 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA PrimeCare Medical Network - Sun City Professional 4010A1 Claim Level Accept/Reject

Trans IP079 Commercial CA PrimeCare Medical Network - Temecula Professional 4010A1 Claim Level Accept/Reject

Par 61271 Commercial Principal Financial Group Institutional 4010A1 Claim Level Accept/Reject

09/01/2011 Non-Par 61271 Commercial MU Principal Life Insurance Remittance 4010A1 Enrollment

Par 61271 Commercial Principal Life Insurance Co. Institutional 4010A1 Claim Level Accept/Reject

Par 61271 Commercial Principal Life Insurance Company (Principal Financial Group) Professional 4010A1 No Response From Payer Yes

Trans 61271 Commercial Principal Life Insurances Dental 4010A1 No Response From Payer

Par 61271 Commercial Principal Mutual Life Insurance Company (Principal Mutual Life Assurance) Professional 4010A1 No Response From Payer Yes

Non-Par 38217 Commercial Priority Health Remittance 4010A1 Enrollment

Non-Par 38217 Commercial Priority Health Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 38217 Commercial Priority Health Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 37303 Commercial Prism - First Health Professional 4010A1 No Response From Payer

Non-Par 37315 Commercial Prism - Univera - Professional 4010A1 No Response From Payer

Non-Par 37268 Commercial Prism Health Networks Professional 4010A1 No Response From Payer

Non-Par 37268 Commercial Prism Network Professional 4010A1 No Response From Payer

Non-Par 37268 Commercial Prism Network Inc. Institutional 4010A1 File Level Acknowledgement

Non-Par 37303 Commercial Prism-First Health Institutional 4010A1 File Level Acknowledgement

Non-Par 37315 Commercial Prism-Univera Institutional 4010A1 File Level Acknowledgement

U: 01/10/2011 Non-Par 38329 Commercial Pro Care Health Plan, Inc. Institutional 4010A1 File Level Acknowledgement

A: 01/10/2011 Non-Par 38329 Commercial Pro Care Health Plan, Inc. Professional 4010A1 File Level Acknowledgement

Non-Par 70259 Commercial ProCare Health Plan Medicaid Professional 4010A1 Claim Level Acknowledgement

Non-Par 70259 Commercial ProCare Health Plan Medicaid Institutional 4010A1 Claim Level Acknowledgement

Non-Par 59296 Commercial Professional Benefit Administrators (Winter Park FL) Institutional 4010A1 Claim Level Acknowledgement Yes

Payer ID is valid only for claims with billing address of Professional Benefit

Non-Par 36331 Commercial IL Professional Benefit Administrators, Inc. Professional 4010A1 Claim Level Acknowledgement Administrators, Inc., Oak Brook, IL

Non-Par 36331 Commercial Professional Benefit Administrators, Inc. (Oak Brook, IL) Institutional 4010A1 No Response From Payer

Non-Par 59296 Commercial Professional Benefits Administrators Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Trans WZ046 Commercial Professional Claims Management (PCM) Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 34134 Commercial Professional Risk Management Institutional 4010A1 No Response From Payer

Non-Par 34134 Commercial Professional Risk Management Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WS080 Commercial MN Progress Casting Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS080 Commercial MN Progress Casting Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS080 Commercial MN Progress Casting Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK476 Commercial Progressive Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK476 Commercial Progressive Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK476 Commercial Progressive Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par IP105 Commercial CA Prospect Medical Group Professional 4010A1 No Response From Payer

Non-Par 37309 Commercial Protective Life Insurance Company Professional 4010A1 File Level Acknowledgement

Non-Par 37309 Commercial Protective Life Insurance Company Institutional 4010A1 Claim Level Rejects Only

Par PHP01 Commercial Providence Choice Option Professional 4010A1 Claim Level Accept/Reject Yes

Par PHP01 Commercial Providence Good Health Plan Professional 4010A1 Claim Level Accept/Reject Yes

Par PHP01 Commercial Providence Health Plan Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par PHP01 Commercial Providence Health Plan (HMO) Remittance 4010A1 Enrollment

Par PHP01 Commercial Providence Health Plan HMO Professional 4010A1 Claim Level Accept/Reject Yes

Par PHP01 Commercial Providence Medicaid Professional 4010A1 Claim Level Accept/Reject Yes

Par PHP01 Commercial Providence Medicaid Option Professional 4010A1 Claim Level Accept/Reject Yes

Par PHP01 Commercial Providence Medicare Extra Professional 4010A1 Claim Level Accept/Reject Yes

Par PHP01 Commercial Providence Option Professional 4010A1 Claim Level Accept/Reject Yes

Par PHP00 Commercial Providence Preferred (PPO) Professional 4010A1 Claim Level Accept/Reject

Non-Par WK012 Commercial Providence Property Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK012 Commercial Providence Property Prof. Work Comp 4010A1 Claim Level Accept/Reject

Par PHP01 Commercial Providence Traditional Option Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WK440 Commercial TX, MN Providence Washington Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 62308 Commercial Provident Healthsource (Cigna) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial Provident Life & Accident Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial Provident Life & Casualty Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 62308 Commercial Provident Preferred Network Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WS091 Commercial TX, MN Prudential / Everst National Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS091 Commercial TX, MN Prudential / Everst National Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS091 Commercial TX, MN Prudential / Everst National Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par 51052 Commercial PSYCHCARE LLC Institutional 4010A1 File Level Acknowledgement

Non-Par 51052 Commercial PSYCHCARE LLC Professional 4010A1 File Level Acknowledgement



Call PEHP EDI Support at (801)366-7544 or (800)753-7818. Notify PEHP you

Non-Par SX106 Commercial Public Employees Health Programs Professional 4010A1 Enrollment Claim Level Accept/Reject will be submitting your claims through Emdeon UHIN submitter ID HT0001

Non-Par 91136 Commercial Puget Sound Benefits Trust Institutional 4010A1 No Response From Payer

Non-Par 91136 Commercial Puget Sound Benefits Trust, Grp# F25 Professional 4010A1 Claim Level Accept/Reject

Non-Par 91136 Commercial Puget Sound Electrical Workers Trust Institutional 4010A1 No Response From Payer





11/10/2011 50 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 91136 Commercial Puget Sound Electrical Workers Trust, Grp# 33 Professional 4010A1 Claim Level Accept/Reject

Non-Par 39197 Commercial QuadMed Institutional 4010A1 No Response From Payer

Non-Par 39197 Commercial QuadMed Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WS093 Commercial MN Quadrangle Group Self-Insurance Association Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS093 Commercial MN Quadrangle Group Self-Insurance Association Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS093 Commercial MN Quadrangle Group Self-Insurance Association Auto 4010A1 Claim Level Accept/Reject

Non-Par 35174 Commercial Qual Choice of Arkansas Institutional 4010A1 No Response From Payer

Non-Par 35174 Commercial AR Qual Choice of Arkansas Professional 4010A1 No Response From Payer

Non-Par 23342 Commercial QualCare Inc. Institutional 4010A1 No Response From Payer

Non-Par 23342 Commercial QualCare, Inc. Professional 4010A1 Claim Level Acknowledgement

A: 09/26/2011 Non-Par 59375 Commercial FL Quality Health Plans, Inc Professional 4010A1 File Level Acknowledgement

Non-Par 73067 Commercial QuikTrip Institutional 4010A1 File Level Acknowledgement

Non-Par 73067 Commercial QuikTrip Professional 4010A1 File Level Acknowledgement

Non-Par 57117 Commercial QVI Risk Solutions Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS094 Commercial TX, MN Qwest Communications International Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS094 Commercial TX, MN Qwest Communications International Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS094 Commercial TX, MN Qwest Communications International Inc. Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS095 Commercial TX R E M (Dallas) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS097 Commercial TX R E M (Nashville) Prof. Work Comp 4010A1 Claim Level Accept/Reject

U:10/07/2011 Non-Par MR018 Government Railroad Medicare - Palmetto GBA Professional 4010A1 and 5010A1 Enrollment Claim Level Rejects Only Yes

Non-Par MR018 Government Railroad Medicare - Palmetto GBA Remittance 4010A1 Enrollment

A: 04/06/2010 Trans WK130 Commercial TX, MN Rampart Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK130 Commercial TX, MN Rampart Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK130 Commercial TX, MN Rampart Insurance Company Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS098 Commercial MN Range Regional Health Services Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS098 Commercial MN Range Regional Health Services Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS098 Commercial MN Range Regional Health Services Auto 4010A1 Claim Level Accept/Reject

Non-Par 91176 Commercial RBMS LLC Institutional 4010A1 File Level Acknowledgement

Non-Par 91176 Commercial AK RBMS, LLC Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS099 Commercial RCI Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS099 Commercial RCI Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WS099 Commercial RCI Auto 4010A1 Claim Level Accept/Reject

Non-Par WK131 Commercial Recovery and Claims Services (RCS) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK131 Commercial Recovery and Claims Services (RCS) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX049 Commercial Red Lake Band Of Chippewa Ind. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX049 Commercial Red Lake Band Of Chippewa Ind. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX049 Commercial Red Lake Band Of Chippewa Ind. Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK181 Commercial TX, MN Red Oak Independent School District Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK181 Commercial TX, MN Red Oak Independent School District Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK181 Commercial TX, MN Red Oak Independent School District Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK457 Commercial TX, MN Redland Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par IP122 Commercial CA Regal Bakerfield Professional 4010A1 No Response From Payer

Non-Par IP120 Commercial CA Regal Medical Group Professional 4010A1 No Response From Payer

Non-Par IP123 Commercial CA Regal Victor Valley Professional 4010A1 No Response From Payer

Non-Par 38221 Commercial Regency Employee Benefits Professional 4010A1 Claim Level Accept/Reject

Non-Par 38221 Commercial Regency Employee Benefits Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WK444 Commercial TX, MN Regent Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 47076 Commercial Regional Care, Inc Professional 4010A1 Claim Level Accept/Reject

Non-Par 47076 Commercial Regional Care, Inc. Institutional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WX050 Commercial Reliance Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX050 Commercial Reliance Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX050 Commercial Reliance Insurance Company Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX055 Commercial TX, MN Reliance National Indemnity Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX055 Commercial TX, MN Reliance National Indemnity Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX055 Commercial TX, MN Reliance National Indemnity Auto 4010A1 Claim Level Accept/Reject

Non-Par RENGQ Commercial Renaissance Gulf Quest Professional 4010A1 Claim Level Accept/Reject

Non-Par 76066 Commercial Renaissance Physicians Organization Institutional 4010A1 File Level Acknowledgement

Non-Par 76066 Commercial Renaissance Physicians Organization Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WX158 Commercial TX, MN Rentokil Initial Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX158 Commercial TX, MN Rentokil Initial Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX158 Commercial TX, MN Rentokil Initial Auto 4010A1 Claim Level Accept/Reject

Par WK103 Commercial Reny Inst. Work Comp 4010A1 Claim Level Acknowledgement

Par WK103 Commercial Reny Prof. Work Comp 4010A1 Claim Level Acknowledgement

Non-Par WK040 Commercial Republic Franklin Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK040 Commercial Republic Franklin Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

Par WK008 Commercial Republic Indemnity Company of America Inst. Work Comp 4010A1 Claim Level Acknowledgement

Par WK008 Commercial Republic Indemnity Company of America Prof. Work Comp 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Trans WB022 Commercial Rescare, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB022 Commercial Rescare, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 73066 Commercial Reserve National Insurance Professional 4010A1 File Level Acknowledgement Yes

Non-Par 73066 Commercial Reserve National Insurance Institutional 4010A1 File Level Acknowledgement Yes

A: 04/06/2010 Trans WK132 Commercial TX, MN Residential Services Group Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK132 Commercial TX, MN Residential Services Group Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK132 Commercial TX, MN Residential Services Group Auto 4010A1 Claim Level Accept/Reject

Non-Par 20481 Commercial Resolve Health Plan Administrators Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK133 Commercial TX, MN Restaurant Reinsurance Limited Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK133 Commercial TX, MN Restaurant Reinsurance Limited Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK133 Commercial TX, MN Restaurant Reinsurance Limited Auto 4010A1 Claim Level Accept/Reject

Non-Par 36396 Commercial Resurrection Health Care Preferred/FKA Family Medical Network Institutional 4010A1 File Level Acknowledgement

Non-Par RPPG1 Commercial Resurrection Physician Providers Grop Professional 4010A1 File Level Acknowledgement

Non-Par 26316 Commercial Retiree Health Trust Professional 4010A1 File Level Acknowledgement Yes

Non-Par WK048 Commercial Return to Work (RTW) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK048 Comm Return to Work (RTW) Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par CHAT1 Commercial Reunion Industries Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK134 Commercial TX, MN Rhone-Poulenc,Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK134 Commercial TX, MN Rhone-Poulenc,Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject







11/10/2011 51 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Trans WK134 Commercial TX, MN Rhone-Poulenc,Inc. Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX186 Commercial MN Ridgeview Medical Center Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX186 Commercial MN Ridgeview Medical Center Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX186 Commercial MN Ridgeview Medical Center Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK135 Commercial TX, MN Rieth-Riley Construction Compa Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK135 Commercial TX, MN Rieth-Riley Construction Compa Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK135 Commercial TX, MN Rieth-Riley Construction Compa Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX204 Commercial TX, MN RIO TINTO Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX204 Commercial TX, MN RIO TINTO Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX204 Commercial TX, MN RIO TINTO Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX235 Commercial MN Riscomp Industries Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX235 Commercial MN Riscomp Industries Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX235 Commercial MN Riscomp Industries Inc Auto 4010A1 Claim Level Accept/Reject

Par WK105 Commercial SD Risk Administrators Services, Inc (RAS) Inst. Work Comp 4010A1 Claim Level Acknowledgement

Par WK105 Commercial SD Risk Administrators Services, Inc (RAS) Prof. Work Comp 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Trans WK136 Commercial TX, MN Risk Transfer Technologies, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK136 Commercial TX, MN Risk Transfer Technologies, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK136 Commercial TX, MN Risk Transfer Technologies, Inc. Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX238 Commercial MN Riverport - Great Divide Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX238 Commercial MN Riverport - Great Divide Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX238 Commercial MN Riverport - Great Divide Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX355 Commercial MN Riverport Insurance Company WC Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX355 Commercial MN Riverport Insurance Company WC Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX355 Commercial MN Riverport Insurance Company WC Auto 4010A1 Claim Level Accept/Reject

Non-Par MPM08 Commercial Riverside Family Health Medical Group Professional 4010A1 File Level Acknowledgement

A: 08/12/2011 Par RMC01 Commercial CA Riverside Medical Clinic Professional 5010A1 Claim Level Acknowledgement Will accept claims with a date of service of 08/01/11 or later only

Non-Par 16117 Commercial RMSCO INC. Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 16117 Commercial RMSCO, Inc. Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WX356 Commercial TX, MN Roadlink USA Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX356 Commercial TX, MN Roadlink USA Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX377 Commercial MN Rochester Public Schools Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX377 Commercial MN Rochester Public Schools Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX377 Commercial MN Rochester Public Schools Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK470 Commercial TX, MN Rockwell Automation Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 84065 Commercial Rocky Mountain Health Plan- Grand Junction Institutional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par RMHMO Commercial CO Rocky Mountain HMO Professional 4010A1 Enrollment Claim Level Acknowledgement

Trans 37602 Commercial Rooney Life Inc. Institutional 4010A1 No Response From Payer

Trans 37602 Commercial Rooney Life Inc. Professional 4010A1 No Response From Payer Yes

Non-Par 36215 Commercial Rosemont of Des Plaines, IL Institutional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK182 Commercial TX, MN Roth Staffing Companies Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK182 Commercial TX, MN Roth Staffing Companies Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK182 Commercial TX, MN Roth Staffing Companies Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX640 Commercial Roto-Rooter Services Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX640 Commercial Roto-Rooter Services Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX641 Commercial Royal Caribbean Cruise Lines Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX641 Commercial Royal Caribbean Cruise Lines Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX641 Commercial Royal Caribbean Cruise Lines Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK446 Commercial TX, MN Royal Indemnity Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK451 Commercial TX, MN Royal Insurance Co of America Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX643 Commercial Royal Insurance Company of America Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX643 Commercial Royal Insurance Company of America Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX643 Commercial Royal Insurance Company of America Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK137 Commercial TX, MN RSC Insurance Services, Ltd. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK137 Commercial TX, MN RSC Insurance Services, Ltd. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK137 Commercial TX, MN RSC Insurance Services, Ltd. Auto 4010A1 Claim Level Accept/Reject

Non-Par 36332 Commercial Rush Health Providers Professional 4010A1 No Response From Payer Yes

Non-Par 36389 Commercial Rush Prudential Health Plans (HMO Only) Institutional 4010A1 No Response From Payer

Non-Par 36389 Commercial RUSH Prudential Health Plans (HMO Only) Professional 4010A1 Claim Level Acknowledgement

Non-Par 63070 Commercial RWDSU BENEFIT FUND Institutional 4010A1 File Level Acknowledgement

Non-Par 63070 Commercial RWDSU BENEFIT FUND Professional 4010A1 File Level Acknowledgement

Par WK009 Commercial Ryder Services, Inc. Inst. Work Comp 4010A1 Claim Level Acknowledgement

Par WK009 Commercial Ryder Services, Inc. Prof. Work Comp 4010A1 Claim Level Acknowledgement

Non-Par 31441 Commercial S & S Healthcare Strategies Institutional 4010A1 No Response From Payer

Non-Par 31441 Commercial S & S Healthcare Strategies Professional 4010A1 Claim Level Acknowledgement

Non-Par WK013 Commercial SafeCo Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK013 Commercial SafeCo Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK414 Commercial TX, MN Safety First Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX647 Commercial TX, MN Safety National Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX647 Commercial TX, MN Safety National Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX647 Commercial TX, MN Safety National Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK421 Commercial TX, MN Safety National Casualty Corp Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK138 Commercial TX, MN Safety-Kleen Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK138 Commercial TX, MN Safety-Kleen Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK138 Commercial TX, MN Safety-Kleen Corporation Auto 4010A1 Claim Level Accept/Reject

Non-Par 35164 Commercial Sagamore Health Network Institutional 4010A1 No Response From Payer

Par 35164 Commercial IN Sagamore Health Network Professional 4010A1 Claim Level Accept/Reject

Non-Par 37137 Commercial Sage Technologies - PBS Institutional 4010A1 File Level Acknowledgement

Non-Par 37137 Commercial Sage Technologies - PBS Professional 4010A1 File Level Acknowledgement

Non-Par 88029 Commercial SAINT MARY'S HEALTH PLAN Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WR765 Commercial Salvation Army (Adult Rehab Cntr) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR765 Commercial Salvation Army (Adult Rehab Cntr) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par SLOS1 Commercial CA San Luis Obispo Select IPA Professional 4010A1 File Level Acknowledgement

U: 09/19/2011 Non-Par SVH01 Commercial MU Sanford Health Plan Remittance 4010A1 Enrollment

Non-Par SVH01 Commercial Sanford Health Plan Institutional 4010A1 No Response From Payer

Non-Par SVH01 Commercial SD Sanford Health Plan (formally Sioux Valley Health Plan) Professional 4010A1 Claim Level Rejects Only

Non-Par SBIPA Commercial Santa Barbara Select IPA Professional 4010A1 File Level Acknowledgement







11/10/2011 52 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



U: 01/10/2011 Non-Par 10378 Commercial Santa Clara County IPA (SCCIPA) Professional 4010A1 File Level Acknowledgement

Non-Par 24077 Commercial SANTA CLARA FAMILY HEALTH PLAN Institutional 4010A1 File Level Acknowledgement

Non-Par 24077 Commercial SANTA CLARA FAMILY HEALTH PLAN Professional 4010A1 File Level Acknowledgement

Non-Par 77038 Commercial CA Sante Health System Professional 4010A1 Claim Level Acknowledgement

Non-Par 77038 Commercial Sante Health System and Affiliates Institutional 4010A1 File Level Acknowledgement

Non-Par SCAN1 Commercial CA SCAN Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 72261 Commercial SCAN Health Plan Institutional 4010A1 Claim Level Acknowledgement

Non-Par 73172 Commercial Scan Health Plan Arizona Professional 4010A1 Claim Level Acknowledgement

Non-Par 73172 Commercial Scan Health Plan Arizona Institutional 4010A1 Claim Level Acknowledgement

Non-Par 20460 Commercial SCAN Long Term Care Professional 4010A1 Claim Level Acknowledgement

Non-Par 20460 Commercial SCAN Long Term Care Institutional 4010A1 Claim Level Acknowledgement

Non-Par 16146 Commercial NY SCHC Total Care Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX649 Commercial MN Scherer Brors Lumber Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX649 Commercial MN Scherer Brors Lumber Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX649 Commercial MN Scherer Brors Lumber Company Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX650 Commercial TX, MN Schertz/Cibolo/Universal City ISD Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX650 Commercial TX, MN Schertz/Cibolo/Universal City ISD Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX650 Commercial TX, MN Schertz/Cibolo/Universal City ISD Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK139 Commercial TX, MN Schlumberger Technology Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK139 Commercial TX, MN Schlumberger Technology Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK139 Commercial TX, MN Schlumberger Technology Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR839 Commercial SCIF (State Compensation Insurance Fund) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR839 Commercial SCIF (State Compensation Insurance Fund) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 88030 Commercial TX Scott & White Health Care Plan Professional 4010A1 Claim Level Accept/Reject Contact (254) 298-3195 to obtain 5-digit Provider ID.

A: 04/06/2010 Trans WK140 Commercial TX, MN Scotts Miracle-Gro Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK140 Commercial TX, MN Scotts Miracle-Gro Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK140 Commercial TX, MN Scotts Miracle-Gro Company Auto 4010A1 Claim Level Accept/Reject

Par SCHPC Commercial CA Scripps Clinic Health Plan Services - Capitated encounters Professional NSF Claim Level Accept/Reject This payer is not accepting new enrollments at this time

Par SCHPS Commercial CA Scripps Clinic Health Plan Services - Fee for service claims Professional NSF No Response From Payer This payer is not accepting new enrollments at this time

Non-Par IP112 Commercial CA Sea View IPA Professional 4010A1 No Response From Payer

Non-Par WK014 Commercial Seabright (SBIC) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK014 Commercial Seabright (SBIC) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX727 Commercial MN Sears Holdings Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX727 Commercial MN Sears Holdings Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX727 Commercial MN Sears Holdings Corporation Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX728 Commercial MN Seaton Corporation-Chicago Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX728 Commercial MN Seaton Corporation-Chicago Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par SVIPA Commercial CA Seaview IPA Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WZ082 Commercial SECURA Insurance A Mutual Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ082 Commercial SECURA Insurance A Mutual Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX754 Commercial TX Secura Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 28530 Commercial Secure Health Plans of Georgia, LLC Institutional 4010A1 No Response From Payer

Non-Par 28530 Commercial Secure Health Plans of Georgia, LLC Professional 4010A1 Claim Level Acknowledgement

Trans 95959 Commercial CA Secure Horizon CA - Pacificare Professional 4010A1 Claim Level Accept/Reject

Trans COFHP Commercial CO Secure Horizons of Colorado Professional 4010A1 Claim Level Acknowledgement

Non-Par 42142 Commercial Securecare of Iowa-Infotrust Professional 4010A1 Claim Level Acknowledgement

Non-Par 39045 Commercial Security Health Plan Institutional 4010A1 No Response From Payer

Non-Par 39045 Commercial Security Health Plan Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WX865 Commercial TX, MN Security National Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX865 Commercial TX, MN Security National Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX865 Commercial TX, MN Security National Insurance Company Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB176 Commercial Sedgwick Claims Management Services, Inc. (TPA) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX868 Commercial TX Sedgwick Claims Mgmt-Dallas Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX910 Commercial TX Sedgwick Claims Mgmt-Memphis Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 64088 Commercial Select Administrative Services (SAS) Institutional 4010A1 No Response From Payer

Non-Par 64088 Commercial MS Select Administrative Services (SAS) Professional 4010A1 No Response From Payer

Non-Par 37282 Commercial Select Benefit Admin of America Professional 4010A1 Claim Level Acknowledgement

Non-Par 42137 Commercial IA Select Benefit Administrators Professional 4010A1 No Response From Payer

Non-Par 42137 Commercial Select Benefit Administrators (Des Moines, IA) Institutional 4010A1 No Response From Payer

Non-Par 93031 Commercial Select Benefit Administrators Inc. Institutional 4010A1 File Level Acknowledgement

Non-Par 37282 Commercial Select Benefit Administrators of America Institutional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WR921 Commercial Select Build (#8830) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WR921 Commercial Select Build (#8830) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 23285 Commercial Select Health of South Carolina Institutional 4010A1 No Response From Payer Yes

Non-Par 23285 Commercial Select Health of South Carolina Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 23285 Commercial Select Health of South Carolina Remittance 4010A1 Enrollment

Non-Par 20415 Commercial Select Senior Clinic Institutional 4010A1 File Level Acknowledgement

Non-Par 20415 Commercial Select Senior Clinic Professional 4010A1 File Level Acknowledgement

Non-Par 00014 Commercial Selectcare Institutional 4010A1 No Response From Payer Yes

Non-Par 00014 Commercial Selectcare Professional 4010A1 Claim Level Acknowledgement Yes

U: 12/29/2010 Non-Par GTPA1 Commercial Selectcare of Texas - Beaumont Professional 4010A1 Claim Level Accept/Reject

Non-Par 76045 Commercial SelectCare of Texas (HPN) Heritage Physicians Network Institutional 4010A1 File Level Acknowledgement

Non-Par 61225 Commercial TX SelectCare of Texas (Kelsey-Seybold) Professional 4010A1 Claim Level Accept/Reject

Non-Par 61225 Commercial SelectCare of Texas (Kelsey-Seybold) Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WK183 Commercial TX, MN Selective Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK183 Commercial TX, MN Selective Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK183 Commercial TX, MN Selective Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par 59111 Commercial Self Insured Benefit Administrators Professional 4010A1 Claim Level Acknowledgement

Non-Par 59111 Commercial Self Insured Benefit Administrators (Clearwater, FL) Institutional 4010A1 No Response From Payer

Non-Par 59111 Commercial Self Insured Benefit Administrators (Clearwater, FL) Professional 4010A1 Claim Level Accept/Reject

Non-Par 36404 Commercial Self Insured Plans (Naples, FL) Institutional 4010A1 No Response From Payer



Payer ID valid only for claims with a submission address of 1016 Collier Center

Way, Suite 200, Naples, FL 34110. Please call Customer Service at (239) 403-

Non-Par 36404 Commercial FL Self Insured Plans LLC Professional 4010A1 No Response From Payer 7884 to verify claims submission to Self Insured Plans - Payer ID 36404

Non-Par 34131 Commercial Self-Funded Plans, Inc. Institutional 4010A1 No Response From Payer

Non-Par 34131 Commercial Self-Funded Plans, Inc. Professional 4010A1 Claim Level Accept/Reject





11/10/2011 53 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 36390 Commercial Senior Care Partners Institutional 4010A1 File Level Acknowledgement

Non-Par 36390 Commercial Senior Care Partners Professional 4010A1 File Level Acknowledgement

Non-Par 83035 Commercial Senior Whole Health Professional 4010A1 File Level Acknowledgement

Non-Par 83035 Commercial SENIOR WHOLE HEALTH Institutional 4010A1 File Level Acknowledgement

Non-Par 54154 Commercial Sentara Family Care Professional 4010A1 No Response From Payer

Non-Par 54154 Commercial Sentara Health Management Professional 4010A1 No Response From Payer

Non-Par 54154 Commercial Sentara Optima Plan Professional 4010A1 No Response From Payer

Non-Par 54154 Commercial Sentera Family Care Institutional 4010A1 No Response From Payer

Non-Par 54154 Commercial Sentera Health Management Institutional 4010A1 No Response From Payer

Non-Par 23249 Commercial Sentinel Management Services Institutional 4010A1 No Response From Payer

Non-Par 23249 Commercial PA Sentinel Management Services Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WB140 Commercial TX, MN Sentry Casualty Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB140 Commercial TX, MN Sentry Casualty Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB141 Commercial TX, MN Sentry Insurance A Mutual Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB141 Commercial TX, MN Sentry Insurance A Mutual Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Claims must have the Sentry Life Insurance Co. Group and Subscriber

Numbers. To verify you are using the correct number, you may contact Sentry's

Non-Par 39033 Commercial Sentry Insurance Company Institutional 4010A1 No Response From Payer Customer Service Department (800)426-7234

Claims must have the Sentry Life Insurance Co. Group and Subscriber

Numbers. To verify you are using the correct number, you may contact Sentry's

Non-Par 39033 Commercial Sentry Insurance Company Professional 4010A1 No Response From Payer Customer Service Department (800)426-7234

Claims must have the Sentry Life Insurance Co. Group and Subscriber

Numbers. To verify you are using the correct number, you may contact Sentry's

Non-Par 39033 Commercial Sentry Insurance Company Remittance 4010A1 Enrollment Customer Service Department (800)426-7234

A: 04/06/2010 Non-Par WB142 Commercial TX, MN Sentry Lloyds Of Texas Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB142 Commercial TX, MN Sentry Lloyds Of Texas Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB143 Commercial TX, MN Sentry Select Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB143 Commercial TX, MN Sentry Select Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Par IP080 Commercial CA Seoul Medical Group Professional 4010A1 Claim Level Accept/Reject

Non-Par 76056 Commercial Seton CHIP Institutional 4010A1 Claim Level Accept/Reject

Non-Par SHEBP Commercial TX Seton Employee Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par SHPCH Commercial TX Seton Health Plan - CHIP Professional 4010A1 Claim Level Accept/Reject

Non-Par EPNSH Commercial TX Seton Health Plan - Exclusive Provider Network (EPN) Professional 4010A1 Claim Level Accept/Reject

Non-Par 25404 Commercial Seven Corners Institutional 4010A1 File Level Acknowledgement

Non-Par 25404 Commercial Seven Corners Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WX930 Commercial MN Shakopee Mdewakaton/Mystic Lake Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX930 Commercial MN Shakopee Mdewakaton/Mystic Lake Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX930 Commercial MN Shakopee Mdewakaton/Mystic Lake Auto 4010A1 Claim Level Accept/Reject

Trans 87726 Commercial IL Share Health Plan - ILL/PPO Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial IL Share Health Plan - ILX/HMO Professional 4010A1 Claim Level Accept/Reject Yes

U: 12/30/2010 Non-Par SCG01 Commercial CA Sharp Community Medical Group Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par SCG01 Commercial CA Sharp Community Medical Group Remittance 4010A1 Enrollment

U: 12/30/2010 Non-Par SHP12 Commercial CA Sharp Healthplan Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par SHP12 Commercial CA Sharp Healthplan Remittance 4010A1 Enrollment

Non-Par SRS01 Commercial CA Sharp Rees-Stealy Medical Group Professional 4010A1 Claim Level Accept/Reject

Non-Par SRS01 Commercial CA Sharp Rees-Stealy Medical Group Remittance 4010A1 Enrollment

Non-Par 75280 Commercial Shasta Administrative Services Institutional 4010A1 No Response From Payer

Non-Par 75280 Commercial Shasta Administrative Services Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WB130 Commercial Shaws / StarMarket Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB130 Commercial Shaws / StarMarket Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par SMW99 Commercial Sheet Metal Workers Local 91 Professional 4010A1 No Response From Payer

Par WK011 Commercial Sierra Administrators Inst. Work Comp 4010A1 Claim Level Acknowledgement

Par WK011 Commercial Sierra Administrators Prof. Work Comp 4010A1 Claim Level Acknowledgement

Non-Par 76342 Commercial Sierra Health Services Institutional 4010A1 Claim Level Accept/Reject Yes



U: 12/07/2010 Non-Par 76342 Commercial NV Sierra Health Services Remittance 4010A1 Enrollment EFT is a requirement to receive ERA transactions from Sierra Health Services

U: 12/07/2010 Trans 76342 Commercial NV Sierra Health Services Professional 4010A1 Claim Level Accept/Reject Yes

Trans 76343 Commercial NV Sierra Health Services - Encounters Professional 4010A1 Claim Level Accept/Reject

Only send claims with a billing address of P.O. Box 22419, Nashville, TN 37202-

Non-Par 62159 Commercial TN Signature Health Alliance Professional 4010A1 Claim Level Acknowledgement 2419

Non-Par 62159 Commercial Signature Health Alliance (SHA) Institutional 4010A1 No Response From Payer

Non-Par 23250 Commercial Significa Benefits Services Inc. Remittance 4010A1 Enrollment

Non-Par 36387 Commercial Silver Cross Managed Care Organization Institutional 4010A1 File Level Acknowledgement

Non-Par 36387 Commercial Silver Cross MCO Professional 4010A1 No Response From Payer

Non-Par 27094 Commercial Simply Healthcare Plans Professional 4010A1 File Level Acknowledgement

Non-Par 84076 Commercial Sinclair Health Plan Institutional 4010A1 No Response From Payer

Non-Par 84076 Commercial Sinclair Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par SVH01 Commercial Sioux Valley Health Plan Institutional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ033 Commercial TX Skilled Healthcare, LLC Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ033 Commercial TX Skilled Healthcare, LLC Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 20310 Commercial Skyland Benefits Professional 4010A1 Claim Level Accept/Reject

Non-Par 84096 Commercial Sloans Lake Managed Care Institutional 4010A1 No Response From Payer

Non-Par 84096 Commercial Sloans Lake Managed Care Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WZ149 Commercial SMARCA Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ149 Commercial SMARCA Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ149 Commercial SMARCA Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ268 Commercial TX Smart & Final Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ268 Commercial TX Smart & Final Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 02057 Commercial TX Smith Administrators Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 02057 Commercial Smith Administrators Institutional 4010A1 Claim Level Acknowledgement Yes

A: 04/06/2010 Trans WK141 Commercial TX, MN Snap-On Incorporated Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK141 Commercial TX, MN Snap-On Incorporated Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK141 Commercial TX, MN Snap-On Incorporated Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK142 Commercial TX, MN Solvay America Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK142 Commercial TX, MN Solvay America Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK142 Commercial TX, MN Solvay America Inc Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ280 Commercial TX, MN Sompo Japan Insuarnce Company of America Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ280 Commercial TX, MN Sompo Japan Insuarnce Company of America Inst. Work Comp 4010A1 Claim Level Accept/Reject







11/10/2011 54 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Non-Par WZ280 Commercial TX, MN Sompo Japan Insuarnce Company of America Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK415 Commercial TX, MN Sompo Japan Insurance Co of America Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB227 Commercial Sonic Automotive Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB227 Commercial Sonic Automotive Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par SCPCI Commercial Sonoma County Primary Care IPA Professional 4010A1 File Level Acknowledgement

Trans AMS01 Commercial SoNoran Desert Health Professional 4010A1 No Response From Payer

Trans AMS01 Commercial Sooner Health Network Professional 4010A1 No Response From Payer

Non-Par 91131 Commercial Sound Health (now knoown as First Choice Health Network) Institutional 4010A1 No Response From Payer

Non-Par 91131 Commercial Sound Health (Now known as First Choice Health Network) Professional 4010A1 Claim Level Acknowledgement

Non-Par 42172 Commercial Soundpath Health (formerly known as Puget Sound Health Partners) Institutional 4010A1 File Level Acknowledgement

Non-Par 42172 Commercial Soundpath Health (formerly known as Puget Sound Health Partners) Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WZ300 Commercial MN Sourn Minnesota Beet Sugar Cooperative Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ300 Commercial MN Sourn Minnesota Beet Sugar Cooperative Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ300 Commercial MN Sourn Minnesota Beet Sugar Cooperative Auto 4010A1 Claim Level Accept/Reject

Non-Par 32266 Commercial South Central Preferred Professional 4010A1 Claim Level Accept/Reject

Non-Par 37314 Commercial South FL Community Care Network - NBHD Institutional 4010A1 File Level Acknowledgement

Non-Par 35227 Commercial South Point Hotel & Casino Professional 4010A1 File Level Acknowledgement

Non-Par 35227 Commercial South Point Hotel & Casino Institutional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WZ511 Commercial TX South San Antonio ISD Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ511 Commercial TX South San Antonio ISD Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 25147 Commercial Southcare/ Healthcare Preferred Institutional 4010A1 No Response From Payer Yes

Non-Par 25147 Commercial Southcare/ Healthcare Preferred Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 86068 Commercial IA Southeast Iowa Health Plan Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WB177 Commercial Southeastern Claims Services Inc. (SCS) Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par SEI99 Commercial Southeastern Service Employees International Union (SEIU) Health & Welfare Fund Professional 4010A1 No Response From Payer

Non-Par 37318 Commercial Southern Benefit Services Institutional 4010A1 File Level Acknowledgement

Non-Par 37318 Commercial Southern Benefits Services, LLC Professional 4010A1 No Response From Payer

Non-Par SCP01 Commercial Southern Cal Physicians Managed Care Services Professional 4010A1 Claim Level Acknowledgement

Non-Par 56131 Commercial Southern Group Administrators Institutional 4010A1 No Response From Payer

Non-Par 56131 Commercial Southern Group Administrators Professional 4010A1 Claim Level Accept/Reject

Non-Par SX142 Commercial Southern Indiana Health Organization Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par SWSTA Commercial Southwest Administrators Professional 4010A1 Claim Level Accept/Reject

Non-Par IP113 Commercial CA Southwest Administrators Professional 4010A1 No Response From Payer All claims require the rendering provider's state license number.

Non-Par 37266 Commercial Southwest Service Life Institutional 4010A1 No Response From Payer

Please enter the unique policy number or ID card when submitting claims. Payer

ID valid only for claims with a billing submission address of PO Box 982005 Ft.

Non-Par 37266 Commercial TX Southwest Service Life Professional 4010A1 No Response From Payer Worth, TX 76182

Non-Par 52190 Commercial Special Risk International (SRI) Institutional 4010A1 No Response From Payer

Non-Par 52190 Commercial Special Risk International (SRI) Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ618 Commercial TX Specialty Claims-N Little Rock Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 23253 Commercial Spectrum Administrators Inc. - TPA Allentown PA (IHS Gateway Payer) Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 23253 Commercial Spectrum Administrators Inc., (I.H.S. Gateway Payer) Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WZ619 Commercial TX, MN Spherion Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ619 Commercial TX, MN Spherion Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ619 Commercial TX, MN Spherion Corporation Auto 4010A1 Claim Level Accept/Reject

Non-Par 84146 Commercial Spina Bifida - VA HAC Institutional 4010A1 No Response From Payer Yes

A: 04/06/2010 Non-Par WZ621 Commercial St Marys Duluth Clinic Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ621 Commercial St Marys Duluth Clinic Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ621 Commercial St Marys Duluth Clinic Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK447 Commercial TX, MN St Paul Fire & Marine Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK448 Commercial TX, MN St Paul Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 35199 Commercial St. Anthony Memorial Healthcare Centers - MDWISE Institutional 4010A1 Claim Level Accept/Reject

Non-Par 22240 Commercial St. Barnabas System Health Plan Institutional 4010A1 No Response From Payer

Non-Par 22240 Commercial St. Barnabas System Health Plan Professional 4010A1 Claim Level Acknowledgement

Non-Par 35199 Commercial St. Catherine Hospital PHO - MDWISE Institutional 4010A1 Claim Level Accept/Reject

Non-Par 35199 Commercial St. Francis Health Network Institutional 4010A1 Claim Level Accept/Reject

Non-Par IP116 Commercial CA St. Francis IPA (Applecare Medical Management) Professional 4010A1 No Response From Payer

Non-Par 37264 Commercial St. John's Claim Administration Professional 4010A1 No Response From Payer

Non-Par 37264 Commercial St. Johns Claims Administration Institutional 4010A1 No Response From Payer

Non-Par IP106 Commercial CA St. Joseph Heritage Healthcare Professional 4010A1 No Response From Payer

Non-Par IP106 Commercial CA St. Joseph Heritage Medical Group (formerly Yorba Park Medical Group) Professional 4010A1 No Response From Payer

Non-Par IP106 Commercial CA St. Joseph Hospital Affiliated Physicians Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WZ622 Commercial MN St. Joseph's Medical Center Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ622 Commercial MN St. Joseph's Medical Center Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ622 Commercial MN St. Joseph's Medical Center Auto 4010A1 Claim Level Accept/Reject

Non-Par IP106 Commercial CA St. Jude Professional 4010A1 No Response From Payer

Non-Par IP106 Commercial CA St. Jude Affiliated Physicians Professional 4010A1 No Response From Payer

Non-Par IP106 Commercial CA St. Jude Heritage Medical Group Professional 4010A1 No Response From Payer

Non-Par 35199 Commercial St. Margaret Mercy Healthcare Centers - MDWISE Institutional 4010A1 Claim Level Accept/Reject

Non-Par 88029 Commercial St. Marys Health Plan Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ623 Commercial St. Paul Fire & Marine Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ623 Commercial St. Paul Fire & Marine Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ623 Commercial St. Paul Fire & Marine Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 37116 Commercial IL St. Therese Physician Associates Professional 4010A1 No Response From Payer

Non-Par 37116 Commercial St. Therese Physician Association Institutional 4010A1 No Response From Payer

A: 04/06/2010 Trans WZ297 Commercial TX, MN STANDARD FORWARDING CO Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ297 Commercial TX, MN STANDARD FORWARDING CO Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ297 Commercial TX, MN STANDARD FORWARDING CO Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB023 Commercial Stanley Works, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB023 Commercial Stanley Works, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK143 Commercial TX, MN Stant Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK143 Commercial TX, MN Stant Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK143 Commercial TX, MN Stant Corporation Auto 4010A1 Claim Level Accept/Reject

Non-Par 59225 Commercial Star HRG Institutional 4010A1 No Response From Payer Yes

Non-Par 59225 Commercial Star HRG Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 61425 Commercial Starmark Institutional 4010A1 No Response From Payer







11/10/2011 55 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 61425 Commercial Starmark Professional 4010A1 No Response From Payer

Non-Par 46450 Commercial State Auto Insurance Companies Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 46450 Commercial State Auto Insurance Companies Professional 4010A1 File Level Acknowledgement Yes

Non-Par 31059 Commercial State Farm (Casualty & Property Claims) Professional 4010A1 Claim Level Rejects Only Yes

Non-Par 31053 Commercial State Farm First Health Remittance 4010A1 Enrollment

Non-Par 31053 Commercial State Farm Insurance Companies Professional 4010A1 Claim Level Accept/Reject

Non-Par 31053 Commercial State Farm Insurance Companies Remittance 4010A1 Enrollment

Non-Par 31053 Commercial State Farm Insurance Companies Institutional 4010A1 No Response From Payer

Non-Par 57254 Commercial State of Texas Dental Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 57254 Commercial State of Texas Dental Plan Institutional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB125 Commercial TX State Office of Risk Management Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB125 Commercial TX State Office of Risk Management Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 75087 Commercial States General Life Insurance Institutional 4010A1 No Response From Payer

Non-Par 75087 Commercial States General Life Insurance Professional 4010A1 Claim Level Accept/Reject

Non-Par 14163 Commercial FL Staywell Health Plan Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 14163 Commercial FL Staywell Health Plan Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 91151 Commercial Sterling Option 1 Institutional 4010A1 No Response From Payer

Non-Par 91151 Commercial Sterling Option 1 Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 67829 Commercial Sterling Partners PPO Professional 4010A1 Claim Level Acknowledgement

Non-Par 31121 Commercial Stoner & Associates Professional 4010A1 Claim Level Acknowledgement

Non-Par 31121 Commercial Stoner & Associates (Cincinnati, OH) Institutional 4010A1 No Response From Payer

Non-Par 31121 Commercial Stoner and Associates (Cincinnati OH) Professional 4010A1 Claim Level Accept/Reject

Non-Par 15752 Commercial Stones River Regional IPA- Windsor Professional 4010A1 File Level Acknowledgement

Par WK104 Commercial Stonetrust Commercial Insurance Company Inst. Work Comp 4010A1 Claim Level Acknowledgement

Par WK104 Commercial Stonetrust Commercial Insurance Company Prof. Work Comp 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WB131 Commercial Strategic Outsourcing Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB131 Commercial Strategic Outsourcing Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

Trans 74227 Commercial Student Insurance Institutional 4010A1 No Response From Payer Yes

Trans 74227 Commercial Student Insurance - Mid-West National Life Insurance Company of Tennessee Institutional 4010A1 No Response From Payer Yes

Trans 74227 Commercial Student Insurance - Mid-West National Life Insurance Company of TN Professional 4010A1 Claim Level Acknowledgement Yes

Trans 74227 Commercial Student Insurance - The Mega Life & Health Insurance Company Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par WK042 Commercial SUA Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK042 Commercial SUA Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 35199 Commercial Suburban Health Organization Institutional 4010A1 Claim Level Accept/Reject

Non-Par 95202 Commercial SummaCare Health Plan Institutional 4010A1 No Response From Payer Yes

Non-Par 95202 Commercial Summacare Health Plan (HMO) Professional 4010A1 Claim Level Accept/Reject Yes All claims require a claim level rendering provider id.

Non-Par 95202 Commercial Summacare Health Plan (HMO) Remittance 4010A1 Enrollment All claims require a claim level rendering provider id

Non-Par 86071 Commercial HI, NV Summerlin Life & Health Professional 4010A1 Claim Level Accept/Reject

Non-Par 37301 Commercial NASCC claims

Summit America Insurance Services LC: Student Accident and Sickness, College Sports and Professional only 4010A1 No Response From Payer

Non-Par 37301 Commercial Summit America Insurance Services, Inc. Institutional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK144 Commercial TX, MN Summit Health Ltd Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK144 Commercial TX, MN Summit Health Ltd Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK144 Commercial TX, MN Summit Health Ltd Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ627 Commercial TX Sunrise Senior Living Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ627 Commercial TX Sunrise Senior Living Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Par 68057 Commercial Sunshine State Health Plan Professional 4010A1 Claim Level Acknowledgement

Non-Par 23218 Commercial Superior Administrators, Inc. Institutional 4010A1 No Response From Payer

Payer ID valid for claims with a submission address of P.O. Box 27730, Santa

Non-Par 23218 Commercial CA Superior Administrators, Inc. Professional 4010A1 Claim Level Accept/Reject Ana, CA 92799-7730.

Non-Par 39188 Commercial TX Superior Health Plan - Centene Institutional 4010A1 No Response From Payer

U: 12/29/2010 Non-Par 39188 Commercial TX Superior Health Plan - Centene Remittance 4010A1 Enrollment

(Prior to submitting claims, call Provider Relations Dept. at 866-475-3129 to verify

your provider info is on file in the Health Plans claim system to avoid any

U: 12/29/2010 Par 39188 Commercial TX Superior Health Plan - Centene Professional 4010A1 Claim Level Accept/Reject rejections)

A: 04/06/2010 Non-Par WZ629 Commercial MN Supermarket Grp. Self-Insur. Assoc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ629 Commercial MN Supermarket Grp. Self-Insur. Assoc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ629 Commercial MN Supermarket Grp. Self-Insur. Assoc. Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB132 Commercial SuperValu Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB132 Commercial SuperValu Inst. Work Comp 4010A1 Claim Level Accept/Reject

Par IP131 Commercial CA Sutter Connect - Central Valley Med Group Professional 4010A1 Enrollment Claim Level Accept/Reject

U: 12/30/2010 Non-Par IP131 Commercial CA Sutter Connect - Central Valley Med Grp Remittance 4010A1 Enrollment

Non-Par IP100 Commercial CA Sutter Connect - Delta Remittance 4010A1 Enrollment

Par IP100 Commercial CA Sutter Connect - Delta - Claims Professional 4010A1 Enrollment Claim Level Accept/Reject

Trans HM063 Commercial CA Sutter Connect - Delta - Encounters Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par IP130 Commercial CA Sutter Connect - East Bay Med Fn Remittance 4010A1 Enrollment

Par IP130 Commercial CA Sutter Connect - East Bay Med Fn. - Claims Professional 4010A1 Enrollment Claim Level Accept/Reject

Trans HM065 Commercial CA Sutter Connect - East Bay Med Fn. - Encounters Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par IP090 Commercial CA Sutter Connect - Santa Rosa Network Remittance 4010A1 Enrollment

Par IP090 Commercial CA Sutter Connect - Santa Rosa Network - Claims Professional 4010A1 Enrollment Claim Level Accept/Reject

Trans HM057 Commercial CA Sutter Connect - Santa Rosa Network - Encounters Professional 4010A1 Enrollment Claim Level Accept/Reject

Trans HM064 Commercial CA Sutter Connect - Select Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par IP092 Commercial CA Sutter Connect - SIP, SMG, SWMG Remittance 4010A1 Enrollment

Par IP092 Commercial CA Sutter Connect - SIP, SMG, SWMG - Claims Professional 4010A1 Enrollment Claim Level Accept/Reject

Trans HM059 Commercial CA Sutter Connect - SIP, SMG, SWMG - Encounters Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par IP099 Commercial CA Sutter Connect - Solano Regional Medical Group Remittance 4010A1 Enrollment

Par IP099 Commercial CA Sutter Connect - Solano Regional Medical Group - Claims Professional 4010A1 Enrollment Claim Level Accept/Reject

Trans HM062 Commercial CA Sutter Connect - Solano Regional Medical Group - Encounters Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par IP091 Commercial CA Sutter Connect - Sutter Gould Medical Foundation Remittance 4010A1 Enrollment

Par IP091 Commercial CA Sutter Connect - Sutter Gould Medical Foundation - Claims Professional 4010A1 Enrollment Claim Level Accept/Reject

Trans HM058 Commercial CA Sutter Connect - Sutter Gould Medical Foundation - Encounters Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par 36411 Commercial Swedish Covenant Hospital Institutional 4010A1 File Level Acknowledgement

Non-Par 36411 Commercial Swedish Covenant Hospital Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WB178 Commercial SWIF (State Workers Insurance Fund) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK145 Commercial TX, MN Swift Transportation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK145 Commercial TX, MN Swift Transportation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK145 Commercial TX, MN Swift Transportation Auto 4010A1 Claim Level Accept/Reject

Non-Par IP127 Commercial Synermed Professional 4010A1 No Response From Payer





11/10/2011 56 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par TALMG Commercial Talbert Medical Group Professional 4010A1 Claim Level Accept/Reject

Non-Par 88067 Commercial Tall Tree Administrators Institutional 4010A1 File Level Acknowledgement

Non-Par 88067 Commercial Tall Trees/Managed Care Administrators Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WX670 Commercial Tansguard Insurance Company of America Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX670 Commercial Tansguard Insurance Company of America Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP335 Commercial Target Corporate (WC Only) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP335 Commercial Target Corporate (WC Only) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 37228 Commercial TX Tarrant Health Services Professional 4010A1 No Response From Payer

Non-Par 39157 Commercial WI TBG Administrative Services Professional 4010A1 Claim Level Accept/Reject

Non-Par 94304 Commercial TBT Institutional 4010A1 File Level Acknowledgement

Non-Par 94304 Commercial TBT Professional 4010A1 File Level Acknowledgement

Non-Par 88019 Commercial Teacher's Health Trust Professional 4010A1 Claim Level Acknowledgement

Non-Par 75133 Commercial Team Choice PNS Institutional 4010A1 No Response From Payer

Non-Par 75133 Commercial Team Choice PNS Professional 4010A1 Claim Level Accept/Reject

10/17/11 Non-Par 75261 Commercial Team Choice PNS Professional 5010A1 File Level Acknowledgement Yes

Non-Par 36215 Commercial Teamcare Institutional 4010A1 No Response From Payer

Non-Par 36215 Commercial Teamcare Professional 4010A1 Claim Level Accept/Reject

Non-Par SWSTA Commercial NV Teamster Local 631 - NV Professional 4010A1 Claim Level Accept/Reject

Non-Par 94304 Commercial Teamsters Benefit Trust Institutional 4010A1 File Level Acknowledgement

Non-Par 94304 Commercial Teamsters Benefit Trust Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WZ632 Commercial Technology Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ632 Commercial Technology Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ632 Commercial Technology Insurance Co Auto 4010A1 Claim Level Accept/Reject

Non-Par 20212 Commercial Tehtys Health Ventures Professional 4010A1 File Level Acknowledgement

Non-Par 20212 Commercial Tehtys Health Ventures Institutional 4010A1 Claim Level Acknowledgement

U: 12/29/2010 Non-Par GTPA1 Commercial Texan Plus - Beaumont Professional 4010A1 Claim Level Accept/Reject

Non-Par WK023 Commercial Texas A&M TAMU Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK023 Commercial Texas A&M TAMU Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK043 Commercial TX Texas Association of School Boards Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK043 Commercial TX Texas Association of School Boards Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 76048 Commercial Texas Childrens Health Plan Institutional 4010A1 No Response From Payer

Non-Par 76048 Commercial TX Texas Children's Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 75228 Commercial Texas Childrens Health Plan (Medicaid) Professional 4010A1 Claim Level Acknowledgement

Non-Par 75228 Commercial Texas Childrens Health Plan (Medicaid) Institutional 4010A1 File Level Acknowledgement

Non-Par TXCSM Commercial TX Texas Children's Star Medical Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC138 Commercial TX, MN Texas Construction Trust Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC138 Commercial TX, MN Texas Construction Trust Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC139 Commercial TX, MN Texas Cotton Ginners Trust Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC139 Commercial TX, MN Texas Cotton Ginners Trust Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR891 Commercial TX, MN Texas Cotton Ginners' Trust Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR891 Commercial TX, MN Texas Cotton Ginners' Trust Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 13185 Commercial TX Texas First Health Professional 4010A1 Claim Level Accept/Reject

Non-Par 76046 Commercial Texas First Health Plans (TIOPA) Institutional 4010A1 File Level Acknowledgement

Non-Par 33104 Commercial Texas HealthSpring Institutional 4010A1 File Level Acknowledgement

Non-Par WK024 Commercial TX Texas Municipal League Intergov Risk Pool Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK024 Commercial TX Texas Municipal League Intergov Risk Pool Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 74214 Commercial TX Texas Municipal League TML Professional 4010A1 No Response From Payer

Non-Par WK002 Commercial TX Texas Mutual Insurance Co. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK002 Commercial TX Texas Mutual Insurance Co. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK146 Commercial TX, MN Texas Small Business Pool Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK146 Commercial TX, MN Texas Small Business Pool Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK146 Commercial TX, MN Texas Small Business Pool Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ640 Commercial TX Texas Sonic Employers Trade Association Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ640 Commercial TX Texas Sonic Employers Trade Association Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ640 Commercial TX Texas Sonic Employers Trade Association Auto 4010A1 Claim Level Accept/Reject

Non-Par TTCEC Commercial TX Texas True Choice Professional 4010A1 Claim Level Accept/Reject

Non-Par TTCEC Commercial TX Texas True Choice Institutional 4010A1 Claim Level Acknowledgement

Non-Par 13185 Commercial TexasFirst Health Plan (NTX) Institutional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WK471 Commercial TX, MN Textron Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par TBGRP Commercial The Benefit Group Professional 4010A1 Claim Level Accept/Reject

Non-Par BOONG Commercial The Boon Group Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ084 Commercial The Builders Group of MN Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ084 Commercial The Builders Group of MN Inst. Work Comp 4010A1 Claim Level Accept/Reject

Trans 74227 Commercial The Chesapeake Life Insurance Company - Student Insurance Institutional 4010A1 No Response From Payer Yes

Trans 74227 Commercial The Chesapeake Life Insurance Company - Student Insurance Professional 4010A1 Claim Level Acknowledgement Yes

A: 04/06/2010 Non-Par WB144 Commercial TX, MN The Dial Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB144 Commercial TX, MN The Dial Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 37305 Commercial The Ford Meter Box Company, Inc. Institutional 4010A1 No Response From Payer

Non-Par 20356 Commercial The Health Exchange Professional 4010A1 No Response From Payer

Non-Par 20356 Commercial The Health Exchange (Cerner Corporation) Institutional 4010A1 Claim Level Acknowledgement

Services ordered by outside provider require referring provider on a HCFA and

attending Physician on a UB. Please provide physician name and UPIN if

Trans 34150 Commercial OH The Health Plan Professional 4010A1 No Response From Payer available.

Non-Par 34150 Commercial The Health Plan (Massillon, Ohio and St. Clairsville, Ohio only) Institutional 4010A1 No Response From Payer

Non-Par 35206 Commercial The Healthcare Group Institutional 4010A1 No Response From Payer

Non-Par 35206 Commercial The Healthcare Group Professional 4010A1 Claim Level Acknowledgement

Non-Par 58200 Commercial GA The Integrity Benefit Network, Inc. (Marietta, GA) Institutional 4010A1 No Response From Payer

Non-Par 58200 Commercial GA The Integrity Benefit Network, Inc. (Marietta, GA) Professional 4010A1 Claim Level Acknowledgement

Non-Par 23223 Commercial The Loomis Company Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 23223 Commercial The Loomis Company - TPA Wyomissing PA (IHS Gateway Payer) Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 59221 Commercial The MEGA Life & Health Insurance Company - Insurance Center Remittance 4010A1 Enrollment

Non-Par 59227 Commercial The MEGA Life & Health Insurance Company - OKC Professional 4010A1 Claim Level Accept/Reject

Non-Par 59227 Commercial The MEGA Life & Health Insurance Company – OKC Institutional 4010A1 No Response From Payer

Non-Par 59225 Commercial The MEGA Life & Health Insurance Company - Starbridge StarHRG Institutional 4010A1 No Response From Payer Yes

Trans 74227 Commercial The Mega Life & Health Insurance Company - Student Insurance Institutional 4010A1 No Response From Payer Yes

Trans 74227 Commercial The Mega Life & Health Insurance Company - Student Insurance Professional 4010A1 Claim Level Acknowledgement Yes







11/10/2011 57 of 66

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Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 59221 Commercial The MEGA Life and Health Insurance Professional 4010A1 Claim Level Accept/Reject

Par 70491 Commercial The Mutual Group (US) Professional 4010A1 No Response From Payer

Par 70491 Commercial The Mutual Group/TMG Life Insurance Group Professional 4010A1 No Response From Payer

Non-Par 59087 Commercial The National Radiology Network Institutional 4010A1 No Response From Payer

Non-Par 13522 Commercial The Perfect Health Insurance Co. Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 13522 Commercial The Perfect Health Insurance Co. Institutional 4010A1 Claim Level Acknowledgement Yes

Non-Par 31074 Commercial The Physicians Assurance Corp (TPAC) /Employee Benefit Management Corp (EBM Institutional 4010A1 File Level Acknowledgement Yes

A: 04/06/2010 Non-Par WB134 Commercial The Salvation Army Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB134 Commercial The Salvation Army Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX357 Commercial TX, MN The Scotts Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX357 Commercial TX, MN The Scotts Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX357 Commercial TX, MN The Scotts Company Auto 4010A1 Claim Level Accept/Reject

Non-Par WK147 Commercial The Scotts Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK147 Commercial The Scotts Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK017 Commercial The Zenith Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK017 Commercial The Zenith Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 75305 Commercial Therapy Review Systems Professional 4010A1 File Level Acknowledgement Yes

Non-Par 75305 Commercial Therapy Review Systems Institutional 4010A1 File Level Acknowledgement Yes

A: 04/06/2010 Non-Par WC203 Commercial MN Thro Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC203 Commercial MN Thro Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WC203 Commercial MN Thro Company Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ641 Commercial TI Automotive Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ641 Commercial TI Automotive Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par TIC99 Commercial TIC International, Inc. Professional 4010A1 No Response From Payer

A: 04/06/2010 Trans WZ642 Commercial Tidewater Marine Western Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ642 Commercial Tidewater Marine Western Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ642 Commercial Tidewater Marine Western Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ642 Commercial MN TIG Claims Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX123 Commercial TIG Insurance -Transamerica Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX123 Commercial TIG Insurance -Transamerica Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WX123 Commercial TIG Insurance -Transamerica Auto 4010A1 Claim Level Accept/Reject

U:10/27/2011 Non-Par 39065 Commercial Time Insurance Company Institutional 5010A2 No Response From Payer

Non-Par 39065 Commercial Time Insurance Company Professional 4010A1 Claim Level Accept/Reject

Non-Par 74214 Commercial TX TML Intergovernmental Employee Benefits Pool Institutional 4010A1 No Response From Payer

Non-Par 74214 Commercial TX TML Intergovernmental Employee Benefits Pool Professional 4010A1 No Response From Payer

Non-Par 15750 Commercial TN IPA Professional 4010A1 File Level Acknowledgement

Non-Par WITH1 Commercial Today’s Health Professional 4010A1 Claim Level Accept/Reject

Non-Par 20081 Commercial Today's Health Wisconsin/ Abri Health Plan Inc Institutional 4010A1 Claim Level Acknowledgement

Non-Par 48055 Commercial Today's Option - Pyramid Professional 4010A1 Claim Level Acknowledgement

Non-Par 48055 Commercial Today's Option - Pyramid Institutional 4010A1 Claim Level Acknowledgement

Non-Par 48055 Commercial MU Todays Option, Pyramid Remittance 4010A1 Enrollment

Non-Par 92620 Commercial AK Tongass Timber Trust Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 92620 Commercial Tongass Timber Trust Institutional 4010A1 Claim Level Acknowledgement Yes

Non-Par 61425 Commercial Tooling & Manufacturing Association Institutional 4010A1 No Response From Payer

Non-Par 61425 Commercial Tooling & Manufacturing Association Professional 4010A1 No Response From Payer

Non-Par THIPA Commercial Torrance Hospital IPA Professional 4010A1 Claim Level Accept/Reject

Non-Par TCARE Commercial NY Total Care Professional 4010A1 Claim Level Accept/Reject

Non-Par 68055 Commercial SC Total Carolina Care Professional 4010A1 Claim Level Accept/Reject

Non-Par 37314 Commercial Total Claims Administration Institutional 4010A1 File Level Acknowledgement

Non-Par TCS99 Commercial Total Claims Solutions Professional 4010A1 No Response From Payer

Non-Par 31182 Commercial Total Community Care Institutional 4010A1 File Level Acknowledgement

Non-Par 31182 Commercial Total Community Care Professional 4010A1 File Level Acknowledgement

Non-Par 38201 Commercial Total Healthcare, Inc. Institutional 4010A1 No Response From Payer

Non-Par 38201 Commercial Total Healthcare, Inc. Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK148 Commercial TX, MN Total Petroleum, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK148 Commercial TX, MN Total Petroleum, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK148 Commercial TX, MN Total Petroleum, Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 97910 Commercial Touchpoint Health Plan HMO Professional 4010A1 Claim Level Rejects Only

Non-Par 13402 Commercial Touchstone Health / Health Net Smart Choice Professional 4010A1 Claim Level Accept/Reject

Non-Par 23856 Commercial Touchstone Health PSO Professional 4010A1 Claim Level Accept/Reject

Non-Par 23856 Commercial Touchstone Health PSO Institutional 4010A1 File Level Acknowledgement

Non-Par 13402 Commercial TOUCHSTONE HEALTH/HEALTH NET SMART CHOICE Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WZ308 Commercial MN Tower Group Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ308 Commercial MN Tower Group Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 69493 Commercial Tower Life Insurance Co. Institutional 4010A1 No Response From Payer

Non-Par 69493 Commercial Tower Life Insurance Company Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ014 Commercial Tower National Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ014 Commercial Tower National Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ014 Commercial Tower National Insurance Co Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ706 Commercial Toyota Motor Sales, USA., Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ706 Commercial Toyota Motor Sales, USA., Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ706 Commercial Toyota Motor Sales, USA., Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 31074 Commercial TPAC/Employee Benefit Management Corp Institutional 4010A1 File Level Acknowledgement Yes

A: 04/06/2010 Non-Par WK433 Commercial TX, MN TPCIGA for Casualty Reciprocal Exchange Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK442 Commercial TX, MN TPCIGA for Legion Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK445 Commercial TX, MN TPCIGA for Reliance Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK443 Commercial TX, MN TPCIGA for Reliance National Indemnity Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK461 Commercial TX, MN TPCIGA for Reliance National Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC140 Commercial TX, MN TPS Joint Self Insurance Fund Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC140 Commercial TX, MN TPS Joint Self Insurance Fund Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 37230 Commercial TR Paul Professional 4010A1 No Response From Payer

Non-Par 37230 Commercial TR Paul Inc. Institutional 4010A1 No Response From Payer

Non-Par 59222 Commercial TransAmerica Life Insurance Co Institutional 4010A1 No Response From Payer

The insured ID number is 10 digits numeric, please add leading zeros to the

Non-Par 59222 Commercial TransAmerica Life Insurance Co. Professional 4010A1 Claim Level Accept/Reject number to make it 11 digits

Trans 37284 Commercial TransChoice-KBA Professional 4010A1 No Response From Payer







11/10/2011 58 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 37284 Commercial TransChoice-Key Benefit Administrators Institutional 4010A1 No Response From Payer

Trans 37284 Commercial TransChoice-Key Benefit Administrators Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WK427 Commercial TX, MN Transcontinental Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK428 Commercial TX, MN Transportation Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par TRAN1 Commercial Transwestern Professional 4010A1 Claim Level Accept/Reject

Trans 87726 Commercial CA Travelers Health Network - HMO (Metrahealth) Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WZ813 Commercial TX, MN Travelers Indemnity Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ813 Commercial TX, MN Travelers Indemnity Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ813 Commercial TX, MN Travelers Indemnity Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP467 Commercial Travelers Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP467 Commercial Travelers Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

Trans 87726 Commercial Travelers/CGT-PPO Professional 4010A1 Claim Level Accept/Reject Yes

A: 04/06/2010 Non-Par WZ814 Commercial TX Travis County Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ814 Commercial TX Travis County Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par TCHD1 Commercial Travis County Healthcare District Professional 4010A1 Claim Level Accept/Reject

Non-Par 36397 Commercial Trellis Health Partners Institutional 4010A1 File Level Acknowledgement

Non-Par 36397 Commercial Trellis Health Partners Professional 4010A1 File Level Acknowledgement

Non-Par PDT01 Commercial Tri Cities IPA Professional 4010A1 Claim Level Accept/Reject

Non-Par 73117 Commercial Tribute /SelectCare of Oklahoma Institutional 4010A1 File Level Acknowledgement

Non-Par 73117 Commercial Tribute /SelectCare of Oklahoma Professional 4010A1 File Level Acknowledgement

9/15/11 Non-Par CH001 Government AL TRICARE - Alabama - South Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government AK TRICARE - Alaska - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Par CH003 Government AZ TRICARE - Arizona - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

9/15/11 Non-Par CH001 Government AR TRICARE - Arkansas - South Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government CA TRICARE - California - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Par CH003 Government CO TRICARE - Colorado - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

9/15/11 Non-Par CH002 Government CT TRICARE - Connecticut - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH002 Government DE TRICARE - Delaware - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH002 Government DC TRICARE - District of Columbia - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH001 Government FL TRICARE - Florida - South Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH001 Government GA TRICARE - Georgia - South Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government HI TRICARE - Hawaii - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Par CH003 Government ID TRICARE - Idaho - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

9/15/11 Non-Par CH002 Government IL TRICARE - Illinois - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH002 Government IN TRICARE - Indiana - North Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government IA TRICARE - Iowa (excluding Rock Island [Illinois] area) - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

9/15/11 Non-Par CH002 Government IA TRICARE - Iowa (the Rock Island [Illinois] Arsenal area) - North Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government KS TRICARE - Kansas - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

9/15/11 Non-Par CH002 Government KY TRICARE - Kentucky - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH001 Government LA TRICARE - Louisiana - South Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH002 Government ME TRICARE - Maine - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH002 Government MD TRICARE - Maryland - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH002 Government MA TRICARE - Massachusetts - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH002 Government MI TRICARE - Michigan - North Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government MN TRICARE - Minnesota - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

9/15/11 Non-Par CH001 Government MS TRICARE - Mississippi - South Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government MO TRICARE - Missouri (excluding the St. Louis area) - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

9/15/11 Non-Par CH002 Government MO TRICARE - Missouri (the St. Louis area, including MO zip codes in the Scott AFB [Illinois] catchment area; and the eastern MO/ St. Louis non-catchment area) - North RegionAccept/Reject

Professional 4010A1 Claim Level Yes

Par CH003 Government MT TRICARE - Montana - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Par CH003 Government NE TRICARE - Nebraska - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Par CH003 Government NV TRICARE - Nevada - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

9/15/11 Non-Par CH002 Government NH TRICARE - New Hampshire - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH002 Government NJ TRICARE - New Jersey - North Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government NM TRICARE - New Mexico - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

9/15/11 Non-Par CH002 Government NY TRICARE - New York - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH002 Government NC TRICARE - North Carolina - North Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government ND TRICARE - North Dakota - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

9/15/11 Non-Par CH002 Government TRICARE - North Region Institutional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par CH002 Government TRICARE - North Region Remittance 4010A1 Enrollment

9/15/11 Non-Par CH002 Government OH TRICARE - Ohio - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH001 Government OK TRICARE - Oklahoma - South Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government OR TRICARE - Oregon - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

9/15/11 Non-Par CH002 Government PA TRICARE - Pennsylvania - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH002 Government RI TRICARE - Rhode Island - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH001 Government SC TRICARE - South Carolina - South Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government SD TRICARE - South Dakota - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par CH001 Commercial TRICARE - South Region Remittance 4010A1 Enrollment

9/15/11 Non-Par CH001 Government TN TRICARE - Tennessee (excluding the Fort Campbell, Kentucky area) - South Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH002 Government TN TRICARE - Tennessee (the Fort Campbell, Kentucky catchment area) - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH001 Government TX TRICARE - Texas (excluding, only, the extreme southwestern El Paso area) - South Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government TX TRICARE - Texas (the southwestern corner including El Paso, only) - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Par CH003 Government UT TRICARE - Utah - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

9/15/11 Non-Par CH002 Government VT TRICARE - Vermont - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH002 Government VA TRICARE - Virginia - North Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government WA TRICARE - Washington - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Par CH003 Government TRICARE - West Region Institutional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par CH003 Government TRICARE - West Region Remittance 4010A1 Enrollment

9/15/11 Non-Par CH002 Government WV TRICARE - West Virginia - North Region Professional 4010A1 Claim Level Accept/Reject Yes

9/15/11 Non-Par CH002 Government WI TRICARE - Wisconsin - North Region Professional 4010A1 Claim Level Accept/Reject Yes

Par CH003 Government WY TRICARE - Wyoming - West Region Professional 4010A1 Enrollment Claim Level Rejects Only Yes

Non-Par TDDIR Government Tricare for Life Remittance 4010A1 Enrollment

Par TDDIR Government Tricare For Life Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Par TDDIR Government Tricare For Life Institutional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par 31144 Commercial TRIHEALTH PHYSICIAN SOLUTIONS Institutional 4010A1 File Level Acknowledgement

10/17/11 Non-Par 31144 Commercial TRIHEALTH PHYSICIAN SOLUTIONS Professional 5010A1 File Level Acknowledgement

Non-Par 31143 Commercial TRIHEALTH PHYSICIAN SOLUTIONS - CONCERN Institutional 4010A1 File Level Acknowledgement







11/10/2011 59 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par 31143 Commercial TRIHEALTH PHYSICIAN SOLUTIONS - CONCERN Professional 4010A1 File Level Acknowledgement

Non-Par 62061 Commercial Trilogy Health Insurance Professional 4010A1 Claim Level Accept/Reject

Non-Par 62061 Commercial Trilogy Health insurance Institutional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WZ815 Commercial TX, MN Trinity Universal Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ815 Commercial TX, MN Trinity Universal Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ815 Commercial TX, MN Trinity Universal Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 12M15 Government MO Trispan Health Services Institutional 4010A1 Enrollment No Response From Payer

Trans AMS01 Commercial Tristate Professional 4010A1 No Response From Payer

Non-Par 98514 Commercial TRLHN/AS Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 98514 Commercial TRLHN/AS Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 50884 Commercial TRLHN/AU Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 50884 Commercial TRLHN/AU Professional 4010A1 File Level Acknowledgement Yes

Non-Par 62777 Commercial TRLHN/EB Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 62777 Commercial TRLHN/EB Professional 4010A1 File Level Acknowledgement Yes

Non-Par TCUSA Commercial TX True Choice USA Professional 4010A1 Claim Level Accept/Reject

Non-Par 54210 Commercial True Choice USA Institutional 4010A1 Claim Level Acknowledgement

Non-Par 91078 Commercial Trusteed Plan Service Corporation Institutional 4010A1 No Response From Payer

Non-Par 91078 Commercial Trusteed Plans Service Corporation Professional 4010A1 Claim Level Acknowledgement

Non-Par 06056 Commercial TrustMark - 4Most Professional 4010A1 No Response From Payer

Non-Par 61425 Commercial Trustmark Insurance Company Institutional 4010A1 No Response From Payer

Non-Par 61425 Commercial Trustmark Insurance Company Professional 4010A1 No Response From Payer

Non-Par 61425 Commercial Trustmark Insurance Company Remittance 4010A1 Enrollment

U: 08/22/2011 Non-Par 01043 Commercial MA Tufts Health Plan Professional 4010A1 and 5010A1 Batch Level Acknowledgement

U: 08/23/2011 Non-Par 04298 Commercial MA Tufts Health Plan Professional 4010A1 and 5010A1 Enrollment Claim Level Accept/Reject

10/04/11 Non-Par 04298 Commercial MA Tufts Health Plan Remittance 4010A1 Enrollment

10/04/11 Non-Par 04298 Commercial MA Tufts Health Plan Institutional 4010A1 Enrollment Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ822 Commercial TX, MN Tyco Electronics Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ822 Commercial TX, MN Tyco Electronics Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ822 Commercial TX, MN Tyco Electronics Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ830 Commercial TX, MN Tyco International LTD Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ830 Commercial TX, MN Tyco International LTD Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ830 Commercial TX, MN Tyco International LTD Auto 4010A1 Claim Level Accept/Reject

Trans 87726 Commercial UBH - United Behavioral Health (RIOS) (ERA's are not available for UBH) Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial UBH Rios Professional 4010A1 Claim Level Acknowledgement Yes

Trans 87726 Commercial Professional 4010A1

UBH- United Behavioral Health (former MetraHealth - UNET)(ERA's are not available for UBH)(ERA's are not available for UBH) Claim Level Accept/Reject Yes

Non-Par 52629 Commercial UCARE Institutional 4010A1 Claim Level Acknowledgement

Non-Par SX178 Commercial MN Ucare of Minnesota Remittance 4010A1 Enrollment

Non-Par SX178 Commercial MN Ucare Of Minnesota Professional 4010A1 Claim Level Accept/Reject

Non-Par UFC98 Commercial OH UFCW- Central Ohio Professional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WB145 Commercial TX, MN UFP Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB145 Commercial TX, MN UFP Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB145 Commercial TX, MN UFP Insurance Auto 4010A1 Claim Level Accept/Reject

Trans 87726 Commercial UHB - United Behavioral Health (Health Plan - HMO)(ERA's are not available for UBH) Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 36273 Commercial UHC Ovations Insurance Solution (AARP) Remittance 4010A1 Enrollment

Non-Par 36273 Commercial UHC Ovations Insurance Solution (AARP) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 74223 Commercial NV UICI - Administrators - Nevada only (through Benefit Planners, Inc.) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 75240 Commercial UICI Administrators Professional 4010A1 Claim Level Acknowledgement Yes

A: 10/26/2011 Non-Par 75130 Commercial TX UMC HEALTH PLAN Professional 4010A1 No Response From Payer

Non-Par 95266 Commercial UMR - Harrington (formerly known as Harrington Benefit Services-Columbus) Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 95266 Commercial UMR - Harrington (formerly known as Harrington Benefit Services-Columbus) Professional 4010A1 File Level Acknowledgement Yes

Non-Par 75196 Commercial UMR - Harrington (formerly known as Harrington Benefit Services-Westerville) Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 75196 Commercial UMR - Harrington (formerly known as Harrington Benefit Services-Westerville) Professional 4010A1 File Level Acknowledgement Yes

Non-Par 79480 Commercial UMR -- Onalaska Professional 4010A1 Claim Level Accept/Reject

Non-Par 74223 Commercial UMR - San Antonio (Formerly Benefit Planners, Inc) Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 74223 Commercial UMR - San Antonio (Formerly Benefit Planners, Inc.) Institutional 4010A1 No Response From Payer Yes

Non-Par 74223 Commercial UMR - San Antonio (Formerly benefit Planners, Inc.) Professional 4010A1 Claim Level Accept/Reject Yes

9/20/11 Non-Par 39026 Commercial UMR - Wausau/UHIS (Fiserv Health - Wausau Benefits/Benesight) Institutional 4010A1 No Response From Payer Yes

9/20/11 Non-Par 39026 Commercial UMR - Wausau/UHIS (Formaerly FIserv Health - Wausa Benefits/Benesight) Professional 4010A1 Claim Level Acknowledgement Yes

9/20/11 Non-Par 39026 Commercial UMR - Wausau/UHIS (formerly Fiserv Heath - Wausau Benefits/Benesight) Remittance 4010A1 Enrollment

Par UMRC1 Commercial UMR/Cincinnati (Repricing for HealthSpan Network Only) Professional 4010A1 Claim Level Accept/Reject

Par UMRC1 Commercial UMR/Cincinnati (Repricing for HealthSpan Network Only) Institutional 4010A1 Claim Level Accept/Reject

Non-Par 52180 Commercial UMWA Health & Retirement Funds Institutional 4010A1 No Response From Payer Yes

Non-Par 52180 Commercial UMWA Health & Retirement Funds Professional 4010A1 No Response From Payer Yes

Non-Par WK022 Commercial TX Underwriters Safety and Claim Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK022 Commercial TX Underwriters Safety and Claim Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 80314 Commercial UNICARE Institutional 4010A1 Enrollment No Response From Payer Yes

Par 80314 Commercial UNICARE Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 80314 Commercial UNICARE Remittance 4010A1 Enrollment

Par 65099 Commercial UNICARE (Old John Hancock) Professional 4010A1 Claim Level Accept/Reject

Par 47195 Commercial Unicare of Texas - HMO Professional 4010A1 Claim Level Acknowledgement

Non-Par 35198 Commercial Unified Group Services Professional 4010A1 Claim Level Acknowledgement

Non-Par 62170 Commercial Unified Health Services Institutional 4010A1 No Response From Payer

Non-Par 62170 Commercial Unified Health Services (Workman's Comp Only) Professional 4010A1 No Response From Payer

For claims rejections, please contact Unified Physicians Claims Department at

Non-Par 34638 Commercial Unified Physicians Network Professional 4010A1 Enrollment No Response From Payer 847-763-1700

Non-Par 75243 Commercial Uniform Medical Plan/ Harrington Benefit Services Professional 4010A1 No Response From Payer Yes

Non-Par 75243 Commercial Uniform Medical Plan/Harrington Benefit Services Institutional 4010A1 No Response From Payer Yes

Non-Par 13407 Commercial Uniformed Services Family Health Plan Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB158 Commercial Unimed - AmCOMP Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB158 Commercial Unimed - AmCOMP Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB184 Commercial Unimed - AmCOMP (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB184 Commercial Unimed - AmCOMP (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB184 Commercial Unimed - AmCOMP (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB157 Commercial Unimed - America First Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB157 Commercial Unimed - America First Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB159 Commercial Unimed - City of Carrollton/TriStar Prof. Work Comp 4010A1 Claim Level Accept/Reject







11/10/2011 60 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Non-Par WB159 Commercial Unimed - City of Carrollton/TriStar Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB160 Commercial Unimed - International Solutions Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB160 Commercial Unimed - International Solutions Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB223 Commercial Unimed Direct, Inc. (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB223 Commercial Unimed Direct, Inc. (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB223 Commercial Unimed Direct, Inc. (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC141 Commercial TX, MN Union Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC141 Commercial TX, MN Union Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK149 Commercial TX, MN Union Insurance Company of Providence Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK149 Commercial TX, MN Union Insurance Company of Providence Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK149 Commercial TX, MN Union Insurance Company of Providence Auto 4010A1 Claim Level Accept/Reject

Non-Par 87042 Commercial Union Pacific Railroad Employees Health Institutional 4010A1 No Response From Payer

Non-Par 87042 Commercial Union Pacific Railroad Employees Health System Professional 4010A1 Claim Level Accept/Reject

U:10/27/2011 Non-Par 70408 Commercial Union Security Insurance Co. Institutional 5010A2 No Response From Payer

Non-Par 70408 Commercial Union Security Insurance Co. Remittance 4010A1 Enrollment Claim Level Accept/Reject

Non-Par 70408 Commercial Union Security Insurance Company - (Formerly Fortis Benefits Insurance Company) Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC155 Commercial TX, MN Union Standard Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WC155 Commercial TX, MN Union Standard Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 25175 Commercial PA Unison Health Plan Remittance 4010A1 Enrollment

Trans 25175 Commercial Unison Health Plan Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par 25175 Commercial Unison Health Plan/Three Rivers Health Plans, Inc. Institutional 4010A1 No Response From Payer

A: 04/06/2010 Non-Par WZ957 Commercial TX, MN Unisource Worldwide Inc Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ957 Commercial TX, MN Unisource Worldwide Inc Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ957 Commercial TX, MN Unisource Worldwide Inc Auto 4010A1 Claim Level Accept/Reject

Non-Par IP126 Commercial CA United Agriculture Benefit Trust Professional 4010A1 No Response From Payer

If you are currently receiving ERA with another clearinghouse you will need to

Non-Par UFNEP Commercial NE United Americhoice of Nebraska Remittance 4010A1 Enrollment contact the payer to verify change of ERA Enrollment to Emdeon

Trans 87726 Commercial United Behavioral Health (UBH) (ERA's are not available for UBH) Professional 4010A1 Claim Level Accept/Reject Yes

Trans 16412 Commercial United Behavioral Health Employer Division Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ962 Commercial United Components, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ962 Commercial United Components, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ962 Commercial United Components, Inc. Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK150 Commercial TX, MN United Dominion Realty Trust Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK150 Commercial TX, MN United Dominion Realty Trust Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK150 Commercial TX, MN United Dominion Realty Trust Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ997 Commercial United Fire Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ997 Commercial United Fire Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WZ997 Commercial United Fire Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA001 Commercial United Fire & Auto Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA001 Commercial United Fire & Auto Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA001 Commercial United Fire & Auto Auto 4010A1 Claim Level Accept/Reject

Non-Par 36659 Commercial UNITED FOOD & COMM. WORKERS MIDWEST UNIONS & EMPLOYERS HEALTH BENEFITS FUND Professional 4010A1 File Level Acknowledgement

Non-Par 87726 Commercial United Healthcare Remittance 4010A1 Enrollment

Trans 87726 Commercial United HealthCare Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial Professional 4010A1 Claim Level Accept/Reject

United HealthCare (formerly MetraHealth Care Plans, Met Life, Metropolitan Life Ins Co, MetraHealth Elect, MetraHealth Healthcare Network HMO) (no vision claims) Yes

Trans 87726 Commercial Professional 4010A1 Claim Level

United HealthCare (formerly MetraHealth Healthcare Network PPO, New York State Employees (Empire), Travelers Ins Co, Travelers Plan Administrators) (no vision claims) Accept/Reject Yes

Trans 87726 Commercial United HealthCare (formerly The Travelers, Travelers Health Network) Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial AL United HealthCare of Alabama Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial AZ United HealthCare of Arizona, Inc. Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial AR United HealthCare of Arkansas Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial CA United HealthCare of California - Northern Calif. Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial CA United HealthCare of California - Southern Calif. Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial CO United HealthCare of Colorado, Inc. Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial FL United HealthCare of Florida Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial GA United HealthCare of Georgia Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial IL United HealthCare of Illinois Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial KY United HealthCare of Kentucky, Ltd. Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial MS United HealthCare of Mississippi Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial United HealthCare of New England Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial NY United HealthCare of New York (includes New York and New Jersey) Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial NC United HealthCare of North Carolina, Inc. Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial OH United HealthCare of Ohio Professional 4010A1 Claim Level Accept/Reject Yes

U: 12/07/2010 Non-Par 95378 Commercial United Healthcare of River Valley Remittance 4010A1 Enrollment

U: 12/07/2010 Trans 95378 Commercial United Healthcare of River Valley Institutional 4010A1 Claim Level Accept/Reject

U: 12/07/2010 Trans 95378 Commercial United Healthcare of River Valley Professional 4010A1 Claim Level Accept/Reject

Trans 87726 Commercial TX United HealthCare of Texas -Dallas Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial TX United HealthCare of Texas- Houston Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 04567 Commercial United Healthcare of the Mid-Atlantic, Inc. (ERA Only) Remittance 4010A1 Enrollment

Trans 87726 Commercial United HealthCare of the Mid-Atlantic Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial United HealthCare of the Midlands - HMO (Choice Select) Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial United HealthCare of the Midlands - PPO (Choice Plus, Select Plus, Self Funded) Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial United HealthCare of the Midwest - Choice, Choice Plus, Select, Select Plus Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial United HealthCare of the Midwest - Medicare Complete Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial NY United HealthCare of Upstate New York Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial UT United HealthCare of Utah Professional 4010A1 Claim Level Accept/Reject Yes

Trans 87726 Commercial VA United HealthCare of Virginia Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 36273 Commercial United Healthcare Ovations Insurance Solutions (AARP) Institutional 4010A1 Claim Level Rejects Only Yes

Trans 87726 Commercial United HealthCare Plans of Puerto Rico Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 84132 Commercial United Medical Alliance Institutional 4010A1 No Response From Payer

Trans 31107 Commercial United Medical Resources Institutional 4010A1 No Response From Payer

Trans 31107 Commercial United Medical Resources Professional 4010A1 Claim Level Accept/Reject

Non-Par 31107 Commercial United Medical Resources Remittance 4010A1 Enrollment

Par 71412 Commercial United of Omaha Institutional 4010A1 Claim Level Accept/Reject No

Par 71412 Commercial United of Omaha Professional 4010A1 Claim Level Acknowledgement No

Non-Par 84132 Commercial United Physicians of Northern Colorado (UPNC) Professional 4010A1 Claim Level Acknowledgement

Non-Par 41194 Commercial United Resource Network Professional 4010A1 Claim Level Accept/Reject Yes







11/10/2011 61 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Trans WK151 Commercial TX, MN United States Cold Storage Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK151 Commercial TX, MN United States Cold Storage Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK151 Commercial TX, MN United States Cold Storage Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP582 Commercial TX, MN United States Fire Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP582 Commercial TX, MN United States Fire Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX956 Commercial United Wisconsin Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX956 Commercial United Wisconsin Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX956 Commercial United Wisconsin Insurance Company Auto 4010A1 Claim Level Accept/Reject

Trans 87726 Commercial UnitedHealthcare Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par WK015 Commercial Unitrin Business Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK015 Commercial Unitrin Business Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA061 Commercial MN Unitrin Direct Property & Casualty Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA061 Commercial MN Unitrin Direct Property & Casualty Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA061 Commercial MN Unitrin Direct Property & Casualty Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 66705 Commercial Unity Health Insurance Professional 4010A1 File Level Acknowledgement

Trans AMS01 Commercial Unity/Precision Health Plans Professional 4010A1 No Response From Payer

Non-Par HC001 Commercial Univera Healthcare Professional 4010A1 Enrollment Claim Level Accept/Reject

Non-Par HC001 Commercial Univera Healthcare - CNY Professional 4010A1 Enrollment Claim Level Acknowledgement

Non-Par UNINW Commercial Univera PPO Professional 4010A1 No Response From Payer

Non-Par 33001 Commercial CA Universal Care - California Institutional 4010A1 No Response From Payer

Non-Par 33001 Commercial CA Universal Care - California Professional 4010A1 Claim Level Acknowledgement

Non-Par 09908 Commercial Universal Family Care - Maricopa Professional 4010A1 Claim Level Rejects Only

A: 04/06/2010 Non-Par WB146 Commercial TX, MN Universal Forest Products Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB146 Commercial TX, MN Universal Forest Products Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 50528 Commercial Universal Health Care, Inc Institutional 4010A1 Claim Level Accept/Reject

Non-Par 50528 Commercial Universal Health Care, Inc Professional 4010A1 Claim Level Accept/Reject

Non-Par 50528 Commercial MU Universal Health Care, Inc. Remittance 4010A1 Enrollment

A: 04/06/2010 Non-Par WA005 Commercial TX Universal Health Services Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA005 Commercial TX Universal Health Services Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 12/21/2010 Non-Par 09908 Commercial University Institutional 4010A1 No Response From Payer

Non-Par 09830 Commercial University Family Care Professional 4010A1 Claim Level Acknowledgement

A: 12/21/2010 Non-Par 09830 Commercial University Family Care Institutional 4010A1 Claim Level Acknowledgement

Non-Par 09830 Commercial MU University Family Care Remittance 4010A1 Enrollment

Once enrolled with UHA, the payer will forward an e-mail identifying the Payer ID.

Par CALL Commercial HI University Health Alliance Professional 4010A1 Enrollment Claim Level Rejects Only (808)535-5981

Once enrolled with UHA, the payer will forward an e-mail identifying the Payer ID

Non-Par CALL Commercial HI University Health Alliance Remittance 4010A1 Enrollment (808)535-5981

A: 04/06/2010 Non-Par WK472 Commercial TX, MN University Medical Center Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 37601 Commercial University of Illinois at Chicago Div of Specialized Care for Children Professional 4010A1 Claim Level Acknowledgement

Non-Par 37601 Commercial University of Illinois at Chicago Div of Specialized Care for Children Institutional 4010A1 File Level Acknowledgement

All submitters call for detailed information and Payer ID prior to sending claims.

Non-Par CALL Commercial University of Miami Behavioral Health Professional 4010A1 No Response From Payer Contact UMBH Provider Relations (305) 243-7270

A: 04/06/2010 Non-Par WA006 Commercial MN University of Minnesota Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA006 Commercial MN University of Minnesota Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA006 Commercial MN University of Minnesota Auto 4010A1 Claim Level Accept/Reject

Non-Par 25133 Commercial University of Missouri Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par SX155 Commercial UT University of Utah Health Plans Professional 4010A1 Claim Level Accept/Reject

Non-Par 91136 Commercial University of Washington Students & Graduate Appts., Grp# P67 Professional 4010A1 Claim Level Accept/Reject

Non-Par 07503 Commercial University Physicians Healthcare Group Professional 4010A1 Claim Level Accept/Reject

Non-Par ATEND Commercial MU UNIVITA Professional 4010A1 File Level Acknowledgement Prior Authorization Number Required ( 2300: REF01 =G1)

Non-Par 23281 Commercial UPMC Health Plan Remittance 4010A1 Enrollment

U:10/27/2011 Non-Par 23281 Commercial UPMC Health Plan Institutional 5010A2 No Response From Payer

10/17/11 Non-Par 23281 Commercial UPMC Health Plan Professional 5010A1 Claim Level Accept/Reject

U: 01/10/2011 Non-Par 37324 Commercial Upper Peninsula Health Group (TPA) Institutional 4010A1 No Response From Payer

A: 01/10/2011 Non-Par 37324 Commercial Upper Peninsula Health Group (TPA) Professional 4010A1 No Response From Payer

Non-Par 38337 Commercial Upper Peninsula Health Plan Institutional 4010A1 No Response From Payer

Non-Par 38337 Commercial Upper Peninsula Health Plan Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WA008 Commercial Upper Sioux Indian Reservation Tribal Council - Prairie'S Edge Casino Resort Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA008 Commercial Upper Sioux Indian Reservation Tribal Council - Prairie'S Edge Casino Resort Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA008 Commercial Upper Sioux Indian Reservation Tribal Council - Prairie'S Edge Casino Resort Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB180 Commercial US Airways (Philadelphia Hub Based Employees Only) Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 93092 Commercial OR US Benefits Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 93092 Commercial US Benefits Institutional 4010A1 Claim Level Acknowledgement Yes

Please contact the USFHP Provider Relation Department at (713) 683-2018 to

Non-Par USFHP Commercial US Family Health Plan (USFHP) - Texas and Louisiana Professional 4010A1 Claim Level Accept/Reject enroll as an EDI Submitter for professional claims.

A: 04/06/2010 Trans WK152 Commercial TX, MN US Foodservice, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK152 Commercial TX, MN US Foodservice, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK152 Commercial TX, MN US Foodservice, Inc. Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK153 Commercial TX, MN US National Resources (Aigrm) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK153 Commercial TX, MN US National Resources (Aigrm) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK153 Commercial TX, MN US National Resources (Aigrm) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP635 Commercial USAA Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP635 Commercial USAA Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP635 Commercial USAA Auto 4010A1 Claim Level Accept/Reject

Non-Par 74095 Commercial USAA (United States Automobile Association) Institutional 4010A1 No Response From Payer

Non-Par 74095 Commercial USAA (United States Automobile Association) Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WB192 Commercial USC - CBS Companies (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB192 Commercial USC - CBS Companies (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB192 Commercial USC - CBS Companies (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB194 Commercial USC - CompServices, Inc. (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB194 Commercial USC - CompServices, Inc. (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB199 Commercial USC - Employers Insurance (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB199 Commercial USC - Employers Insurance (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB199 Commercial USC - Employers Insurance (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB200 Commercial USC - FCCI (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB200 Commercial USC - FCCI (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB200 Commercial USC - FCCI (LIMITED) Auto 4010A1 Claim Level Accept/Reject







11/10/2011 62 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Non-Par WB203 Commercial USC - Guarantee Insurance (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB203 Commercial USC - Guarantee Insurance (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB203 Commercial USC - Guarantee Insurance (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB205 Commercial USC - Insurance Company of the West (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB205 Commercial USC - Insurance Company of the West (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB206 Commercial USC - InterCare (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB206 Commercial USC - InterCare (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB211 Commercial USC - Ohio Casualty Group - Fairfield (specialty) (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB211 Commercial USC - Ohio Casualty Group - Fairfield (specialty) (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB211 Commercial USC - Ohio Casualty Group - Fairfield (specialty) (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB217 Commercial USC - St. Tammy Parish School Board (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB217 Commercial USC - St. Tammy Parish School Board (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB221 Commercial USC - Tristar (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB221 Commercial USC - Tristar (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB221 Commercial USC - Tristar (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB222 Commercial USC - UPS - only Physical Therapy Bills (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB222 Commercial USC - UPS - only Physical Therapy Bills (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB201 Commercial USC Firstier Administrators (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB201 Commercial USC Firstier Administrators (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB201 Commercial USC Firstier Administrators (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB183 Commercial USC-Accent (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB183 Commercial USC-Accent (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB183 Commercial USC-Accent (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB185 Commercial USC-Amerihealth Insurance Co. (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB185 Commercial USC-Amerihealth Insurance Co. (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB186 Commercial USC-Attenta (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB186 Commercial USC-Attenta (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB186 Commercial USC-Attenta (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB187 Commercial USC-Babb Absence Management Services (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB187 Commercial USC-Babb Absence Management Services (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB187 Commercial USC-Babb Absence Management Services (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB190 Commercial USC-Cambridge - Genex (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB190 Commercial USC-Cambridge - Genex (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB190 Commercial USC-Cambridge - Genex (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB191 Commercial USC-Cambridge Integrated Services (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB191 Commercial USC-Cambridge Integrated Services (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB193 Commercial USC-Chesterfield Services (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB193 Commercial USC-Chesterfield Services (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB193 Commercial USC-Chesterfield Services (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB195 Commercial USC-Crawford and Company (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB195 Commercial USC-Crawford and Company (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB195 Commercial USC-Crawford and Company (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB196 Commercial USC-Cunningham Lindsey (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB196 Commercial USC-Cunningham Lindsey (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB196 Commercial USC-Cunningham Lindsey (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB197 Commercial USC-Dallas National Insurance (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB197 Commercial USC-Dallas National Insurance (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB197 Commercial USC-Dallas National Insurance (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB198 Commercial USC-Eastern Alliance Insurance Group (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB198 Commercial USC-Eastern Alliance Insurance Group (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB202 Commercial USC-Furmanite (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB202 Commercial USC-Furmanite (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB202 Commercial USC-Furmanite (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB204 Commercial USC-Harbor America (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB204 Commercial USC-Harbor America (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB204 Commercial USC-Harbor America (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB207 Commercial USC-InServco (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB207 Commercial USC-InServco (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB208 Commercial USC-Kemper Insurance Company (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB208 Commercial USC-Kemper Insurance Company (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB208 Commercial USC-Kemper Insurance Company (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB209 Commercial USC-Odyssey One Source (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB209 Commercial USC-Odyssey One Source (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB209 Commercial USC-Odyssey One Source (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB210 Commercial USC-Ohio Casualty Group - Cincinnati (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB210 Commercial USC-Ohio Casualty Group - Cincinnati (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB210 Commercial USC-Ohio Casualty Group - Cincinnati (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB212 Commercial USC-Ohio Casualty Group - Lombard (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB212 Commercial USC-Ohio Casualty Group - Lombard (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB212 Commercial USC-Ohio Casualty Group - Lombard (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB213 Commercial USC-Ohio Casualty Group - Raleigh (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB213 Commercial USC-Ohio Casualty Group - Raleigh (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB213 Commercial USC-Ohio Casualty Group - Raleigh (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB214 Commercial USC-Ohio Casualty Group - Voorhees (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB214 Commercial USC-Ohio Casualty Group - Voorhees (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB214 Commercial USC-Ohio Casualty Group - Voorhees (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB215 Commercial USC-Penn National (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB215 Commercial USC-Penn National (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB216 Commercial USC-Rising Medical (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB216 Commercial USC-Rising Medical (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB216 Commercial USC-Rising Medical (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB218 Commercial USC-Secura Insurance-Appleton (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB218 Commercial USC-Secura Insurance-Appleton (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB218 Commercial USC-Secura Insurance-Appleton (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB219 Commercial USC-Staff Force (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB219 Commercial USC-Staff Force (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject







11/10/2011 63 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Non-Par WB219 Commercial USC-Staff Force (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB220 Commercial USC-TNT Staffing (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB220 Commercial USC-TNT Staffing (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB220 Commercial USC-TNT Staffing (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB224 Commercial USC-Valleon (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB224 Commercial USC-Valleon (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB224 Commercial USC-Valleon (LIMITED) Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB225 Commercial USC-Wal Mart (LIMITED) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB225 Commercial USC-Wal Mart (LIMITED) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB225 Commercial USC-Wal Mart (LIMITED) Auto 4010A1 Claim Level Accept/Reject

Non-Par 13407 Commercial NY USFHP - St. Vincent Catholic Medical Centers of New York Institutional 4010A1 No Response From Payer

Non-Par WK044 Commercial NY Utica Mutual Insurance Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK044 Commercial NY Utica Mutual Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK045 Commercial TX Utica National Insurance Co of Texas Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK045 Commercial TX Utica National Insurance Co of Texas Prof. Work Comp 4010A1 Claim Level Accept/Reject

U: 12/30/2010 Non-Par 12115 Commercial VA Fee Basis Program Remittance 4010A1 Enrollment

Non-Par 12115 Commercial VA Fee Basis Program Institutional 4010A1 No Response From Payer Yes

Non-Par 12115 Commercial VA Fee Basis Programs Professional 4010A1 Claim Level Acknowledgement Yes

Non-Par VPN01 Commercial VA Premier Health Plan Inc. Professional 4010A1 Enrollment No Response From Payer

Non-Par 94999 Commercial Valley Baptist Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par VCIPA Commercial Valley Care IPA Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK429 Commercial TX, MN Valley Forge Insurance Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par VHP99 Commercial Valley Health Plan Professional 4010A1 No Response From Payer

Non-Par SX173 Commercial Value Options Commercial Professional 4010A1 Enrollment Claim Level Accept/Reject Yes

Non-Par 12X56 Commercial Value Options Institutional Institutional 4010A1 Claim Level Accept/Reject

Non-Par WK019 Commercial Vanliners Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK019 Commercial Vanliners Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 72128 Commercial Vantage Health Plan Inc. Institutional 4010A1 Claim Level Accept/Reject

Non-Par 72128 Commercial Vantage Health Plan, Inc. Professional 4010A1 No Response From Payer

Non-Par PPM01 Commercial Vantage Medical Group - Claims Only Professional 4010A1 Claim Level Accept/Reject

Trans PPM02 Commercial CA Vantage Medical Group - Encounters Only Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP676 Commercial Varsity Contractors Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP676 Commercial Varsity Contractors Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WP676 Commercial Varsity Contractors Auto 4010A1 Claim Level Accept/Reject

U:09/30/2011 Non-Par 73288 Commercial VENCOR Professional 4010A1 and 5010A1 Claim Level Rejects Only

Non-Par 86062 Commercial VentureNet Healthcare Institutional 4010A1 Claim Level Accept/Reject

U: 12/28/2010 Par VHMG1 Commercial Verdugo Hills Medical Group Professional 4010A1 Claim Level Accept/Reject No Payer Response, please contact payer directly at 818-707-9603

Non-Par 75256 Commercial Verity National Group Institutional 4010A1 File Level Acknowledgement Yes

Non-Par 75256 Commercial Verity National Group Professional 4010A1 File Level Acknowledgement Yes

A: 04/06/2010 Non-Par WA013 Commercial TX, MN Verizon Wireless Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA013 Commercial TX, MN Verizon Wireless Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA013 Commercial TX, MN Verizon Wireless Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ307 Commercial TX, MN Vermeer Mfg. Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ307 Commercial TX, MN Vermeer Mfg. Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ307 Commercial TX, MN Vermeer Mfg. Company Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA014 Commercial MN Verso Paper Holdings LLC Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA014 Commercial MN Verso Paper Holdings LLC Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA014 Commercial MN Verso Paper Holdings LLC Auto 4010A1 Claim Level Accept/Reject

Par 00243 Commercial Vestica Healthcare LLC Professional 4010A1 Claim Level Accept/Reject

Non-Par 23173 Commercial VHP Community Care Institutional 4010A1 No Response From Payer

Non-Par 23173 Commercial VHP Community Care Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Trans WZ278 Commercial MN Viad Corp Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ278 Commercial MN Viad Corp Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK154 Commercial TX, MN Vicorp Restaurants, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK154 Commercial TX, MN Vicorp Restaurants, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK154 Commercial TX, MN Vicorp Restaurants, Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 24818 Commercial Vida Care Institutional 4010A1 No Response From Payer

Non-Par 24818 Commercial Vida Care Professional 4010A1 Claim Level Accept/Reject

Non-Par 73743 Commercial Village Family Practice Institutional 4010A1 File Level Acknowledgement

Non-Par 73743 Commercial Village Family Practice Professional 4010A1 File Level Acknowledgement

Non-Par 12M86 Commercial Virginia Premier Gold Institutional 4010A1 File Level Acknowledgement

Non-Par SX198 Government Virginia Premier Gold Professional 4010A1 File Level Acknowledgement

Non-Par 54176 Commercial Virginia Premier Health Plan Professional 4010A1 Enrollment File Level Acknowledgement

Non-Par 54176 Commercial Virginia Premier Health Plan Remittance 4010A1 Enrollment

Non-Par 12K83 Commercial Virginia Premier Health Plan Institutional 4010A1 Enrollment Claim Level Accept/Reject

A: 04/06/2010 Trans WZ067 Commercial Virginia Surety Company, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ067 Commercial Virginia Surety Company, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ067 Commercial Virginia Surety Company, Inc. Auto 4010A1 Claim Level Accept/Reject

Non-Par 37297 Commercial Vision Care Incorporated Professional 4010A1 No Response From Payer

Non-Par 63114 Commercial Viva Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 77073 Commercial VNS CHOICE Medicare Institutional 4010A1 File Level Acknowledgement

Non-Par 77073 Commercial VNS CHOICE Medicare Professional 4010A1 File Level Acknowledgement

Non-Par 59266 Commercial Volusia Professional 4010A1 No Response From Payer

Non-Par 59266 Commercial VOLUSIA HEALTH NETWORK Institutional 4010A1 File Level Acknowledgement

A: 04/06/2010 Trans WB024 Commercial Vought Aircraft Industries Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WB024 Commercial Vought Aircraft Industries Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par 22264 Commercial NY Vytra Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 22264 Commercial Vytra Healthcare Institutional 4010A1 No Response From Payer Yes

Non-Par 62111 Commercial TN W.C. Beeler & Company Professional 4010A1 Claim Level Acknowledgement

Non-Par 85256 Commercial Wabash Memorial Hospital Association Institutional 4010A1 File Level Acknowledgement

Non-Par 85256 Commercial Wabash Memorial Hospital Association Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WA021 Commercial Walgreen Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA021 Commercial Walgreen Co Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA021 Commercial Walgreen Co Auto 4010A1 Claim Level Accept/Reject

Non-Par 73155 Commercial Waterstone Benefit Administrators Institutional 4010A1 File Level Acknowledgement

Non-Par 73155 Commercial Waterstone Benefits Administrators Professional 4010A1 Claim Level Accept/Reject







11/10/2011 64 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



Non-Par MPM09 Commercial Watts Healthcare Corp Professional 4010A1 File Level Acknowledgement

A: 04/06/2010 Non-Par WA023 Commercial TX, MN Wausau Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB181 Commercial Wausau Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA023 Commercial TX, MN Wausau Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA023 Commercial TX, MN Wausau Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ637 Commercial Wausau Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ637 Commercial Wausau Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ637 Commercial Wausau Insurance Auto 4010A1 Claim Level Accept/Reject

Non-Par 39151 Commercial Wea Insurance Group Institutional 4010A1 No Response From Payer

Non-Par 39151 Commercial Wea Insurance Group Professional 4010A1 Claim Level Acknowledgement

10/17/11 Non-Par 75261 Commercial TX Web TPA Professional 5010A1 File Level Acknowledgement Yes

U:10/27/2011 Non-Par 75261 Commercial webTPA/Community Health Electronic Claims/CHEC Institutional 5010A2 No Response From Payer

Non-Par 36337 Commercial Weiss Health Providers Institutional 4010A1 File Level Acknowledgement

Non-Par 36337 Commercial Weiss Health Providers Professional 4010A1 Claim Level Accept/Reject

Non-Par 59354 Commercial Wellcare Health Plans - Encounters Professional 4010A1 Claim Level Accept/Reject

Non-Par 14163 Commercial Wellcare HMO, Inc. Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 14163 Commercial Wellcare HMO, Inc. Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 14163 Commercial GA Wellcare HMO/GA Medicaid Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 14164 Commercial CT Wellcare of Connecticut, Inc. Institutional 4010A1 Claim Level Accept/Reject Yes

U: 09/15/2011 Non-Par 14164 Commercial CT Wellcare of Connecticut, Inc. Professional 4010A1 Claim Level Accept/Reject Yes

Non-Par 14163 Commercial GA Wellcare of Georgia Institutional 4010A1 Claim Level Accept/Reject Yes

9/27/11 Non-Par 14163 Commercial WellCare of Kentucky Professional 4010A1 Claim Level Accept/Reject

Non-Par 14163 Commercial LA Wellcare of Louisiana Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 14163 Commercial NY Wellcare of New York, Inc. Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 14163 Commercial NY Wellcare of New York, Inc. Professional 4010A1 Claim Level Accept/Reject Yes

U: 12/30/2010 Non-Par 77072 Commercial Wellcare PFFS Professional 4010A1 Claim Level Accept/Reject

Non-Par 77072 Commercial Wellcare Private Fee for Service Plans Institutional 4010A1 File Level Acknowledgement

Non-Par WELM2 Commercial Wellmed Professional 4010A1 Claim Level Accept/Reject

Non-Par 25133 Commercial WellPathCoventry Health Care (Formerly WellPath 25129) Remittance 4010A1 Enrollment

U: 12/30/2010 Non-Par 12B15 Commercial MO Wellpoint Missouri Institutional 4010A1 No Response From Payer

U: 12/30/2010 Non-Par 12B65 Commercial MO Wellpoint Missouri Institutional 4010A1 No Response From Payer

Par 87815 Commercial Wells Fargo TPA Professional 4010A1 No Response From Payer Yes

Par 87815 Commercial Wells Fargo TPA Institutional 4010A1 No Response From Payer Yes

Non-Par 22925 Commercial WELS Benefit Plan Office Institutional 4010A1 No Response From Payer

Non-Par 22925 Commercial WELS Benefit Plan Office Professional 4010A1 Claim Level Accept/Reject

Non-Par 91064 Commercial Wenatchee Valley Medical Center Professional 4010A1 File Level Acknowledgement

Non-Par 91064 Commercial Wenatchee Valley Medical Center Institutional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WA025 Commercial TX, MN Werner Enterprises Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA025 Commercial TX, MN Werner Enterprises Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA026 Commercial TX, MN Wesco Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA026 Commercial TX, MN Wesco Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA026 Commercial TX, MN Wesco Insurance Company Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ081 Commercial West Bend Mutual Insurance Co. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ081 Commercial West Bend Mutual Insurance Co. Inst. Work Comp 4010A1 Claim Level Accept/Reject

Responses could take up to 30-45 business days.

Please contact the payer for further claim inquiry

U: 12/28/2010 Par WCMG1 Commercial West Covina Medical Group Professional 4010A1 Claim Level Accept/Reject @ (818) 707-9603, ext. 6014

Non-Par 93128 Commercial Western Benefits (Western Grocers) Professional 4010A1 Claim Level Accept/Reject

Non-Par 24735 Commercial Western Growers Institutional 4010A1 No Response From Payer

Non-Par 24735 Commercial Western Growers Assurance Trust Institutional 4010A1 No Response From Payer

Par 24735 Commercial Western Growers Assurance Trust Professional 4010A1 No Response From Payer

Par 24735 Commercial Western Growers Insurance Company Professional 4010A1 No Response From Payer

Non-Par 68039 Commercial Western Health Advantage Professional 4010A1 File Level Acknowledgement

Non-Par 68039 Commercial Western Health Advantage Institutional 4010A1 Claim Level Accept/Reject

Non-Par 37247 Commercial Western Mutual Insurance / WMI-TPA (located in Murray, UT) Professional 4010A1 No Response From Payer

Non-Par 37247 Commercial Western Mutual Insurance WMI-TPA Institutional 4010A1 No Response From Payer

Non-Par 31048 Commercial Western Southern Financial Group Institutional 4010A1 No Response From Payer

Non-Par 31048 Commercial Western Southern Financial Group Professional 4010A1 Claim Level Acknowledgement

Non-Par 90560 Commercial WestLake Financial Group Inc. Institutional 4010A1 File Level Acknowledgement

Non-Par 90560 Commercial WestLake Financial Group Inc. Professional 4010A1 File Level Acknowledgement

Non-Par 38232 Commercial Weyco Inc. Institutional 4010A1 No Response From Payer

Non-Par 38232 Commercial Weyco, Inc. Professional 4010A1 Claim Level Acknowledgement

A: 04/06/2010 Non-Par WK473 Commercial TX, MN Weyerhaeuser Co Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA029 Commercial MN White Earth Rtc-Shooting Star Casino Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA029 Commercial MN White Earth Rtc-Shooting Star Casino Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA029 Commercial MN White Earth Rtc-Shooting Star Casino Auto 4010A1 Claim Level Accept/Reject

Non-Par WCMAP Commercial Wilco Care Indigent / Williamson Professional 4010A1 Claim Level Accept/Reject

Non-Par 93050 Commercial William C Earhart Co., Inc. Professional 4010A1 No Response From Payer Yes

Non-Par 93050 Commercial William C. Earhart Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par 98010 Commercial William J Sutton & Co. Ltd Professional 4010A1 Claim Level Acknowledgement

Non-Par 98010 Commercial William J Sutton & Co. Ltd (Toronto) Institutional 4010A1 No Response From Payer

Non-Par 98010 Commercial William J. Sutton & Company, LTD. (Toronto, Canada) Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB135 Commercial Williams & Sonoma Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WB135 Commercial Williams & Sonoma Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ309 Commercial Wilson Mutual Insurance Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ309 Commercial Wilson Mutual Insurance Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ309 Commercial Wilson Mutual Insurance Auto 4010A1 Claim Level Accept/Reject

A: 01/10/2011 Non-Par 41095 Commercial Wilson-McShane Professional 4010A1 No Response From Payer

A: 12/21/2010 Non-Par 41095 Commercial Wilson-McShane Institutional 4010A1 No Response From Payer

Non-Par 62153 Commercial Windsor Medicare Extra Institutional 4010A1 No Response From Payer

Non-Par 62153 Commercial Windsor Medicare Extra Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA030 Commercial TX Winn-Dixie Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA030 Commercial TX Winn-Dixie Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA030 Commercial TX Winn-Dixie Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA031 Commercial MN Winona Health Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA031 Commercial MN Winona Health Inst. Work Comp 4010A1 Claim Level Accept/Reject







11/10/2011 65 of 66

Updated Par/ Non- Payer Comm / ST Payer Name Capario Payer ID

Line of Business EDI Version Table Enrollment / Payer Response Level Payer Accepts Payer Testing Notes/Special Instructions:

Par/ ID Govt / Paper Authorization COB Required

Trans



A: 04/06/2010 Non-Par WA031 Commercial MN Winona Health Auto 4010A1 Claim Level Accept/Reject

Non-Par 73159 Commercial Winterbrook Healthcare Professional 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA033 Commercial Wisconsin Assigned Risk Plan Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA033 Commercial Wisconsin Assigned Risk Plan Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA033 Commercial Wisconsin Assigned Risk Plan Auto 4010A1 Claim Level Accept/Reject

Non-Par 39200 Commercial Wisconsin Auto & Truck Dealers Ins Corp Professional 4010A1 Claim Level Acknowledgement

Non-Par 39200 Commercial Wisconsin Auto and Truck Dealers Professional 4010A1 Claim Level Accept/Reject

Non-Par 39200 Commercial Wisconsin Auto and Truck Dealers Institutional 4010A1 Claim Level Acknowledgement

Non-Par WPS01 Commercial WI Wisconsin Commercial Professional 4010A1 Enrollment Claim Level Rejects Only

Non-Par 74101 Commercial Wisconsin Department of Corrections Institutional 4010A1 Enrollment File Level Acknowledgement Yes

Non-Par 74101 Commercial Wisconsin Department of Corrections Professional 4010A1 Enrollment File Level Acknowledgement Yes

Non-Par 95930 Commercial Wisconsin Physician Services-Midlands Institutional 4010A1 File Level Acknowledgement Yes

A: 01/10/2011 Non-Par 13413 Commercial Women's Integrated Network, Inc. Professional 4010A1 Claim Level Rejects Only

A: 04/06/2010 Trans WP893 Commercial Woodland Farms Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP893 Commercial Woodland Farms Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP893 Commercial Woodland Farms Auto 4010A1 Claim Level Accept/Reject

Non-Par WOA99 Commercial Woodman of the World/ Omaha Woodman Professional 4010A1 No Response From Payer Yes

Non-Par 20333 Commercial Worksite Benefit Services LLC Professional 4010A1 Claim Level Acknowledgement

Non-Par 20333 Commercial Worksite Benefit Services LLC Institutional 4010A1 Claim Level Acknowledgement

Non-Par 75276 Commercial World Insurance Company Institutional 4010A1 No Response From Payer

Non-Par 75276 Commercial World Insurance Company Professional 4010A1 Claim Level Acknowledgement

Non-Par 75276 Commercial World Insurance Company Remittance 4010A1 Enrollment

Non-Par 77080 Commercial WPP Eldercare CLA Professional 4010A1 File Level Acknowledgement

Non-Par 77080 Commercial WPP-ElderCare Wisconsin Institutional 4010A1 File Level Acknowledgement

Non-Par 34080 Commercial WPPN (Multiplan Wisconsin Preferred Provider) Institutional 4010A1 No Response From Payer

Non-Par WPS01 Commercial WI WPS Commercial Professional 4010A1 Enrollment Claim Level Rejects Only

Non-Par 12X29 Commercial WPS Commercial Institutional 4010A1 Claim Level Accept/Reject Yes

Non-Par WPS01 Commercial WPS Commercial Insurance Remittance 4010A1 Enrollment

Non-Par 23710 Commercial Writer's Guild Industry Health Plan Professional 4010A1 Claim Level Accept/Reject

Non-Par 23710 Commercial Writer's Guild Industry Health Plan Institutional 4010A1 No Response From Payer

A: 04/06/2010 Trans WK155 Commercial TX, MN Wyman-Gordon Companies Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK155 Commercial TX, MN Wyman-Gordon Companies Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK155 Commercial TX, MN Wyman-Gordon Companies Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ277 Commercial MN Xchanging - SPX Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WZ277 Commercial MN Xchanging - SPX Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR841 Commercial Xchanging, Inc. (formerly Cambridge Integrated Services Group) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WR841 Commercial Xchanging, Inc. (formerly Cambridge Integrated Services Group) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA034 Commercial Xerox Corporatn Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA034 Commercial Xerox Corporatn Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA034 Commercial Xerox Corporatn Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK156 Commercial TX, MN Xl Environmental, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK156 Commercial TX, MN Xl Environmental, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK156 Commercial TX, MN Xl Environmental, Inc. Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA035 Commercial TX, MN XL Insurance America, Inc. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA035 Commercial TX, MN XL Insurance America, Inc. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA035 Commercial TX, MN XL Insurance America, Inc. Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA036 Commercial XL Specialty Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA036 Commercial XL Specialty Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA036 Commercial XL Specialty Insurance Company Auto 4010A1 Claim Level Accept/Reject

Non-Par 09829 Commercial Yavapai County Professional 4010A1 Enrollment Claim Level Acknowledgement Yes

A: 04/06/2010 Trans WX778 Commercial York Claim Services Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WX778 Commercial York Claim Services Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA037 Commercial Young America Corporation Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA037 Commercial Young America Corporation Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA037 Commercial Young America Corporation Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP921 Commercial Zachry Construction (Comp ONLY) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WP921 Commercial Zachry Construction (Comp ONLY) Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WK475 Commercial TX, MN Zenith Insurance Co (Texas ONLY) Prof. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK046 Commercial Znat Insurance (Zenith National) Inst. Work Comp 4010A1 Claim Level Accept/Reject

Non-Par WK046 Commercial Znat Insurance (Zenith National) Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA039 Commercial TX, MN Zurich American Insurance Company Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA039 Commercial TX, MN Zurich American Insurance Company Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA039 Commercial TX, MN Zurich American Insurance Company Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA040 Commercial TX, MN Zurich American of Illinois Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA040 Commercial TX, MN Zurich American of Illinois Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Non-Par WA040 Commercial TX, MN Zurich American of Illinois Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK184 Commercial TX, MN Zurich Farmers Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK184 Commercial TX, MN Zurich Farmers Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK184 Commercial TX, MN Zurich Farmers Auto 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK185 Commercial TX, MN Zurich Insurance N.A. Prof. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK185 Commercial TX, MN Zurich Insurance N.A. Inst. Work Comp 4010A1 Claim Level Accept/Reject

A: 04/06/2010 Trans WK185 Commercial TX, MN Zurich Insurance N.A. Auto 4010A1 Claim Level Accept/Reject









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