Mortgagee Coverage Notification, Billing and Payment of Insurance Premium. Electronic Data Interchange Transaction Set Implementation Guide

Size: px
Start display at page:

Download "Mortgagee Coverage Notification, Billing and Payment of Insurance Premium. Electronic Data Interchange Transaction Set Implementation Guide"

Transcription

1 Electronic Data Interchange Transaction Set Implementation Guide 811/820 MORTGAGEE COVERAGE NOTIFICATION, BILLING AND PAYMENT OF INSURANCE PREMIUM Implementation Guide Version 2.0 (3030) 1

2 1. State 2. State Mortgagee Coverage Notification, Billing and Payment of Insurance Premium State Farm Insurance Companies Specific information for using the ANSI Standard Format Farm will send the two position Operation Center Code in the REF02 (REF*32) of the 811 invoice which must be returned in the REF02 element (REF*32) of the 820 remittance. Farm expects the following information to be supplied in the BPR segment of the 820 remittance. BPR12 01 BPR BPR14 DA BPR BPR16 The settlement date BPR17 VEN 3. State Farm will only accept a 15-position trace number in the TRN02 element of the 820 remittance. Additionally, the TRN02 element of the 820 remittance must be unique with each transmission sent to State Farm. 4. State Farm requires the REF02 element (REF*IV) in the 820 remittance be returned with the same number that was sent in the BIG02 element of the 811 invoice. 5. State Farm requires the use of code LN in the ENT03 element of the 820 remittance and the existing loan number in the ENT04. When the loan number is a corrected loan number, then code CL should be used. If the billing cannot be identified, then the ENT03 and ENT04 need not be sent. 6. State Farm will receive in the 820 remittance both escrow and non-escrow policy information. Non Escrow policy information will be identified by returning zero in the RMR05 element of the 820 remittance. Escrow policy information will be identified by returning the value of the IT104 element in the 811 invoice in the RMR05 element of the 820 remittance. 7. Reason Codes H1, H2, H3 H4, H5, H7, H9, K1, and K2 in the ADX02 element of the 820 remittance should only be sent when the RMR04 element is zero. 8. Reason Code H6 in the ADX02 element of the 820 remittance should only be used when the RMR04 element is less than the RMR05 element 9. Reason Code K3 in the ADX02 element of the 820 remittance should not be used. 2

3 10. State Farm Numbers State Farm Tax ID State Farm Fire NAIC State Farm Lloyds NAIC State Farm General NAIC State Farm Florida NAIC

4 Table of Contents State Farm Insurance Companies...2 Table of Contents...4 Preface...7 Background Information (811 and 820)...7 Document Mapping...8 How to Use the Tables and Segment Definitions...9 Special Notes for Financial EDI...10 Interchange Control Structure...10 Interchange Control Structure...12 Functional Group Control Segments...12 Transaction Set Control Segments...12 Segment: ISA - Interchange Control Header...13 Segment: IEA - Interchange Control Trailer...16 Segment: GS - Functional Group Header...17 Segment: GE - Functional Group Trailer Mapping - Segment Uses and Sequence...20 Header (Table 1)...20 Detail (Table 2)...21 Trailer (Table 3)...27 Segment: ST - Transaction Set Header...28 Segment: BIG - Beginning Segment for Invoice...29 Segment: N1 - Name...30 Segment: N2 - Additional Name Information...32 Segment: N3 - Address Information...33 Segment: N4 - Geographic Location...34 Segment: PER - Administrative Communications Contact...36 Segment N1- Name...38 Segment: N2 - Additional Name Information...40 Segment: N3 - Address Information...41 Segment: N4 - Geographic Location...42 Segment: HL - Hierarchical Level...44 Segment: LX - Assigned Number...45 Segment: REF - Reference Numbers...46 Segment: HL - Hierarchical Level...48 Segment: LX - Assigned Number...49 Segment: AMT - Monetary...50 Segment: DTM - Date/Time Reference...51 Segment: QTY - Quantity...52 Segment: N1 - Name...53 Segment: N2 - Additional Name Information...54 Segment: N3 - Address Information...55 Segment: N4 - Geographic Location...56 Segment: HL - Hierarchical Level

5 Segment: LX - Assigned Number...59 Segment: PID - Product Item Description...60 Segment: REF - Reference Numbers...62 Segment: AMT - Monetary Amount...64 Segment: DTM - Date/Time Reference...66 Segment: IT1 - Baseline Item Data...68 Segment: SI - Service Characteristic Identification...71 Segment: MSG - Message Text...73 Segment: N1 - Name...74 Segment: N2 - Additional Name Information...75 Segment: N3 - Address Information...76 Segment: N4 - Geographic Location...77 Segment: HL - Hierarchical Level...78 Segment: SLN - Subline Item Detail...79 Segment: SI - Service Characteristic Identification...82 Segment: REF - Reference Numbers...84 Segment: DTM - Date/Time...86 Segment: TDS - Total Monetary Value Summary...87 Segment: CTT - Transaction Totals...88 Segment: SE - Transaction Set Trailer Mapping - Segment Uses and Sequence...90 Header (Table 1)...90 Detail (Table 2)...91 Trailer (Table 3)...92 Segment: ST - Transaction Set Header...93 Segment: BPR - Beginning Segment for Payment Order/Remittance Advice...94 Segment: TRN - Trace...99 Segment: REF - Reference Numbers Segment: DTM - Date/Time Reference Segment: N1 - Name Segment: N2 - Additional Name Information Segment: N3 - Address Information Segment: N4 - Geographic Location Segment: PER - Administrative Communications Contact Segment: N1 - Name Segment: N2 - Additional Name Information Segment: N3 - Address Information Segment: N4 - Geographic Location Segment: REF - Reference Numbers Segment: PER - Administrative Communications Contact Segment: N1 - Name Segment: N2 - Additional Name Information Segment: N3 - Address Information Segment: N4 - Geographic Location Segment: PER - Administrative Communications Contact Segment: ENT Entity

6 Segment: N1 - Name Segment: N2 - Additional Name Information Segment: N3 - Address Information Segment: N4 - Geographic Location Segment: RMR - Remittance Advice Segment: REF - Reference Numbers Segment: DTM - Date/Time Reference Segment: ADX - Adjustment Segment: SE - Transaction Set Trailer Appendix A: Payment Alternatives Appendix B: 811 Example Appendix C: 820 Example Appendix D: Payment Exception Codes Appendix E: Acord Table Line of Business Appendix F: Acord Table Type of Trans Appendix G: Functional Acknowledgment Change Summary

7 Preface This implementation guide contains the recommended format and data standards for use of the ANSI X12 Consolidated Service Invoice/Statement (811 transaction) and Payment Order/Remittance Advice (820 transaction) developed for "Mortgagee Coverage Notification, Billing and Payment of Insurance Premiums." Mortgage Companies and Insurance Companies are to be considered as "Trading Partners" in this endeavor. The following recommendations were developed by the Property and Casualty Policy Task Group within the ANSI X12 Insurance Sub-committee. The group includes representatives from insurance carriers, mortgage companies and service providers, banks, software companies, ACORD and independent agencies. Background Information (811 and 820) The ANSI 811 and 820 formats are being used for an electronic application to eliminate the need for insurance companies to send paper billing and coverage documents to mortgage companies (or their servicing agents), as well as to simplify the payment of these insurance premiums. The project capitalizes on the ANSI 811 Invoice as the method of billing and coverage notification from an insurance company to a mortgage company. The 811 insurance "invoice" includes data to indicate whether the policy premiums are held in escrow (impound) by the mortgage company, or whether they are direct billed (non-impound) to the customer. The ANSI 820 Remittance Advice is used for the payment information from the mortgage company to the insurance company for those premiums that were held in Escrow. The 820 may be "enveloped" into addenda records as an ACH (CTX) electronic payment transaction originated by the mortgage company bank to the insurance company bank. Or, it may be used as an EDI remittance transmission from the mortgage company to the insurance company, with the funds to be settled separately. This option allows some flexibility for varying systems capabilities between the trading partners. The basic data elements conform to requirements set forth by the MBA (Mortgage Bankers Association). These facts are important in order to understand the concept and vision of the project. The Task Group envisions that this format will ultimately be used by most insurance companies and mortgage companies using national EDI and EFT network(s). Using this format, insurance companies may (if they so choose) direct invoices from multiple branches too many mortgage companies through one "mailbox" network. A mortgage company may receive data from many insurance companies, in one transmission, by "connecting" to the same mailbox network. The mortgage company may, (if they so choose) subsequently pay all of the invoices too many insurance companies through one (ACH or EDI) network in one process. 7

8 Document Mapping 1. Purpose The purpose of this section is to present and explain the application of the ANSI X12 standards. This will enable the user of these guidelines to successfully translate their own internal format to the ANSI standards. The following data element list is based on the definitions of the ANSI X12 version Consolidated Service Invoice/Statement (811) document and version of the Payment Order/Remittance Advice (820) document. This document does not specifically state all of the ANSI syntax, and the reader should reference ANSI requirements. 2. X12 Standards Each element within a segment is separated by a "Data Element Separator". An asterisk (*) will be used as the separator, unless otherwise agreed upon as an exception by specific trading partners. "*" is HEX '5C' in EBCDIC, HEX '2A' in ASCII. The element separator is defined in the ISA envelope. The end of a segment is denoted by a "segment terminator" or "new line" character. "N/L" will be used as the terminator, unless otherwise agreed upon as an exception by specific trading partners. "N/L" is HEX '15' in EBCDIC, and a HEX 'OD' (carriage control) in ASCII. The segment terminator is defined in the ISA envelope. Optional data elements are not required to be transmitted unless specifically agreed upon by the trading partners. When an optional data element is not used, the separator is used to acknowledge the omitted optional data. This will result in back-to-back separators (**). When the data element(s) being omitted is at the end of a segment, the segment terminator immediately follows the last data element being used. The ANSI standard provides means for verifying the content and completeness of each transmission. Every transmission should be monitored to be certain it has successfully completed. 3. Mapping Documentation - ANSI X12 Attributes (Codes) Data Element Attributes M X Mandatory - must be transmitted. Relational - dependant on the value or presence of other data elements within the segment. 8

9 O NU Optional - appearance of this element is at the option of the sending party, or by agreement of the trading partners. Not used in this application (Mortgagee Billing/Remittance Usage Only) Data Element Type AN Nn R ID DT Alpha Numeric - left justified and space filled if field is required to be a specific length. Numeric - the first "N" signifies numeric, the second "n" signifies the number of decimal places to the right of a fixed decimal point. (The decimal point is not transmitted for this data element type.) Numeric decimal - the decimal point is required to be transmitted when fractional values are present. Contains a code value - Codes are contained within predetermined lists maintained by the ANSI X12 standards committee. Date format - yymmdd is: yy - last two digits of year (00-99) mm - numeric month (01-12) dd - numeric day (01-31) TM Time format - hhmm is: Data Element Length hh - military hour (00-23) mm - minute (00-59) The number to the left of the "/" specifies the minimum length of the field as required by the standard. The number to the right of the "/" specifies the maximum length of the field as required by the standard. The field has a fixed length when the minimum and maximum lengths are the same. For data type "R", the length does not include the sign or decimal point. How to Use the Tables and Segment Definitions Table 1 is essentially "header" data that identifies the transaction originator, the transaction receiver, other routing information, and the payment total. Table 2 provides the details: loan and policy data, insurance customer names, addresses, policy line codes, and payment amounts. 9

10 Table 3 is essentially trailer information and provides segment counts and totals used to generate functional acknowledgements to the sender. In the following examples for Table 1 and Table 2, note the sequence that the Segment ID's are listed. The subsequent pages, that provide the details for these segments, follow the same sequence as Table 1 and Table 2. These examples are provided as an aid in understanding the format of the transaction set tables and the segment definitions. The tables show the ANSI X12 requirements. (Remember, trading partner options can be used only with "optional" fields.) The Segment ID (Seg. ID), Sequence Number (Seq. ), and Reference Number (Ref. ) columns are ANSI X12 identifiers. The data in the column labeled ANSI X12 Attributes is identified in Item 3, above. The Maximum Use (Max. Use) and the Loop Repeat are also ANSI standard. Special Notes for Financial EDI To standardize the use of the ISA/IEA envelope for financial EDI transactions that move through the banking system, the following convention is recommended: 1. All financial EDI transactions should be treated as point-to-point so that the addresses carried in the ISA/IEA envelop will reflect the identity of the immediate sender and receiver as they move through the banking system. 2. Receivers of financial EDI transactions that move through the banking system can obtain the originating company ID from the BPR10 element. In order to facilitate this process, the originating company must consistently provide the originating company ID when formatting the BPR segment. 3. The sender and receiver codes in the GS loop should be passed along without modification. Interchange Control Structure An EDI message is comprised of several components. These include the Interchange Control Header/Trailer (ISA/IEA), Functional Group Header/Trailer (GS/GE), Transaction Set Header/Trailer (ST/SE), and Detail Segments. A transaction set is the collection of data that is exchanged between trading partners equivalent to an electronic business document intended to convey pertinent information. A hierarchical structure of headers and trailers allows transaction sets of different types to be transmitted from one trading partner to another in the same transmission. This allows the information to be separated logically for easy interpretation by the receiver. The hierarchical structure of an EDI message is illustrated below. 10

11 ISA Interchange Control Header I GS Functional Group Header F T N U E ST Transaction Set Header T N R R C C A T H N I A Detail Data S O N N G S E E T G SE Transaction Set Trailer R E P N GE Functional Group Trailer V IEA Interchange Control Trailer L E Note: The shaded area above represents the Consolidated Service/Invoice (811 Transaction Set) or the Payment Order/Remittance Advice (820 Transaction Set) described in their own sections later in this document. 11

12 Interchange Control Structure Interchange Control Header/Trailer (ISA/IEA) An interchange "envelope" consists of an "ISA" header and an "IEA" trailer. The interchange header and trailer envelop one or more functional groups in a transmission. The interchange control segments (ISA/IEA) provide identifying information between communicating partners that applies to the entire transmission as defined in ANSI X12.5 Interchange Control Structures standard. Functional Group Control Segments Functional Group Header/Trailer (GS/GE) A functional group "envelope" consists of a "GS" header and a "GE" trailer. The functional group envelops like transaction sets. The functional group segments (GS/GE) provide information including the application sender code, application receiver code, version number, and control information. The GS/GE segments may be used to envelop batches of similar transactions for audit and control purposes. Transaction Set Control Segments Transaction Set Header/Trailer (ST/SE) A transaction set consists of segments that are intended to communicate pertinent business related information (for example, an invoice or a payment order/remittance advice). The ST/SE segments are used to indicate the beginning and end of a transaction set and provide identifying control numbers and a count of transmitted segments. 12

13 Segment: ISA - Interchange Control Header Level: Control Loop: Usage: Mandatory Max Use: 1 Purpose: To start and identify an interchange of one or more functional groups and interchange-related control segments. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes ISA01 I01 Authorization Information Qualifier M M ID 02/02 ISA02 I02 Authorization Information M M AN 10/10 ISA03 I03 Security Information Qualifier M M ID 02/02 ISA04 I04 Security Information M M AN 10/10 ISA05 I05 Interchange ID Qualifier M M ID 02/02 ISA06 I06 Interchange Sender ID M M AN 15/15 ISA07 I05 Interchange ID Qualifier M M ID 02/02 ISA08 I07 Interchange Receiver ID M M AN 15/15 ISA09 I08 Interchange Date M M DT 06/06 ISA10 I09 Interchange Time M M TM 04/04 ISA11 I10 Interchange Control Std ID M M ID 01/01 ISA12 I11 Interchange Version Number M M ID 05/05 ISA13 I12 Interchange Control Number M M N0 09/09 ISA14 I13 Acknowledgement Requested M M ID 01/01 13

14 Seq. Ref. ANSI X12 Name Mrtg Req ANSI X12 Attributes ISA15 I14 Test Indicator M M ID 01/01 ISA16 I15 Subelement Separator M M AN 01/01 Mortgagee Billing/Payment Usage Notes This segment is required. It is used to indicate the start of an interchange. ISA01 ISA02 ISA03 ISA04 ISA05 ISA06 ISA07 ISA08 ISA09 ISA10 This element contains a code to identify the type of information in the Authorization Information. This element contains information used for additional identification or authorization of the sender or the data in the interchange. The type of information is sent by the Authorization Information Qualifier. This element contains a code to identify the type of information in the Security Information. This element is used for identifying the security information about the sender or the data in the interchange. The type of information is set by the Security Information Qualifer. This element contains a qualifier to designate the system/method of code structure used to designate the sender or receiver ID element being qualified. This element will contain an identification code published by the sender for other parties to use as the receiver ID to route data to them. The sender always codes this number in the sender ID element. Typically this number is a 9-digit DUNS number or other number agreed upon trading partner/mailbox identifier. This element contains a qualifier to designate the system/method of code structure used to designate the sender or receiver ID element being qualified. This element will contain the identification code published by the receiver of the data. When sending, it is used by the sender as their sender ID, thus other parties sending to them will use this as a receiving ID to route data to them. This element contains the interchange date (YYMMDD). This element contains the interchange time (HHMM). 14

15 Mortgagee Billing/Payment Usage Notes ISA11 ISA12 ISA13 ISA14 ISA15 ISA16 This element contains a code identifying the agency responsible for the control standard used by the message that is enclosed by the interchange header and trailer. This element should be coded as "U", U.S. EDI Community of ASC X12, TDCC, and UCS. This element contains a version number which covers the interchange control segments. The recommended value is "00303", Draft Standard for Trial Use Aproved for Publication by ASC X12 Procedures Review Board Through October This element will contain a unique control number assigned by the sender. Typically this number is automatically assigned by the sending software. It is suggested that the sender, receiver and all third parties be able to maintain an audit trail of interchanges using this number. This element contains a code sent by the sender to request an interchange acknowledgment. This element contains a code to indicate whether data enclosed by this interchange envelope is test or production. This element should be coded "T" during testing and altered to a "P" when the trading partners are ready to enter production status. This element is reserved for future expansion in separating data element subgroups. (In the interest of a migration to international standards, this must be different from the data element separator.) Example: ISA*00*THEINSCO*00** *01* *070125*1448*U*00303* * 1*P*;(NL) Note: * = blanks 15

16 Segment: IEA - Interchange Control Trailer Level: Trailer Loop: Usage: Mandatory Max Use: 1 Purpose: To define the end of an interchange of one or more functional groups and interchange-related control segments. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes IEA01 I16 Number of Included Functional Groups M M N0 01/05 IEA02 I12 Interchange Control Number M M N0 09/09 Mortgagee Billing/Payment Usage Notes This segment is required. It is used to indicate the end of an interchange. IEA01 IEA02 This element contains the total number of functional groups in this interchange. This element contains the control number used in the corresponding header (ISA13). Example: IEA*1* (NL) 16

17 Segment: GS - Functional Group Header Level: Control Loop: Usage: Mandatory Max Use: 1 Purpose: To indicate the beginning of a functional group and to provide control information. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes GS Functional ID Code M M ID 02/02 GS Application Sender's Code M M AN 02/15 GS Application Receiver's Code M M AN 02/15 GS Group Date M M DT 06/06 GS Group Time M M TM 04/04 GS Group Control Number M M N0 01/09 GS Responsible Agency Code M M ID 01/02 GS Version/Release Identifier Code M M ID 01/12 17

18 Mortgagee Billing/Payment Usage Notes This segment is required. It is used to indicate the beginning of a functional group. GS01 GS02 GS03 GS04 GS05 GS06 GS07 GS08 This element contains a code identifying a group of application related Transaction Sets. For Mortgagee Billing, it should be coded "CI", Consolidated Service Invoice/Statement (811). For Mortgagee Payment, it should be coded "RA", Payment Order/Remittance Advice (820). This element contains a code identifying the party sending the transmission. Codes are agreed to by trading partners. This element contains a code identifying the party receiving the transmission. Codes are agreed to by trading partners. This element contains the date (YYMMDD) format. This element contains the time (HHMMSS) format. This element will contain an assigned number originated and maintained by the sender. It must be identical to the same data element in the associated Functional Group Trailer GE02 element. This element is used to identify the issuer of the standard. It will be coded "X", Accredited Standards Committee X12. This element contains a code indicating the version, release, and sub release and industry identifier of the EDI standard being used, including the GS and GE segments. Positions 1-3, version number; positions 4-6, release and sub release level of version; positions 7-12, industry or trade association identifier (optionally assigned by the user). Recommended value is "003030". Example: GS*RA* * *070125*1448*2*X*003030(NL) 18

19 Segment: GE - Functional Group Trailer Level: Trailer Loop: Usage: Mandatory Max Use: 1 Purpose: To indicate the end of a functional group and to provide control information. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes GE Number of Included Sets M M N0 01/06 GE Group Control Number M M N0 01/09 Mortgagee Billing/Payment Usage Notes This segment is required. It is used to indicate the end of a functional group. GE01 GE02 This element contains the total number of transaction sets in the functional group. This element contains the control number used in the corresponding header (GS06). Example: GE*1*2(NL) 19

20 811 Mapping - Segment Uses and Sequence Header (Table 1) Page Pos. Seg ID Name Mrtg X1 Max. Use Loop Repeat ST Transaction Set Header M M BIG Beginning Segment for Invoice M M NTE Note/Special Instruction NU O CUR Currency NU O REF Reference Numbers NU O >1 060 PER Administrative Communications Contact NU O ITD Terms of Sale/Deferred Terms of Sale NU O DTM Date/Time Reference NU O >1 090 TXI Tax Information NU O N1 Name Insurance Company (Sending Partner) M O 1 N1/>1 110 N2 Additional Name Information O O N3 Address Information O O N4 Geographic Location O O REF Reference Number NU O PER Administrative Communication Contact O O Occurrence 1: Sending Partner (Insurance Entity) Occurrence 2: Receiving Partner (Mortgage Co./Service Bureau) 20

21 Detail (Table 2) Page Pos. Seg ID Name HL Hierarchical Level Level 1 (Branch/Region) Mrtg X12 Max. Use Loop Repeat M M 1 HL/> LX Assigned Number M O 1 LX/>1 025 VEH Vehicle Information NU O SI Service Characteristic Identification NU O PID Product/Item Description NU O MEA Measurements NU O REF Reference Numbers Occurrence 1: Routing Transit Number Occurrence 2: Account Number Occurrence 3: Branch Number M O >1 060 AMT Monetary Amount NU O DTM Date/Time Reference NU O TXI Tax Information NU O >1 090 QTY Quantity NU O 1 QTY/ SI Service Characteristic Ident. NU O 1 HL Hierarchical Level 2 NU HL Hierarchical Level Level 3 (Mortgagee Level) M M 1 HL/> LX Assigned Number M O 1 LX/>1 025 VEH Vehicle Information NU O SI Service Characteristic Identification NU O PID Product/Item Description NU O MEA Measurements NU O REF Reference Numbers NU O > AMT Monetary Amount Total Policy Premiums DTM Date/Time Reference Remittance Due Date M O 5 M O TXI Tax Information NU O > QTY Quantity Total Number of Policies M O 1 QTY/ SI Service Characteristic Ident. NU O 1 21

22 Page Pos. Seg ID Name Mrtg X12 Max. Use Loop Repeat N1 Name Mortgagee Name N2 Additional Name Information Mortgagee Name Line 2 Mortgagee Name Line 3 M O 1 N1/1 O O N3 Address Information O O N4 Geographic Location O O REF Reference Numbers NU O PER Administrative Communications NU O >1 170 TXI Tax Information NU O > HL Hierarchical Level Level 4 (Policy Detail) M M 1 HL/> LX Assigned Number M O 1 LX/>1 025 VEH Vehicle Information NU O SI Service Characteristic Identification NU O PID Product/Item Description M O MEA Measurements NU O REF Reference Numbers Occurrence 1: Line of Business M O >1 Occurrence 2: NAIC Co. Code Occurrence 3: Loan Number Occurrence 4: Policy Number Occurrence 5: Account Number Occurrence 6: Number of Units in Building AMT Monetary Amount Occurrence 1: Dwelling Coverage Occurrence 2: Policy Premium Occurrence 3: Estimated Replacement Cost M O DTM Date/Time Reference Occurrence 1: Effective Date Occurrence 2: Expiration Date Occurrence 3: Cancellation Date Occurrence 4: Policy Issue Date M O TXI Tax Information NU O >1 090 QTY Quantity NU O 1 QTY/ SI Service Characteristic Ident. NU O 1 22

23 Page Pos. Seg ID Name Mrtg X12 Max. Use Loop Repeat 110 N1 Name NU O 1 N1/1 120 N2 Additional Name Information NU O N3 Address Information NU O N4 Geographic Location NU O REF Reference Numbers NU O PER Administrative Communications NU O >1 170 TXI Tax Information NU O >1 180 ITA Allowance, Charge or Service NU O 1 ITA/>1 190 DTM Date/Time Reference NU O TXI Tax Information NU O > IT1 Baseline Item Data(Invoice) M O 1 IT1/ SI Service Characteristic Identification M O PID Product/Item Description NU O MEA Measurements NU O INC Installment Information NU O TXI Tax Information NU O >1 260 REF Reference Numbers NU O DTM Date/Time Reference NU O MSG Message Text O O >1 285 AMT Monetary Amount NU O QTY Quantity NU O 1 QTY/>1 300 SI Service Characteristic Ident. NU O ITA Allowance, Charge or Service NU O 1 ITA/ DTM Date/Time Reference NU O 1 23

24 330 TXI Tax Information NU O >1 24

25 Page Pos. Seg ID Name Mrtg X12 Max. Use Loop Repeat N1 Name M O 1 N1/> N2 Additional Name Information O O N3 Address Information M O N4 Geographic Location M O PER Administrative Communications NU O 3 HL Hierarchical Level 5-7 NU HL Hierarchical Level Level 8 (Policy Transaction Detail) O M 1 HL/> SLN Subline Item Detail M O 1 SLN/> SI Service Characteristic Identification M O PID Product/Item Description NU O MEA Measurements NU O CUR Currency NU O INC Installment Information NU O ITA Allowance, Charge or Service NU O TXI Tax Information NU O > REF Reference Numbers Occurrence 1: Policy Number Occurrence 2: Line of Business Occurrence 3: Account Number M O >1 470 PER Administrative Communications NU O DTM Date/Time Reference M O AMT Monetary Amount NU O MSG Message Text NU O >1 510 QTY Quantity NU O 1 QTY/>1 520 SI Service Characteristic Identification NU O N1 Name NU O 1 N1/>1 540 N2 Additional Name Information NU O N3 Address Information NU O 2 25

26 Page Pos. Seg ID Name Mrtg X12 Max. Use Loop Repeat 560 N4 Geographic Location NU O REF Reference Numbers NU O PER Administrative Communications NU O TCD Itemized Call Detail NU O 1 TCD/>1 600 SI Service Characteristic Identification NU O TXI Tax Information NU O >1 620 USD Usage sensitive Detail NU O 1 USD/>1 630 ITA Allowance, Charge or Service NU O TRF Rating Factors NU O QTY Quantity NU O 1 QTY/>1 660 SI Service Characteristic Identification NU O 1 26

27 Trailer (Table 3) Page Pos. Seg ID Name Mrtg X12 Max. Use Loop Repeat TDS Total Monetary Value Summary M M ITA Allowance, Charge or Service NU O 1 ITA/>1 030 DTM Date/Time Reference NU O BAL Balance Detail NU O 1 BAL/>1 050 DTM Date/Time Reference NU O N1 Name NU O 1 N1/>1 070 BAL Balance Detail NU O 1 BAL/>1 080 DTM Date/Time Reference NU O ITA Allowance, Charge or Service NU O 1 ITA/>1 100 DTM Date/Time Reference NU O CTT Transaction Totals M O SE Transaction Trailer Set M M 1 27

28 Segment: ST - Transaction Set Header Level: Heading Loop: Usage: Mandatory Max Use: 1 Purpose: To indicate the start of a transaction set and to assign a control number. Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes ST Transaction Set ID M M ID 03/03 ST Transaction Set Control Number M M AN 04/09 Mortgagee Billing Usage Notes This segment is required and indicates the transaction set number '811'. ST01 ST02 This element contains a code uniquely identifying a Transaction Set. It should be coded "811", Consolidated Service Invoice Statement. This element contains an identifying control number that must be unique within the transaction set function group assigned by the originator for a transaction set. This number is used to aid in error reconciliation and research and must be the same as the number in the SE02 element. Example: ST*811*0002(NL) 28

29 Segment: BIG - Beginning Segment for Invoice Level: Heading Loop: Usage: Mandatory Max Use: 1 Purpose: To indicate the start of an invoice transaction set and to transmit identifying numbers and dates. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes BIG Invoice Date M M DT 06/06 BIG02 76 Invoice Number Assigned by Sender M M AN 01/22 BIG PO Date NU O DT 06/06 BIG PO Number NU O AN 01/22 BIG Release Number NU O AN 01/30 BIG Change Order Sequence Number NU O AN 01/08 BIG Transaction Type Code NU O ID 02/02 Mortgagee Billing Usage Notes This segment is required. It provides information that uniquely identifies the bill. BIG01 BIG02 This element should contain the billing cycle date of the 811 as YYMMDD.. This element should contain the invoice number assigned to the 811 transaction. Example: BIG*070125* A (NL) 29

30 Segment: N1 - Name Level: Heading Loop: N1 Repeat: >1 Usage: Mandatory Max Use: 1 Purpose: To identify party by type of organization. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes N Entity ID Code M M ID 02/02 N Name O X AN 01/35 N ID Code Qualifier M X ID 01/02 N ID Code M X AN 02/17 Mortgagee Billing Usage Notes At least two N1 loops should be used for all transaction sets to identify the sending partner (Insurance Entity) and receiving partner (Mortgage Entity/Service Bureau) as parties to the transaction. Occurrence 1: This segment is required and is used to communicate insurance company identification information. N101 N102 N103 N104 This element should be coded "IN" to indicate an insurance company is sending the data. If used, this element will contain the name of the insurance company. This element should be coded "FI" to indicate the taxpayer identification number is being used. This element should contain the taxpayer ID number of the insurance company. 30

31 Example: N1*IN**FI* (NL) 31

32 Segment: N2 - Additional Name Information Level: Heading Loop: N1 Repeat: >1 Usage: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes N Name O M AN 01/35 N Name O O AN 01/35 Mortgagee Billing Usage Notes Occurrence 1: This segment is optional. If used, it will contain additional name information for the insurance company. N201 N202 If used, this element should contain additional name information that would not fit in N102. If used, this element should contain additional name information that would not fit in N201. Example: N2*ADDITIONAL NAME*AND MORE NAME(NL) 32

33 Segment: N3 - Address Information Level: Heading Loop: N1 Repeat: >1 Usage: Optional Max Use: 1 Purpose: To specify the location of the named party. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes N Address Information O M AN 01/35 N Address Information O O AN 01/35 Mortgagee Billing Usage Notes Occurrence 1: This segment is optional. If used, it will occur once containing the address of the insurance company. N301 N302 This element contains the first 35 characters of the address of the insurance company. This element may be used if the address specified in element N301 is longer than 35 characters, or requires two lines. Example: N3*P O BOX *RURAL ROUTE 1(NL) 33

34 Segment: N4 - Geographic Location Level: Heading Loop: N1 Repeat: >1 Usage: Optional Max Use: 1 Purpose: To specify the geographic place of the named party. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes N City Name O X AN 02/19 N State/Prov. Code O O ID 02/02 N Postal Code O O ID 04/09 N Country Code O O ID 02/02 N Location Qualifier NU X ID 01/02 N Location Identifier NU X AN 01/25 Mortgagee Billing Usage Notes Occurrence 1: This segment is optional for the insurance company. N401 N402 N403 N404 If used, this element contains the trading partner city name. If used, this element contains the trading partner state or province name. If used, this element contains the trading partner postal code. If used, this element is used to indicate a country code other than the United States. 34

35 Example: N4*CITY NAME*IL*61761(NL) 35

36 Segment: PER - Administrative Communications Contact Level: Heading Loop: N1 Repeat: >1 Usage: Optional Max Use: 1 Purpose: To specify a contact name to be called for trading partner issues. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes PER Contact Function Code O M ID 02/02 PER02 93 Name O O AN 01/35 PER Communication Number Qualifier O X AN 02/02 PER Communication Number O X AN 07/21 PER Communication Number Qualifier NU X ID 02/02 PER Communication Number NU X AN 01/25 Mortgagee Billing Usage Notes Occurrence 1: This segment is optional. If used, it appears once for the insurance company and contains information on a contact person. PER01 PER02 PER03 If used, this element should be coded as one of the following: "AD" - Indicating the contact is the Accounting Department. "AR" - Indicating the contact is the Accounts Receivable Department. "EA" - Indicating the contact is the EDI Coordinator. If used, this element should contain the name of the person to be contacted for trading partner communication. If used, this element should be coded as "TE", to indicate the communication number will be a telephone number. 36

37 Mortgagee Billing Usage Notes PER04 If used, this element should contain the telephone number of the communication contact listed in PER02. Example: PER*AD*JOHN DOE*TE* (NL) 37

38 Segment N1- Name Level: Heading Loop: N1 Repeat: >1 Usage: Mandatory Max Use: 1 Purpose: To identify party by type of organization. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes N Entity ID Code M M ID 02/02 N Name O X AN 01/35 N ID Code Qualifier M X ID 01/02 N ID Code M X AN 02/17 Mortgagee Billing Usage Notes Occurrence 2: This segment is required. The second occurrence in the N1 Loop describes the recipient of the transaction set. N101 N102 N103 N104 This element should be coded as one of the following: "SQ" - Indicating the recipient is a service bureau. "MM" - Indicating the recipient is a mortgage company. If used, this element should contain the name of the recipient. This element should be coded "FI" to indicate the taxpayer identification number is being used. This element should contain the taxpayer ID number of the service bureau or mortgage company. 38

39 Example: N1*SQ*SERVICE BUREAU NAME*FI* (NL) 39

40 Segment: N2 - Additional Name Information Level: Heading Loop: N1 Repeat: >1 Usage: Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes N Name O M AN 01/35 N Name O M AN 01/35 Mortgagee Billing Usage Notes Occurrence 2: This segment is optional. If used, it will contain additional name information for the recipient. N201 N202 If used, this element should contain additional name information that would not fit in N102. If used, this element should contain additional name information that would not fit in N201. Example: N2*ADDITIONAL NAME*MORE ADDITIONAL NAME(NL) 40

41 Segment: N3 - Address Information Level: Heading Loop: N1 Repeat: >1 Usage: Optional Max Use: 1 Purpose: To specify the location of the named party. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes N Address Information O M AN 01/35 N Address Information O O AN 01/35 Mortgagee Billing Usage Notes Occurrence 2: This segment is optional. If used, it will contain address information for the recipient. N301 N302 This element contains the first 35 characters of the address of the recipient. This element may be used if the address specified in element N301 is longer than 35 characters, or requires two lines. Example: N3*P O BOX *RURAL ROUTE 1(NL) 41

42 Segment: N4 - Geographic Location Level: Heading Loop: N1 Repeat: >1 Usage: Optional Max Use: 1 Purpose: To specify the geographic place of the named party. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes N City Name O X AN 02/19 N State/Prov. Code O O ID 02/02 N Postal Code O O ID 04/09 N Country Code O O ID 02/02 N Location Qualifier O X ID 01/02 N Location Identifier O X AN 01/25 Mortgagee Billing Usage Notes Occurrence 2: This segment is optional. If used, it provides the branch or region information identification number of the recipient. N401 N402 N403 If used, this element contains the service bureau or mortgage company city name. If used, this element contains the service bureau or mortgage company state or province name. If used, this element contains the service bureau or mortgage company postal code. 42

43 N404 N405 N406 If used, this element contains the country code of the service bureau or mortgage company that is different from the United States. If used, this element should be coded "RJ" to indicate the following location ID will be the branch or regional office of the service bureau or mortgage company. If used, this element contains the service bureau or mortgage company branch or regional office identification. Example: N4****RJ*01(NL) 43

44 Segment: HL - Hierarchical Level Level: Level 1 (Insurance Company Branch or Billing Center) Loop: HL Repeat: >1 Usage: Mandatory Max Use: 1 Purpose: To identify dependencies among the content of hierarchically related groups of data segments. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes HL Hierarchical ID Number M M AN 01/12 HL Hierarchical Parent ID M O AN 01/12 HL Hierarchical Level Code M M ID 01/02 HL Hierarchical Child Code NU O ID 01/01 Mortgagee Billing Usage Notes This segment is required. It will occur once for every insurance company region or billing center. HL01 HL02 This element should be valued with a unique number to identify a particular HL data segment within the transaction set. This element is omitted at the first HL level. This element contains the number of the next higher hierarchical data segment that the current HL level is subordinate to. Since HL level 1 is the highest level in the hierarchy, this element is not needed. HL03 This element should be valued with a '1', indicating that this hierarchical level 1, Service Billing Provider (Insurance Company Branch or Billing Center). Example: HL*1**1(NL) 44

45 Segment: LX - Assigned Number Level: Level 1 (Branch or Billing Center) Loop: HL/LX Repeat: >1 Usage: Optional Max Use: 1 Purpose: To reference a line number in a transaction set. Data Element Summary Seq. Ref. ANSI X12 Name Mrt ANSI X12 Attributes LX Assigned Number M M N0 01/06 Mortgagee Billing Usage Notes This segment is required. LX01 This element should be assigned a value of "1" in the HL level 1 loop. Example: LX*1(NL) 45

46 Segment: REF - Reference Numbers Level: Loop: Usage: Level 1 (Branch or Billing Center) HL/LX Optional Max Use: >1 Purpose: To specify identifying numbers. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes REF Reference Number Qualifier M M ID 02/02 REF Reference Number M X AN 01/30 REF Description NU X AN 01/80 Mortgagee Billing Usage Notes This segment is required and will occur three times. The REF segments in HL level 1 (Branch or Billing Center) are used to communicate Branch or Billing Center Number, Bank Routing Number and Transit Numbers. This information is coded using the following sequence. Occurrence 1: REF01 REF02 This element should be coded "01", indicating that the following REF02 contains a Bank Routing Transit Number. This element will contain the Bank Routing number of the Branch or Billing Center that is to receive the payment for the policies listed in this bill. Occurrence 2: REF01 REF02 This element should be coded "11", indicating that the following REF02 contains a Bank Account Number. This element will contain the Bank Account Number of the Branch or Billing Center that is to receive the payment for the policies listed in this bill. 46

47 Occurrence 3: REF01 REF02 This element should be coded "BF", indicating that the following REF02 contains a Branch or Billing Center Number. This element will contain the Branch or Billing Center Number. Example: REF*RR* (NL) REF*11* (NL) REF*BF*01(NL) 47

48 Segment: HL - Hierarchical Level Level: Level 3 (Mortgage Company) Loop: HL Repeat: >1 Usage: Mandatory Max Use: 1 Purpose: To identify dependencies among the content of hierarchically related groups of data segments. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes HL Hierarchical ID Number M M AN 01/12 HL Hierarchical Parent ID M O AN 01/12 HL Hierarchical Level Code M M ID 01/02 HL Hierarchical Child Code NU O ID 01/01 Mortgagee Billing Usage Notes This segment is required. It provides mortgage company identification information and will occur once for every mortgage company included on the bill. HL01 HL02 This element should be valued with a unique number to identify a particular HL data segment in the transaction set. This element should contain the number of the next higher hierarchical data segment that the current HL level is subordinate to. The HL01 value of the corresponding level 1 HL. HL03 This element should be valued with '3', indicating that this is hierarchical level 3, Group (Mortgage Company). Example: HL*2*1*3(NL) 48

49 Segment: LX - Assigned Number Level: Level 3 (Mortgage Company) Loop: HL/LX Repeat: >1 Usage: Optional Max Use: 1 Purpose: To reference a line number in a transaction set. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes LX Assigned Number M M N0 01/06 Mortgagee Billing Usage Notes This segment is required. LX01 This element should be assigned a value of "1" in the HL level 3 loop. Example: LX*1(NL) 49

50 Segment: AMT - Monetary Level: Loop: Usage: Level 3 (Mortgage Company) HL/LX Optional Max Use: 10 Purpose: To indicate the total monetary amount. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes AMT Amount Qualifier Code M M ID 01/02 AMT Monetary Amount M M R 01/15 Mortgagee Billing Usage Notes This segment is required. It occurs only once per Mortgage Company and describes the total of all the line item premium amounts indicated in IT104. AMT01 AMT02 This element should be coded as '1' indicating the following amount is the total of all the line items. This element should contain the total of all premium amounts (escrow and nonescrow) found in the IT104 in Level 4. Example: AMT*1*60000(NL) 50

51 Segment: DTM - Date/Time Reference Level: Loop: Usage: Level 3 (Mortgage Company) HL/LX Mandatory Max Use: 1 Purpose: To specify pertinent dates and times. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes DTM Date/Time Qualifier M M ID 03/03 DTM Date M X DT 06/06 DTM Time NU X TM 04/06 DTM Time Code NU O ID 02/02 DTM Century O O N0 02/02 Mortgagee Billing Usage Notes This segment is required. It is used to communicate the Remittance Due Date. DTM01 DTM02 DTM05 This element must be coded as "013", indicating that the following element contains a "Due Date". This element will contain the due date for the policies billed. Optional. If used, this element contains the century of the remittance due date. Example: DTM*013*071103***20(NL) 51

52 Segment: QTY - Quantity Level: Loop: Usage: Level 3 (Mortgage Company) HL/LX/QTY Optional Max Use: 10 Purpose: To indicate a quantity count. Data Element Summary Seq. Ref. ANSI X12 Name Mrt ANSI X12 Attributes QTY Quantity Qualifier M M ID 02/02 QTY Quantity M M R 01/15 QTY Unit or Basis for Measurement Code NU O ID 02/02 Mortgagee Billing Usage Notes This segment is required. It occurs once per Mortgage Company and indicates the number of policies (escrow and non-escrow) that are included in Level 4. QTY01 This element should be coded as "46", indicating that the quantity is the total number of transactions, for a Mortgage Company. QTY02 This element should contain the total number of policies included in Level 4. Example: QTY*46*1(NL) 52

53 Segment: N1 - Name Level: Level 3 (Mortgage Company) Loop: HL/N1 Repeat: 1 Usage: Mandatory Max Use: 1 Purpose: To identify party by type of organization. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes N Entity ID Code M M ID 02/02 N Name O X AN 01/35 N ID Code Qualifier M X AN 01/02 N Identification Code M X AN 02/17 Mortgagee Billing Usage Notes This segment is required and is used to communicate the taxpayer number of the mortgage company. N101 N102 N103 N104 This element should be assigned a value of "MM", indicating the entity identified by the N1 segment is a mortgage company. This element's use is optional, if used this element will contain the mortgage company's name. This element should be assigned a value of "FI", indicating the next element is the mortgage company's "Federal Tax Id Number". This element contains the mortgage company's tax id number. Example: N1*MM**FI* (NL) 53

54 Segment: N2 - Additional Name Information Level: Loop: Usage: Level 3 (Mortgage Company) HL/N1 Optional Max Use: 2 Purpose: To specify additional names or those longer than 35 characters in length. Data Element Summary Seq. Ref. ANSI X12 Name Mrtg ANSI X12 Attributes N Name O M AN 01/35 N Name O O AN 01/35 Mortgagee Billing Usage Notes The segment is optional. If used, it will contain additional mortgage company name information. N201 N202 If used, this element will contain additional name information that would not fit in N102. If used, this element should contain additional name information that would not fit in N201. Example: Use of this field should not be necessary. Tax Identification Number (TIN) should be sufficient to identify the Mortgage Company and therefore, no example is given. 54

Kansas Department of Revenue 915 SW Harrison Street Topeka, KS ED-100 G (Rev. 07/2004)

Kansas Department of Revenue 915 SW Harrison Street Topeka, KS ED-100 G (Rev. 07/2004) ED-100 G (Rev. 07/2004) Kansas Department of Revenue 915 SW Harrison Street Topeka, KS 66626 Table of Contents 1. TRANSACTION SET 811 SEGMENT STRUCTURE ANSI X12 V.3050...2 2. TRANSACTION SET 811 MAPPING

More information

PREMIUM PAYMENTS TRANSACTIONS 820 (004010X061)

PREMIUM PAYMENTS TRANSACTIONS 820 (004010X061) PREMIUM PAYMENTS TRANSACTIONS 820 (00400X06) SECTION I - NARRATIVE 820 Payment Order/Remittance Advice - Header The header section of the 820 file contains information related to the total payment. Examples

More information

820 Payment Order/Remittance Advice

820 Payment Order/Remittance Advice 820 Payment Order/Remittance Advice Functional Group=RA This Draft Standard for Trial Use contains the format and establishes the data contents of the Payment Order/Remittance Advice Transaction Set (820)

More information

Farmers Group, Inc. Implementation Standards for EDI Documents

Farmers Group, Inc. Implementation Standards for EDI Documents Farmers Group, Inc Implementation Standards for EDI Documents ASC X12 Transaction Set 811 Version 3050 Consolidated Service Invoice/Statement Daily Auto Notification/Billing Created 10/04/2005 Revised

More information

Payment Order/Remittance Advice

Payment Order/Remittance Advice 820 Payment Order/Remittance Advice Functional Group=RA This Draft Standard for Trial Use contains the format and establishes the data contents of the Payment Order/Remittance Advice Transaction Set (820)

More information

Payroll Deducted and Other Group Premium Payment for Insurance Products

Payroll Deducted and Other Group Premium Payment for Insurance Products 004010X061 820 GROUP PREMIUM PAYMENT FOR INSURANCE PRODUCTS National Electronic Data Interchange Transaction Set Implementation Guide Payroll Deducted and Other Group Premium Payment for Insurance Products

More information

820 Payment Order/Remittance Advice

820 Payment Order/Remittance Advice 820 Payment Order/Remittance Advice HIPAA/V5010X218: 820 Payment Order/Remittance Advice, Louisiana Medicaid Version: 1.0 Created: 9/20/2011 The purpose of this guide is to clarify the usage of the X12

More information

Premium Payment Submission Companion Guide. to the. ANSI X (version 4010x61) implementation guide

Premium Payment Submission Companion Guide. to the. ANSI X (version 4010x61) implementation guide Premium Payment Submission Companion Guide to the Premium Payment Submission ANSI X 820 (version 4010x61) implementation guide Document History Revision date Revision Commentary May 2003 1.0 Creation date

More information

835 Health Care Claim Payment/Advice

835 Health Care Claim Payment/Advice 835 Health Care Claim Payment/Advice Functional Group ID=HP Introduction: This document contains the format and establishes the data contents of the Health Care Claim Payment/Advice Transaction Set (835)

More information

Refers to the Technical Reports Type 3 Based on ASC X12 version X279A1

Refers to the Technical Reports Type 3 Based on ASC X12 version X279A1 HIPAA Transaction Standard Companion Guide Refers to the Technical Reports Type 3 Based on ASC X12 version 005010X279A1 270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide Version

More information

State of Arizona Department of Transportation Motor Vehicle Division. Arizona Mandatory Insurance Reporting System. Guide for Insurance Companies

State of Arizona Department of Transportation Motor Vehicle Division. Arizona Mandatory Insurance Reporting System. Guide for Insurance Companies State of Arizona Department of Transportation Motor Vehicle Division Arizona Mandatory Insurance Reporting System Guide for Insurance Companies Version 2.4 October 2009 Table of Contents 1. Introduction

More information

KyHealth Choices MMIS Batch Health Care Institutional Health Care Claim and Encounter Claims (837I) Companion Guide Version 3.0 Version X096A1

KyHealth Choices MMIS Batch Health Care Institutional Health Care Claim and Encounter Claims (837I) Companion Guide Version 3.0 Version X096A1 KyHealth Choices MMIS Batch Health Care Institutional Health Care Claim and Encounter Claims (837I) Companion Guide Version 3.0 Version 004010 X096A1 Cabinet for Health and Family Services Department for

More information

Illinois CPWB. Electronic Data Interchange. Implementation Guide For

Illinois CPWB. Electronic Data Interchange. Implementation Guide For Illinois Implementation Guide For Electronic Data Interchange CPWB Transaction Set ANSI ASC X12 Version 004010 820 UCB/POR Remittance Advice Version 1.2 CPWG 820 UCB/POR Remittance Advice Version 1.2 Page

More information

MERCURY MARINE EFT (ACH) IMPLEMENTATION GUIDE (FINANCIAL EDI)

MERCURY MARINE EFT (ACH) IMPLEMENTATION GUIDE (FINANCIAL EDI) MERCURY MARINE EFT (ACH) IMPLEMENTATION GUIDE (FINANCIAL EDI) The following guide is intended to facilitate the user in implementing Electronic Data Interchange transactions with Mercury Marine. Every

More information

New Jersey. Gas Implementation Guideline

New Jersey. Gas Implementation Guideline New Jersey Gas Implementation Guideline For Electronic Data Interchange TRANSACTION SET 810 LDC Consolidated Bill Ver/Rel 004010 810 LDC Consolidated Bill (4010) 1 IG810v_1-6.doc Summary of Changes...4

More information

PGW EDI Implementation Guideline

PGW EDI Implementation Guideline PGW EDI Implementation Guideline For Transaction Set 810 LDC (Rate Ready) Invoice X12 v4010 810 LDC Invoice Rev 1.5 February 4, 2016 Contents Revision Notes:... 3 810 LDC Invoice X12 Structure... 4 Segment:

More information

Tax Payment (TXP) Banking Convention

Tax Payment (TXP) Banking Convention Tax Payment (TXP) Banking Convention A Guide for Formatting Electronic Tax Payments NACHA s Banker s EDI Council Revised December 2012 1996, revised 2012 National Automated Clearing House Association 13450

More information

KyHealth Choices MMIS Batch Health Care Dental Health Care Claim and Encounter Claims (837D) Companion Guide Version 2.0 Version X097A1

KyHealth Choices MMIS Batch Health Care Dental Health Care Claim and Encounter Claims (837D) Companion Guide Version 2.0 Version X097A1 KyHealth Choices MMIS Batch Health Care Dental Health Care Claim and Encounter Claims (837D) Companion Guide Version 2.0 Version 004010 X097A1 Cabinet for Health and Family Services Department for Medicaid

More information

HP S ystems U nit. Companion Guide: 820 MCE Capitation Payment Transaction

HP S ystems U nit. Companion Guide: 820 MCE Capitation Payment Transaction HP S ystems U nit I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Companion Guide: 820 MCE Capitation Payment Transaction L I B R A R Y R E F E R E N C E N U M B E R : C L E L 1 0 0 1 7 [ A S

More information

EDS Systems Unit. Companion Guide 820 MCE Capitation Payment Transaction

EDS Systems Unit. Companion Guide 820 MCE Capitation Payment Transaction EDS Systems Unit I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Companion Guide 820 MCE Capitation Payment Transaction L I B R A R Y R E F E R E N C E N U M B E R : C L E L 1 0 0 1 7 [ A S C

More information

Check Payment UCS & X12

Check Payment UCS & X12 820 Heading: Check Payment 005010 UCS & X12 Functional Group=RA Pos Id Segment Name Req Max Use Repeat Notes Usage 0200 BPR Beginning Segment for M 1 Must use Payment Order/Remittance Advice 0350 TRN Trace

More information

837 Health Care Claim: Institutional

837 Health Care Claim: Institutional 837 Health Care Claim: Institutional HIPAA/V4010X096A1/837: 837 Health Care Claim: Institutional Version: Final Modified: 11/29/2006 Current: 11/29/2006 837I4010a1.ecs 1 For internal use only 837I4010a1.ecs

More information

05/04/07 Invoice Invoice X12. Pos Id Segment Name Req Max Use Repeat Notes Usage 020 BIG Beginning Segment for M 1 Must use

05/04/07 Invoice Invoice X12. Pos Id Segment Name Req Max Use Repeat Notes Usage 020 BIG Beginning Segment for M 1 Must use 810 Heading: Invoice 004010 X12 Functional Group=IN Pos Id Segment Name Req Max Use Repeat Notes Usage 020 BIG Beginning Segment for M 1 Must use Invoice 050 REF Reference Identification O 12 Used LOOP

More information

814 General Request, Response or Confirmation

814 General Request, Response or Confirmation 814 General Request, Response or Confirmation Introduction: Functional Group ID=GE This Draft Standard for Trial Use contains the format and establishes the data contents of the General Request, Response

More information

EDI Implementation Guide COMMERCIAL AIRPLANES GROUP. SUPPLIER NETWORK Electronic Data Interchange. Enterprise Resource Planning

EDI Implementation Guide COMMERCIAL AIRPLANES GROUP. SUPPLIER NETWORK Electronic Data Interchange. Enterprise Resource Planning COMMERCIAL AIRPLANES GROUP SUPPLIER NETWORK Electronic Data Interchange Enterprise Resource Planning EDI Implementation Guide Revision Number 8 May 31 st, 2001 Supporting DCAC/MRM (BAANERP) . Telephone

More information

ANSI ASC X12N 277P Pending Remittance

ANSI ASC X12N 277P Pending Remittance ANSI ASC X12N 277P Pending Remittance Acute Care COMPANION GUE For Non-covered Transactions April 29, 2016 Texas Medicaid & Healthcare Partnership Page 1 of 19 Revision Date: 5/5/2016 Table of Contents

More information

834 Benefit Enrollment and Maintenance

834 Benefit Enrollment and Maintenance Companion Document 834 834 Benefit Enrollment and Maintenance Basic Instructions This section provides information to help you prepare for the ANSI ASC X12.84, Benefit Enrollment and Maintenance (834)

More information

837 Professional Health Care Claim - Outbound

837 Professional Health Care Claim - Outbound Companion Document 837P 837 Professional Health Care Claim - Outbound Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care transaction for professional

More information

Fallon Health. 835 Fallon Health Companion Guide. Health Care Payment Advice. 835 Companion Guide

Fallon Health. 835 Fallon Health Companion Guide. Health Care Payment Advice. 835 Companion Guide Fallon Health Health Care Payment Advice 835 Companion Guide Refers to the ASC X12N 835 Technical Report Type 3 Guide (Version 005010X221A1) Companion Guide Version Number: 1.3 October 2017 1 Disclosure

More information

Standard Companion Guide

Standard Companion Guide Standard Companion Guide Refers to the Implementation Guide Based on X12 Version 005010X221A1 Health Care Claim Payment/Advice (835) Companion Guide Version Number: 2.0 February 2018 Page 1 of 13 CHANGE

More information

Tax. Third (TPP. d Party. Payments 7/29/2013. All Rights Reserved

Tax. Third (TPP. d Party. Payments 7/29/2013. All Rights Reserved Third d Party Tax Payments (TPP P) Banking Convention Standardized Formatting for Remittance Information in Third Party Tax Paymen nt Addenda Record 7/29/2013 2013 National Automated Clearing Housee Association

More information

Costco Wholesale EDI TRADING PARTNER PROFILE REMITTANCE ADVICE

Costco Wholesale EDI TRADING PARTNER PROFILE REMITTANCE ADVICE EDI TRADING PARTNER PROFILE REMITTANCE ADVICE Contacts: Misti Reed Supervisor (425) 313-8677 mreed@costco.com Heidi Dirkes EDI Coordinator Vendors A-F (425) 313-6868 hdirkes@costco.com Sue Crippe EDI Coordinator

More information

Appendix 3B. Crosswalk from Retired Minimum Data Element List to Appendix 3A MA Companion Guide

Appendix 3B. Crosswalk from Retired Minimum Data Element List to Appendix 3A MA Companion Guide Appendix 3B. Crosswalk from Retired Minimum Data Element List to Appendix 3A MA A3B.1 LOOPS AND SEGMENTS APPLIED TO EDR AND CRR SUBMISSIONS... 3 A3B.2 COLUMN HEADING CROSSWALK FROM APPENDIX 3A MA COMPANION

More information

EDS SYSTEMS UNIT. Pre-Release Companion Guide: 835 Remittance Advice Transaction

EDS SYSTEMS UNIT. Pre-Release Companion Guide: 835 Remittance Advice Transaction EDS SYSTEMS UNIT I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Pre-Release Companion Guide: 835 Remittance Advice Transaction L I B R A R Y R E F E R E N C E N U M B E R : C L E L 1 0 0 1 9

More information

810 FM Non-Food/Jewelry Invoice

810 FM Non-Food/Jewelry Invoice 810 FM Non-Food/Jewelry Invoice Functional Group=IN Applies to: Fred Meyer Group Refer to Program & Requirements for Fred Meyer Non-Food/Jewelry Group for EDI Invoice Business & Technical Requirements

More information

HIPAA 837I (Institutional) Companion Guide

HIPAA 837I (Institutional) Companion Guide Companion Guide Prepared for Health Care Providers For use with the Cardinal Innovations claims processing system Version 5.0 January 2011 Table of Contents 1. Introduction...3 2. Approval Procedures...4

More information

EyeMed Vision Care. HEALTHCARE BENEFIT ELIGIBILITY INQUIRY Companion Document to ASC X12N 270 (004010X092)

EyeMed Vision Care. HEALTHCARE BENEFIT ELIGIBILITY INQUIRY Companion Document to ASC X12N 270 (004010X092) HEALTHCARE BENEFIT ELIGIBILITY INQUIRY Companion Document to ASC X12N 270 (004010X092) Welcome to EyeMed Vision Care s HIPAA TCS implementation process. We have developed this guide to assist you in preparing

More information

CREDIT CARD BULK PROVIDER REQUIREMENTS

CREDIT CARD BULK PROVIDER REQUIREMENTS CREDIT CARD BULK PROVIDER REQUIREMENTS 1 Nature of Changes Date/Version Page Paragraph Change Description 3/13/2012 v0 76-81, Annual Updates 115 3/13/2012 v0 64, 65, Added table footnotes 73, 82 3/13/2012

More information

835 Health Care Claim Payment/Advice LA Medicaid

835 Health Care Claim Payment/Advice LA Medicaid 835 Health Care Claim Payment/Advice LA edicaid HIPAA/V5010X221A1/835: 835 Health Care Claim Payment/Advice Version: 1. 1 Created 10/21/2011 Revision 9/23/2013 Author: Publication: EDI Department LA edicaid

More information

837I Institutional Health Care Claim - for Encounters

837I Institutional Health Care Claim - for Encounters Companion Document 837I - Encounters 837I Institutional Health Care Claim - for Encounters Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care

More information

- - - Virginia. Implementation Standard. For Electronic Data Interchange. March 21, 2003 Open Access Version 2.3

- - - Virginia. Implementation Standard. For Electronic Data Interchange. March 21, 2003 Open Access Version 2.3 Virginia Implementation Standard For Electronic Data Interchange - - - TRANSACTION SET 814 Reinstatement Request and Response Ver/Rel 004010 VA 814 Reinstatement 1 814r-stan2-3.doc August 27, 2001 Version

More information

HEALTHpac 835 Message Elements

HEALTHpac 835 Message Elements Version 1.2 April 21, 2003 1 Table of Contents 1 INTRODUCTION...3 1.1 GENERAL COMMENTS...3 1.2 RELATED DOCUMENTS...4 2 835 MESSAGE ELEMENTS...5 2.1 HEADER - INITIAL...5 2.2 PAYER IDENTIFICATION...6 2.3

More information

Benefit Enrollment and Maintenance

Benefit Enrollment and Maintenance 004010X095 834 BENEFIT ENROLLMENT AND MAINTENANCE National Electronic Data Interchange Transaction Set Implementation Guide Benefit Enrollment and Maintenance 834 ASC X12N 834 (004010X095) May 2000 MAY

More information

Standard Companion Guide

Standard Companion Guide Standard Companion Guide Refers to the Implementation Guide Based on X12 Version 005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271) Companion Guide Version Number 3.0 November

More information

ADJ. SYSTEM FLD LEN. Min. Max.

ADJ. SYSTEM FLD LEN. Min. Max. Loop Loop Repeat Segme nt Element Id Description X12 Page No. ID Min. Max. ADJ. SYSTEM FLD LEN Usage Req. ANSI VALUES COMMENTS 1 ISA Interchange Control Header B.3 1 R ISA08 Interchange Receiver ID AN

More information

Implementation Guideline

Implementation Guideline Pennsylvania New Jersey Delaware Maryland Implementation Guideline For Electronic Data Interchange TRANSACTION SET 824 Application Advice Ver/Rel 004010 824 Application Advice (4010) 1 IG824v4-01x Table

More information

USVI HEALTH CARE CLAIM 837 Companion Guide. Version 0.1 February 6, 2013

USVI HEALTH CARE CLAIM 837 Companion Guide. Version 0.1 February 6, 2013 USVI HEALTH CARE CLAIM 837 Companion Version 0.1 February 6, 2013 Table of Contents 1.0 COMPANION GUE PURPOSE... 4 2.0 ATYPICAL PROVERS... 4 3.0 CONTROL STRUCTURE DEFINITIONS... 5 3.1 ISA - INTERCHANGE

More information

CANADIAN PAYMENTS ASSOCIATION ASSOCIATION CANADIENNE DES PAIEMENTS RULE E3 RULES APPLICABLE TO ELECTRONIC DATA INTERCHANGE TRANSACTIONS

CANADIAN PAYMENTS ASSOCIATION ASSOCIATION CANADIENNE DES PAIEMENTS RULE E3 RULES APPLICABLE TO ELECTRONIC DATA INTERCHANGE TRANSACTIONS CANADIAN PAYMENTS ASSOCIATION ASSOCIATION CANADIENNE DES PAIEMENTS RULE E3 RULES APPLICABLE TO ELECTRONIC DATA INTERCHANGE TRANSACTIONS 2017 CANADIAN PAYMENTS ASSOCIATION 2017 ASSOCIATION CANADIENNE DES

More information

Appendix 3A. MA Companion Guide: CMS Supplemental Instructions for EDR and CRR Data Elements

Appendix 3A. MA Companion Guide: CMS Supplemental Instructions for EDR and CRR Data Elements Appendix 3A. MA Companion Guide: CMS Supplemental Instructions for EDR and CRR Data s A3A.1 LOOPS AND SEGMENTS APPLIED TO EDR AND CRR SUBMISSIONS... 3 A3A.2 CONTROL SEGMENTS: CMS SUPPLEMENTAL INSTRUCTIONS

More information

HP SYSTEMS UNIT. Companion Guide: 270/271 Eligibility Benefit Transaction

HP SYSTEMS UNIT. Companion Guide: 270/271 Eligibility Benefit Transaction HP SYSTEMS UNIT I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Companion Guide: 270/271 Eligibility L I B R A R Y R E F E R E N C E N U M B E R : C L E L 1 0 0 1 2 A S C X 1 2 N 2 7 0 / 2 7

More information

Chapter 10 Companion Guide 835 Payment & Remittance Advice

Chapter 10 Companion Guide 835 Payment & Remittance Advice Chapter 10 Companion Guide 835 Payment & Remittance Advice This companion guide for the ANSI ASC X12N 835 Healthcare Claim PaymentAdvice transaction has been created for use in conjunction with the ANSI

More information

Implementation Guideline

Implementation Guideline Pennsylvania New Jersey Delaware Maryland Implementation Guideline For Electronic Data Interchange TRANSACTION SET 824 Application Advice Ver/Rel 004010 824 Application Advice (4010) 1 E EDI 824 Application

More information

HEALTHpac 837 Message Elements Institutional

HEALTHpac 837 Message Elements Institutional HEALTHpac 837 Message Elements Version 1.2 March 17, 2003 1 Table of Contents 1 INTRODUCTION...2 1.1 GENERAL COMMENTS...2 1.2 RELATED DOCUMENTS...3 2 MESSAGE ELEMENTS...4 2.1 HEADER...4 2.2 INFO SOURCE...5

More information

Seg Loop Name TR3 Values Notes Delimiter: Data Element. (:) Colon Separator

Seg Loop Name TR3 Values Notes Delimiter: Data Element. (:) Colon Separator Companion Guide for the 005010X223A1 Health Care Claim: Institutional (837I) Lines of Business: Private Business, 65C Plus, QUEST, Blue Card, FEP, Away From Home Care Delimiter: Data Element (*) Asterisk

More information

Fuel Systems Inc Purchase Order Ver ANSI ASC X Fuel Systems Inc. 850 Purchase Order VERSION: ANSI ASC X

Fuel Systems Inc Purchase Order Ver ANSI ASC X Fuel Systems Inc. 850 Purchase Order VERSION: ANSI ASC X Fuel Systems Inc 850 Purchase Order VERSION: ANSI ASC X12 4010 Created: October 19, 2007 Modified: July 23, 2008 850 v4010 Purchase Order.doc Page 1 of 18 850 Purchase Order Functional Group=PO This standard

More information

Phone: FAX: Topeka KS Department of Revenue ACH CREDIT Payment Information

Phone: FAX: Topeka KS Department of Revenue  ACH CREDIT Payment Information Electronic Services 915 SW Harrison St Kansas State Treasurer s ABA Number: 101101154 EFT Deposit Account Number: 0200005177 US Bank 719 S Kansas Avenue Topeka, KS 66603 Phone: 785-296-6993 FAX: 785-296-0153

More information

EDS SYSTEMS UNIT. Pre-Release Companion Guide: 270/271 Eligibility Benefit Transaction

EDS SYSTEMS UNIT. Pre-Release Companion Guide: 270/271 Eligibility Benefit Transaction EDS SYSTEMS UNIT I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Pre-Release Companion Guide: 270/271 Eligibility Benefit Transaction L I B R A R Y R E F E R E N C E N U M B E R : C L E L 1 0

More information

837 Institutional Health Care Claim. Section 1 837I Institutional Health Care Claim: Basic Instructions

837 Institutional Health Care Claim. Section 1 837I Institutional Health Care Claim: Basic Instructions Companion Document 837I This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained

More information

Commonwealth of Virginia (State Programs) 834 Benefit Enrollment and Maintenance: Audit File

Commonwealth of Virginia (State Programs) 834 Benefit Enrollment and Maintenance: Audit File Sample: ISA*00* *00* *30*54-6024817 *30*99-9999999 *050503*1436*U*00401*100000411*0*P*~ GS*BE*COMMW VIRGINIA*99-9999999*20050503*053645*50320059*X*004010X095A1~ ST*834*1001~ BGN*00*125839*20050503*053645*ET***4~

More information

Purpose of the 837 Health Care Claim: Professional

Purpose of the 837 Health Care Claim: Professional Oklahoma Medicaid Management Information System Interface Specifications 837 Professional Health Care Claim HIPAA Guidelines for Electronic Transactions Companion Document The following is intended to

More information

Texas Medicaid. HIPAA Transaction Standard Companion Guide

Texas Medicaid. HIPAA Transaction Standard Companion Guide Texas Medicaid HIPAA Transaction Standard Companion Guide Refers to the Implementation Guide Long Term Care 837 Health Care Claim: Institutional Based on ASC X12 version 005010 CORE v5010 Companion Guide

More information

834 Benefit Enrollment and Maintenance

834 Benefit Enrollment and Maintenance New Mexico Health Insurance Exchange (NMHIX) 834 Benefit Enrollment and Maintenance Standard Companion Guide Transaction Information Version 1.5 06/17/2014 PREFACE This Companion Guide to the v5010 Accredited

More information

Early Intervention Central Billing Office. Companion Document and Transaction Specifications for HIPAA 837 Claim Transactions

Early Intervention Central Billing Office. Companion Document and Transaction Specifications for HIPAA 837 Claim Transactions Early Intervention Central Billing Office Companion Document and Transaction Specifications for HIPAA 837 Claim Transactions Version 1.0 - January 2012 Table of Contents 1. Introduction... 1 1.1 Document

More information

EyeMed Vision Care. HEALTH CARE CLAIM: PROFESSIONAL Companion Document to ASC X12N 837 (004010X098A1)

EyeMed Vision Care. HEALTH CARE CLAIM: PROFESSIONAL Companion Document to ASC X12N 837 (004010X098A1) HEALTH CARE CLAIM: PROFESSIONAL Companion Document to ASC X12N 837 (004010X098A1) Welcome to EyeMed Vision Care s HIPAA TCS implementation process. We have developed this guide to assist you in preparing

More information

Geisinger Health Plan

Geisinger Health Plan Geisinger Health Plan Companion Guide for the 834 Benefit Enrollment and Maintenance Refers to the Implementation Guides Based on X12 version 005010X220 Version Number: 1.01 Revised, October 28, 2010 1

More information

837 Health Care Claim: Professional HIPAA/V4010X098A1/837: 837 Health Care Claim: Professional Version: 1.3 Update 06/17/04

837 Health Care Claim: Professional HIPAA/V4010X098A1/837: 837 Health Care Claim: Professional Version: 1.3 Update 06/17/04 837 Health Care Claim: Professional HIPAA/V4010X098A1/837: 837 Health Care Claim: Professional Version: 1.3 Update 06/17/04 Author: Publication: EDI Department LA Medicaid Companion Guide The purpose of

More information

Benefit Enrollment and Maintenance X12

Benefit Enrollment and Maintenance X12 834 Benefit Enrollment and Maintenance 004010 X12 Functional Group=BE Heading: Pos Id Segment Req Max Use Repeat Notes Usage 020 BGN Beginning Segment M 1 Must use 030 REF Reference Identification O >1

More information

Vendor Specifications 834 Outbound Benefit Enrollment and Maintenance ASC X12N Version 5010A1. for. State of Idaho MMIS

Vendor Specifications 834 Outbound Benefit Enrollment and Maintenance ASC X12N Version 5010A1. for. State of Idaho MMIS Vendor Specifications 834 Outbound Benefit Enrollment and Maintenance ASC X12N Version 5010A1 for State of Idaho MMIS Date of Publication: 7/31/2017 Document Number: TL421 Version: 5.0 Revision History

More information

835 Health Care Claim Payment / Advice

835 Health Care Claim Payment / Advice Companion Document 835 835 Health Care Claim Payment / Advice This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not

More information

USER'S GUIDE ELECTRONIC DATA INTERFACE 834 TRANSACTION. Capital BlueCross EDI Operations

USER'S GUIDE ELECTRONIC DATA INTERFACE 834 TRANSACTION. Capital BlueCross EDI Operations ELECTRONIC DATA INTERFACE 834 TRANSACTION Capital BlueCross EDI Operations USER'S GUIDE Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage

More information

835 Health Care Claim Payment/Advice

835 Health Care Claim Payment/Advice Companion Document 835 835 Health Care Claim Payment/Advice Basic Instructions This section provides information to help you prepare for the ANSI ASC X12 Health Care Claim Payment/Advice (835) transaction.

More information

Vendor Specifications 837 Institutional Claim ASC X12N Version X223A2. for. State of Idaho MMIS

Vendor Specifications 837 Institutional Claim ASC X12N Version X223A2. for. State of Idaho MMIS Vendor Specifications 837 Institutional Claim ASC X12N Version 005010X223A2 for State of Idaho MMIS Date of Publication: 6/16/2016 Document Number: TL426 Version: 8.0 Revision History Version Date Author

More information

Implementation Guideline

Implementation Guideline Pennsylvania New Jersey Delaware Maryland Implementation Guideline For Electronic Data Interchange TRANSACTION SET 568 Collections Ver/Rel 004010 568 Collections (4010) 1 IG568v6-16-1.docx Table of Contents

More information

EyeMed Vision Care. BENEFIT ENROLLMENT AND MAINTENANCE Companion Document to ASC X12N 834 (004010X095A1)

EyeMed Vision Care. BENEFIT ENROLLMENT AND MAINTENANCE Companion Document to ASC X12N 834 (004010X095A1) BENEFIT ENROLLMENT AND MAINTENANCE Companion Document to ASC X12N 834 (004010X095A1) Welcome to EyeMed Vision Care s HIPAA TCS implementation process. We have developed this guide to assist you in preparing

More information

NCHELP CommonLine Network for FFELP And Alternative Loans. Disbursement Roster File/ Disbursement Roster Acknowledgment File

NCHELP CommonLine Network for FFELP And Alternative Loans. Disbursement Roster File/ Disbursement Roster Acknowledgment File NCHELP CommonLine Network for FFELP And Alternative Loans Disbursement Roster File/ Disbursement Roster Acknowledgment File File Description Release 4 Processing Issued: 04/11/2013 Table of Contents TABLE

More information

834 Template 1 of 16. Comments and Additional. Info

834 Template 1 of 16. Comments and Additional. Info 834 Template 1 of 16 HDR Header (not really a loop) Reference ISA 1 M Required ISA Interchange Control Header R M The ISA is a fixed record length segment and all positions within each of the data elements

More information

835 Health Care Claim Payment / Advice

835 Health Care Claim Payment / Advice Companion Document 835 835 Health Care Claim Payment / Advice This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not

More information

Virginia Implementation Standard. For Electronic Data Interchange. TRANSACTION SET 867 Product Transfer and Resale Report Monthly Usage Ver/Rel

Virginia Implementation Standard. For Electronic Data Interchange. TRANSACTION SET 867 Product Transfer and Resale Report Monthly Usage Ver/Rel Virginia Implementation Standard For Electronic Data Interchange - - - TRANSACTION SET 867 Product Transfer and Resale Report Monthly Usage Ver/Rel 004010 VA 867 Monthly Usage (4010) 1 867mu-stan2-3.doc

More information

837I Institutional Health Care Claim

837I Institutional Health Care Claim Section 2B 837I Institutional Health Care Claim Companion Document Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care transaction for Institutional

More information

Personal Health Record Data Transfer Between Health Plans (275)

Personal Health Record Data Transfer Between Health Plans (275) 005010271 Based on ASC 12 275, Version 005010 Standards for Electronic Data Interchange Personal Health Record Data Transfer Between Health Plans (275) VERSION 3.1.4 BASED ON ASC 12 275 VERSION 005010

More information

Companion Guide for the X223A2 Health Care Claim: Institutional (837I) Lines of Business: Private Business Senior Plans QUEST Blue Card FEP AFHC

Companion Guide for the X223A2 Health Care Claim: Institutional (837I) Lines of Business: Private Business Senior Plans QUEST Blue Card FEP AFHC Companion Guide for the 005010X223A2 Health Care Claim: Institutional (837I) Lines of Business: Private Business Senior Plans QUEST Blue Card FEP AFHC Segment Loop Name TR3 Values Notes Delimiter: Data

More information

Vendor Specifications 837 Professional Claim ASC X12N Version for. State of Idaho MMIS

Vendor Specifications 837 Professional Claim ASC X12N Version for. State of Idaho MMIS Vendor Specifications 837 Professional Claim ASC X12N Version 5010 for State of Idaho MMIS Date of Publication: 12/8/2017 Document Number: TL427 Version: 11.0 Revision History Versio Date Author Action/Summary

More information

HIPAA Transaction Health Care Claim Payment/Advice Standard Companion Guide (835, X221A1)

HIPAA Transaction Health Care Claim Payment/Advice Standard Companion Guide (835, X221A1) (underwritten by Dean Health Plan) HIPAA Transaction Health Care Claim Payment/Advice Standard Companion Guide (835, 005010X221A1) Instructions related to Transactions based on ASC X12 Implementation Guides,

More information

10/2010 Health Care Claim: Professional - 837

10/2010 Health Care Claim: Professional - 837 837 Health Care Claim: Professional HIPAA/V4010X098A1/837: 837 Health Care Claim: Professional Version: 1.8 Update 10/20/10 (Latest Changes in RED font) Author: Publication: EDI Department LA Medicaid

More information

837 Professional Health Care Claim Outbound. Section 1 837P Professional Health Care Claim: Basic Instructions

837 Professional Health Care Claim Outbound. Section 1 837P Professional Health Care Claim: Basic Instructions Companion Document 837P 837 Professional Health Care Claim Outbound This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and

More information

837 Institutional Health Care Claim. Section 1 837I Institutional Health Care Claim: Basic Instructions

837 Institutional Health Care Claim. Section 1 837I Institutional Health Care Claim: Basic Instructions Companion Document 837I This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained

More information

Vendor Specifications 278 Healthcare Services Request for Review and Response ASC X12N Version for. State of Idaho MMIS

Vendor Specifications 278 Healthcare Services Request for Review and Response ASC X12N Version for. State of Idaho MMIS Vendor Specifications 278 Healthcare Services uest for Review and Response ASC X12N Version 5010 for State of Idaho MMIS Date of Publication: 07/25/2017 Document Number: TL418 Version: 5.0 Revision History

More information

Standard Companion Guide

Standard Companion Guide Standard Companion Guide Refers to the Implementation Guide Based on X12 Version 005010X221A1 Health Care Claim Payment/Advice (835) Companion Guide Version Number: 1.0 December 17, 2013 1 Change Log Version

More information

835 Health Care Claim Payment / Advice

835 Health Care Claim Payment / Advice Companion Document 835 835 Health Care Claim Payment / Advice This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not

More information

Copyright Red Raven Productions. Designation X12 Founded in 1979 August of 2000 Transaction Standards

Copyright Red Raven Productions. Designation X12 Founded in 1979 August of 2000 Transaction Standards PRESENTATION HIPAA Privacy & Security X12 ICD GEM It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change. - Charles Darwin HIPAA X12N - ICD

More information

(Delaware business only) HIPAA Transaction Standard Companion Guide

(Delaware business only) HIPAA Transaction Standard Companion Guide AmeriHealth (Delaware business only) HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 Implementation Guides, version 005010 June 2016 June 2016 005010 v1.3

More information

Implementation Guideline

Implementation Guideline Pennsylvania New Jersey Delaware Maryland Implementation Guideline For Electronic Data Interchange TRANSACTION SET 814 Advance Notice of Intent to Drop Request and Response Ver/Rel 004010 814 Advance Notice

More information

AmeriHealth (Pennsylvania Only)

AmeriHealth (Pennsylvania Only) AmeriHealth (Pennsylvania Only) HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 Implementation Guides, version 005010 June 2016 June 2016 005010 v1.2 1 AmeriHealth

More information

- - - Virginia. Implementation Standard. For Electronic Data Interchange. March 21, 2003 Open Access Version 2.3

- - - Virginia. Implementation Standard. For Electronic Data Interchange. March 21, 2003 Open Access Version 2.3 Virginia Implementation Standard For Electronic Data Interchange - - - TRANSACTION SET 814 Enrollment Request and Response Ver/Rel 004010 VA 814 Enrollment 1 814e-stan2-3.doc Summary of Changes August

More information

834 Benefit Enrollment and Maintenance

834 Benefit Enrollment and Maintenance Companion Document 834 834 Benefit Enrollment and Maintenance This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not

More information

837 Institutional Health Care Claim. Section 1 837I Institutional Health Care Claim: Basic Instructions

837 Institutional Health Care Claim. Section 1 837I Institutional Health Care Claim: Basic Instructions Companion Document 837I This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained

More information

810 LDC Consolidated Bill Ver/Rel Implementation Guideline. Pennsylvania New Jersey Delaware Maryland. For Electronic Data Interchange

810 LDC Consolidated Bill Ver/Rel Implementation Guideline. Pennsylvania New Jersey Delaware Maryland. For Electronic Data Interchange Pennsylvania New Jersey Delaware Maryland Implementation Guideline For Electronic Data Interchange TRANSACTION SET 810 LDC Consolidated Bill Ver/Rel 004010 810 LDC Consolidated Bill (4010) 1 IG810LDCv6-2x

More information

837 Institutional Health Care Claim Outbound. Section 1 837I Institutional Health Care Claim: Basic Instructions

837 Institutional Health Care Claim Outbound. Section 1 837I Institutional Health Care Claim: Basic Instructions Companion Document 837I This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained

More information

IAIABC EDI IMPLEMENTATION GUIDE

IAIABC EDI IMPLEMENTATION GUIDE IAIABC EDI IMPLEMENTATION GUIDE for MEDICAL BILL PAYMENT RECORDS RELEASE 1.1 JULY 1, 2009 EDITION INTERNATIONAL ASSOCIATION OF INDUSTRIAL ACCIDENT BOARDS AND COMMISSIONS This page is meant to be blank.

More information

Florida Blue Health Plan

Florida Blue Health Plan Florida Blue Health Plan HIPAA Transaction Standard Companion Guide For Availity Health Information Network Users Refers to the Technical Reports Type 3 Based on ASC X12 version 005010X222A1 837I Health

More information