Standard Companion Guide for the Vision Business · PDF fileRefers to the Implementation Guide...

Standard Companion Guide for the Vision Business Segment

Refers to the Implementation Guide Based on

X12 Version 005010X222A1 Health Care Claim: Professional (837)

Unsolicited Claim Acknowledgement: (277CA)

HIPAA 5010 Companion Guide Version Number: 1.0

March 27, 2011

Twhriitstemnapteee rmiailsisss iopnroovifdUenditoendHtheearltehcciaprieeenist’sparoghreibeimteden. t that it will only be used for thPeapguer1poosfe4o1f describing

written permission of UnitedHealthcare is prohibited. Page 2 of 41

UnitedHealthcare's products and services to the recipient. Any other use, copying or distribution without the express


Change Log

Version Release date Changes

1.0 03/27/2011 Initial Draft

1.1 2/16/2012 837 Transaction Specific Detail clarification

This material is provided on the recipient's agreement that it will only be used for the purpose of describing UnitedHealthcare's products and services to the recipient. Any other use, copying or distribution without the express

HIPAA 837 Professional Claims & 277 Unsolicited

Claim Acknowledgement Companion Guide

This material is provided on the recipient’s agreement that it will only be used for the purpose of describing UnitedHealthcare’s products and services to the recipient. Any other use, copying or distribution without the express


Preface

This companion guide (CG) to the Technical Report Type 3 (TR3) adopted under HIPAA clarifies

and specifies the data content when exchanging transactions electronically with

UnitedHealthcare. Transactions based on this companion guide, used in tandem with the TR3,

also called Health Care Claim: Professional (837) ASC X12N/005010X222A1, are compliant with

both X12 syntax and those guides. This companion guide is intended to convey information that

is within the framework of the TR3 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 TR3.





Table of Contents

1. I

1.1.

TRODUCTION............................................................................................................ 5

SCOPE .................................................................................................................. 5

1.2. OVERVIEW ........................................................................................................... 6

1.3. REFERENCE ........................................................................................................ 6

1.4. ADDITIONAL INFORMATION............................................................................... 6

2. GETTING STARTED ..................................................................................................... 7

2.1. WORKING WITH UNITEDHEALTHCARE ............................................................ 7

2.2. TRADING PARTNER REGISTRATION ................................................................ 7

2.3. CERTIFICATION AND TESTING OVERVIEW ..................................................... 7

3.

2.4. TESTING WITH THE UNITEDHEALTHCARE ...................................................... 7 CONNECTIVITY WITH THE PAYER / COMMUNICATIONS ....................................... 8

3.1. PROCESS FLOW S ............................................................................................... 8

3.2. RE-TRANSMISSION PROCEDURE ..................................................................... 8

3.3. COMMUNICATION PROTOCOL SPECIFICATIONS ........................................... 8

3.4. PASSWORDS ....................................................................................................... 9

3.5. SYSTEM AVAILABILITY ....................................................................................... 9

4.

3.6. COSTS TO CONNECT ......................................................................................... 9 CONTACT INFORMATION ........................................................................................... 9

4.1. EDI BUSINESS CONTACT ................................................................................... 9

4.2. EDI TECHNICAL ASSISTANCE ........................................................................... 9

4.3. CUSTOMER SERVICE NUMBER ...................................................................... 10

4.4. APPLICABLE W EBSITES / E-MAIL .................................................................... 10

5. C ONTROL SEGMENTS / ENVELOPES ..................................................................... 10

5.1. ISA-IEA ................................................................................................................ 10

5.2. GS-GE ................................................................................................................. 11

5.3. ST-SE .................................................................................................................. 11

5.4. CONTROL SEGMENT HIERARCHY .................................................................. 12

5.5. CONTROL SEGMENT NOTES........................................................................... 12

5.6. FILE DELIMITERS .............................................................................................. 12

6. ACKNOWLEDGEMENTS AND OR REPORTS .......................................................... 13

6.1. REPORT INVENTORY........................................................................................ 13

7. TRADING PARTNER AGREEMENTS ........................................................................ 13

7.1. TRADING PARTNERS ........................................................................................ 13

8. TRANSACTION SPECIFIC INFORMATION ............................................................... 13

8.1. 837P – Professional Claim Transaction Set Detail ............................................ 13

8.2. 277CA - Claim Acknowledgement Transaction Set Detail .................................. 38

8.3. 999 Implementation Acknowledgement Transaction Set Detail .......................... 38

9. APPENDECIES........................................................................................................... . 38

9.1. IMPLEMENTATION CHECKLIST ....................................................................... 38

9.2. BUSINESS SCENARIOS .................................................................................... 39

9.3. TRANSMISSION EXAMPLES............................................................................. 39

9.4. FILE NAMING CONVENTIONS .......................................................................... 39

Platform 999 ACK File Names-examples ............................................................................. 39

Platform 277 ACK File Names-examples ............................................................................. 39

9.5. FREQUENTLY ASKED QUESTIONS ................................................................. 40





1. INTRODUCTION

This section describes how Technical Report Type 3 (TR3) Professional (837) ASC

X12N/005010X222A1, also called Health Care Claim, adopted under HIPAA, will be detailed with

the use of a table. The tables contain a row for each segment that UnitedHealthcare has

something additional, over and above, the information in the TR3. That information can:

1. Limit the repeat of loops, or segments

2. Limit the length of a simple data element

3. Specify a sub-set of the TR3’s internal code listings

4. Clarify the use of loops, segments, composite and simple data elements

5. Any other information tied directly to a loop, segment, and composite or simple data element

pertinent to trading electronically with UnitedHealthcare

In addition to the row for each segment, one or more additional rows are used to describe

UnitedHealthcare’s usage for composite and simple data elements and for any other information.

Notes and comments have been placed at the deepest level of detail. For example, a note about

a code value has been placed on a row specifically for that code value.

The following table specifies the columns and suggested use of the rows for the detailed

description of the transaction set companion guides. The table contains a row for each segment

that UnitedHealthcare has something additional, over and above, the information in the TR3. The

following is just an example of the type of information that would be spelled out or elaborated on

in: Section 8 – Transaction Specific Information.

TR3

Page#

Loop ID Reference Name Codes Length Notes/Comments

74 1000A NM1 Submitter

Name This type of row always exists to

indicate that a new segment has

begun. It is always shaded at

10% and notes or comment

about the segment itself goes in

this cell.

122 2100BA NM109 Subscriber

Primary

Identifier

15 This type of row exists to limit

the length of the specified data

element.

226 2300 HI01-2 Code List

Qualifier

Code

BK This row illustrates how to

indicate a component data

element in the Reference

column and also how to specify

that only one code value is

applicable.

1.1. SCOPE





This document is to be used for the implementation of the Technical Report Type 3 (TR3)

HIPAA 5010 Health Care Claim: Professional (837) (referred to Professional Claim in the rest

of this document) and the Unsolicited Claim Acknowledgement (277CA) for the purpose of

submitting Professional Claim(s) electronically and receiving a Claim Acknowledgement

response. This companion guide (CG) is not intended to replace the TR3.

1.2. OVERVIEW

This CG will replace, in total, the previous UnitedHealthcare Vision business segment CG

versions for Health Care Professional Claim and must be used in conjunction with the TR3

instructions. The CG is intended to assist you in implementing electronic Professional Claim

that meet UnitedHealthcare processing standards, by identifying pertinent structural and data

related requirements and recommendations.

1.3. REFERENCE

For more information regarding the ASC X12 Standards for Electronic Data Interchange

Health Care Claim: Professional (837) ASC X12N/005010X222A1 and to purchase copies of

the TR3 documents, consult the Washington Publishing Company web site at

http://www.wpc-edi.com/.

1.4. ADDITIONAL INFORMATION

The American National Standards Institute (ANSI) is the coordinator for information on

national and international standards. In 1979 ANSI chartered the Accredited Standards

Committee (ASC) X12 to develop uniform standards for electronic interchange of business

transactions and eliminate the problem of non-standard electronic data communication. The

objective of the ASC X12 committee is to develop standards to facilitate electronic

interchange relating to all types of business transactions. The ANSI X12 standards is

recognized by the United States as the standard for North America. Electronic Data

Interchange (EDI) adoption has been proved to reduce the administrative burden on

providers.

http://www.wpc-edi.com/





2. GETTING STARTED

2.1. WORKING WITH UNITEDHEALTHCARE

There are three methods to connect with UnitedHealthcare for submitting and receiving EDI

transactions using direct connection or through a clearinghouse.

Clearinghouse Connection:

Physicians and Healthcare professionals should contact their current clearinghouse vendor to

discuss their ability to support the Professional Claim transaction, as well as associated

timeframe, costs, etc.

Direct Connection:

Direct connection to UnitedHealthcare is available via FTP with PGP encryption. With PGP

Encryption, UnitedHealthcare will also require the trading partner PGP key. If you are

interested in this type of direct connection, please contact our EDI Operations via email at

[email protected]

2.2. TRADING PARTNER REGISTRATION



discuss their ability to support the Professional Claim transaction.

Direct Connection:

A signed User Agreement to exchange EDI data is not required for direct connectivity set up.

2.3. CERTIFICATION AND TESTING OVERVIEW

UnitedHealthcare does not certify Providers or Clearinghouses.

2.4. TESTING WITH THE UNITEDHEALTHCARE



discuss testing.

Direct Connection:

If you wish to test the Professional Claim transaction in UnitedHealthcare’s testing region

please contact [email protected]

If there is a connection issue (e.g. password failure, no response), please contact 888-848-

3375 to open a ticket. Please have the ticket assigned to UnitedHealthcare Vision workgroup

and include your FTP login user name (DO NOT INCLUDE YOUR PASSWORD).

mailto:[email protected]






3. CONNECTIVITY WITH THE PAYER / COMMUNICATIONS

3.1. PROCESS FLOWS

Batch Professional Claim:

Claims

File

837P

Provider or

Provider

Clearinghouse

1st

Level

999 UnitedHealthcare

Vision

2

nd Level

277 ACK

3.2. RE-TRANSMISSION PROCEDURE

For sections 3.2 – 3.5, Physicians and Healthcare professionals should contact their current

clearinghouse vendor for information on the most current process.

3.3. COMMUNICATION PROTOCOL SPECIFICATIONS



discuss communication protocol specifications.

Direct Connection:

Direct connection supports the following communication methods:

FTP with PGP for batch

FTP

UnitedHealthcare will provide PGP encryption key.

SFTP

FTP user id and password information will be provided by UnitedHealthcare.





3.4. PASSWORDS



discuss testing.

Direct Connection:

Passwords for direct connection will be sent via secure e-mail.

3.5. SYSTEM AVAILABILITY

UnitedHealthcare will accept 837 claim transaction submissions at any time, 24 hours per

day/7 days a week. No changes to current system availability are expected.

Any scheduled or unplanned outages will be communicated via email.

3.6. COSTS TO CONNECT



discuss costs.

Direct Connection:

There is no cost imposed on the trading partners by UnitedHealthcare to set-up or use direct

connectivity.

4. CONTACT INFORMATION

4.1. EDI BUSINESS CONTACT

Clearinghouse

If you have questions related to transactions submitted through a clearinghouse please

contact your clearinghouse vendor.

Direct Connection

Email - [email protected]

4.2. EDI TECHNICAL ASSISTANCE

Clearinghouse

If you have technical questions related to transactions submitted through a clearinghouse

please contact your clearinghouse vendor.

Direct Connection

Email - [email protected]







Page Loop

Id

Reference

Name

Codes

Length

Notes/Comments

C.3

ISA

INTERCHANGE

CONTROL

HEADER

C.4

ISA01

Authorization

Information

Qualifier

00

ID – 2/2

00 = No

authorization

information present

C.4

ISA03

Security

Information

Qualifier

00

ID – 2/2

00 = No security

information present

C.4

ISA05 Interchange ID

Qualifier

ZZ or 30

ID – 2/2 ZZ = Mutually

Defined

C.4

ISA06

Interchange

Sender ID

Client/TPA to

UHC Vision =

User defined

value

AN –

15/15

Interchange Sender

ID. Left justify and

pad with spaces to

15 characters.

C.5

ISA07 Interchange ID

Qualifier

ZZ

ID – 2/2 ZZ = Mutually

Defined

C.5

ISA08 Interchange

Receiver ID

Client/TPA to

UHC Vision =

AN –

15/15

Receiver ID. Left

justify and pad with

4.3. CUSTOMER SERVICE NUMBER

Customer Service should be contacted at 866-644-3414 instead of EDI Operations if you

have questions regarding the details claim status. Customer Service is available Monday –

Friday 7 a.m. to 10 p.m. and Saturday 8 a.m. to 5:30 p.m.

4.4. APPLICABLE WEBSITES / E-MAIL

Please visit the following web sites for more details:

General HIPAA Information – http://aspe.hhs.gov/admnsimp/

General HIPAA Information – http://hipaadvisory.com/

FAQ’s about Transactions – http://aspe.hhs.gov/admnsimp/faqtx.htm

FAQ’s about Code Sets – http://aspe.hhs.gov/admnsimp/faqcode.htm

Ordering Implementation Guides (AKA File Layouts) - http://www.wpc-

edi.com/hipaa/HIPAA_50.asp

Educational Materials & White Papers – http://wedi.org/

5. CONTROL SEGMENTS / ENVELOPES

5.1. ISA-IEA

Transactions transmitted during a session or as a batch are identified by an interchange

header segment (ISA) and trailer segment (IEA) which form the envelope enclosing the

transmission. Each ISA marks the beginning of the transmission (batch) and provides sender

and receiver identification.

The table below represents only those fields that UnitedHealthcare requires insertion of a

specific value or has additional guidance on what the value should be. The table does not

represent all of the fields necessary for a successful transaction; the TR3 should be reviewed

for that information.

http://aspe.hhs.gov/admnsimp/

http://aspe.hhs.gov/admnsimp/

http://hipaadvisory.com/

http://aspe.hhs.gov/admnsimp/faqtx.htm

http://aspe.hhs.gov/admnsimp/faqtx.htm

http://aspe.hhs.gov/admnsimp/faqcode.htm

http://aspe.hhs.gov/admnsimp/faqcode.htm

http://wedi.org/





Page Loop

Id

Reference

Name

Codes

Length

Notes/Comments

4102656033 spaces to 15

characters.

C.5

ISA11

Repetition

Separator

^

1/1

The delimiter in

ISA11 should be

carat ^ - it cannot

be same as other

delimiters

C.6

ISA16

Component

Element

Separator

:

1/1

The delimiter in

ISA16 must be a

colon

5.2. GS-GE

EDI transactions of a similar nature and destined for one trading partner may be gathered

into a functional group, identified by a functional group header segment (GS) and a functional

group trailer segment (GE). Each GS segment marks the beginning of a functional group.

There can be many functional groups within an interchange envelope.





TR3 Page #

LOOP

ID

Reference NAME Codes Notes/Comments

C.7 None GS Functional Group

Header Required Header

C.7 (60

in

Errata)

GS03 Application

Receiver's Code

4102656033 UnitedHealthcare

Payer ID Code

C.8 (61

in

Errata)

GS08 Version/Release/Ind

ustry Identifier Code

005010X222A1 Version expected to be

received by

UnitedHealthcare.

5.3. ST-SE

The beginning of each individual transaction is identified using a transaction set header

segment (ST). The end of every transaction is marked by a transaction set trailer segment

(SE). For real time transactions, there will always be one ST and SE combination. An 837 file

can only contain 837 transactions.









TR3

Page # LOOP

ID

Reference NAME Codes Notes/Comments

70 None ST Transaction Set

Header

Required Header

70 (14

in

Errata)

ST03 Implementation

Convention

Reference

005010X222A1

5.4. CONTROL SEGMENT HIERARCHY

ISA - Interchange Control Header segment

GS - Functional Group Header segment

ST - Transaction Set Header segment

First 837 Transaction

SE - Transaction Set Trailer segment


Second 837 Transaction



Third 837 Transaction


GE - Functional Group Trailer segment

IEA - Interchange Control Trailer segment

5.5. CONTROL SEGMENT NOTES

The ISA data segment is a fixed length record and all fields must be supplied. Fields that are

not populated with actual data must be filled with space.

• The first element separator (byte 4) in the ISA segment defines the element

separator to be used through the entire interchange.

• The ISA segment terminator (byte 106) defines the segment terminator used

throughout the entire interchange.

• ISA16 defines the component element

5.6. FILE DELIMITERS

UnitedHealthcare requests that you use the following delimiters on your 837 file. If used as

delimiters, these characters (* : ~ ^ ) must not be submitted within the data content of the

transaction sets.

Data Segment: The recommended data segment delimiter is a tilde (~).

Data Element: The recommended data element delimiter is an asterisk (*).

Component-Element: ISA16 defines the component element delimiter is to be used

throughout the entire transaction. The recommended component-element delimiter is a colon

(:).





Repetition Separator: ISA11 defines the repetition separator to be used throughout the

entire transactions. The recommended repetition separator is a carat (^).

6. ACKNOWLEDGEMENTS AND OR REPORTS

6.1. REPORT INVENTORY

999 - This file informs submitter that the transaction arrived and provides information about the

syntactical quality of each of the 837 claims submitted. Level 1 validation.

Unsolicited 277ACK – This file informs the submitter of the disposition of their claims through

Level 2 Front End Validation, it reports both accepted and rejected claims.

7. TRADING PARTNER AGREEMENTS

7.1. TRADING PARTNERS

An EDI Trading Partner is defined as any UnitedHealthcare customer (provider, billing

service, software vendor, employer group, financial institution, etc.) that transmits to, or

receives electronic data from UnitedHealthcare.

Payers have EDI Trading Partner Agreements that accompany the standard implementation

guide to ensure the integrity of the electronic transaction process. The Trading Partner

Agreement is related to the electronic exchange of information, whether the agreement is an

entity or a part of a larger agreement, between each party to the agreement.

For example, a Trading Partner Agreement may specify among other things, the roles and

responsibilities of each party to the agreement in conducting standard transactions.

8. TRANSACTION SPECIFIC INFORMATION In 5010 837 transactions, Vision requires both a Rendering and Billing NPI to be submitted.

Additionally, we require the Claim Authorization Number (Segment REF*G1 in 2310 Loop) as

well.

The below table provides any UnitedHealthcare specific requirements for claim construct and

data values.

8.1. 837P – Professional Claim Transaction Set Detail

TR3

Page

#

LOOP

ID

Reference NAME Codes Length Notes/Comments

76 1000A PER SUBMITTER EDI CONTACT

INFORMATION

1000A PER01 Contact

Function Code

IC -

Information

Contact

2

1000A PER02 Name 1/60 Submitter Contact





Name

1000A PER03 Communicatio

n Number

Qualifier

EM - Electronic

Mail

FX – Facsimile

TE -

Telephone

2 Code identifying the

type of communication

number – Vision

accepts the mapping

value for PER04, if

the PER03 = ‘TE’


n Number 256 (Vision will store

only the first 15

characters of the

Telephone Number)


n Number

Qualifier

EM - Electronic

Mail

EX - Telephone

Extension

FX – Facsimile

TE - Telephone

2 Required when this

information is deemed

necessary By the

submitter. Vision is not

mapping the value from this element to

our system.


n Number 256 Vision is not mapping

the value from this

element to our system.


n Number

Qualifier

EM Electronic

Mail

EX Telephone

Extension

FX Facsimile

TE Telephone

2 Required when this

information is deemed

necessary

By the submitter.

Vision is not mapping

the value from this



n Number 256 Vision is not mapping

the value from this


131 2010B

A

PER PROPERTY

AND

CASUALTY

SUBSCRIBER

CONTACT

INFORMATIO

N

Not used in our

System, Vision

155 2010C

A

PER PROPERTY

AND

CASUALTY

PATIENT

CONTACT

INFORMATIO

N

Not used in our

System, Vision

277 2310C PER SERVICE

FACILITY

CONTACT

INFORMATIO

N

Not used in our

System, Vision

462 2420E PER ORDERING

PROVIDER Not used in our

System, Vision





CONTACT

INFORMATIO

N

81 2000B HL Subscriber

Hierarchical

Level

United Vision

patients cannot be

identified within

Loop 2010CA. If a

United patient can

be uniquely

identified by a

unique Member

Identification

Number, then the

patient is considered

the subscriber and is

identified at this

level.

.

When the patient is

the subscriber, loops

2000C and 2010CA

are not sent.

2000 HL01 Hierarchical ID

Number 1/12 The first HL01 within

each ST-SE envelope

must begin with “1”

2000 HL03 Hierarchical

Level Code

20 =

Information

Source

22 –

Subscriber

23 -

Dependant

1/2 It contains the

hierarchical ID number

of the HL segment

2000 HL04 Hierarchical

Child Code

0 = No

Subordinate HL

Segment in

This

Hierarchical

Structure.

1 = Additional

Subordinate HL

Data Segment

in This

Hierarchical

Structure

1

83 2000A PRV BILLING

PROVIDER

SPECIALTY

INFORMATIO

N

2000A PRV01 Provider Code BI = Billing

Provider PE

-

Performing

1/3 Identifies type of

provider

2000A PRV02 Reference

Identification

Qualifier

PXC = Health

Care Provider

Taxonomy

2/3 Qualifies Reference

Identification





Code 2000A PRV03 Reference

Identification 1/50 Has Provider

Taxonomy Code

116 2000B SBR SUBSCRIBER

INFORMATIO

N

2000B SBR01 Payer

Responsibility

Sequence

Number Code

A - Payer

Responsibility

Four

B - Payer

Responsibility

Five

C - Payer

Responsibility

Six

D - Payer

Responsibility

Seven

E - Payer

Responsibility

Eight

F - Payer

Responsibility

Nine

G - Payer

Responsibility

Ten

H - Payer

Responsibility

Eleven

P - Primary

S - Secondary

T - Tertiary

U - Unknown

1/3

2000B SBR02 Individual

Relationship

Code

18 – Self 2

2000B SBR03 Reference

Identification 1/50 It contains policy or

group number. In our

System, Vision, only

first 30 characters will

be stored

2000B SBR04 Name 1/60 2000B SBR05 Insurance Type

Code

12 - Medicare

Secondary

Working Aged

Beneficiary or

Spouse with

Employer

Group Health

Plan

13 - Medicare

Secondary

End-Stage

Renal Disease

Beneficiary in

the Mandated

1/3 It contains the type of

insurance policy. In

our System, Vision,

only first 2 characters

will be stored





Coordination

Period with

an

Employer’s

Group Health

Plan

14 - Medicare

Secondary,

No-fault

Insurance

including

Auto is Primary

15 - Medicare

Secondary

Worker’s

Compensation

16 - Medicare

Secondary

Public Health

Service

(PHS)or

Other Federal

Agency

41 - Medicare

Secondary

Black Lung

42 - Medicare

Secondary

Veteran’s

Administration

43 - Medicare

Secondary

Disabled

Beneficiary

Under

Age 65 with

Large Group

Health Plan

(LGHP) 47 - Medicare

Secondary,

Other Liability

Insurance is

Primary

2000B SBR09 Claim Filing

Indicator Code

11 - Other

Non-Federal

Programs

12 - Preferred

Provider

Organization

(PPO)

13 - Point of

Service (POS)

14 - Exclusive

Provider

Organization

(EPO)

1/2





15 - Indemnity

Insurance

16 - Health

Maintenance

Organization

(HMO)

Medicare

Risk

17 - Dental

Maintenance

Organization

AM -

Automobile

Medical

BL - Blue

Cross/Blue

Shield

CH - Champus

CI -

Commercial

Insurance Co.

DS - Disability

FI - Federal

Employees

Program HM - Health

Maintenance

Organization

LM - Liability

Medical

MA - Medicare

Part A

MB - Medicare

Part B

MC - Medicaid

OF - Other

Federal

Program

TV - Title V

VA - Veterans

Affairs Plan

WC - Workers’

Compensation

Health Claim

ZZ - Mutually

Defined

295 2320 SBR OTHER

SUBSCRIBER

INFORMATIO

N

2320 SBR01 Payer

Responsibility

Sequence

Number Code

A - Payer

Responsibility

Four

B - Payer

Responsibility

Five

C - Payer

1/3





Responsibility

Six

D - Payer

Responsibility

Seven E - Payer

Responsibility

Eight

F - Payer

Responsibility

Nine

G - Payer

Responsibility

Ten

H - Payer

Responsibility

Eleven

P - Primary

S - Secondary

T - Tertiary

U - Unknown

2320 SBR02 Individual

Relationship

Code

01 - Spouse

18 - Self

19 - Child

20 - Employee

21 - Unknown

39 - Organ

Donor

40 - Cadaver

Donor

53 - Life

Partner

G8 - Other

Relationship

2

2320 SBR03 Reference

Identification 1/50 In our System, Vision,


will be stored

2320 SBR04 Name 1/60 2320 SBR05 Insurance Type

Code

12 - Medicare

Secondary

Working Aged

Beneficiary or

Spouse with

Employer

Group Health

Plan

13 - Medicare

Secondary

End-Stage

Renal Disease

Beneficiary in

the Mandated

Coordination

Period

with an

Employer’s

Group Health

1/3 In our System, Vision,


will be stored.





Plan

14 - Medicare

Secondary,

No-fault

Insurance

including

Auto is Primary

15 - Medicare

Secondary

Worker’s

Compensation 16 - Medicare

Secondary

Public Health

Service

(PHS)or

Other Federal

Agency

41 - Medicare

Secondary

Black Lung

42 - Medicare

Secondary

Veteran’s

Administration

43 - Medicare

Secondary

Disabled

Beneficiary

Under

Age 65 with

Large Group

Health Plan

(LGHP)

47 - Medicare

Secondary,

Other Liability

Insurance is

Primary

2320 SBR09 Claim Filing

Indicator Code

11 - Other

Non-Federal

Programs

12 - Preferred

Provider

Organization

(PPO)

13 - Point of

Service (POS)

14 - Exclusive

Provider

Organization

(EPO)

15 - Indemnity

Insurance

16 - Health

Maintenance

Organization

1/2





(HMO)

Medicare

Risk

17 - Dental

Maintenance

Organization

AM -

Automobile

Medical

BL - Blue

Cross/Blue

Shield

CH - Campus

CI -

Commercial

Insurance Co.

DS - Disability

FI - Federal

Employees

Program

HM - Health

Maintenance

Organization

LM - Liability

Medical

MA - Medicare

Part A

MB - Medicare

Part B

MC - Medicaid

OF - Other

Federal

Program

TV - Title V

VA - Veterans

Affairs Plan

WC - Workers’

Compensation

Health Claim

ZZ - Mutually

Defined

119 2000 PAT PATIENT

INFORMATIO

N

2000 PAT01 Individual

Relationship

Code

01 - Spouse

19 - Child

20 - Employee

21 - Unknown

39 - Organ

Donor

40 - Cadaver

Donor

53 - Life

Partner

G8 - Other

Relationship

2 Contains the

relationship between

two individuals

2000 PAT05 Date Time D8 - Date 2/3 It contains the date of





Period Format

Qualifier

Expressed in

Format

CCYYMMDD

death. Not used in our

System, Vision

2000 PAT06 Date Time

Period 1/35 Not used in our

System, Vision

2000 PAT07 Unit or Basis

for

Measurement

Code

01 - Actual

Pounds

2 Not used in our

System, Vision

2000 PAT08 Weight 1/10 Contains patient’s

weight. Not used in

our System, Vision

2000 PAT09 Yes/No

Condition or

Response Code

Y – Yes

N - No

1 Code

“Y” indicates the

patient is pregnant;

code “N” indicates the

patient is not

pregnant. Not used in

our System, Vision

84 2000A CUR FOREIGN

CURRENCY

INFORMATIO

N

2000A CUR01 Entity

Identifier Code

85 Billing

Provider

2/3 Not used in our

System, Vision

2000A CUR02 Currency Code 3 Not used in our

System, Vision

127 2010B

A

DMG SUBSCRIBER

DEMOGRAPHI

C

INFORMATIO

N

2010 DMG01 Date Time

Period Format

Qualifier

D8 - Date

Expressed in

Format

CCYYMMDD

2/3 It contains the date

format

2010 DMG02 Date Time

Period 1/35 It contains the patient

date of birth. In our

System, Vision, only

first 8 characters will

be stored.

2010 DMG03 Gender Code F - Female

M - Male

U - Unknown

1 It contains the sex of

the individual

158 2300 CLM Claim

Information

2300 CLM01 Claim

Submitter’s

Identifier

1/38 It contains the claim

submitter’s

identification number

2300 CLM02 Monetary

Amount 1/18 It contains the Total

claim amount

2300 CLM05 - 1 Facility Code

Value 2 It contains the facility

code

2300 CLM05 - 2 Facility Code

Qualifier

B - Place of

Service Codes

for Professional

2





or Dental

Services

2300 CLM05 - 3 Claim

Frequency

Type Code

1 It contains the

frequency of the claim

2300 CLM06 Yes/No

Condition or

Response Code

N - No

Y - Yes

1 A “Y” value indicates

the

provider signature is

on file; an “N” value

indicates the provider

signature is not on

file.

2300 CLM07 Provider

Accept

Assignment

Code

A - Assigned

B - Assignment

Accepted on

Clinical Lab

Services Only

C - Not

Assigned

1 It indicates whether a

provider accepts

assignment

2300 CLM08 Yes/No

Condition or

Response Code

N - No W -

Not

Applicable

Y - Yes


insured or authorized

person authorizes

benefits to be assigned

to the provider;

an “N” value indicates

benefits have not been

assigned to the

provider.

2300 CLM09 Release of

Information

Code

I - Informed

Consent to

Release

Medical

Information

for Conditions

or Diagnoses

Regulated by

Federal

Statutes

Y - Yes,

Provider has a

Signed

Statement

Permitting

Release of

Medical Billing

Data Related

to a Claim

1 It indicates whether

the provider has on file

a signed statement by

the patient

2300 CLM10 Patient

Signature

Source Code

P - Signature

generated by

provider

because the

patient

was not

physically

present for

services

1 It indicates how the

patient or subscriber

authorization

signatures were

obtained and how they

are being retained by

the provider

164 2300 DTP DTP - DATE -





ONSET OF

CURRENT

ILLNESS

OR SYMPTOM

2300 DTP01 Date/Time

Qualifier

431 - Onset of

Current

Symptoms or

Illness

454 - Initial

Treatment

304 - Latest

Visit or

Consultation

453 - Acute

Manifestation

of a Chronic

Condition

439 – Accident

484 - Last

Menstrual

Period

455 - Last X-

Ray

471 –

Prescription

314 –

Disability

360 - Initial

Disability

Period Start

361 - Initial

Disability

Period End

297 - Initial

Disability

Period Last

Day Worked

296 - Initial

Disability

Period Return

To Work

435 –

Admission

096 –

Discharge

090 - Report

Start

091 - Report

End

444 - First Visit

or Consultation

050 – Received

573 - Date

Claim Paid

472 - Service

471 -

Prescription

3 It contains the type of

Date





607 -

Certification

Revision

463 - Begin

Therapy

461 - Last

Certification

738 - Most

Recent

Hemoglobin or

Hematocrit or

Both 739 - Most

Recent Serum

Creatine

011 - Shipped

2300 DTP02 Date Time

Period Format

Qualifier

D8 Date

Expressed in

Format

CCYYMMDD

RD8 - Range of

Dates

Expressed in

Format

CCYYMMDDCC

YYMMDD

2/3 It contains the date

format

2300 DTP03 Date Time

Period 1/35 Contains the date .In

our System, Vision,


will be stored.

188 2300 AMT Patient

Amount Paid

2300 AMT01 Amount

Qualifier Code

F5 - Patient

Amount Paid

D - Payor

Amount Paid

A8 -

Noncovered

Charges –

Actual

EAF - Amount

Owed

T - Tax

F4 - Postage

Claimed

1/3 It qualifies the amount

2300 AMT02 Monetary

Amount 1/18 It contains the amount

94 2010 REF Billing

Provider Tax

Identification

2010 REF01 Reference

Identification

Qualifier

EI - Employer’s

Identification

Number

SY - Social

Security

2/3 It qualifies the

Reference

Identification





Number

0B - State

License

Number

1G - Provider

UPIN Number

2U - Payer

Identification

Number

FY - Claim

Office Number

NF - National

Association of

Insurance

Commissioners

(NAIC) Code

Y4 - Agency

Claim Number

G2 - Provider

Commercial

Number

LU - Location

Number

4N - Special

Payment

Reference

Number

F5 - Medicare

Version Code

EW -

Mammography

Certification

Number

9F - Referral

Number G1 -

Prior

Authorization

Number

F8 - Original

Reference

Number

X4 - Clinical

Laboratory

Improvement

Amendment

Number

9A - Repriced

Claim

Reference

Number

9C - Adjusted

Repriced Claim

Reference

Number

LX - Qualified

Products List

D9 - Claim





Number

EA - Medical

Record

Identification

Number

P4 - Project

Code

1J - Facility ID

Number

T4 - Signal

Code

9B - Repriced

Line Item

Reference

Number

9D - Adjusted

Repriced Line

Item Reference

Number

6R - Provider

Control

Number

X4 - Clinical

Laboratory

Improvement

Amendment

Number

F4 - Facility

Certification

Number

BT - Batch

Number

VY - Link

Sequence

Number

XZ - Pharmacy

Prescription

Number

2010 REF02 Reference

Identification 1/50 Contains the

Identification number.

In our System, Vision,


will be stored.

226 2300 HI Health Care

Diagnosis

Code

2300 HI01- 1 Code List

Qualifier Code

ABK -

International

Classification

of Diseases

Clinical

Modification

(ICD-10-CM)

Principal

Diagnosis

BK -

1/3 It identifies a specific

industry code list





International

Classification

of Diseases

Clinical

Modification

(ICD-9-CM)

Principal

Diagnosis

BP - Health

Care Financing

Administration

Common

Procedural

Coding System

Principal

Procedure

BG - Condition

2300 HI01- 2 Industry Code 1/30 It contains a specific

Diagnosis Code

2300 HI02- 1 Code List

Qualifier Code

ABF -

International

Classification

of Diseases

Clinical

Modification

(ICD-10-CM)

Diagnosis

BF -

International

Classification

of Diseases

Clinical

Modification

(ICD-9-CM)

Diagnosis


industry code list


Diagnosis Code

2300 HI03-1 Code List

Qualifier Code

ABF -

International

Classification

of Diseases

Clinical

Modification

(ICD-10-CM)

Diagnosis

BF -

International

Classification

of Diseases

Clinical

Modification

(ICD-9-CM)

Diagnosis


industry code list


Diagnosis Code

2300 HI04-1 Code List

Qualifier Code

ABF -

International


industry code list





Classification

of Diseases

Clinical

Modification

(ICD-10-CM)

Diagnosis

BF -

International

Classification

of Diseases

Clinical

Modification

(ICD-9-CM)

Diagnosis


Diagnosis Code

350 2400 LX01 Assigned

Number 1/6 It contains the line

counter number

301 2320 CAS01 Claim

Adjustment

Group Code

CO -

Contractual

Obligations

CR - Correction

and Reversals

OA - Other

adjustments

PI - Payor

Initiated

Reductions PR

- Patient

Responsibility

1/2 Contains the category

of payment adjustment

301 2320 CAS02 Claim

Adjustment

Reason Code

1/5

301 2320 CAS03 Monetary

Amount 1/18

308 2320 OI OTHER

INSURANCE

COVERAGE

INFORMATIO

N

2320 OI03 Yes/No

Condition or

Response Code

N - No W -

Not

Applicable

Y - Yes


insured or authorized

person authorizes

benefits to be assigned

to the provider;

“N” value indicates

benefits have not been

assigned to the

provider.

2320 OI04 Patient

Signature

Source Code

P - Signature

generated by

provider

because the

patient

was not

physically

present for

1





services 2320 OI06 Release of

Information

Code

I - Informed

Consent to

Release

Medical

Information

for Conditions

or Diagnoses

Regulated by

Federal

Statutes

Y - Yes,

Provider has a

Signed

Statement

Permitting

Release of

Medical Billing

Data Related

to a Claim

1

351 2400 SV101 COMPOSITE

MEDICAL

PROCEDURE

IDENTIFIER

2400 SV101 – 1 Product/Servic

e ID Qualifier

ER -

Jurisdiction

Specific

Procedure and

Supply Codes

HC - Health

Care Financing

Administration

Common

Procedural

Coding System

(HCPCS) Codes

IV - Home

Infusion EDI

Coalition

(HIEC)

Product/Servic

e

Code

WK - Advanced

Billing

Concepts

(ABC) Codes

2 Contains the

identifying the

type/source of the

descriptive number

used in

Product/Service ID

2400 SV101 – 2 Product/Servic

e ID 1/48 Contains the

identification number

for the product or

service

2400 SV101 – 3 Procedure

Modifier 2

2400 SV101 – 4 Procedure

Modifier 2

2400 SV101 – 5 Procedure 2





Modifier 2400 SV101 – 6 Procedure

Modifier 2

2400 SV102 Monetary

Amount 1/18

2400 SV103 Unit or Basis

for

Measurement

Code

MJ - Minutes

UN - Unit

2 It specifies the units in

which a value is being

expressed,

2400 SV104 Quantity 1/15 Contains the numeric

quantity. In our

System, Vision, we will

store only the first 6

characters of this

element rest of the

characters will be

truncated

2400 SV105 Facility Code

Value 1/2 Contains the place of

service code

2400 SV107 -1 Diagnosis Code

Pointer 1/2 Indicates the

importance of service

code

2400 SV107 -2 Diagnosis Code



code

2400 SV107 – 3 Diagnosis Code



code

2400 SV107 - 4 Diagnosis Code



code

209 2300 NTE Claim Note 2300 NTE01 Note Reference

Code

ADD -

Additional

Information

CER -

Certification

Narrative

DCP - Goals,

Rehabilitation

Potential, or

Discharge

Plans

DGN -

Diagnosis

Description

TPO - Third

Party

Organization

Notes

3 It identifies the

functional area or

purpose for which the

note applies

2300 NTE01 Description 1/80 74 1000 NM1 Submitter

Name

1000 NM101 Entity

Identifier Code

41 - Submitter

40 - Receiver

2/3 It contains the

organizational entity or

an individual





1000 NM102 Entity Type

Qualifier

1- Person

2 - Non-Person

Entity

1 Code qualifying the

type of entity

1000 NM103 Name Last or

Organization

Name

1/60 NM102 qualifies

NM103.

Holds Individual last

name or organizational

name. In our System,

Vision, we will store

only the first 35

characters of this

element rest of the

characters will be

truncated.

1000 NM108 Identification

Code Qualifier

46 - Electronic

Transmitter

Identification

Number (ETIN)

2 It contains the

system/method of

code structure used for

Identification

Code


Code 80 Contains the Code to

identify a party or

other code

2010 NM101 Entity

Identifier Code

85 - Billing

Provider

87 - Pay-to

Provider

PE – Payee

IL - Insured or

Subscriber

PR – Payer

QC - Patient

2/3 It contains the


an individual


Qualifier

1- Person

2 - Non-Person

Entity


type of entity


Organization

Name


NM103.





only the first 35

characters of this

element rest of the

characters will be

truncated.

2010 NM104 Name First 1/35 Contains the first

name

2010 NM105 Name Middle 1/25 Contains the middle

name

2010 NM107 Name Suffix 1/10 Contains the Suffix to

individual name


Code Qualifier

XX - Centers

for Medicare

and Medicaid

Services

National

2 It contains the

system/method of


Identification

Code





Provider

Identifier

PI - Payor

Identification

XV - Centers

for Medicare

and Medicaid

Services

PlanID

II - Standard

Unique Health

Identifier for

each Individual

in the United

States

MI - Member

Identification

Number



identify a party or

other code

258 2310 NM1 Referring

Provider

Name

2310 NM101 Entity

Identifier Code

DN - Referring

Provider

P3 - Primary

Care Provider

82 - Rendering

Provider

77 - Service

Location DQ

-

Supervising

Physician

PW - Pickup

Address

45 - Drop-off

Location

2/3 It contains the


an individual


Qualifier

1- Person

2 - Non-Person

Entity


type of entity


Organization

Name


NM103.





only the first 35

characters of this

element rest of the

characters will be

truncated.


name

2310 NM105 Name Middle 1/25 Contains the middle

name






individual name


Code Qualifier

XX - Centers

for Medicare

and Medicaid

Services

National

Provider

Identifier

2 It contains the

system/method of


Identification

Code



identify a party or

other code

314 2330 NM1 Other

Subscriber

Name

2330 NM101 Entity

Identifier Code

IL - Insured or

Subscriber

PR – Payer

DN - Referring

Provider

P3 - Primary

Care Provider

82 - Rendering

Provider

77 - Service

Location DQ

-

Supervising

Physician

85 - Billing

Provider

2/3 It contains the


an individual


Qualifier

1- Person

2 - Non-Person

Entity


type of entity


Organization

Name


NM103.





only the first 35

characters of this

element rest of the

characters will be

truncated.


individual name


Code Qualifier

II - Standard

Unique Health

Identifier for

each Individual

in the United

States

MI - Member

2 It contains the

system/method of


Identification

Code





Identification

Number

PI - Payor

Identification

XV - Centers

for Medicare

and Medicaid

Services

PlanID



identify a party or

other code

430 2420 NM1 Rendering

Provider

Name

2420 NM101 Entity

Identifier Code

82 - Rendering

Provider

QB - Purchase

Service

Provider

77 - Service

Location DQ

-

Supervising

Physician

DK - Ordering

Physician

DN - Referring

Provider

P3 - Primary

Care Provider

PW - Pickup

Address

45 - Drop-off

Location

2/3 It contains the


an individual


Qualifier

1- Person

2 - Non-Person

Entity


type of entity


Organization

Name


NM103.





only the first 35

characters of this

element rest of the

characters will be

truncated.


name

2420 NM105 Name Middle 1/25(3

5)

Contains the middle

name


individual name






Code Qualifier

XX - Centers

for Medicare

and Medicaid

Services

National

Provider

Identifier

2 It contains the

system/method of


Identification

Code



identify a party or

other code

91 2010 N3 Billing

Provider

Address

2010 N301 Address

Information 55 This element contains

the first line address

2010 N302 Address

Information 55 This element contains

address if it has

second address line.

92 2010 N4 Billing

Provider City,

State, Zip

code

2010 N401 City Name 30 In our System, Vision,


will be stored.

2010 N402 State or

Province Code 2 N402 is used only if

the city name (N401)

is in the U.S. or

Canada.

2010 N403 Postal Code 15 Contains international

postal zone code (Zip

Code).In our System,

Vision, only first 9

characters will be

stored

2010 N407 Country

Subdivision

Code

1/3(3) Holds the country

subdivision

837 Transaction Set Header :

Pag

e

Loop

Id

Referen

ce

Name

Codes Lengt

h

Notes/Comments

70 ST01=83

7

Transaction Set

Id Code 3 Header, Transaction

Set Identifier Code





Pag

e

Loop

Id

Referen

ce

Name

Codes Lengt

h

Notes/Comments

70 ST02 Transaction Set

Control Number 9 Header, Transaction

Set Control Number 70 ST03 Implementation

Convention

Reference

35 This will contain the

version number.

005010X222A1

71 BHT01 Hierarchical

Structure Code

0019 -

Information

Source,

Subscriber,

Dependent

4 Indicates the

hierarchical

application structure

of a transaction set

71 BHT02 Transaction Set

Purpose Code

00 =

Original,

18 = Reissue

2 Header Transaction

Set Purpose Code

72 BHT03 Reference

Identification 1/50 In our System,

Vision, we are

storing only the first

30 characters

remaining characters

will be truncated.

72 BHT04 Date 8 Transaction Set

Creation Date,

Format is

CCYYMMDD

72 BHT05 Time 4 Transaction Set

Creation Time,

Format is HHMM

72 BHT06 Transaction Type

Code

31=

Subrogation

Demand

CH =

Chargeable

RP =

Reporting

2 Type of transaction

837 Transaction Set Trailer :

Page Loop

Id

Reference

Name

Codes

Length

Notes/Comments

496 SE01 Number of

Included

Segments

10 Trailer, Number of

Included Segments

496 SE02 Transaction

Set Control

Number

9 Trailer, Transaction

Control Number

which is match in

ST02





8.2. 277CA - Claim Acknowledgement Transaction Set Detail

Page

#

LOOP

ID


71 None BHT Beginning of

Hierarchical

Transaction

BHT02 Transaction Set

Purpose Code


purpose of the

Transaction.

00 = Original

18 = Reissue

8.3. 999 Implementation Acknowledgement Transaction Set Detail

TR3

Page # LOOP

ID


71 None BHT Beginning of

Hierarchical

Transaction

BHT02 Transaction Set

Purpose Code


purpose of the

Transaction.

00 = Original

18 = Reissue

9. APPENDECIES

9.1. IMPLEMENTATION CHECKLIST

The implementation check list will vary depending on your choice of connection; Direct

Connect or Clearinghouse. However, a basic check list would be to:

1. Register with Trading Partner

2. Create and sign contract with trading partner

3. Establish connectivity

4. Send test transactions

5. If testing succeeds, proceed to send production transactions





9.2. BUSINESS SCENARIOS

Please refer to Section 4.4 above, which points to the appropriate website for Washington

Publishing where the reader can view the 5010 Technical Report Type 3 (TR3, formerly

known as Implementation Guide), which contains various business scenario examples.

9.3. TRANSMISSION EXAMPLES

Please refer to Section 4.4 above, which points to the appropriate website for Washington

Publishing where the reader can view the TR3, which contains various transmission

examples.

9.4. FILE NAMING CONVENTIONS

Platform 999 ACK File Names-examples

Submitter Id Payor Expected 999ACK Filename

BFT219999610 NDC - AMERICHOICE OF FL & RI NDCACFLRI.DYYMMDD.T.HHMM.837P.9995010.txt

Platform 277 ACK File Names-examples

Submitter Id Payor Expected 277ACK Filename

BFT219999610 NDC - AMERICHOICE OF FL & RI NDCACFLRI.DYYMMDD.T.HHMM.837P.2775010.txt

The details of the specific filenames are established on a partner by partner basis. Contact

your business team for more specifics.

Node Description Value

ZipUnzip Responses will be sent as either zipped

or unzipped depending how

UnitedHealthcare received the inbound

batch file.

N - Unzipped

Z - Zipped

ResponseType Identifies the file response type. 999 – Implementation

Acknowledgement

Batch ID Response file will include the batch

number from the inbound batch file

specified in ISA13.

ISA13 Value from Inbound File

Submitter ID The submitter ID on the inbound

transaction must be equal to ISA06

value in the Interchange Control

Header within the file.

ISA08 Value from Inbound File

DateTimeStamp Date and time format is in the next

column. Time is expressed in military

format and will be in CDT/CST.

MMDDYYYYHHMMSS





9.5. FREQUENTLY ASKED QUESTIONS

1. What is HIPAA?

It is the acronym for the Health Insurance Portability & Accountability Act of 1996, Public Law

104-191. HIPAA is intended to improve the efficiency of the healthcare system by

standardizing the electronic transmission of health information.

2. Who do the HIPAA standards apply to?

Health plans, health care providers, health care clearinghouses, employee benefits plans,

dental & plans, public health authorities, life insurers, billing agencies, information system

vendors are all considered covered entities. (UnitedHealthcare is a covered entity.)

3. Does this Companion Guide apply to all UnitedHealthcare Specialty Benefits

payers?

No. The changes will apply to commercial and government business for UnitedHealthcare

Vision Business Segment using payer ID 00773.

4. How does UnitedHealthcare support, monitor, and communicate expected and

unexpected connectivity outages?

Our systems do have planned outages. For the most part, transactions will be queued during

those outages. We have identified the planned maintenance windows in the

UnitedHealthcare section 3.5 of this document. W e will send an email communication for

scheduled and unplanned outages.

5. If an 837 is successfully transmitted to UnitedHealthcare, are there any situations

that would result in no response being sent back?

No. UnitedHealthcare will always send a response. Even if UnitedHealthcare’s systems are

down and the transaction cannot be processed at the time of receipt, a response detailing the

situation will be returned.

4. Can we send multiple locations or companies in one file?

The processing of this type of combined file is possible. Please discuss processing

requirements with the UnitedHealthcare EDI coordinator to establish methods of

distinguishing locations or companies on your file.

5. How often should I send my file?

Most of our providers send their claims files daily. However, this is directly related to the

volume of claims involved. You may send your claims file less frequently depending on the

amount of claims you have to submit.

6. How quickly will UnitedHealthcare process my file?

Data that is not correct in terms of file layout or contains other errors may be subject to a

delay in processing. A file that is received via FTP and can be processed in an automated

environment will be processed the same day. The return transactions (999 and 277) will be

returned within 4 hours.

7. How long will it take to go live in processing our claims electronically?

This process varies from trading partner to trading partner. Upon receiving your first test file,

we will examine the file for HIPAA compliance and EDI Standards compliance. We will work





with you in establishing any specific processing requirements for your file. Once a compliant

file is received and any special processing programs are written and tested, we will agree on

a date to start live processing of your claims file.

8. What is Data Encryption?

Encryption is a process that re-formats your data in to a format that can only be read by the

receiver after the use of a decryption key. This protects the content of your file from anyone

who may obtain it in an unauthorized fashion. UnitedHealthcare strongly recommends

encryption of files. PGP is an encryption/decryption product that is in use by

UnitedHealthcare.

9. What are my options for receiving acknowledgements?

Upon request, UnitedHealthcare will return to you a Functional Acknowledgement 999

transaction set for acknowledging your transmission. A Functional Acknowledgment will

indicate errors that were detected during syntax review by our translator.

We will also send an ‘unsolicited’ 277 transaction set which will indicate the status of each

claim processed in your transmission. We will indicate a status of processed or error and

include codes to indicate specifically which error caused the claim to not be processed.

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