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Connecticut interChange MMIS
Connecticut Medical Assistance Program
5010 Companion Guide
June 1, 2012
Connecticut Department of Social Services (DSS)
25 Sigourney Street
Hartford, CT 06106
HP
195 Scott Swamp Road
Farmington, CT 06032
Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
Companion Guide Amendment History
The following log provides a history of changes that have been made to the Companion Guide.
Version Version Reason for Revision Section Page(s)
Date
1.0 3/28/12 Initial Release All All
1.1 5/30/2012 added clarification for eligibility SSN and DOB 2.2 7
search to include client name
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The preparation of this document was financed under an agreement with the Connecticut Department of
Social Services.
Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
Table of Contents
1 DOCUMENT OVERVIEW ......................................................................................... 1
1.1 Purpose of the Document ................................................................................................................................2
1.2 EDI Guide Content Summary ........................................................................................................................2
2 EDI TRANSACTION PROCESSING ........................................................................ 3
2.1 Transaction Processing Overview ..................................................................................................................4
2.2 Connecticut Medical Assistance Program Companion Guides ...................................................................5
2.2.1 Introduction ...............................................................................................................................................5
2.2.2 Included ASC X12 Implementation Guides ..............................................................................................5
2.2.3 Instruction Tables ......................................................................................................................................6
2.2.4 270/271 Health Care Eligibility Benefit Inquiry and Response .................................................................7
2.2.5 276/277 Health Care Claim Status Request and Response ...................................................................... 20
2.2.6 820 Payment Order Remittance Advice................................................................................................... 25
2.2.7 834 Benefit Enrollment and Maintenance ............................................................................................... 27
2.2.8 835 Health Care Payment/Advice ............................................................................................................ 32
2.2.9 837 Health Care Claim: Dental ................................................................................................................ 36
2.2.10 837 Health Care Claim: Institutional ....................................................................................................... 42
2.2.11 837 Health Care Claim: Professional ....................................................................................................... 49
2.3 Getting Started ............................................................................................................................................... 55
2.3.1 Trading Partner Agreement ..................................................................................................................... 55
2.4 Connectivity Testing ...................................................................................................................................... 55
2.5 Transaction Testing ....................................................................................................................................... 55
2.6 Production and Maintenance ........................................................................................................................ 56
3 SYSTEM REQUIREMENTS .................................................................................... 57
3.1 Telecommunications ...................................................................................................................................... 58
3.2 EDI Hardware/Software Selection ............................................................................................................... 58
3.3 Data Transport .............................................................................................................................................. 58
3.4 Application Development .............................................................................................................................. 58
4 APPENDIX .............................................................................................................. 59
4.1 HP Contacts.................................................................................................................................................... 60
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The preparation of this document was financed under an agreement with the Connecticut Department of
Social Services.
Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
4.2 Frequently Asked Questions (FAQ’s) .......................................................................................................... 60
IV
The preparation of this document was financed under an agreement with the Connecticut Department of
Social Services.
1 Document Overview
1
The preparation of this document was financed under an agreement with the Connecticut Department of
Social Services.
Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
1.1 Purpose of the Document
The Connecticut Department of Social Services (DSS) and its fiscal agent, Hewlett-Packard (HP) are
responsible for processing electronic transactions for the Connecticut Medical Assistance Program. This
document provides trading partners with a guide that communicates the Connecticut Medical Assistance
Program specific information required to successfully exchange transactions electronically with HP in
ASC X12 and NCPDP D.0 standard formats and must be used in conjunction with the HIPAA 5010
Implementation Guides. The information contained in these manuals is for both billing providers and
technical staff.
1.2 EDI Guide Content Summary
A summary of the remaining sections of the Companion Guide is provided below.
Section 1 – Document Overview
This section describes the purpose and outlines the content of the Connecticut Medical Assistance
Program Companion Guide. Electronic submitters should use the Implementation Guides and
Companion Guide for format and code set information. In addition to the Implementation Guide and the
Companion Guide, electronic submitters should use Chapter 8 of the Provider Manual for specific
Connecticut Medical Assistance Program claim submission instructions and policy guidelines. Chapter 8
can be found at the following link:
https://www.ctdssmap.com/CTPortal/Information/Publications/tabid/40/Default.aspx
Section 2 – EDI Transaction Processing
This section describes the EDI process that supports the Connecticut Medical Assistance Program and
provides a description of Connecticut-specific requirements for each of the transaction sets currently
supported by the Connecticut Medical Assistance Program.
Section 3 –Trading Partner Enrollment
This section provides trading partner enrollment information that includes a step-by-step description of the
activities each trading partner must complete to successfully exchange electronic transactions in the EDI
environment. Upon completion of these activities, each trading partner receives a “Production Ready”
status with the Connecticut Medical Assistance Program and its fiscal agent, HP, and may begin
submitting transactions.
Section 4 – System Requirements
This section provides a brief description of the system requirements for the transactions and provides
links to documents that contain more detailed information, as well as links to required forms.
Section 5 – Appendix
This section contains links to answers for frequently asked questions, as well as HP contact information.
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The preparation of this document was financed under an agreement with the Connecticut Department of
Social Services.
Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June1, 2012
2 EDI Transaction Processing
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The preparation of this document was financed under an agreement with the Connecticut Department of
Social Services.
Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
2.1 Transaction Processing Overview
Trading Partners exchange batch and interactive transactions with the Connecticut Medical Assistance
Program. Batch X12 transactions are uploaded and downloaded via a Web-based application. A
Functional Acknowledgement is created for batch claim transactions once the syntactical analysis is
complete. Generally, all batches are processed within 24 hours of receipt and Functional
Acknowledgements are available for download during that time. Interactive X12 and NCPDP transactions
are processed real-time through a Value Added Network rather than directly submitting to the Connecticut
Medical Assistance Program. The following table indicates the transactions that are available and the
method of delivery.
Transaction Method of Delivery
ASC X12N 270/271 Health Care Eligibility Batch/Interactive
Benefit Inquiry and Response
ASC X12N 276/277 Health Care Claim Batch/Interactive
Status Request and Response
ASC X12N 835 Health Care Claim Batch
Payment/Advice
ASC X12N 837 Health Care Claim: Batch
Institutional
ASC X12N 837 Health Care Claim: Dental Batch
ASC X12N 837 Health Care Claim: Batch
Professional
ASC X12N 999 Acknowledgement for Batch
Health Care Insurance
NCPDP Telecommunication Standard Interactive
Format Version D.0
ASC X12N 278 Health Care Services Batch/Interactive
Review: Request and Response
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The preparation of this document was financed under an agreement with the Connecticut Department of
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
2.2 Connecticut Medical Assistance Program Companion Guides
2.2.1 Introduction
The Health Insurance Portability and Accountability Act (HIPAA) requires that all health insurance payers
in the United States comply with the electronic data interchange standards for health care as established
by the Department of Health and Human Services. The ASC X12N and NCPDP implementation guides
have been established as the standards for compliance. The implementation guides for ASC X12N
transactions are available at http://www.wpc-edi.com/. The NCPDP implementation guide is available at
http://www.ncpdp.org/.
The following information is intended to serve solely as companion documents to the ASC X12 and
NCPDP transactions. The use of these documents is only for the purpose of clarification allowed within
the HIPAA transaction sets.
Electronic submitters should use the Implementation Guide and Companion Guide for format and code
set information. In addition to the Implementation Guide and Companion Guide, electronic submitters
should use Chapter 8 of the Provider Manual for specific Connecticut Medical Assistance Program claim
submission instructions and policy guidelines.
These documents are subject to change as new information is available. Please check the Connecticut
Medical Assistance Program Web site at www.ctdssmap.com regularly for updated information.
2.2.2 Included ASC X12 Implementation Guides
This table lists the X12N Implementation Guides for which specific transaction Instructions apply
and which are included in Section 2 of this document.
Unique ID Name
005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271)
005010X212 Health Care Claim Status Request and Response (276/277)
005010X218 Payment Order / Remittance Advice
005010X220A1 Benefit Enrollment and Maintenance (834)
005010X221A1 Health Care Claim Payment/ Advice (835)
005010X224A2 Health Care Claim: Dental(837)
005010X223A2 Health Care Claim: Institutional (837)
005010X222A1 Health Care Claim: Professional (837)
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The preparation of this document was financed under an agreement with the Connecticut Department of
Social Services.
Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
2.2.3 Instruction Tables
These tables contain one or more rows for each segment for which supplemental instruction is
needed.
Legend
SHADED rows represent “segments” in the X12N implementation guide.
NON-SHADED rows represent “data elements” in the X12N implementation guide.
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The preparation of this document was financed under an agreement with the Connecticut Department of
Social Services.
Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
2.2.4 270/271 Health Care Eligibility Benefit Inquiry and Response
The 270/271 is a paired transaction set used to send and receive eligibility verification
requests and responses. The following companion document provides data clarification for
the 270/271 Health Care Eligibility Benefit Inquiry and Response (005010X279A1) transaction.
Connecticut Medical Assistance
Data/Information
Program Requirements
Valid minimum required Client ID & SSN
combinations of client data for
eligibility request. Client ID & DOB
Client First and Last Name, SSN &
DOB
When using the name of the client, it is important to enter the name exactly as the client is
listed with the agency. Clients may be registered with two first names, hyphenated names
and middle initial. Example, client name of Sister Mary Brown, may be listed with Sister
Mary as the first name and Brown as the last name.
005010X279 270 Transaction Set
Loop ID Reference Name Codes Notes/Comments
ISA Interchange Control
Header
ISA08 Interchange Receiver ID Always “445498161”
BHT Beginning of Hierarchical
Transaction
BHT02 Transaction Set Purpose “13” – Request
Code
2100A NM1 Information Source Name
2100A NM101 Entity Identifier Code “PR” – Payer
2100A NM102 Entity Type Qualifier “2” – Non-Person Entity
2100A NM103 Name Last or Organization Name, Suggest
Organization Name using “HP/CTMAP”
2100A NM108 Identification Code “PI” – Payer Identification
Qualifier
2100A NM109 Identification Code “75-2548221”
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
Loop ID Reference Name Codes Notes/Comments
2100B NM1 Information Receiver
Name
2100B NM101 Entity Identifier Code “1P” – Provider
2100B NM102 Entity Type Qualifier “2” – Non-Person Entity
2100B NM108 Identification Code “XX” – NPI
Qualifier “SV” - Service Provider
Number
Inquiry by Client ID & SSN
Connecticut Medical Assistance Program and ConnPACE. Note: Do not send 2100D or
2110D loop for CT. Patient is subscriber.
Loop ID Reference Name Codes Notes/Comments
2100C NM1 Subscriber Name
2100C NM101 Entity Identifier Code “IL” – Insured or Subscriber
2100C NM102 Entity Type Qualifier “1” – Person
2100C NM108 Identification Code “MI” – Client ID Number
Qualifier
2100C NM109 Identification Code Client Identification Number
2100C REF Subscriber Additional
Identification
2100C REF01 Reference Identification “SY” – Social Security Number
Qualifier
2100C REF02 Reference Identification Social Security Number
Inquiry by Client ID & DOB
Connecticut Medical Assistance Program and ConnPACE. Note: Do not send 2100D or 2110D
loop for CT. Patient is subscriber.
Loop ID Reference Name Codes Notes/Comments
2100C NM1 Subscriber Name
2100C NM101 Entity Identifier Code “IL” – Insured or Subscriber
2100C NM102 Entity Type Qualifier “1” – Person
2100C NM108 Identification Code “MI” – Client ID Number
Qualifier
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
Loop ID Reference Name Codes Notes/Comments
2100C NM109 Identification Code Client Identification Number
2100C DMG Subscriber Demographic
Information
2100C DMG01 Date Time Period Format “D8” – Date Expressed as
Qualifier CCYYMMDD
2100C DMG02 Date Time Period Client Date of Birth
Inquiry by Client Name, SSN & DOB
Connecticut Medical Assistance Program and ConnPACE. Note: Do not send 2100D or 2110D
loop for CT. Patient is subscriber.
Loop ID Reference Name Codes Notes/Comments
2100C NM1 Subscriber Name
2100C NM101 Entity Identifier Code “IL” – Insured or Subscriber
2100C NM102 Entity Type Qualifier “1” – Person
2100C NM103 Name Last or Client last name
Organization Name
2100C NM104 Name First Client first name
2100C REF Subscriber Additional
Identification
2100C REF01 Reference Identification “SY” – Social Security Number
Qualifier
2100C REF02 Reference Identification Client Social Security Number
2100C DMG Subscriber Demographic
Information
2100C DMG01 Date Time Period Format “D8” – Date Expressed as
Qualifier CCYYMMDD
2100C DMG02 Date Time Period Client Date of Birth
Following DTP segment can be included for the documented inquiries. If no DTP segment sent
for “291” – Eligibility, processing date will be used as eligibility date.
Loop ID Reference Name Codes Notes/Comments
2100C DTP Subscriber Date
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The preparation of this document was financed under an agreement with the Connecticut Department of
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
Loop ID Reference Name Codes Notes/Comments
2100C DTP01 Date/Time Qualifier “291” – Eligibility
2100C EQ Subscriber Eligibility or
Benefit Inquiry
2100C EQ01 Service Type Code “30” – Health Benefit Plan
Coverage
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The preparation of this document was financed under an agreement with the Connecticut Department of
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
005010X279 271 Transaction Set
Loop ID Reference Name Codes Notes/Comments
2000A AAA Request Validation
2000A AAA01 Yes/No Condition or “N” – No
Response Code
2000A AAA03 Reject Reason Code “42” – Unable to Respond at
Current Time
2100B AAA Information Receiver
Request Validation
2100B AAA01 Yes/No Condition or “N” – No
Response Code
2100B AAA03 Reject Reason Code “50” – Provider Ineligible for
Inquiries
“51” – Provider Not on File
Repeating Segment Begins:
st
1 Occurrence: Echo Trace Number from 270 Request (The segment is optional in the 270
Request.)
Loop ID Reference Name Codes Notes/Comments
2000C TRN Subscriber Trace Number
2000C TRN01 Trace Type Code “2” – Referenced Transaction
Trace Numbers
2000C TRN02 Reference Identification This will be equal to the value
in the 2000C – TRN02 data
element that was received on
the 270 request.
2000C TRN03 Originating Company This will be equal to the value
Identifier in the 2000C – TRN03 data
element that was received on
the 270 request.
2nd Occurrence: Interchange MMIS Assigned Trace Number
Loop ID Reference Name Codes Notes/Comments
2000C TRN Subscriber Trace Number
2000C TRN01 Trace Type Code “1” – Current Transaction
Trace Numbers
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The preparation of this document was financed under an agreement with the Connecticut Department of
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
Loop ID Reference Name Codes Notes/Comments
2000C TRN02 Reference Identification Sender Assigned Trace
Number
2000C TRN03 Originating Company Always “9445498161”
Identifier
Repeating Segment Begins:
st
1 Occurrence: Patient Account Number from 270 Request (The segment is optional in the 270
Request.)
Loop ID Reference Name Codes Notes/Comments
2100C REF Subscriber Additional
Identification
2100C REF01 Reference Identification “EJ” – Patient Account
Qualifier Number
2nd Occurrence: Social Security Number from 270 Request (The segment is optional in the 270
Request.)
Loop ID Reference Name Codes Notes/Comments
2100C REF Subscriber Additional
Identification
2100C REF01 Reference Identification “SY” – Social Security Number
Qualifier
2100C AAA Subscriber Request
Validation
2100C AAA01 Yes/No Condition or “N” – No
Response Code
2100C AAA03 Reject Reason Code Refer to Implementation Guide
for Reject Reason Code and
Definition.
2100C DMG Subscriber Demographic
Information
2100C DMG02 Date Time Period Client Birth Date. Client Birth
Date is returned in the 271
response when client match is
found.
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
Loop ID Reference Name Codes Notes/Comments
2100C DTP Subscriber Date
2100C DTP01 Date/Time Qualifier “307” – Eligibility, “346” – Plan
Begin. For Multiple Plans, CT
will return only DTP qualifier
“307” with RD8 at this loop.
2100C DTP02 Date Time Period Format “D8” – Date Expressed as
Qualifier CCYYMMDD if Qualifier 346
or
“RD8” – Date Expressed as
CCYYMMDD-CCYYMMDD if
qualifier 307
Repeating Eligibility Segment Begins - Subscriber Eligibility: Active coverage
Loop ID Reference Name Codes Notes/Comments
2110C EB Subscriber Eligibility or
Benefit Information
2110C EB01 Eligibility or Benefit “1” – Active Coverage
Information Code
2110C EB03 Service Type Code “30” – Health Benefit Plan
Coverage
2110C EB04 Insurance Type Code See list of valid Insurance
Type Codes page 298-299
271 Implementation guide
2110C EB05 Plan Coverage Description Description of benefit plan
2110C DTP Subscriber Date
2110C DTP01 Date/Time Qualifier “307” – Eligibility, “346” – Plan
Begin. For Multiple Plans, CT
will return only DTP qualifier
“307” with RD8 at this loop.
2110C DTP02 Date Time Period Format “D8” – Date Expressed as
Qualifier CCYYMMDD if Qualifier 346
or
“RD8” – Date Expressed as
CCYYMMDD-CCYYMMDD if
qualifier 307
2110C MSG Message Text
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
Loop ID Reference Name Codes Notes/Comments
2110C MSG01 Free-form Message Text Additional information about
the CT Plans. HUSKY A. For
Behavioral Health Services,
call BHP at 877-552-8247.,
HUSKY B. For Behavioral
Health Services, call BHP at
877-552-8247., Limited
Behavioral Health Services
only. Contact CT BHP at 877-
552-8247, Drug coverage
only, under the CADAP
Program, CT Home Care
Community Based Case
Managed State Funded,
Charter Oak. For Behavioral
Health Services, call BHP at
877-286-2524, Drug coverage
only, under the ConnPACE
Program, State Administered
General Assistance Services.
For non-hospital services
contact CHN at 866-361-7242,
and QMB - Medicare Covered
Services
Repeating Eligibility Segment Begins - Subscriber Eligibility: Inactive - no current coverage
Loop ID Reference Name Codes Notes/Comments
2110C EB Subscriber Eligibility or
Benefit Information
2110C EB01 Eligibility or Benefit “6” – Inactive
Information Code
2110C EB03 Service Type Code “30” – Health Benefit Plan
Coverage
2110C DTP Subscriber Date
2110C DTP01 Date/Time Qualifier “307” – Eligibility Will reflect
the dates for the 270 from
Qualifier 291 or the date of the
transaction if no DTP sent in
the 270
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
Loop ID Reference Name Codes Notes/Comments
2110C DTP02 Date Time Period Format “RD8” – Date Expressed as
Qualifier CCYYMMDD-CCYYMMDD if
qualifier 307
Loop ID Reference Name Codes Notes/Comments
2110C EB Subscriber Eligibility or
Benefit Information
2110C EB01 Eligibility or Benefit “1” – Active Coverage
Information Code “6” - Inactive
2110C EB03 Service Type Code May repeat up to 35 times for
CT. CT values: “1” =Medical
Care, “4” = Diagnostic X-Ray ,
“5” = Diagnostic Lab,
“33”=Chiro Practic, “35”=-
Dental Care,”47” =Hospital,
“86”=Emergency Services,
“88”=– Pharmacy, “98”=
Professional (Physician Visit
Office. “AL”= Vision
(Optometry), “MH”= Mental
Health, “UC”= Urgent Care,
“42”=Home Hlth Care,
“44”=Home Hlth Vists, 45-
Hospice, 54-Long Term Care,
56 - Medically Related
Transportation, 75 - Prosthetic
Device, 82 - Family Planning,
93 – Podiatry, AD -
Occupational Therapy, AF -
Speech Therapy, DM -
Durable Medical Equipment,
PT - Physical Therapy, and RT
- Residential Psychiatric
Treatment
MCO – Note: Data in the 2120C loop reflects basic information about other payer or plans. The
receiver should initiate a separate request to the other payer or plan to determine level of
coverage.
Loop ID Reference Name Codes Notes/Comments
2110C LS Loop Header
2110C LS101 Loop Identifier Code “2120”
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
Loop ID Reference Name Codes Notes/Comments
2120C NM1 Subscriber Benefit Related
Entity Name
2120C NM101 Entity Identifier Code “Y2” – Managed Care
Organization
2120C NM102 Entity Type Qualifier “2” – Non-Person Entity if
MCO
2120C NM103 Name Last or MCO Organization Name
Organization Name
2120C PER Subscriber Benefit Related
Entity
2120C PER01 Contact Function Code “IC”
2120C PER03 Communication Number “TE”
Qualifier
2120C PER04 Communication Number Phone number of MCO
2110C LE Loop Trailer
2110C LE01 Loop Identifier Code “2120”
PCP Information Note: Data in the 2120C loop reflects basic information about other payer or
plans. The receiver should initiate a separate request to the other payer or plan to determine
level of coverage.
Loop ID Reference Name Codes Notes/Comments
2110C EB Subscriber Eligibility or
Benefit Information
2110C EB01 Eligibility or Benefit “L” Primary Care Provider.
Information Code
2110C EB05 Plan Coverage Description Description of benefit plan
2110C LS Loop Header
2110C LS101 Loop Identifier Code “2120”
2120C NM1 Subscriber Benefit Related
Entity Name
2120C NM101 Entity Identifier Code “P3” – Primary Care Provider
2120C NM102 Entity Type Qualifier “1” – Person
2120C NM103 Name Last or PCP Last Name
Organization Name
2120C NM104 Name First PCP First Name
2120C NM105 Name Middle PCP Middle Initial
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
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Loop ID Reference Name Codes Notes/Comments
2120C NM108 Identification Code “XX” – National Provider
Qualifier Identifier
2120C NM109 Identification Code NPI number
2120C PER Subscriber Benefit Related
Entity
2120C PER01 Contact Function Code “IC”
2120C PER03 Communication Number “TE”
Qualifier
2120C PER04 Communication Number Phone number of PCP
2110C LE Loop Trailer
2110C LE01 Loop Identifier Code “2120”
Other Insurance/Medicare Note: Data in the 2120C loop reflects basic information about other
payer or plans. The receiver should initiate a separate request to the other payer or plan to
determine level of coverage.
Loop ID Reference Name Codes Notes/Comments
2110C EB Subscriber Eligibility or
Benefit Information
2110C EB01 Eligibility or Benefit “R” – Other Or Additional
Information Code Payer
2110C LS Loop Header
2110C LS101 Loop Identifier Code “2120”
2120C NM1 Subscriber Benefit Related
Entity Name
2120C NM101 Entity Identifier Code “PR” – Payer
2120C NM102 Entity Type Qualifier “2” – Non Person
2120C NM103 Name Last or Other Insurance Company
Organization Name Name
2120C NM108 Identification Code “PI” – Payer Identification
Qualifier
2120C NM109 Identification Code Insurance Carrier Code
2110C LE Loop Trailer
2110C LE01 Loop Identifier Code “2120”
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Connecticut Medical Assistance Program 5010 Companion Guide
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Pharmacy/Lock In Information Note: Data in the 2120C loop reflects basic information about
other payer or plans. The receiver should initiate a separate request to the other payer or plan
to determine level of coverage.
Loop ID Reference Name Codes Notes/Comments
2110C EB Subscriber Eligibility or
Benefit Information
2110C EB01 Eligibility or Benefit “N” - Services Restricted to
Information Code Following Provider
2110C EB05 Plan Coverage Description Description of benefit plan
2110C LS Loop Header
2110C LS101 Loop Identifier Code “2120”
2120C NM1 Subscriber Benefit Related
Entity Name
2120C NM101 Entity Identifier Code “1P” – Provider
2120C NM102 Entity Type Qualifier “1” – Person
2120C NM103 Name Last or Inmate Lock in / Pharmacy
Organization Name Last Name
2120C NM104 Name First Lock in First Name
2120C NM105 Name Middle Lock in Middle Initial
2120C NM108 Identification Code “XX” – National Provider
Qualifier Identifier
2120C NM109 Identification Code NPI number
2120C PER Subscriber Benefit Related
Entity
2120C PER01 Contact Function Code “IC”
2120C PER03 Communication Number “TE”
Qualifier
2120C PER04 Communication Number Phone number
2110C LE Loop Trailer
2110C LE01 Loop Identifier Code “2120”
Hospice/Hospital Information Note: Data in the 2120C loop reflects basic information about
other payer or plans. The receiver should initiate a separate request to the other payer or plan
to determine level of coverage.
Loop ID Reference Name Codes Notes/Comments
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
Loop ID Reference Name Codes Notes/Comments
2110C EB Subscriber Eligibility or
Benefit Information
2110C EB01 Eligibility or Benefit “X” - Health Care Facility
Information Code
2110C EB05 Plan Coverage Description Description of benefit plan
2110C LS Loop Header
2110C LS101 Loop Identifier Code “2120”
2120C NM1 Subscriber Benefit Related
Entity Name
2120C NM101 Entity Identifier Code “FA” – Facility
2120C NM102 Entity Type Qualifier “1” – Person
2120C NM103 Name Last or Facility Last Name
Organization Name
2120C NM108 Identification Code “XX” – National Provider
Qualifier Identifier
2120C NM109 Identification Code NPI number
2120C PER Subscriber Benefit Related
Entity
2120C PER01 Contact Function Code “IC”
2120C PER03 Communication Number “TE”
Qualifier
2120C PER04 Communication Number Phone number
2110C LE Loop Trailer
2110C LE01 Loop Identifier Code “2120”
.
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
2.2.5 276/277 Health Care Claim Status Request and Response
The 276/277 is a paired transaction set used to send and receive health care claim status
requests and responses. The following companion document provides data clarification for the
276/277 Health Care Claim Status Request and Response (005010X212) transaction.
005010X212 276 Transaction Set
Loop ID Reference Name Codes Notes/Comments
ISA Interchange Control
Header
ISA08 Interchange Receiver ID Always “445498161”
GS Functional Group Header
GS03 Application Receiver’s Always “445498161”
Code
2100A NM1 Payer Name
2100A NM103 Name Last or Organization Always “HP/CTMAP”
Name
2100A NM108 Identification Code Always “PI”
Qualifier
2100A NM109 Identification Code Always equal to Connecticut’s
Federal Tax ID – “061274678”
2100B NM1 Information Receiver
Name
2100B NM109 Identification Code The unique nine-digit ID
number assigned by HP, i.e.,
trading partner agreement
number.
2100C NM1 Provider Name
NM108 Identification Code “SV” – Service Provider
Qualifier Number is used for non-
medical provider identifiers.
“XX” – Health Care Financing
Administration National
Provider Identifier is used for
NPI’s.
NM109 Identification Code When 2100C, NM108 equals
SV, enter the non-medical
provider identifier (CT Title XIX
AVRS ID).
When 2100C, NM108 equals
XX, enter the NPI.
2100D NM1 Subscriber Name
2100D NM108 Identification Code Always “MI”
Qualifier
2100D NM109 Identification Code Unique Connecticut Medical
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Loop ID Reference Name Codes Notes/Comments
Assistance Program Client ID;
must be left justified.
2200D TRN Claim Status Tracking
Number
2200D TRN02 Reference Identification For non-pharmacy claims use
the patient account number.
For pharmacy claims use the
prescription number. This is a
required field and must match
the value submitted on the
original claim. It will be
returned in the 277 response
transaction
2200D REF Payer Claim Control
Number
2200D REF01 Reference Identification “1K” – Payor’s Claim Number
Qualifier
2200D REF02 Reference Identification If known, include the unique
thirteen-digit ICN (Internal
Control Number) of claim. If
the claim has been adjusted or
if it has been submitted
multiple times, submit the
Inquiry without ICN to obtain
the status of all claims
matching the other Inquiry
parameters.
2200D REF Institutional Bill Type
Identification
2200D REF01 Reference Identification “BLT” – Billing Type
Qualifier
2200D REF02 Reference Identification Type of bill may be submitted
if known. If submitted, it will
be used to select claims.
2200D REF Pharmacy Description
Number
2200D REF02 Reference Identification Pharmacy Prescription
Number may be sent for
Pharmacy Claim Inquiries.
2200D DTP Claim Service Date
2200D DTP03 Date Time Period The earliest “from date” and
the latest “to date” for all lines
in a claim.
2210D Service Line Information Service Line Information may
be submitted per the
Implementation Guide, but is
not used to locate claims that
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Connecticut Medical Assistance Program 5010 Companion Guide
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Loop ID Reference Name Codes Notes/Comments
match the inquiry. If the user
wishes to receive Service Line
Status information, then the
Inqury must contain Service
Line data in Loop 2210D.
2000E Dependent Level Dependent Level Data is not
used for Medicaid Claim
Status Inquiries
005010X212 277 Transaction Set
Loop ID Reference Name Codes Notes/Comments
BHT Beginning of Hierarchical
Transaction
BHT03 Reference Identification Provider ID + System Date +
System Time
2100A NM1 Payer Name
2100A NM108 Identification Code Always “PI”
Qualifier
2100A NM109 Identification Code Always equal to Connecticut’s
Federal Tax ID – “061274678”
2100D The 277 transaction will
efficiently sort and return
unduplicated occurrences of
subscriber information per
batch cycle.
2100D NM1 Subscriber Name
2100D NM108 Identification Code Always “MI”
Qualifier
2100D NM109 Identification Code Unique Connecticut Medical
Assistance Program Client ID;
must be left justified.
2200D The 277 transaction will
efficiently sort and return
unduplicated occurrences of
claim level status information
per batch cycle.
2200D STC Claim Level Status Identification of an adjusted
Information claim is always sent with the
new claim created by the
adjustment action, and not
with the original claim. The
Claim Status Code value of “1”
indicates that the Inquiry
returned more status codes
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Loop ID Reference Name Codes Notes/Comments
than the 277 Response
transaction could
accommodate, and the user is
directed to refer to the
Remittance Advice for a
comprehensive list of EOB
codes applied to the claim.
2200D STC01-1 Industry Code From Code list 507 Health
Care Claim Status Category
Code.
2200D STC01-2 Industry Code From Code list 508 Health
Care Claim Status Category
Code.
2200D STC01-3 Entity Identifier Code Used to further clarify the
information in STC01-2.
2200D STC02 Date The system date assigned to
the most current status of the
claim.
2200D STC04 Monetary Amount This is the claim level amount
for the submitted charges
associated with this claim.
2200D STC05 Monetary Amount The claim paid amount
associated with this claim at
inquiry time when claim has
been paid. Otherwise “0”
(zero) dollars will be used.
2200D STC06 Date If claim is finalized, contains
the claim payment date.
2200D STC08 Date If claim is finalized, contains
issue date of the check or
EFT.
2200D STC09 Check Number If claim is finalized, contains
actual number of check or
EFT.
2200D STC10-1 Industry Code From Code list 507 Health
Care Claim Status Category
Code.
2200D STC10-2 Industry Code From Code list 508 Health
Care Claim Status Category
Code.
2200D STC10-3 Entity Identifier Code Used to further clarify the
information in STC10-2.
2200D STC11-1 Industry Code From Code list 507 Health
Care Claim Status Category
Code.
2200D STC11-2 Industry Code From Code list 508 Health
Care Claim Status Category
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Connecticut Medical Assistance Program 5010 Companion Guide
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Loop ID Reference Name Codes Notes/Comments
Code.
2200D STC11-3 Entity Identifier Code Used to further clarify the
information in STC11-2.
2200D REF Payer Claim Control
Number
2200D REF01 Reference Identification “1K” – Payor’s Claim Number
Qualifier
2200D REF02 Reference Identification Unique thirteen-digit ICN
(Internal Control Number) from
276 request or claim if found.
2200D REF Institutional Bill Type
Identification
2200D REF01 Reference Identification “BLT” – Payor’s Claim Number
Qualifier
2200D REF02 Reference Identification Institutional Type of Bill from
276 request or claim if found.
2200D REF Patient Control Number
2200D REF01 Reference Identification “EJ” – Patient Account
Qualifier Number
2200D REF02 Reference Identification Patient Account Number from
276 Request if claim found.
2200D REF Pharmacy Prescription
Number
2200D REF01 Reference Identification “XZ” Pharmacy Prescription
Qualifier Number
2200D REF02 Reference Identification Pharmacy Prescription
Number from 276 Request if
found.
2200D DTP Claim Service Date
2200D DTP03 Date Time Period Claim from and through dates
of service from 276 request or
claim if found.
2220D Service Line Information Service Line Data and Status
information will be returned for
each Service Line of the claim
if the original Inquiry contained
Service Line data in Loop
2210D.
2000E Dependent Level Dependent data will not be
included in the 277 Claim
Status Inquiry Response.
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Connecticut Medical Assistance Program 5010 Companion Guide
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2.2.6 820 Payment Order Remittance Advice
The 820 Payment Order/Remittance Advice file is sent to PDP and Primary Care Case
Management (PCCM) entities for premium payments. The following companion document
provides data clarification for the 820 Payment Order/Remittance Advice (005010X218)
transaction.
005010X218 Payment Order Remittance Advice
Loop ID Reference Name Codes Notes/Comments
ISA Interchange Control
Header
ISA11 Repetition Separator “^” CT will use carrot sign.
BPR Financial Information
BPR01 Transaction Handling C, D, I , P, U, X Always “I” = Remit only
Code
BPR03 Credit/Debit Flag Code Always “C” = Credit
BPR04 Payment Method Code Always “NON” = Non payment
TRN REASSOCIATION TRACE
NUMBER
TRN01 Trace Type Code 1, 3 Always “3” = Financial
Reassociation Trace Number
TRN02 Reference Identification If PDP file, Check number is
reported here. If PCCM file, a
unique value will be assigned
e.g. “999990001” where 0001
is a sequential number
REF Premium Receivers
Identification Key
REF01 Reference ID Qualifier “18”=Plan’s Number . This
segment is not used for PCCM
files.
REF02 Identification Code If REF01 = 18 then, 5 digit
plan’s number
Loop ID Reference Name Codes Notes/Comments
1000A N1 Premium Receivers
Name
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Connecticut Medical Assistance Program 5010 Companion Guide
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Loop ID Reference Name Codes Notes/Comments
1000A N103 Identification Code 1, 9, EQ, FI, Always “EQ” = Insurance
Qualifier XV Company Assigned
Identification Number
1000A N104 Identification Code Plan’s Number
1000B N1 Premium Payers Name
1000B N103 Identification Code 1, 9, 24, 75, Always “FI” = Federal
Qualifier EQ, FI, PI Taxpayer’s Identification
Number
N104 Identification Code Always "061274678" CT
DSS
2000B ENT Individual Remittance
2000B ENT03 Identification Code 34, EI, II Always “34” = Social
Qualifier Security Number
2100B NM1 Individual Name
2100B NM101 Entity Identifier Code DO, EY, QE, Always “IL” = Insured or
IL Subscriber
2000B NM108 Identification Code 34, EI, N Always “N” Insured’s
Qualifier Unique Identification
Number
NM109 Identification Code Insured Health Insurance
Claim Number ( HIC)
Medicare number
2300B RMR INDIVIDUAL PREMIUM
REMITTANCE DETAIL
2300B RMR01 Reference Identification 11, 9J, AZ, Always “AZ” = Health
Qualifier B7, CT, ID, Insurance Policy Number
IJ, IK, KW
2300B RMR02 Reference Identification For PDP will be 3-digit plan
code plus “C” for CADAP or
“D” for Dual, for PCCM will
be 9-digit AVRS legacy
provider number of the
Primary Care Manager.
2300B REF INDIVIDUAL PREMIUM
REMITTANCE DETAIL
2300B REF01 Reference Identification 14, 18, 2F, Always “ZZ” = Mutually
Qualifier 38, E9, LU, Defined
ZZ
2300B REF02 Reference Identification Client’s Connecticut
Medicaid number
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Connecticut Medical Assistance Program 5010 Companion Guide
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2.2.7 834 Benefit Enrollment and Maintenance
The 834 Benefit Enrollment and Maintenance – Enrollment file sent to managed care
organizations (MCO. The following companion document provides data clarification for the 834 –
Benefit Enrollment and Maintenance (00501X220A1) transaction set. (Addenda dated June 2010)
Special Notes – Applicable to Entire Transaction
Subscriber, Insured, and Member = Client in the Connecticut Medical
Assistance Program Environment
The Connecticut Medical Assistance Program does not allow for dependents to be enrolled
under a primary subscriber, rather all clients are primary subscribers within each program.
Provider Identification = National Provider Identifier (NPI)
005010X220 Benefit Enrollment and Maintenance
Loop Reference Name Implementation Values Notes/Comments
ID
ISA Interchange
Control Header
ISA11 Repetition “^” Change for 5010. CT
Separator will send a carrot “^”
as the repetition
Separator. There will
be no repeating
fields within the 834
ST Transaction 005010X220A1
Header
ST03 Implementation Change for 5010.
Convention Will be same value
Reference as GS08.
REF Transaction Set
Policy Number
REF02 Reference “HUSKYA” ,
Identification “MLIAMO” or
“SAGART”
DTP File Effective
Date
DTP01 Date/Time Always “007” =
007, 090, 091, 303, 382, 388
Qualifier Effective
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Connecticut Medical Assistance Program 5010 Companion Guide
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Loop Reference Name Implementation Values Notes/Comments
ID
1000A N1 Sponsor Name
1000A N103 Identification 24, 94, FI Always “FI” =
Code Qualifier Federal Taxpayer’s
Identification
Number
1000A N104 Identification Always “061274678”
Code = DSS CT
1000B N1 Payer
1000B N103 Identification 94, FI, XV Always “FI” =
Code Qualifier Federal Taxpayer’s
Identification
Number
1000B N104 Identification Federal Taxpayer’s
Code Identification
Number of MCO
2000 INS Member Level
Detail
2000 INS01 Yes/No Condition Y, N “Y” = Yes indicates
or Response head of the
Code household, “N” = No
indicates dependent
or other household
member
2000 INS02 Individual Always “18” = Self
01, 03-19, 23-26, 31, 38,53, 60,D2,
Relationship G8, G9
Code
2000 INS04 Maintenance If present, always
1-11, 14-18, 20-22, 25-33, 37-41, 43,
Reason Code 59, AA-AE, Ag-AJ, AL, EC, XT , XN “”XN” = Notification
only
2000 INS05 Benefit Status A, C, S, T Always “A” = active
Code
2000 INS08 Employment AO, AC, AU, FT, L1, PT, RT, TE Always “FT” = Full
Status Code Time
2000 REF Member
Supplemental
Identifier
2000 REF01 Reference Always “23” = Client
ABB ,D3 ,DX, F6, P5,Q4, QQ, ZZ, 60,
Identification 17, 23, 3H, 4A Medicaid Number
Qualifier
2000 DTP Member Level
Dates
2000 DTP01 Date/Time Always “356” =
050 ,286, 296, 297, 300, 301,
Qualifier 303,336, 337, 338 ,339, Eligibility begin
340,341,350,351, 356,357,383, 385
,386 ,393,394,473,474
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Connecticut Medical Assistance Program 5010 Companion Guide
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Loop Reference Name Implementation Values Notes/Comments
ID
2100A NM1 Member Name
2100A NM101 Entity Identifier 74,IL Always “IL” = Insured
Code or Subscriber
2100A NM108 Identification 34, ZZ Always “34” = Social
Code Qualifier Security Number
2100A PER Member
Communication
Number
2100A PER03 Communication AP, BN, CP, EM,EX,FX,HP,TE,WP Always “HP” = Home
Number Qualifier Phone number
2100A N4 Member City,
State, Zip Code
2100A N405 Location Qualifier 60, CY Always “60” = Area
2100A LUI Member
Language
2100A LUI01 Identification LD, LE Always “LE”
Code Qualifier
2100A LUI02 Identification Abbreviation for
AR=Arabic, BS=Bosnian, HT=French
Code Creole / Haitian, FR=French, language spoken
DE=German, EN-EnglishIT=Italian,
KM=Khmer, LO=Laotian,
SQ=Albanian, PT=Portuguese,
PL=Polish, RU=Russian,
ES=Spanish, KU=Kurdish,
VI=Vietnamese, FA=Farsi / Persian
2100G NM1 Responsible
Person
2100G NM101 Entity Identifier Always “QD” =
6Y, 9K, E1, EI, EXS, GB, GD, J6, LR,
Code QD, S1, TZ, X4 Responsible Party
2100G PER Responsible
Person
Communication
Number
2100G PER03 Communication Always “HP” = Home
AP, BN, CP, EM, EX, FX, HP, TE, WP
Number Qualifier Phone number
2300 HD Health Coverage
2300 HD01 Maintenance 001, 002, 021, 024, 025, 026, 030, Value may be “021”,
Type Code 032 “024”. “030” or “032”.
2300 HD03 Insurance Line Always “HMO”
AG, AH, AJ, AK, DCP, DMO, DEN,
Code EPO, FAC, HE, HLT, HMO, LTC,
LTD, MM, MOD, PDG, POS, PPO,
PRA, STD, UR, VIS
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Connecticut Medical Assistance Program 5010 Companion Guide
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Loop Reference Name Implementation Values Notes/Comments
ID
2300 HD04 Plan Coverage The following
Description information may be
in this field. Position
1-3 = Coverage
code, Position 4 =
Program Type,
Position 5-6
Unearned Income
Type, Position 7 =
Managed Care
Status Code,
Position 8-9 =
Managed Care
Status Reason,
Position 10-12 =
Assistant Unit Status
Reason Code,
Position 13 = DCF
Category, Position
14-21= DCF
Effective, Position
22= DCF Service
Received, Position
23, 24, 25, 26, 27 =
Race Code,
Position 28
Hispanic/Ethnicity,
Position 29-36 =
Renewal, Position
37= Waiver type ,
Position 38-39= Inst
type , Position 40-
50= Filler
2300 DTP Health Coverage
Dates
2300 DTP01 Date/Time 300, 303, 345, 348, 349, 543, 695 All HIPAA valid value
Qualifier may be seen. Value
303 is a
maintenance
effective date and is
sent only when
member's coverage
is NOT being added
or removed.
2320 COB Coordination of Sent if client ‘s
Benefit record indicated
other insurance
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Connecticut Medical Assistance Program 5010 Companion Guide
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Loop Reference Name Implementation Values Notes/Comments
ID
2320 COB01 Payer P, S, T, U Always “U” Unknown
Responsibility
Sequence
Number Code
2320 COB03 Reference 1, 5, 6 Always “5” Unknown
Identifier
2320 REF Additional
Coordination of
Benefits Identifier
2320 REF01 Identification 60. 6P, SY, ZZ Always “6P”
code qualifier
2330 NM1 Coordination of Sent if client ‘s
Benefits Related record indicated
Entity other insurance
2330 NM101 Entity Identifier 36, GW, IN Change for 5010
qualifier always “IN” = Insurer
2330 NM108 Identification FI, NI, XV Always “NI= National
code qualifier Association of
Insurance
Commissioners
(NAIC) Identification”
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Connecticut Medical Assistance Program 5010 Companion Guide
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2.2.8 835 Health Care Payment/Advice
The 835 Health Care Payment/Advice Transaction is used to provide health care providers with
remittance and payment information regarding claims submitted to the Connecticut Medical
Assistance Program. The 835 Health Care Claim Payment/Advice transactions will supply
remittance advice information only. Pending claim information is excluded from the 835 Health
Care Claim Payment/Advice transactions. The sort order for the 835 Health Care Claim
Payment/Advice transactions will follow the current paper RA sort order. These transactions will
only be available via a Web download to Connecticut Medical Assistance Program Trading
Partners requesting electronic remittance advice information.
The following companion document provides data clarification for the 835 Health Care
Payment/Advice (005010X221A1) transaction set.
Special Notes – Applicable to Entire Transaction
Subscriber, Insured, and Member = Client in Connecticut Environment
The Connecticut Medical Assistance Program does not allow for dependents to be enrolled
under a primary subscriber, rather all clients are primary subscribers within each program.
Provider Identification = National Provider Identifier (NPI) or
Non-medical provider identifier
The Connecticut Medical Assistance Program will use the National Provider ID or Provider
Tax ID in N104 in the 1000B (Payee Identification).
Connecticut Medicaid Health Plan ID = Connecticut Federal Tax ID
The Connecticut Medical Assistance program will use the Federal Tax ID in all instances
requiring a Health Plan ID. At such a time as the National Health Plan ID is approved and
available, that ID will be used.
005010X221A1 835 Health Care Claim Payment/Advice
Loop ID Reference Name Codes Notes/Comments
ST Transaction Set Header
ST02 Transaction Set Control Connecticut’s remittance
Number advice number.
BPR Financial Information
BPR01 Transaction Handling Always “I” = Remittance
Code Information Only
BPR03 Credit/Debit Flag Code Always “C” = Credit
BPR04 Payment Method Code “ACH” = Automated Clearing
House (ACH)
“CHK” = Check
“NON” = No Payment
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Connecticut Medical Assistance Program 5010 Companion Guide
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Loop ID Reference Name Codes Notes/Comments
(applicable for State
Transfers of funds between
State Agencies)
BPR07 (DFI) Identification When BPR06 = “01” value in
Number BPR07 is ABA Routing
Number “011900571”
TRN Reassociation Trace
Number
TRN02 Reference Identification Check Number or EFT
Trace Number
When BPR04 = ACH, the
Trace Number will begin
with 01190057 plus the
payee routing number and a
unique trace number for the
transaction.
TRN03 Originating Company Connecticut’s Federal Tax
Identifier ID preceded by “1” =
“061274678”
1000A N1 Payer Identification
1000A N102 Name “CT DSS MMIS CONTRACT
ADMINISTRATOR”
All caps
1000A PER Payer Business Contact
Information
1000A PER01 PAYER CONTACT CX
INFORMATION
1000A PER02 Name “HP PROVIDER
ASSISTANCE CENTER”
1000A PER03 Communication Number TE Always “TE” = Telephone
Qualifier
1000A PER04 Communication Number Connecticut Provider
Assistance Center phone
number for issues related to
the Remittance/Payment
Advice. (8008428440)
1000A PER PAYER BUSINESS
CONTACT
INFORMATION
(Payer Technical Contact
Information)
1000A PER01 Payer Technical Contact BL Connecticut EDI Help Desk
Information) phone number for file and
technical issues related to
the 835
PER02 Name EDI HELP DESK
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Connecticut Medical Assistance Program 5010 Companion Guide
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Loop ID Reference Name Codes Notes/Comments
PER03 Communication Number TE Always “TE” = Telephone
Qualifier
PER04 Communication Number 8006880503
1000B N1 Payee Identification
1000B N103 Identification Code “FI” – Federal Taxpayer’s
Qualifier Identification Number
“XX” - Centers for Medicare
& Medicaid Services (CMS)
National Provider Identifier.
1000B N104 Identification Code Value based on qualifier
from N103.
1000B REF Payee Additional
Identification
1000B REF01 Reference Identification “PQ” – Payee Identification
Qualifier
1000B REF02 Reference Identification The taxonomy code (10
digits) followed by a comma
(,) followed by zip code of 5
or 9 digits. Total field length
of 20.
1000B REF01 Reference Identification “TJ” – Federal Taxpayer’s
Qualifier Identification Number is
populated in this 2nd REF
segment, when a qualifier
of XX is present in N103 and
the NPI in N104, if
supplied on the incoming
837 transaction.
1000B REF02 Reference Identification Federal Taxpayer’s
Identification Number is
populated in this 2nd REF
segment, when a qualifier
of XX is present in N103
and the NPI is in N104, if
supplied on the incoming
837 transaction.
2100 CLP Claim Payment
Information
2100 CLP05 Monetary Amount Patient Liability Amount on
Nursing Home claims or
Patient Responsibility
Amount for Cost Share.
2100 CLP06 Claim Filing Indicator “MC”=Medicaid
Code
2100 CLP07 Reference Identification Will contain the 13-character
ICN (Internal Control
Number) of Claim –
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Connecticut Medical Assistance Program 5010 Companion Guide
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Loop ID Reference Name Codes Notes/Comments
Important for all inquiries on
claim status and
adjustments to original
claims
2100 NM1 Patient Name
2100 NM108 Identification Code Assigned Client ID; will be
Qualifier left justified
2100 NM109 Identification Code “MC” – Non-medical
Provider Identifier
“XX” - Centers for Medicare
& Medicaid Services (CMS)
National Provider Identifier
2100 NM1 Service Provider Name
2100 NM108 Identification Code “MC” – Non-medical
Qualifier Provider Identifier
“XX” - Centers for Medicare
& Medicaid Services (CMS)
National Provider Identifier
2100 NM109 Identification Code Value based on qualifier
from NM108.
2100 REF Other Claim Related
Identification
2100 REF01 Reference Identification “EA” – Medical Record
Qualifier Identification Number or
“SY” = Social Security
Number
(Only provided if submitted
on original claim)
Format not to include “-
characters. (e.g. 000000000
not 000-00-0000).
2100 REF02 Reference Identification Medical Record
Identification Number or
Social Security Number as
indicated from REF01
qualifier.
(Only provided if submitted
on original claim)
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Connecticut Medical Assistance Program 5010 Companion Guide
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2.2.9 837 Health Care Claim: Dental
The 837 Dental Transaction is used to submit health care claims and encounter data to a payer
for payment. The following companion document provides data clarification for the 837 Health
Care Claim: Dental (005010X224A2 transaction set). (Addenda dated June 2010)
Special Notes – Applicable to Entire Transaction
Provider Identification = National Provider Identifier (NPI)
With the implementation of 5010, files submitted with invalid NPI will reject and claims
will not be processed.
For all providers with NPI, the provider NPI, Taxonomy Code and Zip Code+4 must be
received in the appropriate loops. The loops are:
o 2000A Billing/Pay to Provider Specialty Information(Taxonomy)
o 2010AA Billing Provider (NPI and Zip Code+4)
o 2310B Rendering Provider
o 2420A Rendering Provider
The NPI will be sent in the NM109 where NM108 equals XX. The Taxonomy Code
will be sent in the PRV03 where PRV02 equals PXC and the Zip Code+4 must be sent
in N403. All zip codes must be numeric, no hyphens, length of 9. Please note that the
combination of NPI, Taxonomy Code, and Zip Code+4 is used in determining the
correct Automated Voice Response System (AVRS) Provider Number under which a
claim is to be processed. Claims lacking this information may deny if a match cannot
be made to a valid AVRS Provider Number.
Connecticut Medical Assistance Program Health Plan ID = Connecticut Federal Tax ID
The Connecticut Medical Assistance Program will use the CT Federal Tax ID in all instances
requiring a Health Plan ID. At such a time as the National Health Plan ID is approved and
available, that ID will be used.
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Connecticut Medical Assistance Program 5010 Companion Guide
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Overall 837 Health Care Claim Dental Formatting
Item
Connecticut Medical Assistance Program Specifications
Number
1 A transmission with multiple GS-GE’s within one ISA-IEA will be
accepted.
2 A transmission will be rejected if an invalid
Version/Release/Industry Identifier Code is submitted in GS08.
Dental claims should be submitted with ‘005010X224A2’ in GS08.
3 Dollar amounts in excess of 9,999,999.99, while accepted, will
result in non-payment.
4 Negative values submitted in amount fields, while accepted, will
result in non-payment.
5 A transmission may be rejected if an invalid carrier code is
submitted in the ISA08 Interchange Receiver ID. The
Connecticut Medical Assistance Program carrier code is
‘061274678’
6 Dental and other transactions cannot be mixed within the same
ST-SE envelope.
7 Billing information is to be entered in Loop 2010AA Billing
Provider.
8 Dependent Loops of transactions will not be processed with the
exception of Third Party Claims where the Connecticut Medical
Assistance Program client is a dependent on other primary
insurance.
9 A maximum of 50 details per claim will be processed. Details in
excess of 50 on any one claim will fail HIPAA compliance.
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Connecticut Medical Assistance Program 5010 Companion Guide
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005010X222 Health Care Claim: Dental
Loop ID Reference Name Codes Notes/Comments
ISA Interchange Control
Header
ISA08 Interchange Receiver ID Always “445498161”
Beginning of
Hierarchical
Transaction
BHT02 Transaction Set Purpose 00, 18 “00” – Original
Code
BHT06 Transaction Type Code 31, CH, RP Claim or Encounter Indicator
“CH” – Chargeable (Use with
Dental Health Care Claim)
“RP” – Reporting (Use with
Dental Health Care Encounter)
“31” - Subrogation Demand
(Do not use for CT )
Claims submitted using “RP”
or “31” in BHT06 will process.
However, they will be denied.
1000A NM1 Submitter Name
1000A NM109 Identification Code Unique ID assigned by
DSS/HP; this identification will
be assigned once an EMC
submitter is authorized to
submit claims to HP. A
transmission will be rejected
when sent with an
unauthorized submitter
identification number.
1000B NM1 Receiver Name
1000B NM103 Name Last or “CT DSS MMIS CONTRACT
Organization Name ADMINISTRATOR”
1000B NM109 Identification Code “061274678” designates the
Connecticut Medical
Assistance Program receiver
ID.
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Connecticut Medical Assistance Program 5010 Companion Guide
V1.1
June 1, 2012
For All Provider Identification Sections
For Dental Providers
NM1 segment should contain the NPI in NM109 with NM108 set to XX for health care
providers. The corresponding REF segment, when NM108=XX, must contain REF01 of EI for
Employer’s Identification Number (EIN) or SY for Social Security Number (SSN). REF02
contains the value for the healthcare provider based on the qualifier used in REF01. The
length of EIN must be equal to 10 with hyphen or 9 without. The length of SSN must be equal
to 11 with hyphens or 9 without.
Specialty Information
Under HIPAA guidelines, Provider Specialty Information is situational as to whether it is
required for payer processing of the claim. Now that NPI has been implemented, it is
recommended that the PRV (Taxonomy Code) information always be sent to further assist in
processing the claim since NPI, Taxonomy Code and Zip Code+4 are used to identify a given
provider. Claims lacking specialty information will deny if the correct provider cannot be
identified.
Loop ID Reference Name Codes Notes/Comments
2010AA NM1 Billing Provider Name
2010AA NM109 Identification Code XX For providers with NPI:
Valid 10 digit NPI assigned to
the provider when NM108
qualifier equals XX.
2010AA N4 Billing Provider City, State,
Zip Code
2010AA N403 Postal Code Billing Provider nine digit Zip
Code
2000B HL Subscriber Hierarchical Implement with
Level recommendation of maximum
of 5000 CLM segments in a
single transaction (ST-SE)
2000B HL04 Hierarchical Child Code 0 Always “0” (zero), for
Connecticut Medical
Assistance Program. No
Subordinate HL Segment in
this Hierarchical Structure.
2000B SBR Subscriber Information
2000B SBR04 Name (Insured Group Always “MEDICAID”
Name)
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Loop ID Reference Name Codes Notes/Comments
2000B SBR09 Claim Filing Indicator 11, 12, 13, 14, Always “MC” Medicaid
Code 15, 16, 17, AM,
BL, CH, CI, DS,
FI, HM, LM,
MA, MB, MC,
OF, TV, VA,
WC, ZZ
2010BA NM1 Subscriber Name
2010BA NM102 Entity Type Qualifier 1, 2 Always “1”, Person
2010BA NM108 Identification Code MI, II Always “MI”, Member
Qualifier Identification Number
2010BA NM109 Subscriber Primary 9-character Unique Medicaid
Identifier Client ID assigned by DSS
2010BB NM1 Payer Name
2010BB NM103 Name Last or Organization Name, Suggest
Organization Name using “HP/CTMAP”
2010BB NM108 Identification Code PI , XV “PI” – Payer Identification
Qualifier
2010BB NM109 Identification Code “75-2548221”
2300 CLM Claim Information
2300 CLM01 Claim Submitter’s Identifier Patient Account Number will
accept up to 38 characters.
The value received will be
returned in the 835
transaction.
2300 CLM05-3 Claim Filing Indicator 1, 7,8, The claim frequency type code
Code will indicate Connecticut
Medical Assistance Program
processing as follows: ‘7’
(Replacement claim), ‘8’ (Void
claim). Any other values
submitted in this field will
cause a claim to process as
an original.
2300 REF Original Reference
Number (ICN)
2300 REF01 Claim Original Reference F8 Required when submitting a
Number voided or replacement claim
as indicated by CLM05-3
2300 REF02 Reference Identification Use the control number
assigned to the last approved
claim.
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Loop ID Reference Name Codes Notes/Comments
2300 HI Health Care Diagnosis 3 – 5 byte ICD9-CM Diagnosis
Code codes, no decimal
2400 SV3 Dental Services
2400 SV302 Line Item Charge Amount Total submitted charges
should equal the sum of the
line item charge amounts.
2430 SVD Line Adjudication
Information
2430 SVD06 Assigned Number If services are bundled,
recommend using the
corresponding LX1 value of
the bundled service line, with
up to 3 characters allowed
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2.2.10 837 Health Care Claim: Institutional
The 837 Institutional Transaction is used to submit health care claims and encounter data to a
payer for payment. This format is used to bill long term care, inpatient, outpatient, and home
health claims. The following companion document provides data clarification for the 837 Health
Care Claim: Institutional (005010X223A2) transaction set. (Addenda dated April 2010)
Special Notes – Applicable to Entire Transaction
Subscriber, Insured, and Member = Client in the Connecticut Medical Assistance
Program Environment
The Connecticut Medical Assistance Program does not allow for dependents to be enrolled
under a primary subscriber, rather all clients are primary subscribers within each program.
Provider Identification = National Provider Identifier (NPI) or Non-medical
provider identifier
For all covered entities, the provider NPI, Taxonomy Code and Zip Code+4 must be
received in the appropriate loops. All zip codes must be numeric, no hyphens, length is
9. The loops are:
o 2000A Billing/Pay to Provider Specialty Information (Taxonomy)
o 2010AA Billing Provider (NPI and Zip Code+4)
The NPI will be sent in the NM109 where NM108 equals XX. The Taxonomy Code will
be sent in the PRV03 where PRV02 equals PXC.
For all covered entities, the provider NPI, Taxonomy and Zip Code+4 must be received
in the appropriate loops as required by the 5010 standard. The loops are:
o 2310A Attending Physician - NPI, Taxonomy
o 2310B Operating Physician - NPI
o 2310C Other Operating Physician - NPI
o 2310D Rendering Physician - NPI
o 2310E Service Facility Location – NPI, Address
o 2310F Referring Physician - NPI
The NPI will be sent in the NM109 where NM108 equals XX. The Zip Code+4 will be
sent in N403. All zip codes must be numeric, no hyphens,
length is 5 or 9.
For all Non-medical providers where an NPI is not assigned, the claim must contain the
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Connecticut Medical Assistance Program Provider ID within the appropriate loops within
the REF segment where REF01 equals G2.
Note that the Billing Provider Secondary ID segment which can contain this provider ID is
in a new location, Loop 2010 BB.
Connecticut Medical Assistance Program Health Plan ID = Connecticut Federal Tax ID
The Connecticut Medical Assistance Program will use the CT Federal Tax ID in all
instances requiring a Health Plan ID. At such a time as the National Health Plan ID is
approved and available, that ID will be used.
Overall 837 Health Care Claim Institutional Formatting
Item
Connecticut Medical Assistance Program Specifications
Number
1 A transmission with multiple GS-GE’s within one ISA-IEA will be accepted.
2 A transmission will be rejected if an invalid Version/Release/Industry Identifier
Code is submitted in GS08. Institutional claims should be submitted with
‘005010X223A2’ (dated April 2010) in GS08.
3 Dollar amounts in excess of 9,999,999.99, while accepted, will result in non-
payment.
4 Negative values submitted in amount fields, while accepted, will result in non-
payment.
5 A transmission may be rejected if an invalid receiver ID is submitted in the ISA08
Interchange Receiver ID. The Connecticut Medical Assistance Program Receiver
ID is ‘061274678’.
6 Professional and Institutional transactions cannot be mixed within the same ST-
SE envelope.
7 Billing information is to be entered in Loop 2010AA Billing Provider.
8 A maximum of 999 details per claim will be processed. Details in excess of 999
on any one claim will fail HIPAA compliance.
9 The NPI will be required on all incoming Medicare coinsurance and deductible
claims. The trading partner should enter the NPI in Loop 2010AA NM109–Billing
Provider Identifier on claims submitted to Medicare.
10 The NDC code, N4 Modifier and HCPCS code will be required on outpatient
claims in Loop 2410 when certain physician administered drugs are billed.
005010X223 Health Care Claim: Institutional
Loop ID Reference Name Codes Notes/Comments
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Loop ID Reference Name Codes Notes/Comments
ISA Interchange Control
Header
ISA08 Interchange Receiver ID Always “445498161”
GS Functional Group Header
GS03 Application Receiver’s ID Always “445498161”
BHT Beginning of Hierarchical
Transaction
BHT02 Transaction Set Purpose 00, 18 “00” – Original
Code
BHT06 Transaction Type Code Claim or Encounter Indicator
“CH” – Chargeable (Use with
Institutional Health Care
Claim)
“RP” – Reporting (Use with
Institutional Health Care
Encounter)
Claims submitted using ‘RP’ in
BHT06 will process. However,
they will be denied unless the
submitter is a Connecticut
Managed Care Organization.
Value ‘31’(subrogation) is not
used by CT Medicaid.
1000A NM1 Submitter Name
1000A NM109 Identification Code Unique ID assigned by HP;
this identification will be
assigned once an EMC
submitter is authorized to
submit claims to HP. A
transmission will be rejected
when sent with an
unauthorized submitter
identification number
1000B NM1 Receiver Name
1000B NM103 Name Last or Organization “CT DSS MMIS CONTRACT
Name ADMINISTRATOR”
All caps
1000B NM109 Identification Code “061274678” designates the
Connecticut Medical
Assistance Program receiver
ID.
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For Medical Providers – The following applies to all provider identification sections:
NM1 segment should contain the NPI in NM109 with NM108 set to XX for health care providers.
The corresponding REF segment, when NM108=XX, must contain REF01 of EI for Employer’s
Identification Number (EIN) or SY for Social Security Number (SSN). REF02 contains the value
for the healthcare provider based on the qualifier used in REF01. The length of EIN must be
equal to 10 with hyphen or 9 without. The length of SSN must be equal to 11 with hyphens or 9
without.
For Non-Medical Providers – The following applies to all provider identification sections:
NM108 and NM109 are not populated when the Provider does not have an NPI. The
corresponding REF segment, where REF01=G2 should contain the Non-Medical Provider
Identifier.
Provider Specialty
Provider Specialty Information is made situational as to whether it is required for payer
processing of the claim. It is recommended that the PRV (Taxonomy Code) information always
be sent per Implementation Guide specifications to further assist in processing the claim since
NPI, Taxonomy Code, and Zip Code are used to identify a given provider.
Loop ID Reference Name Codes Notes/Comments
2000B HL Subscriber Hierarchical Implement with
Level recommendation of maximum
of 5000 CLM segments in a
single transaction (ST-SE)
2000B HL04 Hierarchical Child Code Always “0” (zero), for
Connecticut Medical
Assistance Program. No
Subordinate HL Segment in
this Hierarchical Structure.
2000B SBR Subscriber Information
2000B SBR04 Name When submitting a claim to the
CT Medical Assistance
Program field should be
populated with ‘Medicaid’ CT
Medical Assistance program
does not have a group
number.
2000B SBR09 Claim Filing Indicator Code Should be “MC”, Medicaid
2010BA NM1 Subscriber Name
2010BA NM102 Entity Type Qualifier Always “1”, Person
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Loop ID Reference Name Codes Notes/Comments
2010BA NM108 Identification Code Always “MI”, Member
Qualifier Identification Number
2010BA NM109 Identification Code 9-character Unique Medicaid
Client ID assigned by DSS;
must be left justified
2010BB NM1 Payer Name
2010BB NM103 Name Last or Organization Organization Name, Suggest
Name using “HP/CTMAP”
2010BB NM108 Identification Code PI “PI” – Payer Identification
Qualifier
2010BB NM109 Identification Code “75-2548221”
2010BB REF Billing Provider Secondary
Identification
2010BB REF01 Reference Identification New segment Billing Provider
Qualifier Secondary ID, use qualifier
‘G2” when the Billing Provider
is a Non-Covered Entity.
2010BB REF02 Reference Identification New segment Billing Provider
Secondary ID, enter 9 digit
Provider AVRS ID when the
Billing Provider is a Non-
Covered Entity.
2300 CLM Claim Information
2300 CLM01 Claim Submitter’s Identifier Patient Account Number will
accept up to 38 characters.
The value received will be
returned in the 835
transaction.
2300 CLM05-3 Claim Frequency Type The claim frequency type code
Code will indicate Connecticut
Medical Assistance Program
processing as follows: ‘7’
(Replacement claim), ‘8’ (Void
claim). Any other values
submitted in this field will
cause a claim to process as an
original.
2300 REF Payer Claim Control
Number
2300 REF01 Reference Identification “F8” – Original Reference
Qualifier Number
Required when submitting a
voided or replacement claim
as indicated by CLM05-3.
2300 REF02 Reference Identification Use the control number
assigned to the last approved
claim.
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Loop ID Reference Name Codes Notes/Comments
2300 HI Principal, Admitting, Diagnosis codes have a
Patient Reason For Visit, maximum size of five, and
E-Code and Other decimal points must not be
Diagnosis Information entered.
2300 HI Principal Procedure Surgical procedures will be
Information accepted in ICD-9 formats,
and ICD-10 when
implemented by CMS.
Not CTXIX specific.
2300 HI Value Information Value codes beyond 12
occurrences will be ignored.
Value Codes are now used to
report Covered Days ( HI0x-2
= 80) or Non-Covered Days
(HI0x-2 = 81), HI0x-7 =
number of days
2310A REF Attending Provider
Secondary Identification
2310A REF01 Reference Identification For non-medical providers:
Qualifier “G2” – Provider Commercial
Number
2310A REF02 Reference Identification Please enter the 9 digit AVRS
Provider ID with a qualifier of
G2 in the REF01.
2330B NM1 Other Payer Name
2330B NM109 Identification Code Enter the Connecticut Medical
Assistance Program Carrier
Code. These code values can
be found at
http://www.ctdssmap.com
2400 SV2 Institutional Service Line
2400 SV202-1 Product/Service ID “HC” Required if outpatient
Qualifier billing and revenue codes 250-
253, 258-260, 273 or 634-637
are billed.
2400 SV202-2 Product/Service ID HCPCS code required if
outpatient billing and revenue
codes 250-253, 258-260, 273
or 634-637 are billed.
2400 SV105 Quantity Service unit counts in excess
of 9999, while accepted, will
result in non-payment.
2410 LIN Drug Identification NDC information for Outpatient
transactions will be processed
in Loop 2410. Required if
billing HCPCS codes in Q, S
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Loop ID Reference Name Codes Notes/Comments
or J series.
2410 LIN02 Product/Service ID “N4”
Qualifier Outpatient claims must include
the NDC data for all physician
administered drugs.
2410 LIN03 Product/Service ID Enter the NDC code for the
physician administered drug.
Limit one per service
line/detail.
2410 CTP Drug Quantity
2410 CTP04 Quantity Drug unit count
Outpatient claims must include
the NDC data for all physician
administered drugs.
2410 CTP05-1 Unit or Basis for F2 = International Unit
Measurement Code GR = Gram
ME = Milligram
ML = Milliliter
UN = Unit
2430 SVD Line Adjudication
Information
2430 SVD06 Assigned Number If services are bundled,
recommend using the
corresponding LX1 value of
the bundled service line, with
up to 3 characters allowed
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2.2.11 837 Health Care Claim: Professional
The 837 Professional Transaction is used to submit health care claims and encounter data to a
payer for payment. The following companion document provides data clarification for the 837
Health Care Claim: Professional (005010X222A1 transaction set. (Addenda dated June 2010)
Special Notes – Applicable to Entire Transaction
Provider Identification = National Provider Identifier (NPI) or Atypical provider identifier
With the implementation of 5010, files submitted with invalid NPI will reject and claims
will not be processed.
For all providers with NPI, the provider NPI, Taxonomy Code and Zip Code+4 must be
received in the appropriate loops. The loops are:
o 2000A Billing/Pay to Provider Specialty Information(Taxonomy)
o 2010AA Billing Provider (NPI and Zip Code+4)
o 2310B Rendering Provider
o 2420A Rendering Provider
The NPI will be sent in the NM109 where NM108 equals XX. The Taxonomy Code
will be sent in the PRV03 where PRV02 equals PXC and the Zip Code+4 must be sent
in N403. All zip codes must be numeric, no hyphens, length of 9. Please note that the
combination of NPI, Taxonomy Code, and Zip Code+4 is used in determining the
correct Automated Voice Response System (ARVS) Provider Number under which a
claim is to be processed. Claims lacking this information may deny, if a match cannot
be made to a valid AVRS Provider Number.
For all atypical providers where an NPI is not assigned, the claim must contain the
Connecticut Medical Assistance Program Provider ID within the appropriate loops
within the REF segment where REF01 equals G2. Claims lacking this information
may deny, if a match cannot be made to a valid AVRS Provider Number.
Connecticut Medical Assistance Program Health Plan ID = Connecticut Federal Tax ID
The Connecticut Medical Assistance Program will use the CT Federal Tax ID in all instances
requiring a Health Plan ID. At such a time as the National Health Plan ID is approved and
available, that ID will be used.
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Overall 837 Health Care Claim Professional Formatting
Item
Connecticut Medical Assistance Program Specifications
Number
1 A transmission with multiple GS-GE’s within one ISA-IEA will be
accepted.
2 A transmission will be rejected if an invalid
Version/Release/Industry Identifier Code is submitted in GS08.
Professional claims should be submitted with ‘005010X222A1’ in
GS08.
3 Dollar amounts in excess of 9,999,999.99, while accepted, will
result in non-payment.
4 Negative values submitted in amount fields, while accepted, will
result in non-payment.
5 A transmission may be rejected if an invalid carrier code is
submitted in the ISA08 Interchange Receiver ID. The
Connecticut Medical Assistance Program carrier code is
‘061274678’
6 Professional and Institutional transactions cannot be mixed within
the same ST-SE envelope.
7 Billing information is to be entered in Loop 2010AA Billing
Provider. Additional Billing information is to be submitted in Loop
2100BB for atypical providers.
8 Dependent Loops of transactions will not be processed with the
exception of Third Party Claims where the Connecticut Medical
Assistance Program client is a dependent on other primary
insurance.
9 A maximum of 50 details per claim will be processed. Details in
excess of 50 on any one claim will fail HIPAA compliance.
10 The NPI will be required on all incoming Medicare coinsurance
and deductible claims. The trading partner should enter the NPI
in Loop 2010AA NM109–Billing Provider Identifier on claims
submitted to Medicare.
11 The NDC and N4 modifier will be required in Loop 2410 when
billing S, Q or J series HCPCS codes.
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005010X222 Health Care Claim: Professional
Loop ID Reference Name Codes Notes/Comments
ISA Interchange Control
Header
ISA08 Interchange Receiver ID Always “445498161”
Beginning of
Hierarchical
Transaction
BHT02 Transaction Set Purpose 00, 18 “00” – Original
Code
BHT06 Transaction Type Code 31, CH, RP Claim or Encounter Indicator
“CH” – Chargeable (Use with
Professional Health Care
Claim)
“RP” – Reporting (Use with
Professional Health Care
Encounter)
Claims submitted using “RP”
in BHT06 will process.
However, they will be denied.
1000A NM1 Submitter Name
1000A NM109 Identification Code Unique ID assigned by
DSS/HP; this identification will
be assigned once an EMC
submitter is authorized to
submit claims to HP. A
transmission will be rejected
when sent with an
unauthorized submitter
identification number.
1000B NM1 Receiver Name
1000B NM103 Name Last or “CT DSS MMIS CONTRACT
Organization Name ADMINISTRATOR”
All caps
1000B NM109 Identification Code “061274678” designates the
Connecticut Medical
Assistance Program receiver
ID.
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For All Provider Identification Sections
For Medical Providers
NM1 segment should contain the NPI in NM109 with NM108 set to XX for health care
providers. The corresponding REF segment, when NM108=XX, must contain REF01 of EI for
Employer’s Identification Number (EIN) or SY for Social Security Number (SSN). REF02
contains the value for the healthcare provider based on the qualifier used in REF01. The
length of EIN must be equal to 10 with hyphen or 9 without. The length of SSN must be equal
to 11 with hyphens or 9 without.
For Non-Healthcare Providers
The corresponding REF segment, where REF01=G2 should contain the AVRS Provider ID
Specialty Information
Under HIPAA guidelines, Provider Specialty Information is situational as to whether it is
required for payer processing of the claim. Now that NPI has been implemented, it is
recommended that the PRV (Taxonomy Code) information always be sent to further assist in
processing the claim since NPI, Taxonomy Code and Zip Code+4 are used to identify a given
provider. Claims lacking specialty information will deny if the correct provider cannot be
identified.
Loop ID Reference Name Codes Notes/Comments
2010AA NM1 Billing Provider Name
2010AA NM109 Identification Code XX For providers with NPI
Valid 10 digit NPI assigned to
the provider when NM108
qualifier equals XX.
For atypical providers:
NM108 and NM109 at this
loop should not be submitted.
Send AVRS provider number
in 2010BB REF02
2010AA N4 Billing Provider City, State,
Zip Code
2010AA N403 Postal Code Billing Provider nine digit Zip
Code
2000B HL Subscriber Hierarchical Implement with
Level recommendation of maximum
of 5000 CLM segments in a
single transaction (ST-SE)
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Loop ID Reference Name Codes Notes/Comments
2000B HL04 Hierarchical Child Code 0 Always “0” (zero), for
Connecticut Medical
Assistance Program. No
Subordinate HL Segment in
this Hierarchical Structure.
2000B SBR Subscriber Information
2000B SBR04 Name (Insured Group Always ‘Medicaid’
Name)
2000B SBR09 Claim Filing Indicator 11, 12, 13, 14, Should be “MC”, Medicaid
Code 15, 16, 17, AM,
BL, CH, CI, DS,
FI, HM, LM,
MA, MB, MC,
OF, TV, VA,
WC, ZZ
2010BA NM1 Subscriber Name
2010BA NM102 Entity Type Qualifier 1, 2 Always “1”, Person
2010BA NM108 Identification Code MI, II Always “MI”, Member
Qualifier Identification Number
2010BA NM109 Subscriber Primary 9-character Unique Medicaid
Identifier Client ID assigned by DSS;
must be left justified
2010BB NM1 Payer Name
2010BB NM103 Name Last or Organization Name, Suggest
Organization Name using “HP/CTMAP”
2010BB NM108 Identification Code PI , XV “PI” – Payer Identification
Qualifier
2010BB NM109 Identification Code “75-2548221”
2010BB REF Payer Secondary
Identification
2010BB REF01 Reference Identification 2U, EI, FY, NF, ‘G2” when the Billing Provider
Qualifier G2 is a atypical
2010BB REF02 Reference Identification AVRS id of an atypical
provider
2300 CLM Claim Information
2300 CLM01 Claim Submitter’s Identifier Patient Account Number will
accept up to 38 characters.
The value received will be
returned in the 835
transaction.
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Loop ID Reference Name Codes Notes/Comments
2300 CLM05-3 Claim Filing Indicator 1, 7,8 The claim frequency type code
Code will indicate Connecticut
Medical Assistance Program
processing as follows: ‘7’
(Replacement claim), ‘8’ (Void
claim). Any other values
submitted in this field will
cause a claim to process as
an original.
2300 REF Original Reference
Number (ICN)
2300 REF01 Reference Identification F8 Required when submitting a
Qualifier voided or replacement claim
as indicated by CLM05-3
2300 REF02 Claim Original Reference Use the control number
Number assigned to the last approved
claim.
2300 CRC EPSDT Referral EPSDT information must be
entered in Loop 2300 if the
EPSDT indicator in Loop 2400
SV111 equals ‘Y’.
2300 HI Health Care Diagnosis 3-5 byte ICD9 CM Diagnosis
Code codes , no decimal points.
2310B REF Rendering Provider
Secondary Identification
2310B REF01 Reference Identification OB, 1G, G2 ‘G2” when the Billing Provider
Qualifier is a atypical
2310B REF02 Reference Identification AVRS id of an atypical
provider
2400 SV1 Professional Service
2400 SV104 Quantity Service unit counts in excess
of 9999 while accepted, will
result in non-payment.
2410 LIN Drug Identification NDC information for
Professional transactions will
be processed in Loop 2410.
Required if billing HCPCS
codes in Q, S or J series.
2410 CTP Drug Pricing NDC information for
Professional transactions will
be processed in Loop 2410.
Required if billing HCPCS
codes in Q, S or J series.
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Loop ID Reference Name Codes Notes/Comments
2420A REF Rendering Provider
Secondary Identification
2420A REF01 Reference Identification 0B, 1G, G2 ‘G2” when the Billing Provider
Qualifier is a atypical
2420A REF02 Reference Identification AVRS id of an atypical
provider
2430 SVD Line Adjudication
Information
2430 SVD06 Assigned Number If services are bundled,
recommend using the
corresponding LX1 value of
the bundled service line, with
up to 3 characters allowed
2.3 Getting Started
Any entity intent upon becoming a trading partner should review the Connecticut Medical Assistance
Program’s requirements presented in this document in order to assess any changes required by both
their business and technical operations to comply with the state’s EDI processing requirements.
2.3.1 Trading Partner Agreement
The Trading Partner Agreement (TPA) is a contract between parties who have chosen to become
electronic business partners. The TPA stipulates the general terms and conditions under which the
partners agree to exchange information electronically. The document defines participant roles,
communication, privacy and security requirements, and identifies the electronic documents to be
exchanged. The Trading Partner Agreement is used by all entities that wish to establish an electronic
relationship with the Connecticut Medical Assistance Program. However, EDI production transactions will
not be allowed until all testing has been successfully completed. A Trading Partner Agreement must be
signed and received by the state’s fiscal agent HP before testing can begin. HP’s EDI team will work with
the trading partner’s staff to exchange and analyze technical information.
Click here to view the Trading Partner User’s Guide.
2.4 Connectivity Testing
HP and the trading partner will test their communication links. A successful test will occur when
transaction sets can be sent and an appropriate response is returned. For example, an ASC X12N 837
Claim submission will be responded to with an ASC X12N 999 Implementation Acknowledgement for
Health Care Insurancetransaction in return.
2.5 Transaction Testing
HP and the trading partner will ensure that all participants in the process are communicating with each
other properly. HP and the trading partner will mutually agree to the test period for this phase. The
trading partner cannot begin production transmissions until transaction testing has been successfully
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completed. The Trading Partner Agreement must be signed and received by HP before testing can
begin.
2.6 Production and Maintenance
Trading partners shall receive advance notice prior to changes being made to any of the transaction sets.
Updates may or may not involve software changes. EDI update notification will be sent to the designated
trading partner representatives at the specified locations. The state requires notification if there is a
change in the trading partner representative or location to which updates are sent.
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3 System Requirements
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V1.1
June 1, 2012
3.1 Telecommunications
The Connecticut Medical Assistance Program currently supports a Web-based connection. To obtain
information regarding the telecommunication requirements, please see the Vendor Interface Specification
document.
Click here to view the Vendor Interface Specification document.
3.2 EDI Hardware/Software Selection
Each trading partner will determine if any modifications to their technical infrastructure will be needed to
perform and support EDI functions. (If the organization is currently EDI-enabled, this step may already be
completed.) Assuming that the current platform is adequate to meet our processing requirements, the
primary focus for evaluation and selection will be for a software package.
There are a number of commercially available software packages on the market. Trading Partners need
to evaluate and select the software package that will meet their needs. HP offers a free software
package named Provider Electronic Solutions, to Connecticut Medical Assistance Program providers.
3.3 Data Transport
Specific information about what types of transactions are supported and modes of data transportation are
included in the Vendor Interface Specification document.
3.4 Application Development
The trading partner will need to modify their business application systems and test their accuracy to
ensure that the systems will effectively process all of the required data from transactions received and
also provide the data that will ultimately be transmitted in an EDI format.
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The preparation of this document was financed under an agreement with the Connecticut Department of
Social Services.
Connecticut Medical Assistance Program 5010 Companion Guide
V1.0
March 28, 2012
4 Appendix
59
The preparation of this document was financed under an agreement with the Connecticut Department of
Social Services.
Connecticut Medical Assistance Program 5010 Companion Guide
V1.0
March 28, 2012
4.1 HP Contacts
For information about electronic claims submission or how to become a trading partner, please contact
the Provider Assistance Center at:
1-800-842-8440 Toll free
4.2 Frequently Asked Questions (FAQ’s)
The following link will bring you to a list of the most frequently asked questions regarding HIPAA.
https://www.ctdssmap.com/CTPortal/Information/HIPAA/tabId/42/Default.aspx
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The preparation of this document was financed under an agreement with the Connecticut Department of
Social Services.
