Transcription

Aetna SSI 276/277 Companion Guide276/277 HIPAA Transaction Companion GuideHIPAA/V005010X212VERSION: 1.0DATE: 02/05/2014www.aetnaseniorproducts.com1

Aetna SSI 276/277 Companion GuideDisclosure StatementThis material contains confidential, proprietary information. Unauthorized use or disclosure of theinformation is strictly prohibited.The information in this document is furnished for Aetna Senior Supplemental Insurance (Aetna SSI) andTrading Partner use only. Changes are periodically made to the information in this document; thesechanges will be incorporated in new editions of this publication. Aetna Senior Supplemental Insurancemay make improvements and/or changes in the product and/or program described in this publication atany time.Below are the Medicare Supplement companies that are either owned or administered by Aetna SeniorSupplemental Insurance. Payer ID for all the companies for Eligibility and Claim Status transaction isAESSI. These companies will be referred as Aetna SSI in the document hereinafter. Aetna Health and Life Insurance CompanyAetna Life Insurance CompanyAllianz Life Insurance Company of New YorkAmerican Continental Insurance CompanyAmerican General Life Insurance CompanyCombined Insurance Company of AmericaContinental Life Insurance Company of Brentwood, TennesseeGenworth Life and Annuity Insurance CompanyGenworth Life Insurance CompanyUnion Fidelity Life Insurance CompanyVirginia Surety Company, Inc.Washington National Insurance Company2

Aetna SSI 276/277 Companion GuidePrefaceThis Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adoptedunder HIPAA clarifies and specifies the data content when exchanging electronically with Aetna SSI.Transmissions based on this Companion Guide, used in tandem with the v5010 ASC X12NImplementation Guides, are compliant with both ASC X12 syntax and those guides. This CompanionGuide is intended to convey information that is within the framework of the ASC X12N ImplementationGuides adopted for use under HIPAA. The Companion Guide is not intended to convey information thatin any way exceeds the requirements or usages of data expressed in the Implementation Guides.3

Aetna SSI 276/277 Companion GuideEDITOR’S NOTE:This page is blank because major sections of a book should begin on a right hand page.4

Aetna SSI 276/277 Companion GuideTable of Contents1.INTRODUCTION . 6SCOPE . 6OVERVIEW. 6REFERENCES . 7ADDITIONAL INFORMATION . 72.GETTING STARTED. 7WORKING WITH AETNA SSI. 7TRADING PARTNER REGISTRATION. 8CERTIFICATION AND TESTING OVERVIEW . 83.TESTING WITH THE PAYER . 84.CONNECTIVITY WITH THE PAYER/COMMUNICATIONS . 8PROCESS FLOW . 8TRANSMISSION ADMINISTRATIVE PROCEDURES. 9RE-TRANSMISSION PROCEDURE . 9COMMUNICATION PROTOCOL SPECIFICATIONS . 9PASSWORDS . 105.CONTACT INFORMATION . 10EDI CUSTOMER SERVICE . 10EDI TECHNICAL ASSISTANCE . 10PROVIDER SERVICE NUMBER . 10APPLICABLE WEBSITES/E-MAIL . 106.CONTROL SEGMENTS/ENVELOPES . 10ISA/IEA . 10GS-GE . 11ST-SE . 127.PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS . 128.ACKNOWLEDGEMENTS AND/OR REPORTS . 13REPORT INVENTORY. 139.10.TRADING PARTNER AGREEMENTS . 13TRANSACTION SPECIFIC INFORMATION . 145

Aetna SSI 276/277 Companion Guide1. INTRODUCTIONThis is the Companion Guide to the v5010 ASC X12N 276 and 277 Implementation Guides and associatederrata adopted under HIPAA; clarifies and specifies the data content when exchanging eligibility dataelectronically with Aetna SSI. Transmissions based on this Companion Guide, used in tandem with thev5010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. ThisCompanion Guide is intended to convey information that is within the framework of the ASC X12NImplementation Guides adopted for use under HIPAA. The Companion Guide is not intended to conveyinformation that in any way exceeds the requirements or usages of data expressed in theImplementation Guides.SCOPEThis Companion Guide is intended for Trading Partners trading ASC/X12N 276/277 5010 transactionswith Aetna SSI.The purpose of the Communications/Connectivity Guide is to convey the information needed tocommence and maintain communication exchange with Aetna SSI’s clearing house Real-Time ExchangeServices, for the purpose of conducting real-time X12N/276/277 5010 Eligibility/Benefit Inquiry andResponse transactions.This guide is intended to supplement information from the ASC X12 Technical Reports Type 3(TR3s).OVERVIEWThis guide is composed of the following sections: Section 1 Introduction: scope, overview, and related references. Section 2 Getting Started: How to interact with Aetna SSI’s clearing house implementation team,how to register as a trading partner and complete payer enrollment, and an overview of testingand certification. Section 3 Testing with Aetna SSI: Details about the testing and certifying process. Section 4 Connectivity with Emdeon/Communications: process flows, transmissionadministrative procedures, communication protocols, security protocols, and passwords. Section 5 Contact Information: how to get help. Section 6 Control Segments/Envelopes: ISA/ISE, GS/GE, and ST/SE values specific to Aetna SSI’sclearing house. Section 7 Payer Specific Business Rules and Limitations: Describes Aetna SSI’s business rules. Section 8 Acknowledgements and Reports: Information about Aetna SSI’s use ofacknowledgements and reports. Section 9 Trading Partner Agreements: Instructions regarding agreements that must be madebetween trading partners. Section 10 Transaction Specific Information: general supplemental instructions for each of theHIPAA-adopted transaction types.6

Aetna SSI 276/277 Companion GuideREFERENCESASC X12 Technical Reports Type 3 (TR3s)ASC X12 publishes implementation guides, known as Technical Reports Type 3 (TR3s), which define thedata contents and compliance requirements for the health care implementation of the ASCX12N/005010 transaction sets. Following are the TR3s referenced in this guide:ASC X12N/005010X212 Health Care Claim Status Inquiry and Response (276/277) and Errata 1,hereinafter 005010X212 TR3s.You are expected to comply with the requirements set forth in the TR3s. You can purchase these guidesfrom the ASC X12 store at http://store.x12.org/ or from Washington Publishing Company(http://www.wpc-edi.com). The TR3s are copyrighted.ADDITIONAL INFORMATIONFor getting Information of Patient Eligibility for Aetna SSI companies, trading partners have to develop aconnection between your interface and Emdeon.For more detailed information refer to Emdeon Companion guide dard-Companion-Guide.pdfThis Companion Guide assumes that you, the reader, are a representative of the Trading Partner, andthat as such, you understand basic X12 structure, looping, and standard data requirements as set forthin the TR3 for each transaction set you wish to exchange.This Companion Guide also assumes that: You have a real-time EDI interface that supports the transaction sets the Trading Partner wishesto exchange. You have resources to develop a connection between your interface and Emdeon.2. GETTING STARTEDWORKING WITH AETNA SSIAETNA SSI currently uses Emdeon as their exclusive clearinghouse for managing 276/277 connections.This guide includes the instructions you will need to get connected and start sending/receiving standard276 and 277 transactions with Emdeon. Make sure you read the entire guide in order to take advantageof the full functionality of the system.7

Aetna SSI 276/277 Companion GuideTRADING PARTNER REGISTRATIONBefore submitting or receiving a 276 or 277 transaction, you must register as a Trading Partner withEmdeon to ensure you are established and recognized in the system. To register, complete theEnrollment Application and Trading Partner Agreements and submit to:Email: [email protected]: 615-885-3713Real Time Provider Setup Form available @ CATION AND TESTING OVERVIEWThe interface with Emdeon will involve utilization of Emdeon’s proprietary software suite. TradingPartners who have not used it before may need to go through a testing phase with Emdeon.3. TESTING WITH THE PAYERTesting has to happen with Emdeon. Before you can test with Emdeon: You must have established connectivity with Emdeon’s Real-Time Exchange Services. TheImplementation Coordinator will work with you to facilitate the setup and testing ofconnectivity and communications. You are responsible for developing HIPAA and ASC/X12-compliant transaction sets. You canbegin to develop transaction sets before connectivity with Emdeon is established.It is strongly recommended that you check your transactions for compliance to 005010 standards usinga compliance checker. Emdeon has partnered with Edifecs for this purpose and will activate an Edifecsaccount for your use. If you need assistance with your Edifecs account, your ImplementationCoordinator can assist you; send questions to [email protected] If you do not wishto use Edifecs, you can use your preferred compliance checker.4. CONNECTIVITY WITH THE PAYER/COMMUNICATIONSPROCESS FLOWThe process flow for the 276/277 transaction exchanges will involve three separate entities: Aetna SSI,the provider or clearinghouse sending the benefit request, and Emdeon. Emdeon will serve as anintermediary between the request source and Aetna SSI, exchanging the benefit request and Aetna SSI’sbenefit response through their secure connections with both entities.8

Aetna SSI 276/277 Companion GuideTRANSMISSION ADMINISTRATIVE PROCEDURESAetna SSI will return a 277 response or 999 (in case of failed validation) within 20 seconds of receivingthe 276 request from Emdeon to provide as close to a real-time response as possible. Automation iscurrently configured to run 24 hours a day in order to process requests as they come in.For more detailed information refer to Emdeon Companion guide dard-Companion-Guide.pdfRE-TRANSMISSION PROCEDUREAetna SSI’s Real-Time Exchange Services do not perform re-transmissions. It is the Trading Partner’sresponsibility to resubmit.COMMUNICATION PROTOCOL SPECIFICATIONSAetna SSI has provided connectivity that complies with the CORE Safe Harbor principle (§5 Safe Harbor)according to the CORE Connectivity Phase II Rule 270 version 2.2.0 and Phase II Rule 250 version 2.1.0.Information receivers can submit eligibility (270), claim status (276) in Real time via Safe Harbor.Emdeon’s security protocol is Username/Password. Emdeon does not use X.509.The currently supported protocol for CORE is HTTP/S. The following is a list of standards and theirversions that this Rule is based on: HTTP Version 1.1 SSL Version 3.0 MIME Version 1.09

Aetna SSI 276/277 Companion Guide The MIME Multipart/Form-Data (IETF RFC 2388)SOAP Version 1.2WSDL Version 1.1Web Services-Security 1.1Emdeon utilizes SOAP, MIME/Multipart, and WSDL.For more information on the required protocols and envelopes, see CORE 270: Phase II ConnectivityRule, version 2.2.0 section 4.PASSWORDSAs a secure connection between Emdeon and Aetna SSI has already been established, any passwords toprotect the security of the data would only need to be setup between the trading partner and Emdeon.Emdeon requires each interchange submitter ID to be accompanied with a unique password for securityreasons. The interchange submitter ID and password are authenticated against a database.5. CONTACT INFORMATIONEDI CUSTOMER SERVICEFor customer service type inquiries in relation to the 276/277 setup and its efficiency, please contactEmdeon EDI support @ 1-866-742-4355 option 3.EDI TECHNICAL ASSISTANCEFor EDI technical assistance, please contact Emdeon EDI support @ 1-866-742-4355, option 3.PROVIDER SERVICE NUMBERFor provider services, please contact Aetna SSI @ 1-800-264-4000, option 2.APPLICABLE WEBSITES/E-MAILFor more about Aetna SSI, visit our website at www.aetnaseniorproducts.comor e-mail us at [email protected] CONTROL SEGMENTS/ENVELOPESISA/IEAThe following is what Aetna SSI expects as far the interchange control segments. It includes adescription of expected sender and receiver codes, authorization information, and delimiters, for boththe Interchange Control Header (ISA) and the Interchange Control Trailer (IEA).10

Aetna SSI 276/277 Companion GuideISA RECORD LAYOUTReferenceDesignatorUsageDescriptionPossible ValuesMinMax(preferred in RAuthorization Information QualifierAuthorization InformationSecurity Information QualifierSecurity InformationInterchange ID QualifierInterchange Sender IDInterchange ID QualifierInterchange Receiver IDInterchange DateInterchange TimeRepetition SeparatorInterchange Control Version No.Interchange Control NumberAcknowledgement RequestedUsage IndicatorComponent Element SeparatorSegment Terminator00(leave blank)01TPG Serial NumberZZTPG Terminal NumberZZEMDEONYYMMDD formatHHMM format , :, 00501See TR30P: 210210215215641591111210210215215641591111IEA RECORD LAYOUTReferenceDesignatorUsageDescriptionPossible ValuesMinMaxIEA01IEA02RRNumber of Included Functional GroupsGroup Control Number1(must match ISA13)1959GS-GEThe following is what Aetna SSI expects as far as the functional group control segments. It includes adescription of expected application sender and receiver codes, for both the Group Control Header (GS)and the Group Control Trailer (GE). On inbound transmissions, we expect the trading partner to definethe group control number to be sent. On outbound transmissions Aetna SSI will generate a uniquesequenced control number.Aetna SSI’s Real-Time Exchange Services support only one functional group per request and response.GS RECORD LAYOUTReferenceDesignatorUsageDescriptionPossible RRFunctional Identifier CodeApplication Sender’s CodeApplication Receiver’s CodeDateTimeGroup Control NumberResponsible Agency CodeVersion/Release/Industry IdentifierHS (inbound)(defined by sender)MTEXECCYYMMDD fmtHHMM format(defined by sender)X005010X212222841112151588921211

Aetna SSI 276/277 Companion GuideGE RECORD LAYOUTReferenceDesignatorUsageDescriptionPossible ValuesMinMaxGE01GE02RRNumber of Transaction Sets IncludedGroup Control Number(must match GS06)1169ST-SEThe following is what Aetna SSI expects as far as the transaction set segments. It includes a descriptionof expected transaction codes, for both the Transaction Set Header (ST) and the Transaction Set Trailer(SE). On inbound transmissions, we expect the trading partner to define the transaction set controlnumber to be sent. On outbound transmissions Aetna SSI will generate a unique sequenced controlnumber.ST RECORD LAYOUTReferenceDesignatorUsageDescriptionPossible ValuesMinMaxST01ST02ST03RRRTransaction Set Identifier CodeTransaction Set Control NumberImplementation Convention Ref.276(incrementing no.)005010X2123413935SE RECORD LAYOUTReferenceDesignatorUsageDescriptionPossible ValuesMinMaxSE01SE02RRNumber of Included SegmentsTransaction Set Control Number(must match ST02)141097. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONSSubmitters may send a 276 claim status request on claims filed electronically (an 837 Health Care Claimtransaction) or on paper. Aetna SSI interchange does not distinguish between paper or electronic claimswhen issuing a 277 response.Date ranges returned on the 277 response (DTP03) are those submitted on the 276 request. The 276requests that use date ranges for service dates receive all claims within the range, unless otherqualifiers, such as claim numbers or amounts billed, preclude their return. To avoid extraneousresponses, users should enter date ranges for an inquiry only when the date range represents the datesof a single service or claim.Aetna SSI does not support service line-specific status requests. When sent, this data will be ignored andthe request will be processed using the claim level data.12

Aetna SSI 276/277 Companion GuideAetna SSI provides claim status information at the claim level for institutional (Medicare Part A) andprofessional (Medicare Part B).Aetna SSI does not support the Dependent Loop since all Aetna SSI members can be uniquely identifiedat the Subscriber Level (loop 2000D).For the 276 claim status request transaction, the TRN segment is required when the subscriber is thepatient. Because in the Aetna SSI implementation of HIPAA, the subscriber is always the patient, thissegment is always required. The TRN segment received on the 276 claim status request transaction willbe returned unaltered on the 277 response transaction, except that TRN01 will be changed to “2”.8. ACKNOWLEDGEMENTS AND/OR REPORTSAs the 276 transaction is designed to be exchanged for a 277 response containing the benefitinformation sought in the 276 request, Aetna SSI will not send any other sort of acknowledgement thatthe 276 has been received, unless there is a problem processing the request. Should the 276 failstructural validation upon receipt, a 999 acknowledgement file will be returned detailing the specificerrors. No 277 response will be generated unless the 276 is corrected and resubmitted.REPORT INVENTORY999 Implementation Acknowledgements (005010X231A1)9. TRADING PARTNER AGREEMENTSThis section contains general information concerning Trading Partner Agreements (TPA).TRADING PARTNERSAn EDI Trading Partner is defined as any Aetna SSI’s customer (provider, billing service, software vendor,employer group, financial institution, etc.) that transmits to, or receives electronic data from Aetna SSI.Payers have EDI Trading Partner Agreements that accompany the standard implementation guide toensure the integrity of the electronic transaction process. The Trading Partner Agreement is related tothe electronic exchange of information, whether the agreement is an entity or a part of a largeragreement, between each party to the agreement.For example, a Trading Partner Agreement may specify among other things, the roles andresponsibilities of each party to the agreement in conducting standard transactions.13

Aetna SSI 276/277 Companion GuideAs Aetna SSI only will be directly exchanging data with Emdeon, the existing Trading Partner Agreementbetween Aetna SSI and Emdeon will cover these transmissions. It may be necessary for thoseoriginating these transactions to complete similar documents with Emdeon.10.TRANSACTION SPECIFIC INFORMATIONAetna SSI’s Trading Partners must adhere to the following business rules and limitations for submittingtransactions in real time: Only one patient per transaction.Only one transaction per functional group.Only one functional group per interchange.Interchange acknowledgements for successful deliveries will be honored for submitters usingthe dual-port method.If no date of service is received, the current date (based on Central time) will be considered asthe date of service.14

Aetna Life Insurance Company Allianz Life Insurance Company of New York American Continental Insurance Company American General Life Insurance Company Combined Insurance Company of America Continental Life Insurance Company of Brentwood, Tennessee Genworth Life and Annuity Insurance Co