MaineCare 278 EDI 5010 Service Request Companion Guide

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MaineCare 278 EDI 5010 Service Request Companion Guide Powered By Docstoc
					                        State of Maine

         Department of Health & Human Services (DHHS)

                          MaineCare




     Medicaid Management Information Systems
      Maine Integrated Health Management Solution
278 Health Care Services Review – Request Companion Guide
             ASC X12N Version 005010X217
                                            Date of Publication: 09/21/2012
                                            Document Number: UM00076
                                            Version: 3.0
                          MaineCare Integrated Health Information Solutions
                                278 Service Request Companion Guide

Revision History
Version    Date            Author                Action/Summary of Changes              Status
0.1        07/01/2011      Molina                Initial Document                       Draft

0.1        08/01/2011      Susan Savage          Quality Assurance                      Draft

0.2        08/16/2011      Kaleb Osgood          Updated per PAG/TAG Comment Log.       Draft
                                                 Additional grammatical updates and
                                                 Header titles for each Loop
0.2        09/08/2011      Pam Foster            Quality Assurance                      Draft

1.0        10/20/2011      Pam Foster            Received approval from State           Final

1.1        12/14/2011      Pam Foster            Updates to Subject to Change per State Draft
                                                 comments
1.2        01/12/2012      Pam Foster            Formatting change Section 1            Draft

2.0        02/06/2012      Pam Foster            Received approval from State           Final

2.1        06/25/2012      Kaleb Osgood          Added value descriptions to header,    Draft
                                                 Deleted 2010A loop, NM104, NM105
                                                 and NM107 Segments.
2.1        07/09/2012      Pam Foster            Quality Assurance                      Draft

2.2        08/08/2012      K. Osgood and P.      Updates per 7/26/2012 email from J.    Draft
                           Foster                Palow with State comments and
                                                 removed all non-MaineCare specific
                                                 information.
                                                 Quality Assurance
3.0        09/21/2012      Pam Foster            Received approval from State           Final




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                          MaineCare Integrated Health Information Solutions
                                278 Service Request Companion Guide



Usage Information
Documents published herein are furnished “As Is.” There are no expressed or implied warranties.
The content of this document herein is subject to change without notice.
HIPAA Notice
This Maine Health PAS Online portal is for the use of authorized users only. Users of the Maine
Health PAS Online portal may have access to protected and personally identifiable health data.
As such, the Maine Health PAS Online portal and its data are subject to the Privacy and security
Regulations within the Health Insurance Portability and Accountability Act of 1996, Public Law
104-191 (HIPAA).
By accessing the Maine Health PAS Online portal, all users agree to protect the privacy and
security of the data contained within as required by law. Access to information on this site is
only allowed for necessary business reasons, and is restricted to those persons with a valid user
name and password.




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                          MaineCare Integrated Health Information Solutions
                                278 Service Request Companion Guide



Table of Contents
1.    Companion Guide Purpose                                                           1
      1.1   Required Information                                                        1
      1.2   Trading Partner ID                                                          1
      1.3   Delimiters                                                                  2
      1.4   Transmission Constraints                                                    2
2.    278 – Request for Review                                                          3
3.    HIPAA Responses and Acknowledgements                                             17
      3.1   278 Health Care Services Review Response                                   17
      3.2   Retrieving Acknowledgements for X12 Transactions Uploaded via Health PAS
            Online                                                                     17
      3.3   Acknowledgements generated by X12 HIPAA validation                         17
            3.3.1    TA1 Interchange Acknowledgement                                   17
            3.3.2    824 Application Advice                                            19
            3.3.3    Business Rejection Report                                         20
4.    UM03 Service Type PA Crosswalk                                                   22


List of Figures
Figure 2-1: 278 Request for Review                                                      3
Figure 3-1: Older Acknowledgements and Responses via Search Button                     17
Figure 3-2: Interchange Acknowledgement Code                                           18
Figure 3-3: TED segment of the 824 Application Advice                                  20
Figure 3-4: BRR                                                                        21
Figure 4-1: UM03 values                                                                22




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1.       Companion Guide Purpose
The purpose of the MaineCare 278 Health Care Services Request Companion Guide is to provide
trading partners with a guide to communicate information required to successfully exchange
transactions electronically with MaineCare. This Companion Guide document should be used in
conjunction with the Technical Report Type 3s and the national standard code sets referenced in
that Guide. The Companion Guide is intended to clarify MaineCare-specific information while
maintaining compliance with the Technical Report Type 3 Guide.
NOTE: The Companion Guide does not include the complete transaction specification. Refer
to the following HIPAA version 5010 Technical Report Type3s for additional information not
supplied in this document, such as transaction usage, examples, code lists, definitions, and
edits.

        Health Care Services Request for Review and Response ASC X12N 278 (005010X217)
         May 2006

        Health Care Services Request for Review and Response ASC X12N 278
         (005010X217E1) April 2008

        Health Care Services Request for Review and Response ASC X12N 278
         (005010X217E2) January 2009
Copies of the ANSI X12 Implementation Guides can be obtained from the Washington Publishing
Company at http://www.wpc-edi.com.
All required information for populating the X12 EDI transactions can be found by referencing the
MaineCare Companion Guides or the HIPAA Implementation Guides.
For any questions or to begin testing (see Section 1.2), logon to https://mainecare.maine.gov.


1.1      Required Information
All transactions sent for processing are required to be in compliance with the ASC X12N version
5010 Technical Report Type 3s standards. Non-compliant transactions will be rejected during the
HIPAA validation process.
MaineCare will support requests for Health Services Review (Prior Authorizations).
MaineCare will support requests for Specialty Care Review (Referrals).


1.2      Trading Partner ID
A trading partner is defined as any entity with which Molina exchanges electronic data. The term
electronic data is not limited to HIPAA X12 transactions. MaineCare’s Maine Integrated Health
Management Solution (MIHMS) system supports the following categories of trading partner:
      Provider
      Billing Agency
      Clearinghouse
      Internal User


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     Health Plan
Molina will assign trading partner IDs to support the exchange of X12 EDI transactions for
providers, billing agencies and clearinghouses, and other health plans.
All trading partners will be authorized to submit production EDI transactions. Any trading
partner may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange
Control Header (ISA) of any X12 file, indicates if a file is test or production. Authorization is
granted on a per transaction basis. For example, a trading partner may be certified to submit
837P professional claims, but not certified to submit 837I institutional claim files.
Trading partners will submit three test files of a particular transaction type, with a minimum of
fifteen transactions within each file, and have no failures or rejections to become certified for
production. Users will be notified (E-mail) of the Trading Partner Status page of Health PAS
Online portal when testing for a particular transaction has been completed.
To obtain a trading partner ID, visit the website: https://mainecare.maine.gov.


1.3     Delimiters
MaineCare does not require the use of specific values for the delimiters used in electronic
transactions. The suggested values are included in the specifications defined below in Figure 2-1.


1.4     Transmission Constraints
The following constraints apply to all 278 file transmissions to MaineCare:
    1. Only one Interchange per transmission
    2. Only one Functional Group (GS/GE) per interchange
    3. Single transmission file size must be less than 4MB
    4. Transaction limit is 5000 transactions per transmission




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2. 278 – Request for Review
Figure 2-1 should be used as a reference for populating transactions sent to MaineCare. Figure 2-1 contains the specific data values and
descriptions used in processing the transaction.
Column Descriptions:
       Loop – Implementation Guide Loop
       Segment ID – Implementation Guide Segment
       Segment Name / Data Element Name – Implementation Guide segment/element name
       Format – Implementation Guide data format
       Length – MaineCare length. A single number denotes fixed length. Two numbers separated by a slash denotes min/max length.
       DE Ref# – Implementation Guide data element reference number
       Req Des. – MaineCare Requirement designation, R = Required, S = Situational. Note: If the segment is situational then the associated
        elements designated as “R” are only required if the segment is included.
       Value – Data values to be sent for MaineCare transactions. Information contained within “< >” is the description or format of the data that
        should be entered in the field.
Figure 2-1 lists the associated attributes for the 278 Review Request.
Figure 2-1: 278 Request for Review
Loop        Segment       Segment Name/ Data Element            Format    Length     DE Ref #    Req Des.    Value
            ID            Name
Interchange Control Record
HEADER      ISA           Interchange Control Header            AN        3                      R           ISA
                          Element Separator                     AN        1                                  *
            ISA01         Authorization Information Qualifier   ID        2          I01         R           00 = No Authorization Information
                                                                                                             Present




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Loop       Segment      Segment Name/ Data Element       Format   Length   DE Ref #   Req Des.   Value
           ID           Name
                        Element Separator                AN       1                              *
           ISA02        Authorization Information        AN       10       I02        R          <Space fill>
                        Element Separator                AN       1                              *
           ISA03        Security Information Qualifier   ID       2        I03        R          00 = No Security Information
                                                                                                 Present

                        Element Separator                AN       1                              *
           ISA04        Security Information             AN       10       I04        R          <Space fill>
                        Element Separator                AN       1                              *
           ISA05        Interchange ID Qualifier         ID       2        I05        R          ZZ = Mutually Defined
                        Element Separator                AN       1                              *
           ISA06        Interchange Sender ID            AN       15       I06        R          <Molina assigned trading partner
                                                                                                 ID + 3 spaces>
                                                                                                 (e.g. METPID000001 + 3 spaces)
                        Element Separator                AN       1                              *
           ISA07        Interchange ID Qualifier         ID       2        I05        R          ZZ = Mutually Defined
                        Element Separator                AN       1                              *
           ISA08        Interchange Receiver ID          AN       15       I07        R          ME_MMIS_4MOLINA
                        Element Separator                AN       1                              *
           ISA09        Interchange Date                 DT       6        I08        R          <YYMMDD>
                        Element Separator                AN       1                              *
           ISA10        Interchange Time                 TM       4        I09        R          <HHMM>
                        Element Separator                AN       1                              *




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Loop       Segment        Segment Name/ Data Element    Format   Length   DE Ref #   Req Des.   Value
           ID             Name
           ISA11          Repetition Separator                   1        I65        R          ^
                          Element Separator             AN       1                              *
           ISA12          Interchange Control Version   ID       5        I11        R          00501
                          Number
                          Element Separator             AN       1                              *
           ISA13          Interchange Control Number    N0       9        I12        R          <Interchange Control Number>
                                                                                                NOTE: Must be a positive
                                                                                                unsigned number and must be
                                                                                                identical to the value in IEA02.
                          Element Separator             AN       1                              *
           ISA14          Acknowledgment Requested      ID       1        I13        R          0 = No Interchange
                                                                                                Acknowledgement Requested

                                                                                                1 = Interchange Acknowledgement
                                                                                                Requested (TA1)
                          Element Separator             AN       1                              *
           ISA15          Interchange Usage Indicator   ID       1        I14        R          P = Production Data
                                                                                                T = Test Data
                          Element Separator             AN       1                              *
           ISA16          Component Element Separator            1        I15        R          :

                          Segment End                   B        1                              ~
Functional Group Header
HEADER     GS             Functional Group Header       AN       2                   R          GS
                          Element Separator             AN       1                              *




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Loop       Segment       Segment Name/ Data Element     Format   Length   DE Ref #   Req Des.   Value
           ID            Name
           GS01          Functional Identifier Code     ID       2        479        R          HI = Health Care Services Review
                                                                                                Information (278)
                         Element Separator              AN       1                              *
           GS02          Application Sender's Code      AN       2/15     142        R          <Molina Assigned Trading Partner
                                                                                                ID>
                         Element Separator              AN       1                              *
           GS03          Application Receiver's Code    AN       2/15     124        R          ME_MMIS_4MOLINA
                         Element Separator              AN       1                              *
           GS04          Date                           DT       8        373        R          <CCYYMMDD>
                         Element Separator              AN       1                              *
           GS05          Time                           TM       4/8      337        R          <HHMM>
                         Element Separator              AN       1                              *
           GS06          Group Control Number           N0       1/9      28         R          <Assigned by Sender>
                                                                                                NOTE: Must be identical to
                                                                                                associated Functional Group
                                                                                                Trailer GE02.
                         Element Separator              AN       1                              *
           GS07          Responsible Agency Code        ID       1/2      455        R          X = Accredited Standards
                                                                                                Committee X12
                         Element Separator              AN       1                              *
           GS08          Version / Release / Industry   AN       1/12     480        R          005010X217
                         Identifier Code
                         Segment End                    B        1                              ~
Transaction Set Header




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Loop        Segment      Segment Name/ Data Element        Format   Length   DE Ref #   Req Des.   Value
            ID           Name
HEADER      ST           Transaction Set Header            AN       2                   R          ST
                         Element Separator                 AN       1                              *
            ST01         Transaction Set Identifier Code   ID       3        143        R          278 = Health Care Services
                                                                                                   Review Information
                         Element Separator                 AN       1                              *
            ST02         Transaction Set Control Number    AN       4/9      329        R          <Assigned by sender>
                                                                                                   NOTE: Must be identical to
                                                                                                   associated Transaction Set Control
                                                                                                   Number SE02.
                         Element Separator                 AN       1                              *
            ST03         Implementation Convention         AN       1/35     1705       R          005010X217
                         Reference
                         Segment End                       B        1                              ~
Beginning of Hierarchical Transaction
HEADER      BHT          Beginning of Hierarchical         AN       3                   R          BHT
                         Transaction Segment
                         Element Separator                 AN       1                              *
            BHT01        Hierarchical Structure Code       ID       4        1005       R          0007 = Information Source,
                                                                                                   Information Receiver, Subscriber,
                                                                                                   Dependent, Event, Services
                         Element Separator                 AN       1                              *
            BHT02        Transaction Set Purpose Code      ID       2        353        R          01 = Cancellation
                                                                                                   13 = Request
                         Element Separator                 AN       1                              *




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Loop       Segment      Segment Name/ Data Element       Format   Length   DE Ref #   Req Des.   Value
           ID           Name
           BHT03        Reference identification         AN       1/50     127        R          <Submitter Transaction Identifier>
                        Element Separator                AN       1                              *
           BHT04        Date                             DT       8        373        R          <Transaction Set Creation Date>
                                                                                                 <CCYYMMDD>
                        Element Separator                AN       1                              *
           BHT05        Time                             TM       4/8      337        R          <Transaction Set Creation Time>
                                                                                                 <HHMM>
                        Segment End                      B        1                              ~
Utilization Management Organization (UMO) Name (Loop 2010A)
2010A      NM1          Utilization Management           AN       3                   R          NM1
                        Organization (UMO) Name
                        Element Separator                AN       1                              *
           NM101        Entity Identifier Code           ID       2/3      98         R          X3 = UMO
                        Element Separator                AN       1                              *
           NM102        Entity Type Qualifier            ID       1        1065       R          2 = Non-Person Entity
                        Element Separator                AN       1                              *
           NM103        Name Last or Organization Name   AN       1/60     1035       S          <Utilization Management
                                                                                                 Organization Last or Organization
                                                                                                 Name>
                                                                                                 NOTE: e.g. MaineCare
                        Element Separator                AN       1                              *
                        Element Separator                AN       1                              *
                        Element Separator                AN       1                              *




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Loop       Segment      Segment Name/ Data Element       Format   Length   DE Ref #   Req Des.   Value
           ID           Name
                        Element Separator                AN       1                              *
                        Element Separator                AN       1                              *
           NM108        Identification Code Qualifier    ID       1/2      66         R          PI = Payor Identification
                        Element Separator                AN       1                              *
           NM109        Identification Code              AN       2/80     67         R          ME_MMIS_4MOLINA
                        Segment End                      B        1                              ~
Requester Name (Loop 2010B)
2010B      NM1          Requester Name                   AN       3                   R          NM1
                        Element Separator                AN       1                              *
           NM101        Entity Identifier Code           ID       2/3      98         R          1P = Provider
                                                                                                 FA = Facility
                        Element Separator                AN       1                              *
           NM102        Entity Type Qualifier            ID       1        1065       R          1 = Person
                                                                                                 2 = Non Person Entity
                        Element Separator                AN       1                              *
           NM103        Name Last or Organization Name   AN       1/60     1035       S          <Requester Last Name or
                                                                                                 Organization Name>
                        Element Separator                AN       1                              *
           NM104        Name First                       AN       1/35     1036       S          <Requester First Name>
                                                                                                 NOTE: Required if NM102 = 1
                                                                                                 (Person).
                        Element Separator                AN       1                              *
           NM105        Name Middle                      AN       1/25     1037       S          <Requester Middle Name>
                        Element Separator                AN       1                              *



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Loop       Segment      Segment Name/ Data Element           Format   Length   DE Ref #   Req Des.   Value
           ID           Name
                        Element Separator                    AN       1                              *
           NM107        Name Suffix                          AN       1/10     1039       S          <Requester Name Suffix>
                        Element Separator                    AN       1                              *
           NM108        Identification Code Qualifier        ID       1/2      66         R          24 = Employer’s Identification
                                                                                                     Number
                                                                                                     XX = National Provider Identifier
                                                                                                     NOTE: Qualifier 24 is used to
                                                                                                     report the Tax ID of Atypical
                                                                                                     Providers only.
                        Element Separator                    AN       1                              *
           NM109        Identification Code                  AN       2/80     67         R          <Requester Identifier>
                        Segment End                          B        1                              ~
2010B      REF          Requester Supplemental               AN       3                   S          REF
                        Identification
                        Element Separator                    AN       1                              *
           REF01        Reference Identification Qualifier   ID       2/3      128        R          N5 = Provider Plan Network
                                                                                                     Identification Number
                        Element Separator                    AN       1                              *
           REF02        Reference Identification             AN       1/50     127        R          <Requester Supplemental
                                                                                                     Identifier>
                                                                                                     <Atypical Provider ID>
                        Segment End                          B        1                              ~
Subscriber Name (Loop 2010C)
2010C      NM1          Subscriber Name                      AN       3                   R          NM1




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Loop       Segment      Segment Name/ Data Element       Format   Length   DE Ref #   Req Des.   Value
           ID           Name
                        Element Separator                AN       1                              *
           NM101        Entity Identifier Code           ID       2/3      98         R          IL = Insured or Subscriber
                        Element Separator                AN       1                              *
           NM102        Entity Type Qualifier            ID       1        1065       R          1 = Person
                        Element Separator                AN       1                              *
           NM103        Name Last or Organization Name   AN       1/60     1035       S          <Subscriber Last Name>
                        Element Separator                AN       1                              *
           NM104        Name First                       AN       1/35     1036       S          <Subscriber First Name>
                        Element Separator                AN       1                              *
           NM105        Name Middle                      AN       1/25     1037       S          <Subscriber Middle Name or
                                                                                                 Initial>
                        Element Separator                AN       1                              *
           NM106        Name Prefix                      AN       1/10     1038       S          <Subscriber Name Prefix>
                        Element Separator                AN       1                              *
           NM107        Name Suffix                      AN       1/10     1039       S          <Subscriber Name Suffix>
                        Element Separator                AN       1                              *
           NM108        Identification Code Qualifier    ID       1/2      66         R          MI = Member Identification Number
                        Element Separator                AN       1                              *
           NM109        Identification Code              AN       2/80     67         R          <Subscriber Primary Identifier>
                        Segment End                      B        1                              ~
Patient Event Level (Loop 2000E)
2000E      UM           Health Care Services Review      AN       2                   R          UM
                        Information



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Loop       Segment      Segment Name/ Data Element    Format   Length   DE Ref #   Req Des.   Value
           ID           Name
                        Element Separator             AN       1                              *
           UM01         Request Category Code         ID       1/2      1525       R          HS = Health Services Review
                                                                                              SC = Specialty Care Review
                        Element Separator             AN       1                              *
           UM02         Certification Type Code       ID       1        1322       R          I = Initial
                                                                                              3 = Cancel
                        Element Separator             AN       1                              *
           UM03         Service Type Code             ID       1/2      1365       R          For Prior Authorizations see UM03
                                                                                              Service Type PA Crosswalk in this
                                                                                              guide.
                        Element Separator             AN       1                              *
           UM04-1       Facility Code Value           AN       1/2      1331       R          <Facility Type Code>
                        Component Element Separator            1                              :
           UM04-2       Facility Code Qualifier       ID       1/2      1332       R          A = Uniform Billing Claim Form Bill
                                                                                              Type
                                                                                              B = Place of Service Codes for
                                                                                              Professional or Dental Services
                        Element Separator             AN       1                              *
           UM05-1       Related-Causes Code           ID       2/3      1362       R          <Related Causes Code>
                                                                                              AA = Auto Accident
                                                                                              AP = Another Party Responsible
                                                                                              EM = Employment
                                                                                              NOTE: Always use this data
                                                                                              element if the related cause is an
                                                                                              auto accident.




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Loop       Segment      Segment Name/ Data Element    Format   Length   DE Ref #   Req Des.   Value
           ID           Name
                        Component Element Separator            1                              :
           UM05-2       Related-Causes Code           ID       2/3      1362       S          <Related Causes Code>
                                                                                              AP = Another Party Responsible
                                                                                              EM = Employment
                        Component Element Separator            1                              :
           UM05-3       Related-Causes Code           ID       2/3      1362       S          <Related Causes Code>
                                                                                              AP = Another Party Responsible
                                                                                              NOTE: Required when UM05-1
                                                                                              and UM05-2 are not equal to “AP”
                                                                                              and “AP” applied to this patient
                                                                                              event.
                        Component Element Separator            1                              :
           UM05-4       State or Province Code        ID       2        156        S          NOTE: Required on review
                                                                                              requests if UM05-1 = AA, if the
                                                                                              accident occurred out of the
                                                                                              service provider's state.
                        Component Element Separator            1                              :
           UM05-5       Country Code                  ID       2/3      26         S          NOTE: Required if automobile
                                                                                              accident occurred out of the U.S.
                        Element Separator             AN       1                              *




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Loop       Segment      Segment Name/ Data Element      Format   Length   DE Ref #   Req Des.   Value
           ID           Name
           UM06         Level of Service Code           ID       1/3      1338       S          03 = Emergency
                                                                                                E = Elective
                                                                                                U = Urgent
                                                                                                NOTE: Required when UM02 =1 or
                                                                                                if the patient event requires a level
                                                                                                of service for care other than
                                                                                                routine.
                        Element Separator               AN       1                              *
           UM07         Current Health Condition Code   ID       1        1213       S          <Current Health Condition Code>
                        Element Separator               AN       1                              *
           UM08         Prognosis Code                  ID       1        923        S          <Prognosis Code>
                        Element Separator               AN       1                              *
           UM09         Release of Information Code     ID       1        1363       S          <Release of Information Code>
                        Element Separator               AN       1                              *
           UM10         Delay Reason Code               ID       1/2      1514       S          NOTE: Required if the request is
                                                                                                not submitted within the normal
                                                                                                timeframe of the UMO.
                        Segment End                     B        1                              ~
Patient Event Provider Name (Loop 2010EA)
2010EA     NM1          Patient Event Provider Name     AN       3                   R          NM1
                        Element Separator               AN       1                              *
           NM101        Entity Identifier Code          ID       2/3      98         R          <Entity Identifier Code>
                        Element Separator               AN       1                              *




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Loop       Segment      Segment Name/ Data Element       Format   Length   DE Ref #   Req Des.   Value
           ID           Name
           NM102        Entity Type Qualifier            ID       1        1065       R          1 = Person
                                                                                                 2 = Non-Person Entity
                        Element Separator                AN       1                              *
           NM103        Name Last or Organization Name   AN       1/60     1035       S          <Patient Event Provider Last or
                                                                                                 Organization Name>
                        Element Separator                AN       1                              *
           NM104        Name First                       AN       1/35     1036       S          <Patient Event Provider First
                                                                                                 Name>
                        Element Separator                AN       1                              *
           NM105        Name Middle                      AN       1/25     1037       S          <Patient Event Provider Middle
                                                                                                 Name>
                        Element Separator                AN       1                              *
           NM106        Name Prefix                      AN       1/10     1038       S          <Patient Event Provider Name
                                                                                                 Prefix>
                        Element Separator                AN       1                              *
           NM107        Name Suffix                      AN       1/10     1039       S          <Patient Event Provider Name
                                                                                                 Suffix>
                        Element Separator                AN       1                              *
           NM108        Identification Code Qualifier    ID       1/2      66         S          24 = Employer’s Identification
                                                                                                 Number
                                                                                                 XX = National Provider Identifier
                                                                                                 NOTE: Atypical Providers use
                                                                                                 Code Qualifier 24.
                        Element Separator                AN       1                              *




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Loop       Segment      Segment Name/ Data Element           Format   Length   DE Ref #   Req Des.   Value
           ID           Name
           NM109        Identification Code                  AN       2/80     67         S          <Patient Event Provider Identifier>

                        Segment End                          B        1                              ~
2010EA     REF          Reference Information                AN       3                   S          REF
                        Element Separator                    AN       1                              *
           REF01        Reference Identification Qualifier   ID       2/3      128        R          N5 = Provider Plan Network
                                                                                                     Identifier
                        Element Separator                    AN       1                              *
           REF02        Reference Identification             AN       1/50     127        R          <Patient Event Provider
                                                                                                     Supplemental Identifier>
                                                                                                     <Atypical Provider ID>
                        Segment End                          B        1                              ~




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3. HIPAA Responses and Acknowledgements
HIPAA responses and acknowledgements are available for download via Health PAS Online
portal for a period of two years from the original creation date.


3.1     278 Health Care Services Review Response
The 278 Health Care Services Review Response returned will adhere to the HIPAA version 5010
Technical Report Type 3s Guide.. Refer to the Technical Report Type 3s Guide for further
information.


3.2     Retrieving Acknowledgements for X12 Transactions
        Uploaded via Health PAS Online
Acknowledgments and Responses to transactions submitted via Health PAS Online portal can be
accessed by selecting Download / Responses under the File Exchange menu. Acknowledgement
for the most recently submitted transactions are automatically displayed in the list for download.
Each can be viewed separately by clicking on the appropriate hyperlink or all acknowledgements
for a transaction can be downloaded at once by using the Download All button. Older
acknowledgements and responses can be located by using the Search button – see Figure 3-1.




Figure 3-1: Older Acknowledgements and Responses via Search Button


3.3     Acknowledgements Generated by X12 HIPAA Validation

3.3.1     TA1 Interchange Acknowledgement
The TA1 interchange acknowledgement is used to verify the syntactical accuracy of the envelope
of the X12 interchange. The TA1 interchange will indicate that the file was successfully received;
as well as indicate what errors existed within the envelope segments of the received X12 file.
The structure of a TA1 interchange acknowledgement depends on the structure of the envelope of
the original EDI document. When the envelope of the EDI document does not contain an error
then the interchange acknowledgement will contain the ISA, TA1, and IEA segments. The TA1
segment will have an Interchange Acknowledgement Code of ‘A’ (Accepted) followed by a three
digit code of ‘000’ which indicates that there were not any errors.
If the EDI document contains an error at the interchange level, such as in the Interchange Control
Header (ISA) segment or the Interchange Control Trailer (IEA), then the interchange
acknowledgement will also only contain the ISA, TA1, and IEA segments. The TA1 segment will
have an Interchange Acknowledgement Code of ‘R’ (Rejected) which will be followed by a
three-digit number that corresponds to one of the following codes in Figure 3-2:
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Code                                   Description

000                                    No error

001                                    The Interchange Control Number in the Header and Trailer
                                       Do Not Match. The Value From the Header is Used in the
                                       Acknowledgment

002                                    This Standard as Noted in the Control Standards Identifier
                                       is Not Supported

003                                    This Version of the Controls is Not Supported

005                                    Invalid Interchange ID Qualifier for Sender

006                                    Invalid Interchange Sender ID

009                                    Unknown Interchange Receiver ID

010                                    Invalid Authorization Information Qualifier Value (ISA01 is
                                       not ‘00’ or 03’)

012                                    Invalid Security Information Qualifier Value

013                                    Invalid Security Information Value

018                                    Invalid Interchange Control Number Value

019                                    Invalid Acknowledgment Requested Value

020                                    Invalid Test Indicator Value

021                                    Invalid Number of Included Groups Value

023                                    Improper (Premature) End-of-File (Transmission)

024                                    Invalid Interchange Content (e.g., Invalid GS Segment)

025                                    Duplicate Interchange Control Number

Figure 3-2: Interchange Acknowledgement Code
For additional information regarding the TA1 Interchange Acknowledgement,reference the
Acknowledgements Section, of the Technical Report Type 3s Guide.
999 Implementation Acknowledgement for Health Care Insurance the ASC X12 999 transaction
set is designed to report only on conformance against an implementation guideline (TR3). The
999 is not limited to only IG errors. It can report standard syntax errors, as well as IG errors. The
999 can NOT be used for any application level validations. The ASC X12 999 transaction set is
designed to respond to one and only one functional group (e.g. GS/GE), but will respond to all
transaction sets (e.g. ST/SE) within that functional group. This ASC X12 999 Implementation
Acknowledgement can NOT be used to respond to any management transaction sets intended for
acknowledgements, e.g. TS 997 and 999, or interchange control segments related to
acknowledgments, e.g. TA1 and TA3. Each segment in a 999 functional acknowledgement plays
a specific role in the transaction. For example, the AK1 segment starts the acknowledgement of a
functional group. Each AKx segment has a separate set of associated error codes. The 999
functional acknowledgement includes but is not limited to, the following required segments:

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     ST segment—Transaction Set Header
     AK1 - Functional Group Response Header
     AK2 - Transaction Set Response Header
     IK3 – Error Identification
     CTX – Segment Context
     CTX – Business Unit Identifier
     IK4 – Implementation Data Element Note
     CXT – Element Context
     IK5 – Transaction set response trailer
     AK9 - Functional Group Response Trailer
     SE -Transaction Set Trailer.
For additional information regarding the 999 transaction, please see the Implementation
Acknowledgement Section of the ASC X12 Standards for Electronic Data Interchange Technical
Report Type 3 Guide for the transaction you are submitting.

3.3.2      824 Application Advice
This transaction is not mandated by HIPAA, but will be used to report the results of data content
edits of transaction sets. It is designed to report rejections based on business rules such as; invalid
diagnosis codes, invalid procedure codes, and invalid provider numbers. The 824 Application
Advice does not replace the 999 or TA1 transactions and will only be generated by Health PAS if
there are errors within the transaction set.
The 824 acknowledgment is divided into two levels of segments; header and detail.
     The header level contains general information, such as the transaction set control reference
      number of the previously sent transaction, date, time, submitter, and receiver.
     The detail level reports the results of an application system’s data content edits.
      The 824 Application Advice includes but is not limited to following segments and their
      roles:
Header Segments:
       ST segment—Transaction Set Header
       BGN segment—Beginning Segment
       N1 segment—Submitter Name
       N1 segment—Receiver Name

Detail Segments:
    OTI segment—Original Transaction Identification
    TED segment—Error or Informational Message Location
    RED segment—Error or Informational Message
    SE segment—Transaction Set Trailer
The Health PAS Application output the following errors in the TED segment of the 824
Application Advice (Figure 3-3):




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Figure 3-3: TED segment of the 824 Application Advice

Code - TED01            Description - TED02
O                       Missing or Invalid Issuer Identification
P                       Missing or Invalid Item Quantity
Q                       Missing or Invalid Item Identification
U                       Missing or Unauthorized Transaction Type Code
006                     Duplicate
007                     Missing Data
008                     Out of Range
009                     Invalid Date
010                     Total Out of Balance
011                     Not Matching
012                     Invalid Combination
024                     Other Unlisted Reason
027                     Customer Identification Number Does not Exist
815                     Duplicate Batch
848                     Incorrect Data
DTE                     Incorrect Date
DUP                     Duplicate Transaction
ICA                     Invalid Claim Amount
IID                     Invalid Identification Code
NAU                     Not Authorized
UCN                     Unknown Claim Number


3.3.3     Business Rejection Report
Health PAS also produces a Human Readable version of the 824 called the Business Rejection
Report (BRR). This report helps to facilitate the immediate correction and resubmission of
transactions rejected during HIPAA validation - see Figure 3-4 below:




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Figure 3-4: BRR




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4. UM03 Service Type PA Crosswalk
The cross reference list provided below is to be used to denote which UM03 value to choose
when submitting a 278 Prior Authorization request. The authorization types listed below require
a prior review of services under the Policy Sections of MaineCare. When submitting a Prior
Authorization request for the types listed below please use the corresponding UM03 value in the
278 transaction. The UM03 values listed in Figure 4-1 below correlate to the MaineCare
authorization types and will allow for the proper processing of the request. Note that the Prior
Authorization types and their requirements can be found on the secure portion of the online
portal.
Prior Authorization Type                        UM03 value

Abortion                                        84

Dental Services                                 23

Dentures                                        39

DME / Supplies                                  12
DME Urgent

EPSDT- OTS Services                             1

EPSDT- OTS-DME                                  73

Hearing Aids                                    71

Home Health                                     42

In-State Podiatric Related Services             93

In-State Transportation                         56

Medical Eye Care Program                        77

Orthodontia                                     38

Orthotic/Prosthetic Devices- DME                75
Orthotic/Prosthetic Devices- DME Urgent

Out of State- Inpatient Transplants             70

Out of State- Long Term Placement               54

Out of State- Transportation                    56

Private Duty Nursing- Under 21 Years            74

TMJ Procedures                                  40

Vision                                          AL

Figure 4-1: UM03 values


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