HMSA TRADING PARTNER MANUAL FOR HIPAA 5010 Version 1.2

April 2018

his manual provides information to providers,

vendors, and clearinghouses on submitting electronic

claims and claims related information to HMSA.

This document is meant to supplement any information in the

ASC X12 Standards for Electronic Data Interchange Technical

Report Type 3 (referred to as “5010 Implementation Guides”

throughout this manual).

This manual contains instructions on how to set up and

conduct electronic transactions with HMSA. It also includes

instructions for the physical transfer of the HIPAA transactions,

and reference materials that may influence your internal

workflows. The information provided is meant to be used in

conjunction with the HIPAA 5010 Implementation Guides and

HMSA’s Companion Guide. If you have any questions, an

HMSA representative will be happy to assist you.

HMSA reserves the right to change specifications for

automated input and the contents of this manual as changes are

mandated by federal or state regulations or when information

needs are revised or modified.

T

TABLE OF CONTENTS GENERAL INFORMATION

Approval Process ................................................................................................................1

On-Site Inspection Requirements .......................................................................................1

Signature Waiver Requirements .........................................................................................1

Claims Processing Cycle ....................................................................................................1

HMSA Membership Number and Patient Information ......................................................1

Codes ..................................................................................................................................4

QUEST Integration Attachments…………………………………………………………5

Testing Considerations .......................................................................................................5

TRANSMITTAL PROCEDURES

Data Transmission and Retrieval Procedures .....................................................................6

Remittance Advice …………………………………………… ........................................7

Eligibility & Claim Status……..…………………………………………………………7

Passwords ...........................................................................................................................7

HMSA EDI Center – File Transfer Procedures ..................................................................8

Data Communications Specifications ................................................................................8

Sending & Receiving a File to the HMSA EDI Center ...............................................8

Via HTTPS………………………......……………………………………………..8

Via SFTP or FTPS.…………………………………………………………….…..9

HMSA EDI Center EDI Help Screen…………………………………………………10

EDI Mailbox Maintenance……………………………………………………..….….10

Acknowledgment File from HMSA…………………...………………………..…….11

HMSA EDI Center - File Name Standard .........................................................................12

Security of Data .................................................................................................................13

General Requirements for Submitting Electronic Claims to HMSA General Requirements………………………………………….…….………………………..….14

Batch 27X Guidelines……………………………………………….……………….……...….....16

Real Time 27X Transaction Guidelines…………………………..……………………….….…..16

Matching 27X Request and Responses…………………………………………………..…….....16

270/271 Eligibility and Benefit Inquiry and Response Transaction Guidelines………..…….….17

276/277 Claim Status Inquiry and Response Transaction Guidelines……………………….…..17

APPENDICES

Appendix A Check Digit Routines for Member/Recipient Identification Numbers. ........18

Appendix B Sample of HMSA Private Business Claims Rejected to Provider Report .....20

Physician ........................................................................................................20

Hospital ...........................................................................................................22

Appendix C Complementary Insurer Identifier-Physician ................................................24

Appendix D Definitions ....................................................................................................27

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GENERAL INFORMATION This section discusses a number of items that will be of general interest to anyone who desires to initiate the electronic submission of health care related information. Included in this section is general information on situations that will be encountered in processing claims data; other items refer to areas where HMSA has established minimum standard requirements for participation in this program. Approval Process

HMSA reserves the right to exercise prior approval of EDI submission arrangements from any source. There are two parts to this approval process. The first part relates to the technical details of the data processing arrangement. The second part relates to the specific provider whose transactions are submitted. It will be necessary for HMSA to review and approve each provider and for each approved provider to sign an Electronic Trading Partner Agreement. HMSA reserves the right to revoke approval for a provider, group of providers, or organization performing data processing support.

On-Site Inspection Requirements To ensure that established HMSA requirements are being followed, providers must agree to allow periodic audits by HMSA and its authorized representatives after implementation of this arrangement. Audits will help verify that necessary records are being retained in accordance with the Electronic Trading Partner Agreement.

Signature Waiver Requirements If a provider submits claims via EDI, this requirement will be satisfied by an appropriately signed Electronic Trading Partner Agreement filed with HMSA.

Claims Processing Cycle

By automating the claims submission process, the provider should realize a faster turnaround time since it will eliminate the need for HMSA to process the majority of the claims manually. However, the length of time required to process a claim also depends on many other variables.

HMSA Membership Number and Patient Information HMSA receives thousands of claims each month with incorrect membership numbers and claims for non-HMSA members. This causes problems for providers, their patients, and HMSA. This is more of a problem for providers who use an automated billing system that does not verify the patient’s current health plan membership ID number against the patient’s data file.

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Please note that for all HMSA claims, providers should verify the patients’ data file with current health plan membership identification information from each encounter, since claims with invalid membership numbers will not be accepted for electronic processing. Providers should establish a procedure to contact those patients to obtain information so their health plan information can be updated. The following describes the format of member identification numbers to include on electronic claims for various HMSA health plans: For HMSA Private Business Claims The subscriber number is sixteen (16) characters in length and has the following format: dddannnnnnnnnnnc where: 'd' represents an alpha or numeric character (positions 1-3) 'a' represents an alpha character (position 4) 'n' represents a number (positions 4-15) 'c' represents a check digit (position 16)

The first three (3) characters of the ID are referred to as the prefix: Each character in the prefix can be either alpha or numeric. Positions 1 -3 generally start with “XL*” or ”HFP” however, The following three (3) character prefixes are not allowed for private business claims: XLJ, XLO, XLS, XLU, and XLV Prefix positions 1-3 may include numeric values between 2-9.

The first three characters (prefix) should not be reported when filing claims. The member number filed electronically should have thirteen (13) characters For HMSA Akamai Advantage Claims The subscriber number is sixteen (16) characters in length and has the following format:

XLaaddnnnnnnnndc

where: Positions 1-3 are “XLL”, “XLM”, or “XLK” the 'a' in position 4 represents an alpha character

'd' can be an alpha or numeric character (positions 5, 6 & 15) 'n' represents a numeric character (positions 7-14)

'c' represents a check digit (position 16) The first three characters (prefix) should not be reported when filing claims. The member number filed electronically should have thirteen (13) characters.

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For HMSA QUEST Integration (QT) Claims The subscriber number is thirteen (13) characters in length and has the following format: XLQnnnnnnnnnc where:

Positions 1-3 are “XLQ” 'n' represents a numeric character (positions 4-12) 'c' represents a check digit (position 13)

The first three characters (prefix) should not be reported when filing claims. The member number filed electronically should have ten (10) characters For Federal Employee Plan (FE) – FEP Claims The subscriber number is nine (9) characters in length and has the following format: annnnnnnn where: 'a' represents an alpha character

'n' represents a numeric character

All characters should be reported when filing claims The member number filed electronically should have nine (9) characters For Blue Card (BC) – ITS Claims The subscriber number is between nine (9) and seventeen (17) characters in length and has the following format: ddddddddddddddddd

where: 'd' can be an alpha or numeric character (positions 1-9, and up to 17) Positions 1 and 2 are generally not “XL”, however, the following three character prefixes are allowed: XLJ, XLO, XLS, XLU, and XLV Positions 1-3 are not “HFP.” Positions 1-3 are not “FEP.” Positions 1-4 are not “AFHC.” Positions 1-3 are not all numeric (nnn)

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All characters (positions 1-9, and up to 17) should be reported when filing claims. The member number filed electronically should have between nine (9) and seventeen (17) characters For Away from Home Care (AH) – AFHC Claims The subscriber number is up to 21 characters in length and has the following format: AFHCddddddddddddddddd where: Positions 1 through 4 are “AFHC.” 'd' can be an alpha or numeric character (positions 5- up to 21)

All characters (positions 1- up to 21) should be reported when filing claims The member number filed electronically may have up to twenty one (21) characters Below is a summary of Member ID information:

Priv

ate

Busi

ness

Akam

ai A

dvan

tage

Que

st In

tegr

atio

n

Fede

ral E

mpl

oyee

Pla

n

Blue

Car

d

Away

Fro

m H

ome

Care

Total Character Length of ID on ID Card 16 16 13 9 min 9, max 17 max 21Positions 1-3 or 1-4 (Prefix) Alpha-numaric,

Generally "XL*" or "HFP"

"XLL", "XLM", or "XLK" "XLQ" Position 1 - Alpha Alpha-numeric "AFHC"

Include Prefix on Submited Claims? No No No Yes Yes YesRemaining Characters Numeric Position 4 - Alpha

Position 5, 6 & 15 - Alpha-numericRemaining Positions - Numeric

Numeric Numeric Alpha-numeric Alpha-numeric

Length of ID on Submitted Claims 13 13 10 9 min 9, max 17 max 21

Codes All electronic claims and claims related information submitted must only use code sets and contain codes required by the 5010 Implementation Guides and the HIPAA Administrative Simplification rules that are approved for use in HIPAA standard transactions. HMSA will edit both Internal Codes (those codes in the Implementation Guides) and External Codes (such as ICD-10 CM, ICD-10 PCS, or CPT).

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QUEST Integration Attachments

The following are examples of attachments that are needed: 1) DHS Form 8015 for EPSDT claims, or DHS Form 8016 for EPSDT Catch-Up Exams 2) Reports, notes, or other medical justification for claims that require prior

authorizations, but for which prior authorization has not been obtained.

3) Reports, notes, or other reports that describe "By Report" procedures

4) Hysterectomy Consent Form 1145 for hysterectomy claims, and Sterilization

Required Consent Form 1146 for sterilization claims

5) Med-QUEST member confirmation letters

Attachments should be alphabetized by patient's last name, and packaged in a separate small envelope notated with the following information:

QUEST Integration Dept., Attn: Receiving Submitter's name

Date and time of claim transmission

Attachments should be received by HMSA’s QUEST Integration Dept. by the time the electronic claims are processed prior to and no later than on the same day as the electronic transmission to HMSA.

Testing Considerations After an agreement has been reached between the provider and HMSA regarding EDI claims submission, a testing period may be necessary. The purpose of testing is to ensure that the data from the provider’s data processing system meets all technical requirements, and to work out the data transfer procedures. Depending on the quality of the test data and/or any problems that arise, additional tests may be requested. Frequent coordination between the provider and HMSA will be necessary during this period to ensure rapid resolution of problems. At the successful conclusion of testing the regularly scheduled input of EDI claims will begin.

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Transmittal Procedures Data Transmission and Retrieval Procedures

The procedure for asynchronous data communication: 1. The data is generated by the provider or their representative and set up for transfer to

HMSA.

2. HMSA maintains a secure FTP option.

3. HMSA’s asynchronous data communication allows computer systems to communicate with a front end computer that is connected directly to HMSA’s EDI system. Transmissions are accepted 24 hours a day, seven days a week, including holidays.

4. For security purposes, the provider will be required to log into HMSA’s system by

entering a login ID and account password (initially assigned by HMSA). Once the login process is completed, HMSA’s computer will receive the claims data. If it is not properly completed, HMSA will not accept the submission for processing and will notify the provider or their representative via a 999 transaction. If the transmission is not successful, the provider should verify, and correct, their claims before re-transmitting to HMSA.

5. The claims data will then be edited at the front end of the HMSA claims systems to

ensure that it conforms to the HMSA business edits and the specifications described in this manual and the HIPAA 005010 Implementation Guides.

If data errors are found during this secondary editing process, the claims containing these errors will be rejected by the EDI system and no further processing will be done on these claims. All LOB’s could be impacted by the reject process. Providers will be notified of the claim/file rejection within three working days. A copy of the “Claims Rejected to Provider” (CRTP), which identifies each rejected claim and its associated error condition(s), will be mailed or made available for electronic pickup (eCRTP). It is the responsibility of the provider to correct any claims with errors that are listed on the control report and to resubmit these claims, if appropriate. It is important to emphasize this procedure so that erroneous conditions are corrected promptly and claims are not delayed for extended periods of time. Since the appropriate edits should be part of your computer program, the incidence of errors should be very low.

6. At the completion of the editing process, the claims will be entered into the claims

processing cycle for payment determination. 7. Providers who choose to receive their remittance advice electronically will be able to

retrieve it during the transmission after claim data is sent.

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Remittance Advice

For HMSA participating providers, a major advantage of joining the EDI program is the option of receiving HMSA's remittance advice in the 835 format. With appropriate programming, this could be used to automatically update most of the provider's accounts receivable. The electronic remittance includes all claims regardless of whether they were originally submitted via EDI or hard copy. Providers can continue to receive the hard copy Report to Provider as backup. For more information on conducting the 835 transaction, please see the CAQH CORE Companion Guide: http://www.hmsa.com/portal/provider/CORE_Standard_Companion_Guide_835_CAQH.pdf If you wish to enroll in EFT or 835, you may fill out the electronic enrollment form found on our E-library: http://www.hmsa.com/portal/provider/zav_pel.fm.FOR.500.htm

Eligibility & Claim Status Another advantage of joining the EDI program is the option of sending and

receiving Eligibility & Claim Status requests in the 270/271 & 276/277 format. For more information on conducting 270/271 transactions, please see the CAQH

CORE Companion Guide: http://www.hmsa.com/portal/provider/CORE_Standard_Companion_Guide_270_271.pdf

For more information on conducting 276/277 transactions, please see the CAQH

CORE Companion Guide: http://www.hmsa.com/portal/provider/CORE_Standard_Companion_Guide_276_277.pdf

Passwords

To comply with the HIPAA security regulations, HMSA has the following requirements for passwords on the Electronic Claims System: For the secure FTP/HTTP system: Passwords need to be changed at least every 60 days Eight character minimum

At least two letters, one number, and one special character (with the exception of the “@” symbol)

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HMSA EDI Center – File Transfer Procedures HMSA EDI Center – File Transfer Procedures SENDING A FILE TO THE HMSA EDI CENTER:

1. Make sure to use the HIPAA X12 formats when transmitting to the HMSA EDI Center. Check the EDI Trading Partner Manual or the Provider Section of HMSA’s website (hmsa.com) on the Internet if you are not sure.

2. The file may be compressed using the gzip file compressor. Gzip is available from the Internet at:

http://www.gzip.com or http://www.gzip.org.

3. For secure FTP/HTTP connection to the HMSA EDI Center:

• Use an FTP/HTTP program with the capability to support standard binary file transfers. Most of the popular PC-based HTTP browsers work well (e.g., Microsoft Internet Explorer, Mozilla Firefox) or FTP programs (e.g., CuteFTP Pro, WS FTP Pro, lfpt, cURL, FileZilla, IglooFTP, SmartFTP), or Secure Shell (SSH) programs that also allow for binary file transfers (e.g., Absolute Telnet, OpenSSH, VanDyke SecureFX, PuTTY, SCP/SFTP, WinSCP). You may also want to use one that will allow you to script a procedure to automate and simplify the upload and download process.

• Please contact your HMSA EDI representative or the EMC support line at (808) 948-6355

on Oahu to discuss other FTP clients or to obtain HMSA’s secure FTP site for test and production file transmissions.

The HMSA EDI Center server uses Tumbleweed SecureTransport which supports standard binary file

transfers. RECEIVING A FILE FROM THE HMSA EDI CENTER:

• If the file name has an extension of “gz” or the extension ends with the letter “z,” the file is compressed. Use the gzip program to restore a compressed file to its original form. You can also use WinZip to decompress the file if you are using Windows.

Sending and Receiving a File via HTTPS SENDING A FILE VIA HTTPS: 1. Log into the Tumbleweed Secure Transport server. The system will prompt you for a login ID

and a password. 2. Click on the “Browse” button and locate the file that you want to send on your system. Make

sure the file is named correctly before sending. 3. Once the file has been selected, click on the “Upload File” to being the transfer.

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4. The file will be processed immediately and will not be visible once it is processed. Submitting a file again may result in “duplicate file” errors.

5. Logout by clicking on the “Logout” button located on the upper right hand side of the screen. RECEIVING THE FILE VIA HTTPS: 1. Log into the Tumbleweed Secure Transport server. The system will prompt you for a login ID

and a password. 2. Select the file you want to download by clicking on link that contains the file name. The system

will prompt you to Open, Save or Cancel. Select the “Save” option and begin the download. 3. After the transfer, you should see the file in the directory of your local hard drive. Check the file

size to verify the complete file was transferred. 4. Logout by clicking on the “Logout” button located on the upper right hand side of the screen. Sending and Receiving a File VIA SFTP (FTP/SSH) OR FTPS (FTP/SSL) SENDING A FILE VIA SFTP (FTP/SSH) OR FTPS (FTP/SSL): 1. Log into the Tumbleweed Secure Transport server. The system will prompt you for a login ID

and a password. 2. Select the file that you want to send on your system. Make sure the file name is named correctly

before sending. 3. Upload the file using the “binary” option. 4. The file will be processed immediately and will not be visible once it is processed. Submitting a

file again may result in “duplicate file” errors. 5. Log out by entering the command “exit” if using a command line client or by clicking on the

“disconnect” button if using a GUI client.

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RECEIVING THE FILE VIA SFTP (FTP/SSH) OR FTPS (FTP/SSL): 1. Log into the Tumbleweed Secure Transport server. The system will prompt you for a login ID

and a password. 2. Select the file that you want to send from the list of files in the directory. 3. Download the file using the “binary” option. 4. After the transfer, you should see the file in the directory of your local hard drive. Check the file

size to verify the complete file was transferred. 5. Log out by entering the command “exit” if using a command line client or by clicking on

the “disconnect” button if using a GUI client. HMSA EDI CENTER EDI HELP SCREEN: To display a help screen while connected to the HMSA EDI Center, type “help” or “?” and press ENTER. The help screen will contain the information listed below. Commands: -------------------- cd Change to your login directory cd <directory> Change to specified directory date Display current date and time delete [file(s)] Delete specified files help, ? Display this message exit Log out of system EDI Mailbox Maintenance HMSA has two maintenance windows per month reserved for EDI mailbox maintenance. • The first maintenance window is the first Sunday of the month from 10 p.m. – 2 a.m. HST. • The second maintenance window is the Sunday following the third Saturday of the month from 10PM

- 2AM HST. If your mailbox is unavailable during one of these maintenance windows, please wait until after the maintenance window has ended and then try to access your mailbox again. If you still cannot access your mailbox after the maintenance window has ended, call the HMSA EDI help desk at (808) 948-6355 on Oahu. If no EDI mailbox maintenance is required the EDI mailboxes will be available during the scheduled maintenance periods.

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HMSA EDI Center – File Transfer Procedures ACKNOWLEDGMENT FILE from HMSA The Acknowledgment file (also known as the 999) verifies that the HMSA EDI Center has received your transmission file and it is properly formatted according to the X12 standards. The file will be available the same business day the transmission was completed. It is accessed after ‘logging’ into the HMSA EDI Center system (refer to page B3-‘Receiving a File’). We will have a 999 for each functional group. It will have details down to the transaction set level. PLEASE NOTE – The acknowledgment file’s sole purpose is to state whether your transmission was valid or erroneous – this is not a guarantee that your claims have successfully been processed. Claims rejected by HMSA business edits will be reflected in the “Claims Rejected to Provider” report (see Appendix B). Each transmission to HMSA should have a unique Interchange Control Number (ISA13). HMSA will use this number to determine if it is a duplicate file. If the Interchange Control Number has been previously used, the system will reject the file even if the content of the file is different from the previous file. The speed of the response depends on the number of claims that were submitted and the amount of processing being performed at the time your file is submitted. After you have received your 999, you can type “exit” to logout of the HMSA EDI Center. If you did not receive a 999, and are concerned about whether HMSA has received your file, feel free to contact ETS.

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HMSA EDI Center – FILE NAME STANDARD: Format: CCmmddhhnnss%&.xxz (secure FTP and 271, 277 files) (CC) specifies type of file

aa Functional Acknowledgement (999) ta Interchange Acknowledgment (TA-1) ca Claims (837) - All sa Claims Status Inquiry/Response (276/277) la Eligibility Benefit Inquiry/Response (270/271) ea Benefit Enrollments (834) ma Premium Payments (820) pa Service Review Request And Response(278) rr Electronic Remittance Advice (835) – Private Business rc Electronic Remittance Advice (835) – Senior Plans rq Electronic Remittance Advice (835) – QUEST Integration rf Electronic Remittance Advice (835) – FEP rb Electronic Remittance Advice (835) – ITS jx Claims Rejected to Provider Report (QNXT) gx Report to Provider (QNXT)

(mm) specifies month file was created mm = 01 through 12 (dd) specifies day file was created dd = 01 through 31

(hh) specifies hour file was created hh = 00 through 24

(nn) specifies minute file was created nn = 00 through 59

(ss) specifies second file was created ss = 00 through 59 (%) specifies if file is Inbound or Outbound

i Inbound to EDI center o Outbound from EDI Center

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(&) specifies if the file is a Production or Test file p = Production t = Test (xx) specifies sequence of files submitted 01 through 99 (z) specifies if the file is compressed EXAMPLE:

la1129130516op.01z An eligibility response file created on Nov 29 at 13:05:16 (1:05 pm 16 sec), outbound, production, sequence 01 and compressed.

Security of Data

It is strongly recommended that any provider submitting claims electronically, make the appropriate arrangements to ensure the security of the claims data being submitted to HMSA. At a minimum, we recommend that a duplicate copy of each submission be retained until the provider or their representative has been advised by HMSA that the data has been received and processed.

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General requirements for submitting electronic transactions to HMSA

1. Unique Numbers for Interchange Control and Submission a. Each transmission to HMSA should have a unique Interchange Control Number (ISA13).

HMSA will use this number to determine if it is a duplicate file.

2. Format

a. HMSA will only accept one interchange (ISA/IEA) per input file from a submitter. There can be multiple functional groups (GS/GE) within one interchange (ISA/IEA). There can be multiple transaction sets (ST/SE) in a functional group (GS/GE). There can be multiple claims (with a recommended upper limit of 5000 claims) in each transaction set (ST/SE).

b. HMSA will edit down to the claim level. If a claim does not comply with the HIPAA

Implementation Guide requirements, the claim will be rejected.

c. HMSA wants only one type of GS08 value (or only one type of transaction set) in any file sent to HMSA.

d. Do not use the following characters in any string data element: i. Asterisk “*”

ii. Equal sign “=” iii. Pound sign “#” iv. Not symbol “^ “

e. Formats are subject to change and HMSA will give 90 days notice before any format

changes are made.

3. Acknowledgement

a. The 999 Functional Acknowledgment has been designed to allow trading partners to establish an automated control function as a part of their business exchange process. This transaction is not mandated by HIPAA but can be used to identify the acceptance or rejection of functional groups and transaction sets based on a syntactical analysis of the submitted data. Currently, the 999 reports level 1 and level 2 errors based on the guidelines developed by the Strategic National Implementation Process (SNIP).

b. A provider could be notified that a functional group or transaction set was rejected after the receipt of a 999 that indicated the functional group or transaction set was accepted. This situation is caused by transactions that contain level 4 errors, which are currently not reported in the 999.

c. The trading partner is responsible for retrieving and translating the 999. Errors must be corrected before the transaction (s) is resubmitted.

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4. File, Functional Group, Transaction Set, and Claim Rejection

a. A file level reject occurs when an error is detected in the interchange control header (ISA) or trailer (IEA) segment. A file level reject could also occur when there is a submission of a duplicate file. Following the correction of all errors, the file should be resubmitted.

b. A functional group level reject occurs when there is an error detected in the functional

group header (GS) or trailer (GE) segment. All transaction sets within the functional group are rejected. Following the correction of all errors, only the rejected functional group should be resubmitted.

c. A transaction set level reject occurs when data within a transaction set (ST/SE) does not

comply with the requirements stated in the HIPAA Implementation Guide. Only the transaction set(s) containing errors within a functional group are rejected. Following the correction of all errors, only the rejected transaction set should be resubmitted.

d. A claim level reject occurs when data contained within the claim does not comply with

the requirements stated in the HIPAA Implementation Guide, or business rules for claims submission. The 999 Acknowledgment will only report HIPAA errors. Both HIPAA errors and HMSA business errors will be reported on the Claims Rejected to Provider (CRTP) report. Rejected claims reported on the CRTP should be corrected and resubmitted.

e. A request level reject (27x transaction) occurs when data contained within the request

does not comply with the requirements stated in the Implementation Guide or business rules for eligibility, claim status, or authorization request. Errors will be reported in a 999.

5. 835

a. Tax may be billed to the member only when the 835 contains a CAS adjustment segment

using: Claim Adjustment Group Code = “PR”; and Claim Adjustment Reason Code = “137”

Tax cannot be billed to the member if CAS segment reflects any other claim adjustment group code (e.g. CO).

For example: CAS{PR{137{1.66~ $1.66 tax may be billed to the member CAS{CO{137{2.40~ Tax cannot be billed to the member

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Batch 27x Transaction Guidelines Batch 27x transactions should adhere to the following guidelines: • HMSA will respond to a batch request within eight hours. If the request is for non-HMSA requests

(ie, BlueCard or FEP) the transaction must be routed to another entity outside of HMSA and may not be available for up to 24 hours.

• HMSA may return multiple 27x response files that correspond to a single batch 27x request transmission file depending on the contents and processing requirements of the transactions contained within the original transmission. Refer to the section on: “Matching 27X Requests and Responses.”

Real Time 27x Transaction Guidelines Real Time 27x transactions should adhere to the following guidelines: • Only one Real Time 27x transaction (ST/SE) should be submitted within each transmission file. • For Real Time 27x request transactions, the HIPAA Implementation Guide limits the number of

patient requests to one within a single transaction (ST/SE). Each patient is defined as either one subscriber loop, if the subscriber is the patient, or one dependent loop, if the dependent is the patient.

• Real Time 27x request transactions will be taken in by HMSA for processing as they are received. • HMSA may return multiple 27x response files that correspond to a single Real Time 27x request

transmission file depending on the processing requirements of the transaction contained within the original transmission. Refer to the following section on “Matching 27X Requests and Responses.”

• Real Time processing of 27x requests for BlueCard and FEP members may not be available at all or during certain hours depending on the processing capabilities of the other Blue Cross and Blue Shield plans or the FEP Operations Center. If the other Blue Cross and Blue Shield plan or FEP is not able to process a Real Time request, a 27x response transaction will be returned to the requester indicating that the system is unavailable. The requester has the option of resubmitting the 27x request in a batch mode or contacting the other Blue Cross and Blue Shield plan via telephone, fax, or e-mail.

Matching 27x Request and Responses

• To facilitate the matching of a 27x request transaction with its response, it is recommended that a

unique trace number be submitted in TRN02 at the patient level (Subscriber or Dependent loop) and, for the 278-13 transaction only, at the service level.

• In some situations HMSA will split a 27x request transaction into multiple requests for internal processing and return multiple responses to the requester. Each of the multiple responses will contain the original trace number that was submitted on the request transaction (TRN02). HMSA will split a 27x request transaction when the transaction contains requests for BlueCard and FEP members. A 27x transaction will also be split for the 278-13 transaction when submitting multiple service lines for BlueCard members where the UM06 Level of Service Code has a mixture of values (“03” = Emergency, “U” = Urgent, “E” = Elective) .

To avoid multiple responses for a single 27x request:

o Submit a single patient eligibility request (one Subscriber or one Dependent loop) within a transaction set (ST/SE) for transactions containing BlueCard and FEP members.

o Request claim status for a single claim for a BlueCard member on 276 transactions. o Submit emergency and urgent service requests in a separate transaction from non-

emergency and non-urgent services for BlueCard member on 278-13 transactions.

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270/271 Eligibility and Benefit Inquiry and Response Transaction Guidelines • If multiple payers or multiple HMSA contracts cover a patient, the 271 response will contain multiple

EB segments (where EB01 = “R” Other Payer) and corresponding NM1 segments. • HMSA supports 270 Eligibility and Benefit inquiries for a single supported service type code, as

indicated in the Companion Guide. • If procedure code, diagnosis code, or multiple service type codes are received on 270 Eligibility

inquiry, the default service type code “30” (Health Benefit Plan Coverage) will be processed. • The current HMSA Coverage Codes will be returned on the 271 response in the EB05 Plan Coverage

Description data element. • Subscriber Date or Dependent Date can be up to 30 days from current date and no greater than 12

months in the past. If a Subscriber Date or Dependent Date is not provided on a 270 Eligibility request, current date is used to process request.

• All 270 Eligibility requests for BlueCard and FEP patients must be submitted to HMSA and not directly to the other Blue Cross and Blue Shield plan or the FEP Operations Center.

• 270 Eligibility requests for BlueCard patients should include an Information Receiver Contact Information (PER) segment to allow the other Blue Cross and Blue Shield plan to contact the provider with any questions or follow-up information.

• 271 Eligibility responses for BlueCard and FEP patients may not have the same level of detail as indicated in the Companion Document depending on the processing capabilities of the other Blue Cross and Blue Shield plan or the FEP Operations Center.

• Detailed benefit information will not be returned for Akamai Advantage, Senior Connections and QUEST Integration members. 271 Eligibility responses for Akamai Advantage, Senior Connections and QUEST Integration will contain active/inactive Eligibility information. For Benefit information on 271 Eligibility responses, EB01 value of “U” (Contact Entity for Eligibility or Benefit Information) is returned.

• 271 Eligibility Responses for Private Business, FEP and BlueCard patients will contain co-insurance, co-payment, annual deductible, annual co-payment maximum (stop loss), and benefit limitations for the latest contract within requested date range based on service type requested.

• 271 Eligibility Responses for Private Business, FEP, and Bluecard patients will contain remaining accumulation amounts for annual deductibles, annual co-payment maximum (stop loss) and certain benefit limitations for current date requests.

276/277 Claim Status Inquiry and Response Transaction Guidelines • Claims paid to the HMSA member will report a claim payment amount of $0 and the STC09 Check

Number field will contain the value “PAID TO MEMBER”. • If a member’s name and/or date of birth on HMSA’s records are different from what was submitted

on the 276 request, then the corrected member name and/or date of birth data will be returned on the 277 response. This information may be used to update the requester’s files for that member.

• HMSA does not currently support claim status requests for a specific claim line item. If a 276 request is received for a claim line, the 277 response will contain the entire claim including all line items.

• 276 Claim Status requests for QUEST Integration patients must be submitted at the 2100D Subscriber loop level and not the 2100E Dependent loop level as all QUEST Integration members have unique member IDs assigned to them.

• All 276 Claim Status requests for BlueCard and FEP patients must be submitted to HMSA and not directly to the other Blue Cross and Blue Shield plan or the FEP Operations Center.

• 277 Claim Status responses for BlueCard and FEP patients may not have the same level of detail as indicated in the Companion Document depending on the processing capabilities of the other Blue Cross and Blue Shield plan or the FEP Operations Center.

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APPENDIX A Check Digit Routines for Member/Recipient Identification Numbers

MOD 10 Check Digit Method

The Mod 10 check digit method is used to check the validity of numbers entered for member/recipient identification. 1. Determine the base number.

HMSA–Private Business Membership numbers are 13 positions with the first position (major plan/major category code) being alpha and the last position (check digit) being either numeric or W.* Drop any hyphens and insert, if necessary, leading zeros after the major plan/major category code to fill out the 13 positions. Note: The three position alpha prefix (XLA for example), and other Blue Cross and Blue Shield alpha prefixes should not be incorporated in the check digit routine. [HMSA–Private Business: If the first position alpha is an H, repeat the H in the seventh position of member ID. The movement of the H is to be used only for check digit determination and not for claim submission.] QUEST Integration Member ID's are 10 positions, all numeric.

* This routine is not used to validate member numbers ending in W or C.

Examples:

ID Number Base Number FØ21553Ø78 ØØØØ21553Ø7 HØØØØØØ4721Ø2 ØØØØØH4721Ø RØØØØ117353Ø –5 ØØØØ117353Ø AØ548Ø5546ØD–8 Ø548Ø5546ØD

2. Convert base number to all numeric using the table below.

Alpha Numeric Equivalent A, J 1 B, K, S 2 C, L, T 3 D, M, U 4 E, N, V 5 F, W 6 G, P, X 7 H, Q, Y 8 I, R, Z 9

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3. Starting with the units position (the last number of the base number), multiply every

other number by 2. Multiply the remaining numbers by 1.

8 4 7 2 1 Ø x1 x2 x1 x2 x1 x2

8 8 7 4 1 Ø

4. Crossfoot all the individual digits in the products (e.g., 14 = 1 + 4). 8 + 8 + 7 + 4 + 1 + Ø = 28 5. Subtract the sum from the next higher number ending in zero. The difference is the

check digit. If the difference is 1Ø, the check digit is Ø. 3Ø – 28 = 2

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APPENDIX B

Sample of HMSA Private Business Claims Rejected To Provider Report B1 PHYSICIAN PROGRAM NO.: CLM568 CLAIMS REJECTED TO PROVIDER PAGE: 1 REPORT NO: CLM568A 05/26/99 PROCESS SEQUENCE SUBMITTER/PROVIDER SUBMITTER LINE OF DATE NO NAME ID BUSINESS 99041 01 JANE T. ALOHA ALO001 RG (HMSA PRIVATE BUSINESS) PROV-ACCT# REF# PROV-ID PATIENT-LAST-NAME FIRST NAME MEMBER-ID SEX RL BIRTH-DT SEQ# CLM-FROM CLM-TO REC-ID/ERR-CD EROR-FIELDS ERROR MESSAGE SVC-DT 30001-0007 ABCD059 B012345 MAUI KAREN Y. F000012345674 F 02 120140 0001 02/06/1999 02/06/1999 PC01 EFX NUMBER OF SERVICES/TIME MISSING OR INVALID 020699 95151-0001 ABCD060 B012345 LANAI SHANE K. R000098765439 M 01 062892 0004 12/11/1998 12/11/1998 H3 BDA 00E0067894 REFERRING PROVIDER ID NUMBER NOT VALID HMSA NUMBER H3 BDE MCKALIST:ROBERT REFERRING PROVIDER NAME NOT FOUND ON REFERRING PHYSICIAN DATABASE PC01 HBA 99111 PROCEDURE CODE NOT FOUND ON DATABASE 121198 06051-0013 ABCD061 B012345 MOLOKAI ANTHONY W. R000094863300 M 02 051148 0009 02/06/1999 02/06/1999 TC HF1 00004880:004680 TOTAL CHARGE NOT EQUAL TO SUM OF SERVICE LINE CHARGES 95252-0003 ABCD062 B012345 OAHU ROBERT L. R000052619991 M 01 042442 0014 02/09/1999 02/09/1999 PC01 HBA 99212 PROCEDURE CODE NO FOUND ON DATABASE 020999 PC01 HFX 99212 PROCEDURE CODE MUST HAVE FIRST/SUBSEQUENT INDICATOR (‘F’ OR ‘S’) 020999 33001-0007 33001 B012345 WAIKIKI WADEEN F005762259430 F 01 022933 0021 02/06/1999 02/06/1999 H0 ECG 022933 BIRTHDATE INVALID/MISSING 95451-0001 ABCD018 B012345 KANEOHE CARL M. R000023456789 M 01 050548 0023 02/06/1999 02/06/1999 H3 BDE HALEIWA:JOHN REFERRING PROVIDER NAME NOT FOUND ON REFERRING PHYSICIAN DATABASE H3 EGP 99242 REFERRING PHYSICIAN NAME OR ID REQUIRED 25171-0003 ABCD019 H067895 AIEA LORETTA P. F005756789876 F 01 070835 0057 02/10/1999 02/10/1999

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PROGRAM NO.: CLM568 CLAIMS REJECTED TO PROVIDER PAGE 2 REPORT NO: CLM568A 05/26/1999 PROCESS SEQUENCE SUBMITTER/PROVIDER SUBMITTER LINE OF DATE NO NAME ID BUSINESS 99041 01 JANE T. ALOHA, M.D. ALO001 RG (HMSA PRIVATE BUSINESS) CONTROL TOTALS HMSA TOTALS: CLAIMS IN = 69 TOTALED $6,471.60 IN CHARGES CLAIMS IN ERROR = 7 TOTALED CLAIMS ACCEPTED = 62 TOTALED $5,950.49 IN CHARGES PERCENT CLAIMS IN ERROR = 10.1 % DATA SET TRAILER TOTALS: CLAIMS IN = 69 TOTALED $6,473.60 IN CHARGES

*** CLAIMS IN ERROR WILL NOT BE PROCESSED. PLEASE CORRECT AND RESUBMIT ***

END REPORTING CONTROL TOTALS END REPORT NO. CLM568A

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Sample of HMSA Private Business Claims Rejected To Provider Report

B2 HOSPITAL PROGRAM NO: CLM668 CLAIMS REJECTED TO PROVIDER PAGE 1 REPORT NO: CLM668A 12/10/01 CREATION SUBMISSION SUBMITTER SUBMITTER LINE OF DATE NO NAME ID BUSINESS 20011210 4310252 GENERAL HOSPITAL GENE G MEMBER-ID SX RL BIRTHDATE PATIENT-1ST LAST-NAME PROV-ID SERV-DATE PAT-ACCT-NO CODE LN# ERROR-FIELDS ERROR-MESSAGE __________________________________________________________________________________________________________________________________ A0987654321A1 F 01 19100415 GLADYS KNIGHT D099999 990213 34293852 0043 19990213:011210 THE CLAIM FROM DATE IS MORE THAN ONE YEAR PRIOR TO THE CLAIM RECEIVED DATE 0048 A0987654321A1 SUBSCRIBER NOT FOUND AS AN HMSA SUBSCRIBER(NOT ON HMSA MEMBERSHIP DB) 0055 215 :131 WRONG PROVIDER ID USED BASED ON SUBMITTED SERVICES 0074 1 :8 THE MEMBER CHECK DIGIT IS INVALID END REPORTING ERRORS

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PROGRAM NO: CLM668 CLAIMS REJECTED TO PROVIDER PAGE 2 REPORT NO: CLM668A 12/10/01 CREATION SUBMISSION SUBMITTER SUBMITTER LINE OF DATE NO NAME ID BUSINESS 20011210 4310252 GENERAL HOSPITAL GENE G CONTROL TOTALS HMSA TOTALS: CLAIMS IN = 28 TOTALED CLAIMS IN ERROR = 1 CLAIMS ACCEPTED = 27 TOTALED PERCENT CLAIMS IN ERROR = 3.5 DATA SET TRAILER TOTALS: CLAIMS IN = 28 TOTALED *** CLAIMS IN ERROR NEED TO BE RESUBMITTED *** END REPORTING CONTROL TOTALS

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APPENDIX C Complementary Insurer Identifier-Physician

CODE DESCRIPTION

01 Aetna Life

02 AFL–CIO Hotel/Restaurant

03 American National

04 Banker's Life

05 Blue Cross/Blue Shield

06 California Western Life

07 Tricare for Life

08 Combined Insurance

09 Connecticut General Life

10 Continental Casualty

11 Equitable Life Assurance Soc

12 Equitable Life & Casualty

13 Fireman's Fund Insurance

14 General American Life

15 John Hancock Mutual

16 Hawaii Dental Service

17 HMSA (Medical Only)

18 HMSA 65C

19 HMSA Community Health Plan

20 Kaiser Health Plan

22 Liberty Life Assurance

23 Lincoln National Life

24 Medicare A Only

25 Medicare B Only

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Medicare A & B

CODE DESCRIPTION

27 Metropolitan Life

28 Mutual of Omaha

28 Mutual of Omaha

29 New York Life

30 Occidental Life

31 Paul Revere Life

32 Physicians Mutual Life

33 Prudential Insurance

34 Sears Employee Plan

35 Traveler's Insurance

36 Union Fidelity

37 VA–SVC Conn Disability

38 Workers' Compensation

39 Military Facility (MilFac)

40 Plantation Medical Plan

41 Subrogation for Accident

42 HMSA w/Dental Rider

43 Academy Life Insurance

44 Allstate Medical Plan

48 HMSA with Drug & Vision Plan

49 HMSA with Drug, Dental & Vision Plan

50 HMSA–Dental Plan Only

51 HMSA Health Plan Hawaii

52 Private Motor Vehicle Insurance

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CODE DESCRIPTION

53 Kaiser Drug Plan 54 AmFamily (Aflac) 55 HMSA - Akamai Advantage 56 Alpha Omega Corporation 57 American Income Life 58 American Patriot Health Insurance 59 American Assn of Retired Persons

(AARP) 60 Bay Area Painters Welfare Plan 61 Beneficial Standard Insurance 62 Best Care 63 California Assn of Resolute Employees

(CARE) 64 California Pacific Life 65 Colonial Penn 66 Delta Dental Plan 67 Deseret Mutual 68 Farm and Home Life Insurance 69 Fed Employees Health/Welfare Plan 70 Galbraith and Green 71 Greatwest Life Assurance 72 Hawaii Carpenters Health and Welfare

Program 73 HGEA Dental 74 International Prescription–Clearing

House 75 Mail Handlers Benefit Plan 76 National Assn of Letter Carriers 77 National Benefit Life 78 National Fidelity Life 79 National Home Life 80 Northbrook Life Insurance 81 Operating Engineers Health/Welfare 82 Oral Health Services of Hawaii 83 Pacific Mutual 84 Pay N Save Medical 85 Pensioned Health/Welfare 86 PECA–IBEW 87 Phoenix Mutual Life

CODE DESCRIPTION

88 Queens Health Care Plan 89 Roofers Prescription Plan 90 Seafarer Welfare Plan 92 Southland Medical Insurance 93 Teamsters Health/Welfare 94 United Veterans Group Insurance 95 Valley Clerks Trust Fund 97 Medicaid (for HMSA PB only)

Western Airlines Hlth (for filing to Medicaid/QUEST)

98 Other AN Aloha Care QUEST-Net BN Queen’s HI-Care Qst-Net CC Community Care Service CN QUEST-Net HMSA CV CHAMPVA HA HMAA HD St Health Fund -- Dental HL HI Laborer Self Insured HM HDS - MED/DR/VIS HP St Health Fund -- Drug HV St Health Fund -- Vision KP Kapiolani Health Hawaii KS Kaiser Senior Plan PM Paid Medicare UA University Health Alliance 2A Kaiser Health Plan (Medical) 2B Kaiser Health Plan (Vision) 5A HMSA Health Plan Hawaii (Med

Only) - HMO 5B HMSA Health Plan Hawaii

(Hosp/Med/Dental) A1 University Alliance

(Hosp/Med/Drug/Vision) A2 University Alliance (Medical) A3 University Alliance (Vision) AC Aloha Care Advantage C1 CIGNA Health Care (Dental/Vision) C2 CIGNA Health Care (Medical) CG CIGNA Health Care

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CODE DESCRIPTION H1 HMAA (Dental Only H2 HMAA (Medical & Drug) H3 HMAA (Med/Dental/Vision/Drug) H4 HMAA (Vision Only) HE HI Electricians

(Hosp/Med/Drug/Vision) HX HMSA Drug Only (No Medical) HZ HMSA Vision Only (No Medical) K1 Kaiser Permanente Senior (Vision) K2 Kaiser Permanente Senior

(Hosp/Med/Vision/Drug) LM Longs Medical Plan M1 HMA, Inc. (Medical Only) M2 HMA, Inc. (Medical & Drug) M3 HMA, Inc. (Vision Only) SU Summerlin Life & Health Insurance TA TriCare for Life (Hosp/Med/Drugs) TD TriCare for Life (Dental Only) TV TriCare for Life (Vision) TW Triwest (Hosp/Med/Drugs) U1 United Health Care (Medical) U2 United Health Care (Drug) U3 United Health Care – Evercare

(Medical) UC United Concordia UH United Health Care VS Vision Service Plan W1 Triwest (Hosp/Medical) W2 Triwest (Vision) W3 Triwest (Dental)

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APPENDIX D Definitions

Injury/Accident

Injury/accident means an act which results from an external force (such as a blow, collision, or impact) of sufficient magnitude to require the services of a physician within 48 hours (HMSA–Private Business: only if the initial visit is within 48 hours from the date of onset). Subjective symptoms occurring spontaneously or from trivial movement or exercise such as localized pain of joints, pain from nerves, disturbances of circulation, muscle pains and aches, or headaches, which are of physiological, pathological, toxic or ineffective origin, are not to be considered the result of external force, and therefore, shall not be considered an injury. The following general guide is for your claim filing use. It is not complete and is intended only to give examples of some familiar situations.

Bends. Bends or decompression sickness is considered an accident or injury.

Burn. A burn is considered an accident or injury.

Chemicals. Effects of reduced temperation and excessive dampness, heat or air pressure are not considered an accident or injury.

Contusion. A contusion is considered an accident or injury.

Dislocation. A dislocation with or without a fracture is considered an accident or injury.

However, a congenital dislocation, recurrent or pathological dislocation is not considered an accident or injury.

Drowning. Drowning is an accident.

Drug Overdose. Adverse and effects of chemical or toxic substances poisoning and drug overdose will be considered an accident or injury.

All others (including allergic reaction, alcoholism, chronic effects, contact dermatitis, etc.) are not considered an accident or injury.

Electrocution. Electrocution is an accident.

Food Poisoning. Food poisoning is not considered an accident or injury.

Foreign Body. A foreign body entering through an orifice is considered an accident or injury.

Fracture. A fracture is considered an accident or injury.

Laceration. A laceration is considered an accident or injury.

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Lightning. A person struck by lightning is considered to have an accident or injury.

Sprain. A sprain caused when a person falls and twists the ankle is considered an accident. However, a person bending down and straining the back is not considered an accident.

Strain. A strain caused, for example, when a person lifts a heavy object or suffers a whiplash is considered an accident or injury.

Strangulation. Strangulation is an accident or injury.

Radiation. Effects of radiation are not considered as an accident or injury. Auto Accident (No–Fault)

According to the Motor Vehicle Insurance Division of the Department of Regulatory Agencies, no–fault is the primary carrier for injury or illness resulting from the operation, maintenance, or use of an insured motor vehicle, except for cases covered under Workers’ Compensation, Social Security or Public Assistance laws. Hence, Medicaid is primary to No–Fault, unless the recipient has motor vehicle insurance. The following general guide to possible no–fault liability is for your claim filing use. It is not complete and is intended only to give examples of some familiar situations. Guide to Possible No–Fault Liability No–Fault. Injury resulting from:

Operation, maintenance, or use of licensed motor vehicle. Entering or getting out of car. Hit and run accident. Pedestrian hit by auto. Bus, taxi injuries. Pushing disabled motor vehicle Slamming of finger in door of motor vehicle. Loading or unloading an insured motor vehicle.

NOT No–Fault. Injury resulting from: Pedestrian/tricycle, etc. running into parked car. Building car from other car parts. Playing in/around abandoned/junked motor vehicle. Siphoning gas from motor vehicle. Fixing spare car part (extra transmission, engine, etc.) Federal vehicles (no–fault is a State law) Unlicensed/uninsured dirt bike, mini bike, dune buggy. Intentionally punching motor vehicle.

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Change Summary Page Change Description Date of

Change Version

Throughout Document Change “QUEST” to “QUEST Integration” 9/2015 1.1 Throughout Document Change “Fast Batch” to “Real Time” 9/2015 1.1 Throughout Document Remove references to Dial Up. No longer available 9/2015 1.1 Throughout Document Remove references to 65C Plus. 9/2015 1.1 Page 3 Minor corrections to QUEST Integration Attachments 9/2015 1.1

Throughout Document Delete information related to sending and receiving 27x, and refer to CAQH CORE standard Companion Guides. 9/2015 1.1

Page 16 Corrections to 270/271 Eligibility and Benefit Inquiry & Response Transaction Guidelines 9/2015 1.1

Page 23-24 Code 07 - change "CHAMPUS" to "Tricare for Life" Code 55- change “HMSA- 65 C Plus” to “HMSA- Akamai Advantage”

9/2015 1.1

Page L-11 Remove Appendix – External Code Sources should be as designated by the HIPAA 5010 TR3 9/2015 1.1

Page L-12 Remove Appendix E 9/2015 1.1 Page L-18-22 Remove Appendix - Service Type Codes 9/2015 1.1

Page 1-5 Updated section on HMSA Membership Number and Patient Information 4/1/2018 1.2

Throughout Document Minor spelling & grammar corrections, and clarifying statements to promote readability 4/1/2018 1.2