FMMIS 270/271 Batch and Interactive Health Care Eligibility and Response Transaction Companion Guide

005010X221A1

Version 2.6

June 23, 2016

Florida Medicaid Management Information System Fiscal Agent Services Project

Disclaimer: The information contained in this Companion Guide is subject to change. EDI submitters are advised to check the EDI-Submission Information page on the “My Medicaid Florida” Web site (http://www.mymedicaid-florida.com/) for the latest updates after go-live of version 5010. FMMIS 270/271 Batch and Interactive Health Care Eligibility Inquiry and Response Companion Guide Version 2.6 – June 23, 2016

Document Information Page

Required Information Definition Document: FMMIS 270/271 Batch and Interactive Health Care Eligibility and Response Transaction Companion Guide Document ID: Version: Version 2.6 QA Reviewer: QA Review Approval Date: Location: Located in iTRACE Owner: Heather Lyons Author Heather Lyons Approved by: Approval Date:

Note: The controlled master of this document is available online via iTRACE.

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Disclosure Statement

The Agency for Health Care Administration (AHCA) is committed to maintaining the integrity and security of health care data in accordance with applicable laws and regulations. This document is intended to serve as a companion guide to the corresponding ASC X12N/ 005010X279 Health Care Eligibility/Benefit Inquiry and Information Response (270/271), its related addenda (005010X279A1), and its related errata (005010X279E1).

Disclosure of Medicaid Beneficiary eligibility data is restricted under the provisions of the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Provider Medicaid Beneficiary eligibility transaction is to be used for conducting Medicaid business only.

This document can be reproduced and/or distributed; however, its ownership by Florida Medicaid must be acknowledged and the contents must not be modified.

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Preface

This companion guide to the 005010 ASC X12N Implementation Guide and associated errata and addenda adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Florida Medicaid. Transmissions based on this companion guide, used in tandem with the 005010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. This companion guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The companion guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the implementation guides.

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Table of Contents

1 Introduction ...... 1-1 1.1 Scope ...... 1-1 1.2 Overview ...... 1-1 1.3 References ...... 1-1 1.4 Additional Information ...... 1-1 2 Getting Started ...... 2-1 2.1 Working with Florida Medicaid ...... 2-1 2.2 Trading Partner Registration ...... 2-1 2.3 Certification and Testing Overview ...... 2-1 3 Testing with the Payer ...... 3-1 4 Connectivity with the Payer/Communications ...... 4-1 4.1 Process Flow ...... 4-1 4.2 Transmission Administrative Procedures ...... 4-1 4.3 Re-Transmission Procedure ...... 4-2 4.4 Communication Protocol Specifications ...... 4-2 4.5 Passwords ...... 4-2 5 Contact Information ...... 5-1 5.1 EDI Customer Service ...... 5-1 5.2 Provider Service Number ...... 5-1 5.3 Relevant Websites ...... 5-1 6 Control Segments/Envelope Definitions for 270/271 Transactions ...... 6-1 6.1 ISA - Interchange Control Header Segment ...... 6-1 6.2 IEA – Interchange Control Trailer ...... 6-2 6.3 GS – Functional Group Header ...... 6-3 6.4 GE – Functional Group Trailer ...... 6-4 6.5 ST – Transaction Set Header ...... 6-4 6.6 SE – Transaction Set Trailer ...... 6-5 7 Florida Medicaid Business Rules and Limitations – 270 Transactions ...... 7-1 7.1 Business Rules ...... 7-1 7.2 Valid Delimiters ...... 7-4 8 Acknowledgements ...... 8-1 8.1 Report Inventory ...... 8-1 9 Trading Partner Agreements ...... 9-1 9.1 Trading Partners ...... 9-1 10 270 Health Care Eligibility Inquiry – Transaction Specific Information ...... 10-1 11 271 Health Care Eligibility Response – Transaction Specific Information ...... 11-1

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Appendix A Appendices ...... A-1 A.1 Implementation Checklist ...... A-2 A.2 Business Scenarios ...... A-3 A.3 Transmission Examples ...... A-4 A.4 AAA Error Codes ...... A-6 A.5 CORE-Required Service Codes ...... A-7 A.6 Valid Explicit Inquiry Codes ...... A-8 A.7 Frequently Asked Questions ...... A-10 A.8 Change Summary ...... A-11

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1 Introduction

The Health Insurance Portability and Accountability Act (HIPAA), which was passed in 1996, requires all insurance carriers and payers in the United States to comply with a set of standards adopted by the Secretary of Health and Human Services. These standards were created to assure an efficient and secure exchange of electronic health information.

1.1 Scope

This is the technical report document for the ANSI ASC X12N 270 Health Care Eligibility Inquiry and the ANSI ASC X12N 271 Health Care Eligibility Response transactions. This document provides a definitive statement of what trading partners must be able to support in this version of the 270/271. This document is intended to be compliant with the data standards set out by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its associated rules.

All required segments within the 270 transactions must always be sent by the submitter and received by the payer. Optional information is sent when it is necessary for processing. Segments that are conditional are only sent when special criteria are met.

Additionally, all required segments within the 271 transactions must always be sent back to the submitter by the payer.

This companion guide supplements, but does not replace the information contained within the X12N health care implementation guides.

1.2 Overview

This companion guide has been created to assist in designing Health Care Eligibility transactions to conform to implementation standards and Florida Medicaid's processing rules. This guide should be used to supplement the instructions pertaining to the Health Care Eligibility Benefit Inquiry and Response (270/271) as stated by the X12 Standards for Electronic Data, Addenda A1 (V. 005010X279A1).

1.3 References

Washington Publishing Company (WPC) - http://www.wpc-edi.com - WPC maintains and publishes the X12N Implementation Guides containing the standards for electronic health care transactions.

1.4 Additional Information

AHCA is committed to maintaining the integrity and security of health care data in accordance with applicable laws and regulations. Disclosure of Medicaid Beneficiary eligibility data is restricted under the provisions of the Privacy Act of 1974 and HIPAA.

AHCA monitors Medicaid Beneficiary eligibility inquiries. Trading Partners identified as having aberrant behavior (e.g., high inquiry error rate or high ratio of eligibility inquires to claims

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submitted) may be contacted to verify and/or address improper use of the system or, when appropriate, be referred for investigation.

Authorized Purposes for Requesting Medicare Beneficiary Eligibility Information

In conjunction with the intent to provide health care services to a Medicaid Beneficiary, authorized purposes include to:

1. Verify eligibility, after screening the patient to determine Medicaid eligibility;

2. Determine Medicaid Beneficiary payment responsibility with regard to deductible/copayment;

3. Determine eligibility for other services, such as preventive; and

4. Determine proper billing.

Unauthorized Purposes for Requesting Medicare Beneficiary Eligibility Information

The following are examples of unauthorized purposes for requesting Medicaid Beneficiary eligibility information:

1. To determine eligibility for Medicaid without first screening the patient to determine if they are Medicaid eligible; and

2. To acquire the Medicaid Beneficiary's Health Insurance Claim Number (HICN).

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2 Getting Started

This section contains Payer-specific business rules and limitations for the 270/271 Eligibility Inquiry and Response transactions.

2.1 Working with Florida Medicaid

This section describes how to interact with Florida Medicaid's Electronic Data Interchange (EDI) Department.

Florida Medicaid Trading Partners should exchange electronic health care transactions with Florida Medicaid via the Web Portal, Interactive, or the Safe Harbor connection.

After establishing a transmission method and completing required documentation, each trading partner must successfully complete testing. Additional information is provided in the next section of this companion guide. After successful completion of testing, production transactions may be exchanged.

2.2 Trading Partner Registration

To register as a Trading Partner with Florida Medicaid, visit the enrollment section of the public information section of the Florida Medicaid website at http://www.mymedicaid-florida.com/ to obtain and complete the Electronic Data Interchange (EDI) Agreement.

Clearinghouses wishing to register as billing agent providers with Medicaid must also download and complete the Clearinghouse Provider Enrollment Application.

If there are questions regarding the EDI agreement, please contact our EDI Operations department at 1-866-586-0961 or email your inquiries to [email protected].

Any questions regarding the Clearinghouse Provider Enrollment Application should be directed to Florida Medicaid's Enrollment department at 1-800-289-7799, option 4.

2.3 Certification and Testing Overview

All entities who wish to submit electronic transactions to Florida Medicaid in the HIPAA standard ASC X12 5010 format and receive any corresponding EDI responses must complete testing to ensure that their connections, systems, and software can and will produce data that is able to be processed by Florida Medicaid.

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3 Testing with the Payer

All submitters wishing to test their electronic transactions before submitting production files to Florida Medicaid are required to create an account on the EDIFECS Ramp Manager site used for this purpose: https://sites.edifecs.com/index.jsp?flmedicaid.

The Ramp Manager site contains tools to test all 5010 X12 transaction types accepted by Florida Medicaid and should be used to diagnose any issues that would cause submitted electronic files to reject based on front-end (TA1/997/999 response) error checking.

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4 Connectivity with the Payer/Communications

4.1 Process Flow

4.2 Transmission Administrative Procedures

HP supports several types of data transport depending upon the Trading Partner's need. Providers and their representatives can submit and receive data via the Web Portal and Value Added Networks (VANs) or Switch Vendors for interactive transactions.

1. Web Portal: Transaction files are uploaded/downloaded in the Trade Files menu on the secure Web Portal.

2. VANs or Switch Vendors typically support interactive transactions through a dedicated connection to the fiscal agent. VANs sign a contract with the State and have unique, VAN- specific communication arrangements with the fiscal agent. A list of approved vendors is listed on the fiscal agent website.

Detailed information to assist with EDI related processes are available on the Provider Public website at http://www.mymedicaid-florida.com/. Information available includes: 1. Trading Partner Testing Procedures (Ramp Manager) for all new trading partners, or trading partners adding a new transaction; and

2. Web Upload/Download instructions for submitters uploading/downloading via the secure Web Portal.

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4.3 Re-Transmission Procedure

When the system is unable to provide the status of a requested claim because of invalid or incomplete data on the incoming 270 transaction, a 271 transaction will be generated with an AAA segment in the relevant loop. Upon receipt of this 271 transaction, the originating submitter may review the accompanying code to rectify or correct the original claim information and resubmit the request on a new 270 transaction.

4.4 Communication Protocol Specifications

Florida Medicaid accepts 270 transactions via the following methods:

1. Secure Web Portal;

2. Secure File Transfer Protocol (SFTP) for approved submitters; and

3. Secure Sockets Layer (SSL) for approved VAN or Switch Vendors.

4.5 Passwords

All submitters wishing to submit 270 transactions in batch to Florida Medicaid must have a presence in the secure Web Portal. Providers, including Billing Agent providers, should have been assigned a username and password to access the system.

If you need to obtain a secure Web Portal account for your Provider ID, contact Florida Medicaid's Account Support Group at 1-800-289-7799, option 5.

Those wishing to use SFTP must be approved by AHCA and will be assigned a username and password to the secure FTP server. All inquiries regarding SFTP access should be directed to Heather Lyons ([email protected]).

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5 Contact Information

5.1 EDI Customer Service

For all EDI related inquiries, please contact Florida Medicaid EDI Operations Support:

Phone: 1-866-586-0961

Email: [email protected]

5.2 Provider Service Number

For recipient eligibility information, claim status, billing and payment inquiries, and questions about the Florida Medicaid secure Web Portal, including Direct Data Entry (DDE) claims, please contact Florida Medicaid's Provider Services division at 1-800-289-7799, option 7.

5.3 Relevant Websites

Florida Medicaid (public site) - http://www.mymedicaid-florida.com/ Florida's Agency for Health Care Administration - http://ahca.myflorida.com/ Washington Publishing Company - http://www.wpc-edi.com/

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6 Control Segments/Envelope Definitions for 270/ 271 Transactions

6.1 ISA - Interchange Control Header Segment

This segment within the X12N implementation guide identifies the start of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file header record.

270/271 Health Care Eligibility Request and Response Loop Page Reference Name Code/Value Notes/Comments ID C.3 N/A ISA Interchange Control Header Segment C.4 N/A ISA01 Authorization 00 '00' - No Authorization Information Information Present Qualifier C.4 N/A ISA02 Authorization [space fill] Information C.4 N/A ISA03 Security 00 '00' - No Security Information Information Present Qualifier C.4 N/A ISA04 Security [space fill] Information

C.4 N/A ISA05 Interchange ID ZZ 'ZZ' - Mutually Defined Qualifier

C.4 N/A ISA06 Interchange Sender 270 = TradingPartner ID as supplied ID by Florida Medicaid, left justified and space filled. 271 = '77027' left justified and space filled. Florida Medicaid Sender ID. C.5 N/A ISA07 Interchange ID ZZ 'ZZ' - Mutually Defined Qualifier

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270/271 Health Care Eligibility Request and Response

Page Loop Reference Name Code/Value Notes/Comments ID C.5 N/A ISA08 Interchange 77027 270 = '77027' left justified and space Receiver ID filled. Florida Medicaid Sender ID.271 = Trading Partner ID as supplied by Florida Medicaid, left justified and space filled. C.5 N/A ISA09 Interchange Date Thedateformat is YYMMDD. C.5 N/A ISA10 Interchange Time The time format is HHMM. C.5 N/A ISA11 Repetition ^'^' Separator C.5 N/A ISA12 Interchange 00501 '00501' - Control Version Number Control Version Number C.5 N/A ISA13 Interchange Interchange Unique Control Number Control Number - Must be identical to IEA02 C.6 N/A ISA14 Acknowledgement 1, 0 '1' - Acknowledgement Requested Requested '0' - No Acknowledgement Requested C.6 N/A ISA15 Usage Indicator P 'P' - Production Data C.6 N/A ISA16 Component : ':' - Component Element Separator Element Separator

6.2 IEA – Interchange Control Trailer

This segment within the X12N implementation guide defines the end of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file trailer record.

270/271 Health Care Eligibility Request and Response

Page Loop Reference Name Code/Value Notes/Comments ID C.10 N/A IEA Interchange Control Trailer C.10 N/A IEA01 Number of Number of included Functional Included Groups Functional Groups C.10 N/A IEA02 Interchange Must be identical to the value in Control Number ISA13

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6.3 GS – Functional Group Header

This segment within the X12N implementation guide indicates the beginning of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch header record.

270/271 Health Care Eligibility Request and Response Loop Page Reference Name Code/Value Notes/Comments ID C.7 N/A GS Functional Group Header C.7 N/A GS01 FunctionalID HS, HB 270 = 'HS' - Eligibility, Coverage or Code Benefit Inquiry 271 = 'HB' - Eligibility Coverage or Benefit Information C.7 N/A GS02 Application 270 = TradingPartner ID Supplied Sender's Code by FL Medicaid, left justified, do not space fill. 271 = '77027' - Florida Medicaid Sender ID C.7 N/A GS03 Application 270 = '77027' left justified do not Receiver's Code space fill. Florida Medicaid Receiver ID 271 = Trading Partner Supplied by Florida Medicaid. C.7 N/A GS04 Date The date format is CCYYMMDD. C.8 N/A GS05 Time The timeformat is HHMM. C.8 N/A GS06 Group Control Group Control Number - Must be Number identical to GE02. C.8 N/A GS07 Responsible X 'X' - Responsible Agency Code Agency Code C.8 N/A GS08 Version/ Release/ 005010X27 Ve r s i o n/ Release/ Industry Identifier Industry Identifier 9A1 Code Code

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6.4 GE – Functional Group Trailer

This segment within the X12N implementation guide indicates the end of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch trailer record.

270/271 Health Care Eligibility Request and Response Loop Page Reference Name Code/Value Notes/Comments ID C.9 N/A GE Functional Group Trailer C.9 N/A GE01 Number of Number of included Transaction Transaction Sets Sets Included C.9 N/A GE02 Group Control Must be identical to the value in Number GS06.

6.5 ST – Transaction Set Header

This segment within the X12N implementation guide indicates the start of the transaction set and assigns a control number to the transaction. This segment may be thought of traditionally as the claim header record.

270/271 Health Care Eligibility Request and Response Loop Page Reference Name Code/Value Notes/Comments ID 59 N/A ST Transaction Set Header 59 N/A ST01 Transaction Set 270, 271 270 = Eligibility, Coverage or Identifier Code Benefit Inquiry 271 = Eligibility, Coverage or Benefit Information 59 N/A ST02 Transaction Set Transaction Control Number Control Number Increment by 1 when multiple transaction sets are submitted.

Must be identical to SE02. 60 N/A ST03 Implementation Must be identical to the value in Convention GS08. Reference

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6.6 SE – Transaction Set Trailer

This segment within the X12N implementation guide indicates the end of the transaction set and provides the count of transmitted segments [including the beginning (ST) and ending (SE) segments]. This segment may be thought of traditionally as the claim trailer record.

270/271 Health Care Eligibility Request and Response Loop Page Reference Name Code/Value Notes/Comments ID 199 N/A SE Transaction Set Trailer 199 N/A SE01 Number of To t al number of segments included Included Segments in Transaction Set including ST and SE 199 N/A SE02 Transaction Set Must be identical to the value in Control Number ST02

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7 Florida Medicaid Business Rules and Limitations – 270 Transactions

7.1 Business Rules

This section contains Payer-specific business rules and limitations for the 270 Health Care Eligibility Inquiry transactions.

Subscriber, Insured The Subscriber refers to the Recipient in the Florida Medicaid Eligibility Verification System. The Florida Medicaid Eligibility Verification System does not allow for dependents to be enrolled under a primary subscriber, rather all enrollees/members are primary subscribers within each program or Managed Care Organization.

Provider Identification

The Provider Identification refers to the National Provider Identifier (NPI) or Medicaid ID (Providers without an NPI only).

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 mandated the implementation of a National Provider Identifier (NPI). Most health care providers must register with the National Plan and Provider Enumeration System (NPPES) and receive a unique NPI. The intent of the HIPAA regulations was to require all health plans to convert their claims processing systems to use only the NPI for claims processing and reporting for providers required to obtain an NPI. Because of the complexities of this conversion by health care plans and providers, the use of the NPI has not yet been strictly enforced.

Medicaid claims submitted on and after January 1, 2011, however, have new requirements for the use of the NPI.

Beginning on January 1, 2011, the NPI is required on all electronic claim transactions and paper claims from providers who qualify for an NPI. Florida Medicaid still accepts transactions containing the Provider's Medicaid ID, but any qualifying claims that lack the NPI are denied.

Starting on May 1, 2011, however, Florida Medicaid no longer accepts electronic claim transactions (837D, 837I, and 837P) containing the Florida Medicaid ID submitted by providers who qualify for an NPI. Any electronic claims sent by qualifying providers on or after May 1, 2011 that contain the provider's Florida Medicaid Provider ID are denied, even if they also contain the NPI.

Please note that paper claims are not affected by this change.

For all non-healthcare providers where an NPI is not assigned, the claim must contain the Florida Medicaid Provider Number with the appropriate loops within the REF segment where REF01 equals G2.

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Logical File Structure

1. For Batch 270/271 transactions, there can be only one interchange (ISA-IEA) per logical file. The interchange can contain multiple functional groups (GS-GE) however; the functional groups must be the same type.

2. For Interactive 270/271 transactions, there can be only one interchange (ISA-IEA), one functional group (GS-GE) and one transaction (ST-SE) per logical file. Within the transaction (ST-SE) there can only be one request. This has been defined as the EQ segment within Loop 2110C.

3. For Batch 270/271 transactions, if multiple information source loops (1000A) are received within the 270 transaction (ST-SE) multiple 271 transactions (ST-SE) are generated. For example: 270 submitted with one ST-SE, within that ST-SE there are two information source loops, the 271 returned contains two ST-SEs.

4. For Batch 270/271 transactions, if multiple information receiver loops (1000B) are received within the 270 transaction (ST-SE) multiple 271 transactions (ST-SE) are generated. For example: 270 submitted with one ST-SE, within that ST-SE there are two information receiver loops, the 271 returned contains two ST-SEs.

5. To ensure a timely response, it is suggested that the submitter send more than one inquiry (EQ segment) within a transaction set (ST-SE), but no more than 5,000 inquiries (EQ segments) per transaction set (ST-SE). For example: A 270 batch submitted with 10,000 inquiries would have one ISA-IEA, 1 GS-GE and 2 ST-SE (5,000 inquiries per ST-SE). Should you have a system limitation that requires you to send one transaction (EQ) per ST-SE then we recommend you limit your file to reflect 5,000 ST-SE.

6. To ensure that eligibility information is only returned to active providers, the Florida Medicaid system attempts to perform a validation of the provider's NPI information as submitted on the 270 transaction to map it to a unique Medicaid ID. On the 270 transaction, this information is limited to the NPI and accompanying taxonomy code. The 9-digit ZIP code, which is normally part of the validation process, is not present on the 270 transaction and therefore cannot be used in this manner. Due to this limitation, we recommend that for 270 transactions only, the submitting provider's 9-digit Medicaid ID be included instead of their NPI. This will assure that the inbound transaction is credited to the correct provider profile and will prevent issues when an NPI is linked to both active and inactive profiles.

Valid Combinations of Subscriber Data for Eligibility Requests

There are five (5) valid data combinations that can be used to determine a recipient's eligibility in the Florida Medicaid Management System:

1. Date of service and the recipient's Medicaid ID number;

2. Date of service, the recipient's name, and Social Security Number;

3. Date of service, the recipient's Social Security Number, and date of birth;

4. Date of service, the recipient's name, gender, and date of birth; and

5. Date of service and the recipient's Gold Card Number.

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For each 270 inquiry transmitted, the system looks for each of these data combinations in the order presented above. The system checks each combination of data until it is able to find a Medicaid recipient that matches the data presented or until it has exhausted all five (5) data combinations.

In cases where no valid match can be found, the system returns an error code (AAA03) in the 2100C loop of the 271 response. This code further specifies which of the submitted data was found to be erroneous. A list of these codes can be found in the appendix: “AAA Error Codes” on page A-6.

Note: If a date of service is not received, the system uses the date of transmission as the default date.

Multiple Birth Situations

The Florida Medicaid system does not store birth sequence identifiers. The system uses the first seven (7) positions of recipient's first name and first five (5) positions of recipient's last name when searching for eligibility information to distinguish between individuals in a multiple birth situation.

Submitter

Submissions by non-approved trading partners are rejected.

Response/997 Functional Acknowledgement

A response transaction is returned to the trading partner that is present within the ISA06 data element.

The Agency for Health Care Administration (AHCA) provides a 997 Functional Acknowledgment for all transactions that are received.

NOTE: The 997 will be replaced with the 999 effective June 19, 2015.

You will receive this acknowledgment within 48 hours unless there are unforeseen technical difficulties. If the transaction submitted was translated without errors for a request type transaction, i.e., 270 or 276, you will receive the appropriate response transaction generated from the request. If the transaction submitted was a claim transaction, i.e., 837, you receive either the 835 or the unsolicited 277.

Note: The 835 and unsolicited 277 are only provided weekly.

Document Level

AHCA processes 270 eligibility transaction files at the batch level. Should any of the inquiries on the submitted batch fail to pass HIPAA compliance, the Florida Medicaid Management Information System (FMMIS) marks the entire batch as failing compliance and the erroneous data are reported on the 997.

NOTE: The 997 will be replaced with the 999 effective June 19, 2015.

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Dependent Loop

For AHCA, the subscriber is always the same as the patient (dependent). Claims containing data in the Dependent Hierarchical Level (2000D loop) will not process correctly.

Compliance Checking

Inbound 270 transactions are validated through Strategic National Implementation Process (SNIP) Level 4.

7.2 Valid Delimiters

The delimiters documented below are used for Florida Medicaid, unless otherwise requested by a trading partner.

Definition ASCII Decimal Hexadecimal Segment Separator ~ 126 7E Element Separator *422A Compound Element Separator :583A Repetition Separator ^945E

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8 Acknowledgements

All 270 Claim Status Inquiry transactions submitted to the Florida Medicaid system will generate at least one acknowledgment and/or response.

8.1 Report Inventory

997 Functional Acknowledgement

The 997 Acknowledgement is used to report the result of the analysis of the inbound transactions' compliance with the HIPAA standards set out in the 5010 X12 Transaction Report, assuming the file itself is sent to the Florida Medicaid system in a readable format. The 997 will become available for retrieval within 24 hours of receipt of an uploaded batch file.

For real-time transactions, 997 Functional Acknowledgements will only be generated in cases where the originating transaction failed HIPAA compliance and the system was unable to produce a valid 271 transaction.

NOTE: The 997 will be replaced with the 999 effective June 19, 2015.

999 Functional Acknowledgement

Trading partners submitting X12 batch files through Florida Medicaid's CORE Safe Harbour connection will instead receive a 999 Functional Acknowledgement.

TA1 Acknowledgment

The TA1 Acknowledgement is generated when the submitted file contains errors in the Header- Trailer logic (ISA-IEA), causing the file itself to fail before it reaches the EDI system. When a TA1 Acknowledgement is generated, the system will not generate a 997, 999 or a 271 response.

271 Health Care Eligibility Response Transaction

The 271 Eligibility Response files are generated when a submitted 270 file completely passes the HIPAA compliance checks performed by Florida Medicaid's EDI system. Compliance for Health Care Eligibility transactions are performed on a batch level. If any transaction within the batch fails compliance, the system considers the entire batch as a failed file and will not generate a 271 Response.

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9 Trading Partner Agreements

9.1 Trading Partners

A Trading Partner is defined as any entity (providers, billing services, software vendors, clearinghouses, etc) that has an agreement with the payer to transmit electronic data files to, or receive electronic data files from, Florida Medicaid.

For Florida Medicaid's purposes, any provider that transmits their electronic files directly to the payer (i.e., via the Secure Web Portal) can be considered their own Trading Partner.

To register as a Trading Partner with Florida Medicaid, an entity representative must complete the EDI agreement available for download from Florida Medicaid's public website and submit it to the appropriate address.

The EDI agreement specifies which electronic transactions the submitter wishes to be able to submit and receive from Florida Medicaid.

The agreement also allows Medicaid Providers to assign existing Trading Partners to their profile, giving these entities the right to submit electronic files to Florida Medicaid on their behalf.

Florida Medicaid EDI Agreement:

http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/EDI%20REGISTRATION/ Electronic%20Data%20Interchange%20Agreement_01102012.pdf.

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10 270 Health Care Eligibility Inquiry – Transaction Specific Information

This section specifies X12N 270 fields for which Florida Medicaid has specific requirements.

270 Health Care Eligibility Request and Response Page Loop ID Reference Name Codes/Value Notes/Comments 61 N/A BHT Beginningof Hierarchal Transaction 62 N/A BHT02 HierarchalStructure 13 13 – Request Code 64 HL Information Source Level 65 2000A HL01 HierarchicalID 1Hierarchical ID Number Number 65 2000A HL03 Hierarchical Level 20 Information Source Code 66 2000A HL04 HierarchicalChild 1 Additional subordinate HL Code data segment exists in this hierarchical structure 67 2100A NM1 Information Source Name 68 2100A NM102 EntityType 2Non-Person Entity Qualifier 68 2100A NM103 Last Nameor See Note ‘STATE OF FLORIDA Organization Name MEDICAID’ 69 2100A NM108 IdentificationCode PI Payer Identification Qualifier 69 2100A NM109 IdentificationCode 77027 Florida Medicaid Payer ID 70 2000B HL Information Receiver Level 71 2000B HL01 HierarchicalID 2 Hierarchical ID number Number 71 2000B HL02 Hierarchical Parent 1ParentID number ID Number 72 2000B HL03 Hierarchical Level 21 Information Source Code 72 2000B HL04 HierarchicalChild 1 Additional subordinate HL Code data segment in structure

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270 Health Care Eligibility Request and Response Page Loop ID Reference Name Codes/Value Notes/Comments 73 2100B NM1 Information Receiver Name 73 2100B NM101 EntityIdentifier 1P Provider Code 75 2100B NM108 IdentificationCode SV, XX SV – Service Provider Qualifier Number XX - NPI 76 2100B NM109 IdentificationCode If NM108 = SV, then Florida Medicaid Provider ID If NM108 = XX, then NPI 80 2100B N4 Information Receiver City, State, ZIP Code 81 2100B N403 Postal Code Information Receiver ZIP Code+4 82 2100B PRV Provider Specialty Information Qualifier (Taxonomy Code) 82 2100B PRV01 Provider Code Provider Code 83 2100B PRV02 Reference PXC Health Care Provider Identification Code Taxonomy Code 83 2100B PRV03 Reference Provider’s Taxonomy Code Identification Subscriber Level Note: For Florida Medicaid, the insured and the patient are always the same person. Use this HL segment to identify the recipient and proceed to Loop 2110C. Do not send the Dependent Level (Loop 2000D). Inquiries received with the 2000D Loop may not process correctly. 84 2000C HL Subscriber Level 86 2000C HL01 HierarchicalID 3Hierarchical ID Number Number 86 2000C HL02 Hierarchical Parent 2Parent ID Number. ID Number 87 2000C HL03 Hierarchical Level 22 Subscriber Code 87 2000C HL04 HierarchicalChild 0 No subordinate HL Segment Code in structure Subscriber Information Note: Florida Medicaid can perform eligibility inquiries with different combinations of information. Each of those methods is outlined below.

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270 Health Care Eligibility Request and Response Page Loop ID Reference Name Codes/Value Notes/Comments Eligibility Inquiry by Recipient ID 90 2100C NM1 Subscriber Name 90 2100C NM101 EntityIdentifier IL Insured or Subscriber Code 91 2100C NM102 EntityType 1Person Qualifier 93 2100C NM108 IdentificationCode MI Member Identification Qualifier Number 94 2100C NM109 IdentificationCode Florida Recipient 10-digit Medicaid ID Eligibility Inquiry by Card Control ID Number 95 2100C REF Subscriber Additional Identification 96 2100C REF01 Reference HJ Identity Card Number Identification Qualifier 97 2100C REF02 Reference Card Control Number Identification Eligibility Inquiry by Name, Date of Birth and Gender 90 2100C NM1 Subscriber Name 90 2100C NM101 EntityIdentifier IL Insured or Subscriber Code 91 2100C NM102 EntityType 1Person Qualifier 91 2100C NM103 NameLastor Recipient’s Last Name Organization Name 91 2100C NM104 Name First Recipient’s First Name 105 2100C DMG Subscriber Demographic Information 106 2100C DMG01 Date / Time Period D8 Date expressed as Format Qualifier CCYYMMDD 106 2100C DMG02 Date / Time Period Recipient Birth Date 107 2100C DMG03 Gender Code M, F Recipient’s Gender Eligibility Inquiry by Name and Social Security Number 90 2100C NM1 Subscriber Name 90 2100C NM101 EntityIdentifier IL Insured or Subscriber Code

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270 Health Care Eligibility Request and Response Page Loop ID Reference Name Codes/Value Notes/Comments 91 2100C NM102 EntityType 1Person Qualifier 91 2100C NM103 NameLastor Recipient’s Last Name Organization Name 91 2100C NM104 Name First Recipient’s First Name 95 2100C REF Subscriber Additional Identification 96 2100C REF01 Reference SY Social Security Number Identification Qualifier 97 2100C REF02 Reference Recipient’s Social Security Identification Number

Eligibility Inquiry by Social Security Number and Date of Birth 90 2100C NM1 Subscriber Name 90 2100C NM101 EntityIdentifier IL Insured or Subscriber Code 91 2100C NM102 EntityType 1Person Qualifier 95 2100C REF Subscriber Additional Identification 96 2100C REF01 Reference SY Social Security Number Identification Qualifier 97 2100C REF02 Reference Recipient’s Social Security Identification Number 105 2100C DMG Subscriber Demographic Information 106 2100C DMG01 Date / Time Period D8 Date expressed as Format Qualifier CCYYMMDD 106 2100C DMG02 Date / Time Period Recipient’s Birth Date Note: The DTP (Subscriber Date) segment in the 2100C loop can be included in any of the above documented inquiries. It is, however, required when performing an inquiry by recipient Name, Date of Birth and Gender. In other cases, if a date of service is not submitted on the inquiry, the date of submission is used as the requested date of service. 121 2100C DTP Subscriber Date

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270 Health Care Eligibility Request and Response Page Loop ID Reference Name Codes/Value Notes/Comments 122 2100C DTP01 Date / Time 291 Plan Date Qualifier 122 2100C DTP02 Date / Time Period D8, RD8 D8 – single date: Format Qualifier CCYYMMDD RD8 – Date range: CCYYMMDD- CCYYMMDD 122 2100C DTP03 Date / Time Period Date or date range in the format indicated in DTP02 123 2110C EQ Subscriber Benefit or Eligibility Inquiry 124 2110C EQ01 Service Type Code See Notes For a list of valid codes, please see “Appendices” on page A- 1.

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271 Health Care Eligibility Response – Transaction Specific Information

This section specifies X12N 271 fields for which Florida Medicaid has specific requirements.

271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 211 BHT Beginning of Hierarchical Transaction 211 BHT BHT02 TransactionSet - Response Purpose Code 213 2000A HL Information Source Level 214 2000A HL01 HierarchicalID 1 HierarchicalID Number 214 2000A HL03 Hierarchical 20 InformationSource Level Code 214 2000A HL04 Hierarchical 1 Additional subordinate HL data Child Code segments exist in this structure 215 2000A AAA Request Validation 215 2000A AAA01 Yes/No NNo Condition or Response Code 216 2000A AAA03 RejectReason 42 Unable to respond at current time Code 218 2100A NM1 Information Source Name 219 2100A NM103 NameLastor See ‘STATE OF FLORIDA Organization Notes MEDICAID’ Name 220 2100A NM108 Identification PI PayerIdentifier Code Qualifier 220 2100A NM109 Identification 77027 Florida Medicaid Electronic Payer Code ID 229 2000B HL Information Receiver Level 230 2000B HL01 HierarchicalID 2 HierarchicalID Number

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 230 2000B HL02 Hierarchical 1ParentIDNumber Parent ID Number 231 2000B HL03 Hierarchical 21 InformationReceiver Level Code 231 2000B HL04 Hierarchical 1 Additional subordinate HL data Child Code segments exist in this structure 232 2100B NM1 Information Receiver Name 234 2100B NM108 Identification SV, XX SV – Florida Medicaid Provider Code Qualifier ID number XX - NPI 235 2100B NM109 Identification See If anNPIexists for a valid Service Code notes Provider Number, the NPI is returned even when the Florida Medicaid Provider Number was used in the 270 request. 238 2100B AAA Request Validation 238 2100B AAA01 Yes / No NNo Condition or Response Code 239 2100B AAA03 RejectReason 50,51 – Provider ineligible for Code inquiries – Provider not on file 243 2000C HL Subscriber Level 244 2000C HL01 HierarchicalID 3Hierarchical ID Number Number 244 2000C HL02 Hierarchical Parent ID number (varies based on Parent ID responses place in batch) Number 245 2000C HL03 Hierarchical 22 Subscriber Level Code 245 2000C HL04 Hierarchical 0 No subordinate HL segments in Child Code structure Repeating Segment: TRN (Subscriber Trace Number) Note: The TRN segment in the 2000C loop can repeat up to two times in a 271 response TRN Segment - First Repetition Echo Trace Number Submitted in 270

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 246 2000C TRN Subscriber Trace Number 247 2000C TRN01 Trace Type 1 Current Transaction Trace Code Numbers 248 2000C TRN02 Reference See This is equal to the value in the Identification notes 2000C - TRN02 data element received on the 270. 248 2000C TRN03 Originating See This is equal to the value in the Company notes 2000C – TRN03 data element Identifier received on the 270. TRN Segment - Second Repetition FMMIS Assigned Trace Number 246 2000C TRN Subscriber Trace Number 247 2000C TRN01 Trace Type 1 Current Transaction Trace Code Numbers 248 2000C TRN02 Reference See Sender assigned trace number Identification notes 248 2000C TRN03 Originating ‘97702 OriginatingCompany (FMMIS) Company 7’ identifier Identifier Repeating Segment: REF (Subscriber Additional Information) Note: The REF segment in the 2100C loop can repeat up to five times in a 271 response REF Segment - First Repetition Patient Account Number 253 2100C REF Subscriber Additional Information 254 2100C REF01 Reference EJ Patient Account Number Identification Qualifier REF Segment - Second Repetition Social Security Number 253 2100C REF Subscriber Additional Information 254 2100C REF01 Reference SY Social Security Number Identification Qualifier REF Segment - Third Repetition Medicare HIC

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 253 2100C REF Subscriber Additional Information 254 2100C REF01 Reference F6 Health Insurance Claim (HIC) Identification Number Qualifier REF Segment - Fourth Repetition Card Control Number 253 2100C REF Subscriber Additional Information 254 2100C REF01 Reference HJ Identity Card number Identification Qualifier REF Segment - Fifth Repetition Previous ID Note: This particular repetition is returned if an old / out-of-date Medicaid recipient ID or Card Control Number is used on the submitted 270 eligibility request. 253 2100C REF Subscriber Additional Information 254 2100C REF01 Reference NQ Previous ID. Identification Qualifier 262 2100C AAA Request Validation 262 2100C AAA01 Yes/No NNo Condition or Response Code 263 2100C AAA03 RejectReason See the appendix: “AAA Error Code Codes” on page A-6 for a list of possible values 268 2100C DMG Subscriber Demographic Information 269 2100C DMG02 Date Time See Recipient Date of Birth Period notes 284 2100C DTP Subscriber Date 284 2100C DTP01 Date / Ti me 102 Card Issue Date Qualifier

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 285 2100C DTP02 Date / Ti me D8 Date should be expressed in Period Qualifier format: CCYYMMDD Repeating Loop Begins: Subscriber Eligibility or Benefit Information The Eligibility Information Loop (2110C) may repeat in a 271 response. In each repetition, multiple service codes will be returned in EB03 (where applicable). Each service code in this data element will be separated by the caret symbol (^), as specified by the 5010 X12 formatting rules. Loop 2110C - First Repetition Medicaid Eligibility Information 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or 1, 6, C 1 – Active Coverage 6 – Inactive Benefit (the recipient was found in the Information database, but has no active Code coverage) C – Deductible Information 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 30 Health Benefit Plan Coverage Code 299 2110C EB04 InsuranceType MC Medicaid Code 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 300 2110C EB06 TimePeriod 25, 29 “25” – Base Deductible Qualifier “29” – Deductible Remaining Note: Included only if EB 01= “C” 301 2110C EB07 Monetary Deductible Amount Amount Note: Included only if EB01= “C” 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 318 2110C DTP02 Date Time RD8 RD8 – Range of dates is expressed Period Format in format CCYYMMDD- Qualifier CCYYMMDD 318 2110C DTP03 Date Time See Date(s) of service, expressed in the Period Notes format CCYYMMDD- CCYYMMDD Loop 2110C - Second Repetition QMB (Qualified Medicare Beneficiary) 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or 1, 6 1 – Active Coverage Benefit 6 – Inactive (the recipient was Information found in the database, but has no Code active coverage). 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 30 Health Benefit Plan Coverage Code 299 2110C EB04 InsuranceType QM QualifiedMedicare Beneficiary Code 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 301 2110C EB07 Monetary If EB01=’1’ this containsthe Amount deductible amount. 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier 318 2110C DTP02 Date Time RD8 RD8 – Range of dates is expressed Period Format in format CCYYMMDD- Qualifier CCYYMMDD

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 318 2110C DTP03 Date Time See Date(s) of service, expressed in the Period Notes format CCYYMMDD- CCYYMMDD Loop 2110C - Third Repetition Medicare Part A 290 2110C Subscriber Eligibility or Benefit Information 292 2110C Eligibility or 1, 6 1 – Active Coverage Benefit 6 – Inactive (the recipient was Information found in the database, but has no Code active coverage) C – Deductible Information 293 2110C Coverage Level IND Individual Code 294 2110C Service Type 30 Health Benefit Plan Coverage Code 299 2110C Insurance Type MA Medicare Part A Code 300 2110C Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 300 2110C EB06 TimePeriod 25, 29 “25” – Base Deductible Qualifier “29” – Deductible Remaining Note: Included only if EB01= “C” 301 2110C EB07 Monetary Deductible Amount Amount Note: Included only if EB01= “C” 317 2110C Subscriber Eligibility/ Benefit Date 317 2110C Date / Time 307 Eligibility Qualifier 318 2110C Date Time RD8 RD8 – Range of dates is expressed Period Format in format CCYYMMDD- Qualifier CCYYMMDD

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 318 2110C Date Time See Date(s) of service, expressed in the Period Notes format CCYYMMDD- CCYYMMDD Loop 2110C – Fourth Repetition Medicare Part B 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or 1, 6 1 – Active Coverage Benefit 6 – Inactive (the recipient was Information found in the database, but has no Code active coverage) 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 30 Health Benefit Plan Coverage Code 299 2110C EB04 InsuranceType MB MedicareB Code 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 301 2110C EB07 Monetary If EB01=’1’ this containsthe Amount deductible amount. 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier 318 2110C DTP02 Date Time RD8 RD8 – Range of dates is expressed Period Format in format CCYYMMDD- Qualifier CCYYMMDD 318 2110C DTP03 Date Time See Date(s) of service, expressed in the Period Notes format CCYYMMDD- CCYYMMDD

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value Loop 2110C - Fifth Repetition Third Party Liability 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or R Other or additional payer Benefit Information Code 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 30 Health Benefit Plan Coverage Code 299 2110C EB04 InsuranceType C1 Commercial Code 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 314 2110C REF Subscriber Additional Identification 315 2110C REF01 Reference IL, 18 IL – Group or Policy Number Identification 18 – Plan Number Qualifier 316 2110C REF02 Reference See Subscriber’seligibility or benefit Identification Notes number 316 2110C REF03 Description See Plan Sponsor Name Notes 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 318 2110C DTP02 Date Time RD8 RD8 – Range of dates is expressed Period Format in format CCYYMMDD- Qualifier CCYYMMDD 318 2110C DTP03 Date Time See Date(s) of service, expressed in the Period Notes format CCYYMMDD- CCYYMMDD 328 2110C LS Loop Header 328 2110C LS01 Loop Header 2120 Identifier of nested loop 329 2120C NM1 Subscriber Benefit Related Entity Name 330 2120C NM101 EntityIdentifier IL Subscriber Code 331 2120C NM102 Entity Type 1Person Qualifier 346 2110C LE Loop Trailer 346 2110C LE01 Loop Identifier 2110 Identifier of nested loop Code Loop 2110C - Sixth Repetition Lock-In 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or 1, 6 1 – Active Coverage Benefit 6 – Inactive (the recipient was Information found in the database, but has no Code active coverage) 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 30 Health Benefit Plan Coverage Code 299 2110C EB04 InsuranceType OT Other Code

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier 318 2110C DTP02 Date Time RD8 Range of dates is expressed in Period Format format CCYYMMDD- Qualifier CCYYMMDD 318 2110C DTP03 Date Time See Date(s) of service, expressed in the Period Notes format CCYYMMDD- CCYYMMDD 328 2110C LS Loop Header 328 2110C LS01 Loop Header 2120 Identifier of nested loop 329 2120C NM1 Subscriber Benefit Related Entity Name 330 2120C NM101 EntityIdentifier 1P Provider Code 331 2120C NM102 Entity Type 1, 2 – Person Qualifier – Non-Person 340 2120C PER Subscriber Benefit Related Entity Contact Information 340 2120C PER01 Contact IC InformationContact Function Code 341 2120C PER03 Communication TE TelephoneNumber Number Qualifier 341 2120C PER04 Communication See Contact Telephone Number Number Notes 346 2110C LE Loop Trailer

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 346 2110C LE01 Loop Identifier 2110 Identifier of nested loop Code Loop 2110C - Seventh Repetition Hearing 292 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or FLimitations Benefit Information Code 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 71 AudiologyExam Code 299 2110C EB04 InsuranceType MC Medicaid Code 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 317 2110C Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 472 Date of Service Qualifier 318 2110C DTP02 Date Time RD8 Date range expressed in format Period Format CCYYMMDD-CCYYMMDD Qualifier 318 2110C Date Time See Date(s) expressed in the format Period notes indicated in DTP02 Loop 2110C - Eighth Repetition Vision

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or FLimitations Benefit Information Code 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type AL Optometry Code 299 2110C EB04 InsuranceType MC Medicaid Code 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 300 2110C EB06 Time Period 21 Years Qualifier 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 472 Date of Service Qualifier 318 2110C DTP02 Date Time RD8 Date range expressed in format Period Format CCYYMMDD-CCYYMMDD Qualifier 318 2110C DTP03 Date Time See Date(s) expressed in the format Period notes indicated in DTP02 290 2110C EB Subscriber Eligibility or Benefit Information

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 292 2110C EB01 Eligibility or DBenefitDescription Benefit Information Code 293 2110C EB02 CoverageLevel IND Individual Code 294 EB03 Service Type 68 Well Baby Care Code 299 EB04 Insurance Type MC Medicaid Code 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 472 Date of Service Qualifier 318 2110C DTP02 Date Time D8 Date of service is expressed in Period Format format CCYYMMDD Qualifier 318 2110C DTP03 Date Time See Date expressed in format Period notes CCYYMMDD Loop 2110C - Tenth Repetition Hospice 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or 1, F,CB 1 – Active Coverage Benefit F – Limitations Information CB – Coverage Basis Code 293 2110C EB02 CoverageLevel IND Individual Code

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 294 2110C EB03 Service Type 45 Hospice Code 299 2110C EB04 InsuranceType MC Medicaid Code 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 300 2110C EB06 Time Period 29 Remaining Qualifier 302 2110C EB09 Quantity DY Days Qualifier 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier 318 2110C DTP02 Date Time RD8 Date range is expressed in format Period Format CCYYMMDD-CCYYMMDD Qualifier 318 2110C DTP03 Date Time See Date range expressed in the format Period notes CCYYMMDD-CCYYMMDD Loop 2110C - Eleventh Repetition Managed Care 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or L, MC PrimaryCare Provider Benefit ‘MC’ – MCO, entity Information ‘L’ – PCP, individual Code 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 96 Professional(Physician) Code

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 299 2110C EB04 InsuranceType MC Medicaid Code 300 2110C EB05 Plan Coverage See One of the following occur: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier 318 2110C DTP02 Date Time RD8 Date range is expressed in format Period Format CCYYMMDD-CCYYMMDD Qualifier 318 2110C DTP03 Date Time See Date range expressed in the format Period notes CCYYMMDD-CCYYMMDD 328 2110C LS Loop Header 328 2110C LS01 Loop Header 2120 Identifier of nested loop 330 2120C NM1 Subscriber Benefit Related Entity Name 330 2120C NM101 EntityIdentifier 1P Provider Code 331 2120C NM102 Entity Type 1, 2 – Person Qualifier – Non-Person 340 2120C PER Subscriber Benefit Related Entity Contact Information 340 2120C PER01 Contact IC InformationContact Function Code 341 2120C PER03 Communication TE TelephoneNumber Number Qualifier 341 2120C PER04 Communication See Contact Telephone Number Number Notes 346 2110C LE Loop Trailer

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 346 2110C LE01 Loop Trailer 2120 Identifier of nested loop Loop 2110C - Twelfth Repetition Waiver 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or 1, 6 1 – Active Coverage Benefit 6 – Inactive (the recipient was Information found in the database, but has no Code active coverage) 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 30 Health Benefit Plan Coverage Code 299 2110C EB04 InsuranceType MC Medicaid Code 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier 318 2110C DTP02 Date Time RD8 Date range is expressed in format Period Format CCYYMMDD-CCYYMMDD Qualifier 318 2110C DTP03 Date Time See Date range expressed in theformat Period notes CCYYMMDD-CCYYMMDD Loop 2110C - Thirteenth Repetition MEDIKIDS 290 2110C EB Subscriber Eligibility or Benefit Information

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 292 2110C EB01 Eligibility or 1, 6 1 – Active Coverage Benefit 6 – Inactive (the recipient was Information found in the database, but has no Code active coverage) 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 30 Health Benefit Plan Coverage Code 299 2110C EB04 InsuranceType OT Other Code 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier 318 2110C DTP02 Date Time RD8 Date range is expressed in format Period Format CCYYMMDD-CCYYMMDD Qualifier 318 2110C DTP03 Date Time See Date range expressed in the format Period notes CCYYMMDD-CCYYMMDD Loop 2110C - Fourteenth Repetition Dental 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or FLimitations Benefit Information Code 293 2110C EB02 CoverageLevel IND Individual Code

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 294 2110C EB03 Service Type 39 Prosthodontics Code 299 2110C EB04 InsuranceType MC Medicaid Code 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 300 2110C EB06 Time Period 21 Years Qualifier 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 472 Dates of Service Qualifier 318 2110C DTP02 Date Time RD8 Date range is expressed in format Period Format CCYYMMDD-CCYYMMDD Qualifier 318 2110C DTP03 Date Time See Date range expressed in theformat Period notes CCYYMMDD-CCYYMMDD Loop 2110C - Fifteenth Repetition Home Health 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or FLimitations Benefit Information Code 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 44 Home Health Visits Code 299 2110C EB04 InsuranceType MC Medicaid Code

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 300 2110C EB06 Time Period 29 Remaining Qualifier 302 2110C EB09 Quantity VS Visits Qualifier 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier 318 2110C DTP02 Date Time RD8 Date range is expressed in format Period Format CCYYMMDD-CCYYMMDD Qualifier 318 2110C DTP03 Date Time See Date range expressed in theformat Period notes CCYYMMDD-CCYYMMDD Loop 2110C - Sixteenth Repetition Inpatient Days 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or Limitations Benefit Information Code 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 48 Hospital - Inpatient Code 299 2110C EB04 InsuranceType MC Medicaid Code

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 300 2110C EB06 Time Period 29 Remaining Qualifier 302 2110C EB09 Quantity DY Days Qualifier 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier 318 2110C DTP02 Date Time RD8 Date range is expressed in format Period Format CCYYMMDD-CCYYMMDD Qualifier 318 2110C DTP03 Date Time See Date range expressed in theformat Period notes CCYYMMDD-CCYYMMDD Loop 2110 C - Seventeenth Repetition Outpatient Benefits 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or FLimitations Benefit Information Code 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 50 Hospital - Outpatient Code 299 2110C EB04 InsuranceType MC Medicaid Code

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 300 2110C EB06 Time Period 29 Remaining Qualifier 301 2110C EB07 Monetary See Remaining benefit amountfor the Amount Notes year 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier 318 2110C DTP02 Date Time RD8 Date range is expressed in format Period Format CCYYMMDD-CCYYMMDD Qualifier 318 2110C DTP03 Date Time See Date range expressed in the format Period notes CCYYMMDD-CCYYMMDD Loop 2110 C - Eighteenth Repetition Long Term Care 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or CB Coverage Basis Benefit Information Code 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 54 Long Term Care Code 299 2110C EB04 InsuranceType MC Medicaid Code

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier 318 2110C DTP02 Date Time RD8 Date range is expressed in format Period Format CCYYMMDD-CCYYMMDD Qualifier 318 2110C DTP03 Date Time See Date range expressed in the format Period notes CCYYMMDD-CCYYMMDD Loop 2110C - Nineteenth Repetition Emergency Room Visits 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or F Limitations Benefit Information Code 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 52 Hospital–Emergency Medical Code 299 2110C EB04 InsuranceType MC Medicaid Code

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271 Health Care Eligibility Request and Response Code/ Page Loop ID Reference Name Notes/Comments Value 300 2110C EB05 Plan Coverage See One of the following occurs: Description Notes EB05=Blank EB05=Description Only EB05=Category Code | Description (Note: When category code is present, it only contains four positions and is followed by | then the description.) 300 2110C EB06 Time Period 29 Remaining Qualifier 302 2110C EB09 Quantity VS VS - Visits Qualifier 302 2110C EB10 Quantity Visits remaining 317 2110C DTP Subscriber Eligibility/ Benefit Date 317 2110C DTP01 Date / Ti me 307 Eligibility Qualifier 318 2110C DTP02 Date Time RD8 Date range is expressed in format Period Format CCYYMMDD-CCYYMMDD Qualifier Loop 2110C - Twentieth Repetition MEDP / SIXT 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or 1,6 ‘1’ – Active Coverage (Recipient Benefit is enrolled in MEDP/SIXT and Information LTCC/LTCF)No coverage Code ‘6’ – Inactive (Recipient is enrolled in MEDP or SIXT but not enrolled in LTCC or LTCF) 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type 30 Health Benefit Plan Coverage Code 299 2110C EB04 InsuranceType MC Medicaid Code

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EB05= SIXT: Full Medicaid 317 2110C DTP01 Date / Ti me 291 Plan Qualifier 318 2110C DTP02 Date Time RD8 Date range is expressed in format Period Format CCYYMMDD-CCYYMMDD Qualifier Loop 2110C – Twenty-first Repetition Recipient Financial Information 290 2110C EB Subscriber Eligibility or Benefit Information 292 2110C EB01 Eligibility or A, B ‘A’ – Co-insurance Benefit ‘B’ – Co-Payment Information Code 293 2110C EB02 CoverageLevel IND Individual Code 294 2110C EB03 Service Type See For a list of the CORE-required Code Notes service codes, see “Appendices” on page A-1. 301 2110C EB07 Monetary See If EB01=’A’ this contains the Co- Amount Notes Insurance Amount relevant to the service code in EB03

If EB01=’B’ this contains the Copayment amount relevant to the service code in EB03

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Appendix A. Appendices

This section contains the appendices for the FMMIS 270/271 Batch and Interactive Health Care Eligibility and Response Transaction Companion Guide.

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A.1 Implementation Checklist

This appendix contains all necessary steps for going live with Florida Medicaid.

1. Call the EDI Help Desk with any questions at the toll-free number.

2. Check the MEUPS website for the latest updates regarding our system implementation.

3. Confirm you have a Web Portal User Name and/or Provider ID.

4. Make the appropriate changes to your systems/business processes to support the updated companion guides:

a. If you use third party software, work with your software vendor to have the appropriate software installed. b. If testing system-to-system interface, the Trading Partner or provider must work with your software vendor to have the appropriate software installed at their site(s) prior to performing testing with Florida Medicaid.

5. Identify the functions you will be testing:

a. Health Care Eligibility/Benefit Inquiry and Information Response (270/271); b. Health Care Claim Status Request and Response (276/277/277U); c. Health Care Premium Payment (820); d. Health Care Benefit Enrollment and Maintenance (834); e. Health Care Payment/Advice (835); f. Health Care Claim: Institutional (837I); g. Health Care Claim: Professional (837P); and h. Crossover/COBA Claims.

6. Confirm that you have reported all the NPIs you will use for testing by validating them with Florida Medicaid. If you have multiple Florida Medicaid provider IDs associated to one NPI and/or taxonomy code, ensure your claim(s) successfully pay to your correct Provider ID.

Note: If the entity testing is a billing intermediary or software vendor, they should use the provider's identifier on the test transaction.

7. When submitting test files, make sure the members/claims you submit are representative of the type of service(s) you provide to Florida Medicaid members.

8. Schedule a tentative week for the initial test.

9. Confirm the email/phone number of the testing contact and confirm that the person you are speaking with is the primary contact for testing purposes.

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A.2 Business Scenarios

This appendix contains typical business scenarios of 270 inquiries. The actual data streams linked to these scenarios are included in the Transmission Examples section.

An eligibility request must be submitted with one of the following criteria:

1. Recipient ID;

2. Card Control ID Number;

3. Name, Date of Birth and Gender;

4. Name and Social Security Number; and

5. Social Security Number and Date of Birth.

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A.3 Transmission Examples

Inquiry by Recipient ID

ST*270*604493536*005010X279A1~ BHT*0022*13*604491111*20120207*0659~ HL*1**20*1~ NM1*PR*2*STATE OF FLORIDA MEDICAID*****PI*77027~ HL*2*1*21*1~ NM1*1P*2*NOTRECEIVED*****XX*9999999999~ HL*3*2*22*0~ TRN*1*604493536*8888888888~ NM1*IL*1******MI*0123456789~ DTP*291*RD8*20120207‐ 20120207~ EQ*30~ SE*12*604493536~

Inquiry by Card Control ID Number

ST*270*604493536*005010X279A1~ BHT*0022*13*604491111*20120207*0659~ HL*1**20*1~ NM1*PR*2*STATE OF FLORIDA MEDICAID*****PI*77027~ HL*2*1*21*1~ NM1*1P*2*NOTRECEIVED*****XX*9999999999~ HL*3*2*22*0~ TRN*1*604493536*8888888888~ NM1*IL*1******MI*0123456789~ REF*HJ*1111111111111~ DTP*291*RD8*20120207‐ 20120207~ EQ*30~ SE*13*604493536~

Inquiry by Name, Date of Birth, and Gender ST*270*604493536*005010X279A1~ BHT*0022*13*604491111*20120207*0659~ HL*1**20*1~ NM1*PR*2*STATE OF FLORIDA MEDICAID*****PI*77027~ HL*2*1*21*1~ NM1*1P*2*NOTRECEIVED*****XX*9999999999~ HL*3*2*22*0~ TRN*1*604493536*8888888888~

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NM1*IL*1*LAST NAME*FIRST NAME~ DMG*D8*19821221*M~ DTP*291*RD8*20120207‐20120207~ EQ*30~ SE*12*604493536~

Inquiry by Name and Social Security Number ST*270*604493536*005010X279A1~ BHT*0022*13*604491111*20120207*0659~ HL*1**20*1~ NM1*PR*2*STATE OF FLORIDA MEDICAID*****PI*77027~ HL*2*1*21*1~ NM1*1P*2*NOTRECEIVED*****XX*9999999999~ HL*3*2*22*0~ TRN*1*604493536*8888888888~ NM1*IL*1*LAST NAME*FIRST NAME~ REF*SY*111111111~ DTP*291*RD8*20120207‐20120207~ EQ*30~ SE*13*604493536~

Inquiry by Social Security Number, and Date of Birth ST*270*604493536*005010X279A1~ BHT*0022*13*604491111*20120207*0659~ HL*1**20*1~ NM1*PR*2*STATE OF FLORIDA MEDICAID*****PI*77027~ HL*2*1*21*1~ NM1*1P*2*NOTRECEIVED*****XX*9999999999~ HL*3*2*22*0~ TRN*1*604493536*8888888888~ NM1*IL*1*LAST NAME*FIRST NAME~ DMG*D8*19821221*M~ REF*SY*111111111~ DTP*291*RD8*20120207‐20120207~ EQ*30~ SE*14*604493536~

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A.4 AAA Error Codes

This list includes the codes that can appear in the AAA03 data element of the 2100C loop in cases where the submitted recipient information cannot be matched to a record in the Medicaid recipient database.

The code(s) returned indicate what parts of the submitted recipient information was found to be erroneous.

AAA03 Return Code Eligibility Inquiry Response Description None An inquiryresults in avalid response on the first pass 58 Invalid / Missing Date of Birth 72 Invalid / Missing Subscriber / Insured ID 73 Invalid / Missing Subscriber / Insured Name 74 Invalid / Missing Subscriber / Insured Gender Code 75 Subscriber / Insured Not Found 76 Duplicate Subscriber / Insured ID Number

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A.5 CORE-Required Service Codes

This list contains the thirteen CORE-required service codes that may populate the EB03 (2110C loop) on a generic 271 response. All payers must return recipient financial information (co- insurance, copayment and deductible) for all of these service codes on a 271 response generated due to a generic 270 eligibility request.

Service Code Description 1 MedicalCare 30 Health Plan / Benefit Coverage 33 Chiropractic 35 DentalCare 47 Hospital 48 Hospital – Inpatient 50 Hospital – Outpatient 86 Emergency Services 88 Pharmacy 98 Professional (Physician) Visit – Office AL Vision (Optometry) MH Mental Health UC UrgentCare Note: Repetitions of the 2110C loop containing a service code of ‘30’ in EOB3 will contain relevant financial information in the EB07 of their respective segments. The other twelve service codes will be reflected in the new repetitions of the loop

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A.6 Valid Explicit Inquiry Codes

Service Code Description 1 MedicalCare 2 Surgical 4 Diagnostic X-Ray 5 Diagnostic Lab 6 Radiation Therapy 7 Anesthesia 8 Surgical Assistance 12 Durable Medical EquipmentPurchase 13 Ambulatory Service Center Facility 18 Durable Medical EquipmentRental 20 Second Surgical Opinion 33 Chiropractic 35 Dental Care 40 Oral Surgery 42 Home Health Care 45 Hospice 47 Hospital 48 Hospital – Inpatient 50 Hospital – Outpatient 51 Hospital–Emergency Accident 52 Hospital–Emergency Medical 53 Hospital – AmbulatorySurgical 62 MRI / CATScan 65 NewbornCare 68 Well Baby Care 73 Diagnostic Medical 76 Dialysis 78 Chemotherapy 80 Immunizations 81 Routine Physical 82 Family Planning 86 Emergency Services 88 Pharmacy 93 Podiatry 98 Professional (Physician) Visit – Office 99 Professional (Physician) Visit – Inpatient A0 Professional(Physician) Visit

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Service Code Description A3 Professional (Physician) Visit – Home A6 Psychotherapy A7 Psychiatric – Inpatient A8 Psychiatric – Outpatient AD Occupational Therapy AE Physical Medicine AF Speech Therapy AG Skilled NursingCare AI Substance Abuse AL Vision (Optometry) BG Cardiac Rehabilitation BH Pediatric MH Mental Health UC Urgent Care Note: In addition to these codes, a generic inquiry can be submitted by using “30” (Health Care Benefit Coverage).

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A.7 Frequently Asked Questions

This appendix contains a compilation of questions and answers relative to Florida Medicaid and its providers. A typical question would involve a discussion about code sets and their effective dates.

1. NOTE For SFTP submitters only: The inbound file name should not be more than 40 characters in length including the extension. If the file is received with a file name of more than 40 characters, the system will alter the inbound file name as required to process through the EDI System.

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A.8 Change Summary

Document Modified Modified By Section, Page(s) and Text Revised Version # Date 1.0 1/31/2011 Daniel GrayCreation of document-1stDraft 1.1 3/17/2011 Carl Bunche Updated version number of transaction from “005010X279” to “005010X279A1”. This change impacts the following data elements: GS08, ST03. 1.2 6/29/2011 Reid O’Kelley Removed references to Remove Access Servicer (RAS). 1.2 7/7/2011 Daniel GrayThe following change was made: Updated page number references to the 5010 Implementation Guide; Updated New/updated policy information regarding NPI in Section 8; and Removed Spenddown details from Section 8. 1.3 12/20/2011 Daniel GrayThe following changes were made: Fix / clarified errors in introduction text on page 6-1; Clarified NPI only/Medicaid ID rules for 270s on page 8-4; and Removed valid response options from 2110C loop on pages 8-5 through 8-18. 2/14/2012 Daniel Gray Corrected information pertaining to 271 responses for out-of-date recipient IDs on page 8-5. 2.0 12/28/2012 Daniel Gray Made necessary changes to support CAQH Operat- Carl Bunche ing Rules and formatting. 2.1 08/20/2013 Daniel GrayThe following changes weremade for CO 51780: • Updated text in “Valid Combinations of Subscriber Data for Eligibility Requests” on page 7-2; • Removed language pertaining to name normalization rules from the table in “270 Health Care Eligibility Inquiry – Transaction Specific Information” on page 10-1 and “Transmission Examples” on page A- 4; • Removed extraneous information pertaining to valid data combinations that can be used to request eligibility information from the list in the appendix “Business Scenarios” on page A-3; • Added chapter “271 Health Care Eligibility Response – Transaction Specific Information” on page 11-1; and • Added appendices “AAA Error Codes” on page A-6 and “CORE-Required Service Codes” on page A-7.

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Document Modified Modified By Section, Page(s) and Text Revised Version # Date 2.2 9/24/2013 Daniel GrayThe following changes weremade for CO 51780: • Changed verbiage from “Claim Status” to “Eligibility” throughout; • Updated information throughout regarding Loop 2110C; and • Added “Valid Explicit Inquiry Codes” on page A-8. 2.3 3/17/2015 Heather Lyons Updates madefor 999 Implementation. 2.4 6/8/2015 Heather Lyons • Updates made indicating SFTP contact information. • Updated FAQs to show allowed character length. 2.5 5/27/2016 Molly Marotta The following changes weremade for CO 78594:  MCO sends an ‘MC’ in EB01 ‘L’ for individual, ‘MC’ for entity

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