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

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1 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

2 Revision History Version Date Author Action/Summary of Changes /01/2011 Molina Initial Document /22/2014 M McFadden Added ICD-10 references and updates for CCF10735B1-Edifecs 2.0 8/15/2014 TQD DHW validated 8/15/ /19/2015 Doug Greer Semi-annual review performed - made corrections 3.0 6/8/2015 TQD DHW validated 6/5/ /10/2015 Doug Greer Semi-annual review performed made corrections 4.0 1/25/2016 TQD DHW validated changes 1/22/ /25/2016 Cathy Butler Semi-annual review no changes made /15/2016 Jimmy Phillips Semi-annual review no changes made 4.1 6/2/2017 Douglas Greer Semi-annual review - Minor corrections in tables 2-1 and /25/2017 TQD DHW validate changes 7/25/17 The Molina Healthcare Companion Guide for Idaho is subject to change prior to January 1, 2012 or at the instruction of the Department. Therefore, it is the responsibility of the trading partner to ensure that the latest version of this guide is used when designing/ building X12N 5010 EDI transactions. The trading partner should frequently check for updates to the companion guide. Molina Healthcare accepts no liability for any costs that the trading partner may incur that arise from or are related to changes to the companion guide. Last Updated: 7/25/2017 Page ii

3 Table of Contents 1. Companion Guide Purpose uired Information Trading Partner Delimiters Additional Information uest for Review Response Appendix A Table of Figures Figure 2-1: uest for Review... 3 Figure 2-2: 278 Response Last Updated: 7/25/2017 Page iii

4 1. Companion Guide Purpose This companion guide documents the transaction type listed below and further defines situational and required data elements that are used for processing healthcare service requests for reviews and responses for programs administered by the Idaho Medicaid. This document is not the complete EDI transaction format specifications. Please refer to the 5010 Implementation Guide for information not supplied in this document, such as code lists, definitions, and edits. Health Care Services uest for Review and Response ASC X12N 278 (005010X217) May 2006 Health Care Services uest for Review and Response ASC X12N 278 (005010X217E1) April 2008 Health Care Services uest for Review and Response ASC X12N 278 (005010X217E2) January 2009 For any questions, or to begin testing, please contact the Molina EDI Helpdesk at 1 (866) option 2 and ask for Technical Support, or us at idedisupport@molinahealthcare.com uired Information Data elements, segments, and loops not included in this guide are not used for processing authorization requests by Idaho Medicaid, but must still be sent if the information is required for compliance with the ASC X12N version 5010 format Trading Partner A trading partner is defined as any entity with which Molina exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Idaho Medicaid s Health PAS system supports the following categories of trading partner: Provider Billing Agency Clearinghouse Health Plan Molina will assign trading partner s to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. All trading partners must be authorized to submit production EDI transactions. Any trading partner may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of an X12 file, indicates if a file is test or production. Authorization is granted on a per transaction basis. For example, a trading partner may be certified to submit 837P professional claims but not certified to submit 837I institutional claim files. Trading partners must submit three test files of a particular transaction type, with a minimum of fifteen transactions within each file, and have no failures or rejections in order to become certified for production. Users will be notified via and the Trading Partner Status page of Health PAS-Online when testing for a particular transaction has been completed. Last Updated: 7/25/2017 Page 1 of 61

5 Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may be found in Appendix A of this document. To obtain a trading partner please visit our website at or contact us at 1 (866) Delimiters Idaho Medicaid does not require the use of specific values for the delimiters used in electronic transactions. The suggested values are included in the specifications below Additional Information Please refer to the 5010 Implementation Guide for information not supplied in this document, such as code lists, definitions, and edits. Last Updated: 7/25/2017 Page 2 of 61

6 uest for Review Figure 2-1: uest for Review Name/ Data Format Length DE Ref Interchange Control Record HEADER ISA Interchange Control Header 3 R ISA ISA01 Authorization Information 2 I01 R 00 No Authorization Information Present ISA02 Authorization Information AN 10 I02 R Space fill ISA03 Security Information 2 I03 R 00 No Security Information Present ISA04 Security Information AN 10 I04 R Space fill ISA05 Interchange 2 I05 R ZZ Mutually Defined ISA06 Interchange Sender AN 15 I06 R Molina assigned trading partner ISA07 Interchange 2 I05 R ZZ Mutually Defined ISA08 Interchange Receiver AN 15 I07 R _MMIS_4MOLINA ISA09 Interchange Date DT 6 I08 R YYMMDD ISA10 Interchange Time TM 4 I09 R HHMM ISA11 Repetition Separator 1 I65 R ^ ISA12 Interchange Version Number 5 I11 R ISA13 Interchange Control Number N0 9 I12 R Must be identical to the interchange Last Updated: 7/25/2017 Page 3 of 61

7 Name/ Data Format Length DE Ref trailer IEA02 - defined by sender ISA14 Acknowledgment uested 1 I13 R 0 No Acknowledgment uested 1- Interchange Acknowledgement requested ISA15 Interchange Usage Indicator 1 I14 R P Production Data T Test Data ISA16 Component Element 1 I15 R : Separator Functional Group Header GS Functional Group Header 2 R GS GS01 Functional Identifier Code R HI GS02 Application Sender's Code AN 2/ R Molina Assigned Trading Partner GS03 Application Receiver's Code AN 2/ R _MMIS_4MOLINA GS04 Date DT R CCYYMMDD GS05 Time TM 4/8 337 R HHMM GS06 Group Control Number N0 1/9 28 R Assigned by Sender GS07 Responsible Agency Code 1/2 455 R X Accredited Standards Committee X12 GS08 Version / Release Code AN 1/ R X217 Transaction Set Header ST Transaction Set Header 2 R ST ST01 Transaction Set Identifier Code R 278 Health Care Services Review Information Last Updated: 7/25/2017 Page 4 of 61

8 Name/ Data Format Length DE Ref ST02 Transaction Set Control Number AN 4/9 329 R Sequential number assigned by sender ST and SE must be equal ST03 Implementation AN 1/ R X217 Convention Reference Beginning of Hierarchical Transaction BHT Beginning Hierarchical 3 R BHT Transaction BHT01 Hierarchical Structure Code R 0007 Information Source, Information Receiver, Subscriber, Dependent, Provider of Service, Services BHT02 Transaction Set Purpose Code R 01 = Cancellation 13 uest BHT03 Reference identification AN 1/ R Submitter Transaction Identifier. BHT04 Date DT R CCYYMMDD - Transaction Set Creation Date BHT05 Time TM 4/8 337 R HHMM - Transaction Set Creation Time UMO ( 2000A) 2000A HL Hierarchical Level 2 R HL HL01 Hierarchical Number AN 1/ R 1 HL03 Hierarchical Level Code 1/2 735 R 20 Information Source HL04 Hierarchical Child Code R 1 Additional Subordinate HL Data in This Hierarchical Structure. Last Updated: 7/25/2017 Page 5 of 61

9 Name/ Data Format Length DE Ref 2010A NM1 Individual or Organizational 3 R NM1 Name NM101 Entity Identifier Code 2/3 98 R X3 - UMO NM102 Entity Type R 2 Non-Person Entity NM103 Name Last or Organization AN 1/ R AHO MEDICA Name NM104 Name First AN 1/ S NM105 Name Middle AN 1/ NM107 Name Suffix AN 1/ S NM108 Identification Code 1/2 66 R PI Payor Identification NM109 Identification Code AN 2/80 67 R _MMIS_4MOLINA uester ( 2000B) 2000B HL Hierarchical Level 2 R HL HL01 Hierarchical Number AN 1/ R 2 HL02 Hierarchical Parent AN 1/ R 1 Number HL03 Hierarchical Level Code 1/2 735 R 21 Information Receiver HL04 Hierarchical Child Code R 1 Additional Subordinate HL Data in This Hierarchical Structure. 2010B NM1 Individual or Organizational Name 3 R NM1 Last Updated: 7/25/2017 Page 6 of 61

10 Name/ Data Format Length DE Ref NM101 Entity Identifier Code 2/3 98 R 1P Provider, FA Facility NM102 Entity Type R 1 Person 2 Non Person Entity NM103 Name Last or Organization AN 1/ R Name NM104 Name First AN 1/ S uired if NM102=1 (Person) NM105 Name Middle AN 1/ S NM107 Name Suffix AN 1/ S NM108 Identification Code 1/2 66 R 24=Employer s Identification Number (for Atypical Providers Only) XX= National Provider Identifier 34 = SSN (Atypical providers without EIN) NM109 Identification Code AN 2/80 67 R Provider NPI, Idaho EIN, or SSN 2010B REF Reference Identification 3 S REF REF01 Reference Identification 2/3 128 R N5 REF02 Reference Identification AN 1/ R Medicaid assigned provider for the uesting Provider for Atypical providers only Subscriber ( 2000C) 2000C HL Hierarchical Level 2 R HL HL01 Hierarchical Number AN 1/ R 3 Last Updated: 7/25/2017 Page 7 of 61

11 Name/ Data Format Length DE Ref HL02 Hierarchical Parent AN 1/ R 2 Number HL03 Hierarchical Level Code 1/2 735 R 22=Subscriber HL04 Hierarchical Child Code R C NM1 Individual or Organizational 3 R NM1 Name NM101 Entity Identifier Code 2/3 98 R IL = Insured or Provider NM102 Entity Type R 1 = Person NM103 Name Last or Organization AN 1/ S Name NM104 Name First AN 1/ S NM105 Name Middle AN 1/ S NM106 Name Prefix AN 1/ S NM107 Name Suffix AN 1/ S NM108 Identification Code 1/2 66 R MI = Member Identification Number NM109 Identification Code AN 7/10 67 R Enter the Idaho Medicaid member s 7 or 10 digit identification number as it appears on their card 2010C DMG Demographic Information 3 S DMG DMG01 Date Time Period Format 2/ R D8 DMG02 Date Time Period AN 1/ R Patient Date of Birth Last Updated: 7/25/2017 Page 8 of 61

12 Name/ Data Format Length DE Ref DMG03 Gender Code S Patient Gender Service Provider ( 2000E) 2000E HL Hierarchical Level 2 R HL HL01 Hierarchical Number AN 1/ R 4 HL02 Hierarchical Parent AN 1/ R 3 Number HL03 Hierarchical Level Code 1/2 735 R EV=Event HL04 Hierarchical Child Code 1/1 736 R 0 = No Subordinate HL 1= Additional Subordinate HL Data 2000E TRN Patient Event Tracking 3 S TRN Number TRN01 Trace Type Code 1/2 481 R 1 TRN02 Reference Identification AN 1/ R TRN03 Originating Company AN R Identifier TRN04 Reference Identification AN 1/ S 2000E UM Health Care Services 2 R UM Review Information UM01 uest Category Code 1/ R AR=Admission Review HS=Health Services Review Last Updated: 7/25/2017 Page 9 of 61

13 Name/ Data Format Length DE Ref UM02 Certification Type Code 1/ R I = Initial 3 = Cancel 4 = Extension UM03 Service Type Code 1/ R For Prior Authorizations see UM03 Service Type PA Crosswalk in this guide UM04 Health Care Service C023 S Location Information UM04-1 Facility Code AN 1/ R Component Element 1 : Separator UM04-2 Facility Code 1/ R UM05 Related Causes Information C024 S uired when the patient s condition is accident or employment related UM05-1 Related-Causes Code 2/ R Always use this data element if the related cause is an auto accident Component Element 1 : Separator UM05-2 Related-Causes Code 2/ S Component Element 1 : Separator UM05-3 Related-Causes Code 2/ S Component Element 1 : Separator UM05-4 State or Province Code 2/2 156 S uired on review requests if UM05-1=AA, if the accident occurred out of the service provider's state Component Element Separator 1 : Last Updated: 7/25/2017 Page 10 of 61

14 Name/ Data Format Length DE Ref UM05-5 Country Code 2/3 26 S uired if automobile accident occurred out of the U.S. UM06 Level of Service Code 1/ S Recommended if the service requested would not be authorized unless the patient's condition is Emergency or Urgent UM07 Current Health Condition S Code UM08 Prognosis Code S UM09 Release of Information S Code UM10 Delay Reason Code 1/ S uired if the request is not submitted within the normal timeframe of the UMO 2000E REF Reference Identification 3 S REF REF01 Reference Identification 2/3 128 R BB=Authorization Number REF02 Reference Identification AN 1/ R uired if UM02 segment under 2000E Health Care Services review Information equals a 3, indicating action on previous authorization 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R 439 = Accident Last Updated: 7/25/2017 Page 11 of 61

15 DTP02 Name/ Data Date Time Period Format Format Length DE Ref 2/ R D8 = date expressed in format CCYYMMDD DTP03 Date Time Period AN 1/ R format = CCYYMMDD 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R 484 = Last Menstrual Period DTP02 Date Time Period Format 2/ R D8 = date expressed in format CCYYMMDD DTP03 Date Time Period AN 1/ R format = CCYYMMDD 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R ABC = Estimated Date of Birth DTP02 Date Time Period Format 2/ R D8 = date expressed in format CCYYMMDD DTP03 Date Time Period AN 1/ R format = CCYYMMDD 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R 431 = Onset of Current Symptoms or Illness DTP02 Date Time Period Format 2/ R D8 = date expressed in format CCYYMMDD DTP03 Date Time Period AN 1/ R format = CCYYMMDD Last Updated: 7/25/2017 Page 12 of 61

16 Name/ Data Format Length DE Ref 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R AAH = Event DTP02 Date Time Period Format 2/ R D8 = date expressed in format CCYYMMDD RD8 = date expressed in format CCYYMMDD-CCYYMMDD DTP03 Date Time Period AN 1/ R format = CCYYMMDD if DTP02 = D8 format = CCYYMMDD-CCYYMMDD if DTP02 = RD8 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R 435 =Admission DTP02 Date Time Period Format 2/ R D8 = date expressed in format CCYYMMDD RD8 = date expressed in format CCYYMMDD-CCYYMMDD DTP03 Date Time Period AN 1/ R format = CCYYMMDD if DTP02 = D8 format = CCYYMMDD-CCYYMMDD if DTP02 = RD8 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R 096 = Discharge DTP02 Date Time Period Format 2/ R D8 = date expressed in format CCYYMMDD Last Updated: 7/25/2017 Page 13 of 61

17 Name/ Data Format Length DE Ref DTP03 Date Time Period AN 1/ R format = CCYYMMDD 2000E HI Health Care Information 2 S HI Codes HI01 Health Care Code 4 C022 S Information Alias Diagnosis 1 HI01-1 Code List Code 1/ R BK (ICD-9) Principal Diagnosis ABK (ICD-10) Principal Diagnosis BF (ICD-9) - Diagnosis ABF (ICD-10) - Diagnosis BJ (ICD-9) Admitting Diagnosis ABJ (ICD-10) Admitting Diagnosis Component Element 1 : Separator HI01-2 Industry Code AN 1/ R Diagnosis Code Component Element 1 : Separator HI01-3 Date Time Period Format 2/ S D8 = date expressed in format CCYYMMDD Component Element 1 : Separator HI01-4 Date Time Period AN 1/ S Diagnosis Date. Format date CCYYMMDD HI02 Health Care Code 4 C022 S Information Alias Diagnosis 2 HI02-1 Code List Code 1/ R BF (ICD-9) - Diagnosis Last Updated: 7/25/2017 Page 14 of 61

18 Name/ Data Format Length DE Ref ABF (ICD-10) - Diagnosis BJ (ICD-9) Admitting Diagnosis ABJ (ICD-10) Admitting Diagnosis Component Element 1 : Separator HI02-2 Industry Code AN 1/ R Diagnosis Code Component Element 1 : Separator HI02-3 Date Time Period Format 2/ S D8 = date expressed in format CCYYMMDD Component Element 1 : Separator HI02-4 Date Time Period AN 1/ S Diagnosis Date. Format date CCYYMMDD HI03 Health Care Code 4 C022 S Information Alias Diagnosis 3 HI03-1 Code List Code 1/ R BF (ICD-9) - Diagnosis ABF (ICD-10) - Diagnosis Component Element 1 : Separator HI03-2 Industry Code AN 1/ R Diagnosis Code Component Element 1 : Separator HI03-3 Date Time Period Format 2/ S D8 = date expressed in format CCYYMMDD Component Element 1 : Separator HI03-4 Date Time Period AN 1/ S Diagnosis Date. Format date CCYYMMDD Last Updated: 7/25/2017 Page 15 of 61

19 Name/ Data Format Length DE Ref Note: Can be up to 10 HI0x-1 thru HI0x-4 BF/ABF (Other Diagnosis Code) elements separated by * 2000E HSD Health Care Delivery 3 S HSD Services HSD01 Quantity S HSD02 Quantity R 1/ S HSD03 Unit or Basis for Measurement Code S HSD04 Sample Selection Modulus R 1/ S HSD05 Time Period 1/2 615 S HSD06 Number of Periods N0 1/3 616 S HSD07 Ship/Delivery or Calendar Pattern Code 1/2 678 S HSD08 Ship/Delivery Pattern Time Code S 2000E CRC Conditions Indicator 3 S CRC CRC01 Code Category R 07 = Ambulance Certification CRC02 Yes/No Condition or R Response Code CRC03 Condition Indicator 2/ R Last Updated: 7/25/2017 Page 16 of 61

20 Name/ Data Format Length DE Ref CRC04 Condition Indicator 2/ S CRC05 Condition Indicator 2/ S CRC06 Condition Indicator 2/ S CRC07 Condition Indicator 2/ S 2000E CRC Conditions Indicator 3 S CRC CRC01 Code Category R 08 = Chiropractic Certification CRC02 Yes/No Condition or R Response Code CRC03 Condition Indicator 2/ R CRC04 Condition Indicator 2/ S CRC05 Condition Indicator 2/ S CRC06 Condition Indicator 2/ S CRC07 Condition Indicator 2/ S 2000E CRC Conditions Indicator 3 S CRC CRC01 Code Category R 09 = Durable Medical Equipment Certification CRC02 Yes/No Condition or Response Code R Last Updated: 7/25/2017 Page 17 of 61

21 Name/ Data Format Length DE Ref CRC03 Condition Indicator 2/ R CRC04 Condition Indicator 2/ S CRC05 Condition Indicator 2/ S CRC06 Condition Indicator 2/ S CRC07 Condition Indicator 2/ S 2000E CRC Conditions Indicator 3 S CRC CRC01 Code Category R 11 = Oxygen Therapy Certification CRC02 Yes/No Condition or R Response Code CRC03 Condition Indicator 2/ R CRC04 Condition Indicator 2/ S CRC05 Condition Indicator 2/ S CRC06 Condition Indicator 2/ S CRC07 Condition Indicator 2/ S 2000E CRC Conditions Indicator 3 S CRC CRC01 Code Category R 75 = Functional Limitations CRC02 Yes/No Condition or R Last Updated: 7/25/2017 Page 18 of 61

22 Name/ Data Format Length DE Ref Response Code CRC03 Condition Indicator 2/ R CRC04 Condition Indicator 2/ S CRC05 Condition Indicator 2/ S CRC06 Condition Indicator 2/ S CRC07 Condition Indicator 2/ S 2000E CRC Conditions Indicator 3 S CRC CRC01 Code Category R 76 = Activities Permitted CRC02 Yes/No Condition or R Response Code CRC03 Condition Indicator 2/ R CRC04 Condition Indicator 2/ S CRC05 Condition Indicator 2/ S CRC06 Condition Indicator 2/ S CRC07 Condition Indicator 2/ S 2000E CRC Conditions Indicator 3 S CRC CRC01 Code Category R 77 = Mental Status Last Updated: 7/25/2017 Page 19 of 61

23 CRC02 Name/ Data Yes/No Condition or Response Code Format Length DE Ref R CRC03 Condition Indicator 2/ R CRC04 Condition Indicator 2/ S CRC05 Condition Indicator 2/ S CRC06 Condition Indicator 2/ S CRC07 Condition Indicator 2/ S 2000E CL1 Claim Codes 3 S CL1 uired when UM01 = AR CL101 Admission Type Code S CL102 Admission Source Code R S CL103 Patient Status Code ½ 1352 S CL104 Nursing Home Residential Status Code S 2000E CR1 Ambulance Certification 3 S CR1 Note: 2010EB is required when 2000E/CR1 is used CR101 Unit or Basis for Measurement Code S CR102 Weight R 1/10 81 S Last Updated: 7/25/2017 Page 20 of 61

24 CR103 Name/ Data Ambulance Transport Code Format Length DE Ref R CR104 Ambulance Transport Reason Code R CR105 Unit or Basis for Measurement Code S CR106 Quantity R 1/ S CR109 Description AN 1/ S uired if needed when CR103 = X. Otherwise Not Used. CR110 Description AN 1/ S 2000E CR2 Chiropractic Certification 3 S CR2 CR201 Count N0 1/9 609 S CR202 Quantity R 1/ S CR203 Subluxation Level Code 2/ S CR204 Subluxation Level Code 2/ S CR208 Nature of Condition Code R Last Updated: 7/25/2017 Page 21 of 61

25 CR209 Name/ Data Yes/No Condition or Response Code Format Length DE Ref R Last Updated: 7/25/2017 Page 22 of 61 CR210 Description AN 1/ S CR211 Description AN 1/ S Note: CR211 should not be used when element CR210 is not used CR212 Yes/No Condition or Response Code R 2000E CR6 Home Health Care 3 S CR6 Certification CR601 Prognosis Code R CR602 Date DT R format CCYYMMDD CR603 Date Time Period Format 2/ S RD8 CR604 Date Time Period AN 1/ S format CCYYMMDD-CCYYMMDD CR607 Yes/No Condition or R W Response Code CR608 Certification Type Code R CR609 Date DT S

26 CR610 Name/ Data Product/Service Format Length DE Ref S CR611 Medical Code AN 1/ S CR612 Date DT S CR613 Date DT S CR614 Date DT S CR615 Date Time Period Format 2/ S RD8 uired if the patient had a recent inpatient stay CR616 Date Time Period AN 1/ S format CCYYMMDD-CCYYMMDD uired if the patient had a recent inpatient stay CR617 Patient Location Code S uired if the patient had a recent inpatient stay 2010EA NM1 Individual or 3 R NM1 Organizational Name NM101 Entity Identifier Code 2/3 98 R NM102 Entity Type R 1=Person, 2=Non-Person Entity NM103 Name Last or AN 1/ S Organization Name NM104 Name First AN 1/ S uired if NM102=1 & NM103 is present Last Updated: 7/25/2017 Page 23 of 61

27 Name/ Data Format Length DE Ref Last Updated: 7/25/2017 Page 24 of 61 NM105 Name Middle AN 1/ S Only used if NM102=1 NM106 Name Prefix AN 1/ S NM107 Name Suffix AN 1/ S NM108 Identification Code 1/2 66 S 24=Employer s Identification Number (for atypical providers only) XX= National Provider Identifier NM109 Identification Code AN 2/80 67 S Enter NPI or if provider is atypical enter Employer Identification Number 2010EA REF Reference Information 3 S REF REF01 Reference Identification 2/3 128 R N5 = Provider Plan Network Identifier REF02 Reference Identification AN 1/ R Used for atypical providers only, to enter their assigned Provider 2010EB NM1 Individual or 3 R NM1 Organizational Name NM101 Entity Identifier Code 2/3 98 R NM102 Entity Type R 2 = Non-Person Entity NM103 Name Last or AN 1/ S Organization Name 2010EC NM1 Individual or 3 R NM1

28 Name/ Data Format Length DE Ref Organizational Name NM101 Entity Identifier Code 2/3 98 R NM102 Entity Type R 2 = Non-Person Entity NM103 Name Last or AN 1/ S Organization Name 2010EC REF Reference Information 3 S REF REF01 Reference Identification 2/3 128 R ZZ Mutually Defined REF02 Reference Identification AN 1/ R REF04 Reference Identifier O C040 S REF04-1 Reference Identification 2/3 128 R ZZ Mutually Defined REF04-2 Reference Identification AN 1/ R REF04-3 Reference Identification 2/3 128 S ZZ Mutually Defined REF04-4 Reference Identification AN 1/ S REF04-5 Reference Identification 2/3 128 S ZZ Mutually Defined REF04-6 Reference Identification AN 1/ S Last Updated: 7/25/2017 Page 25 of 61

29 Name/ Data Format Length DE Ref 2000EC DTP Date or Time or Period 3 R DTP DTP01 Date/Time R 598 = Rejected DTP02 Date Time Period Format 2/ R D8 DTP03 Date Time Period AN 1/ R format = CCYYMMDD Service ( 2000F) 2000F HL Hierarchical Level 2 R HL HL01 Hierarchical Number AN 1/ R 5 HL02 Hierarchical Parent AN 1/ R 4 Number HL03 Hierarchical Level Code 1/2 735 R SS HL04 Hierarchical Child Code 1/1 736 R F DTP Date or Time or Period 3 S DTP required if SV2 is used DTP01 Date/Time R 472 Service DTP02 Date Time Period 2/ R D8 Date Format CCYYMMDD RD8 Date Format CCYYMMDD- CCYYMMDD DTP03 Date Time Period AN 1/ R CCYYMMDD if DTP02 = D8 CCYYMMDD-CCYYMMDD if DTP02 = RD8 Last Updated: 7/25/2017 Page 26 of 61

30 Name/ Data Format Length DE Ref 2000F SV1 Professional Service 3 S SV1 SV101 Composite Medical C003 R Procedure Identifier SV101-1 Product/Service R HC = HCPCS Code SV101-2 Product/Service AN 1/ R SV101-3 Procedure Modifier AN S SV101-4 Procedure Modifier AN S SV101-5 Procedure Modifier AN S SV101-6 Procedure Modifier AN S SV101-7 Description AN 1/ S SV101-8 Product/Service AN 1/ S SV102 Monetary Amount R 1/ S SV103 Unit or Basis for S UN = Unit Measurement Code SV104 Quantity R 1/ S SV107 Composite Diagnosis C004 S Code Pointer SV107-1 Diagnosis Code Pointer N0 1/ R Last Updated: 7/25/2017 Page 27 of 61

31 Name/ Data Format Length DE Ref SV107-2 Diagnosis Code Pointer N0 1/ S SV107-3 Diagnosis Code Pointer N0 1/ S SV107-4 Diagnosis Code Pointer N0 1/ S SV111 Yes/No Condition or Response Code S N = No Y = Yes SV120 Level of Care Code S 2000F SV2 Institutional Service 3 S SV2 SV201 Product/Service AN 1/ S SV202 Composite Medical C003 S Procedure Identifier SV202-1 Product/Service R HC = HCPCS Code SV202-2 Product/Service AN 1/ R Last Updated: 7/25/2017 Page 28 of 61

32 Name/ Data Format Length DE Ref SV202-3 Procedure Modifier AN S SV202-4 Procedure Modifier AN S SV202-5 Procedure Modifier AN S SV202-6 Procedure Modifier AN S SV202-7 Description AN 1/ S SV202-8 Product/Service AN 1/ S SV203 Monetary Amount R 1/ S SV204 Unit or Basis for Measurement Code S DA =Days UN = Unit SV205 Quantity R 1/ S SV206 Unit Rate R 1/ S SV209 Nursing Home Residential S Status Code SV210 Level of Care Code S 2000F SV3 Dental Service 3 S SV3 SV301 Composite Medical Procedure Identifier C003 R Last Updated: 7/25/2017 Page 29 of 61

33 SV301-1 Name/ Data Product/Service Format Length DE Ref R AD = American Dental Association Codes SV301-2 Product/Service AN 1/ R SV301-3 Procedure Modifier AN S SV301-4 Procedure Modifier AN S SV301-5 Procedure Modifier AN S SV301-6 Procedure Modifier AN S SV301-7 Description AN 1/ S SV301-8 Product/Service AN 1/ S SV302 Monetary Amount R 1/ S SV304 Oral Cavity Designation C006 S SV304-1 Oral Cavity Designation Code 1/ R SV304-2 Oral Cavity Designation Code 1/ S SV304-3 Oral Cavity Designation Code 1/ S SV304-4 Oral Cavity Designation Code 1/ S Last Updated: 7/25/2017 Page 30 of 61

34 Name/ Data Format Length DE Ref SV304-5 Oral Cavity Designation Code 1/ S SV305 Prosthesis, Crown or Inlay Code S I = Initial Placement R = Replacement SV306 Quantity R 1/ R SV307 Description AN 1/ S 2000F TOO Tooth Identification 3 S TOO TOO01 Code List Code 1/ R JP = Universal National Tooth Designation System TOO02 Industry Code AN 1/ R TOO03 Tooth Surface C005 S TOO03-1 Tooth Surface Code 1/ R TOO03-2 Tooth Surface Code ½ 1369 S TOO03-3 Tooth Surface Code 1/ S TOO03-4 Tooth Surface Code 1/ S TOO03-5 Tooth Surface Code 1/ S Transaction Set Trailer TRAILER SE Transaction Set Trailer 2 R SE SE01 Number of Included N0 1/10 96 R Last Updated: 7/25/2017 Page 31 of 61

35 Name/ Data s Format Length DE Ref SE02 Transaction Set Control AN 4/9 329 R SE02 must be identical to ST02 Number Functional Group Trailer GE Functional Group Trailer 2 R GE GE01 Number of Transaction Sets Included N0 1/6 97 R GE02 Group Control Number N0 1/9 28 R GE02 must be identical to GS06 Interchange Control Trailer IEA Interchange Control 3 R IEA Trailer IEA01 Number of Included Functional Groups N0 1/5 I16 R IEA02 Interchange Control Number N0 9 I12 R Must be identical to the value in ISA13 Last Updated: 7/25/2017 Page 32 of 61

36 Response Figure 2-2: 278 Response Name/ Data Format Length Interchange Control Record HEADER ISA Interchange Control Header 3 R ISA ISA01 Authorization Information 2 I01 R 00 ISA02 Authorization Information AN 10 I02 R ISA03 Security Information 2 I03 R 00 ISA04 Security Information AN 10 I04 R ISA05 Interchange 2 I05 R ZZ=Mutually Defined ISA06 Interchange Sender AN 15 I06 R _MMIS_4MOLINA ISA07 Interchange 2 I05 R ZZ=Mutually Defined ISA08 Interchange Receiver AN 15 I07 R Molina assigned trading partner ISA09 Interchange Date DT 6 I08 R YYMMDD ISA10 Interchange Time TM 4 I09 R HHMM ISA11 Repetition Separator 1 I65 R ^ Last Updated: 7/25/2017 Page 33 of 61 DE Ref

37 Name/ Data Format Length Last Updated: 7/25/2017 Page 34 of 61 DE Ref ISA12 Interchange Version 5 I11 R Number ISA13 Interchange Control N0 9 I12 R Number ISA14 Acknowledgment uested 1 I13 R 0=No Acknowledgment uested ISA15 Interchange Usage 1 I14 R P Indicator ISA16 Component Element 1 I15 R : Separator Functional Group Header GS Functional Group Header 2 R GS GS01 Functional Identifier Code R HI GS02 Application Sender's Code AN 2/ R _MMIS_4MOLINA GS03 Application Receiver's Code AN 2/ R Molina Assigned trading Partner GS04 Date DT R CCYYMMDD GS05 Time TM 4/8 337 R HHMM GS06 Group Control Number N0 1/9 28 R Assigned by Sender

38 Name/ Data Format Length GS07 Responsible Agency Code 1/2 455 R X GS08 Version / Release Code AN 1/ R X217 Transaction Set Header ST Transaction Set Header 2 R ST ST01 Transaction Set Identifier R 278 Code ST02 Transaction Set Control Number AN 4/9 329 R Sequential number assigned by sender ST03 Implementation AN 1/ R X217 Convention Reference Beginning of Hierarchical Transaction BHT Beginning Hierarchical 3 R BHT Transaction BHT01 Hierarchical Structure R 0078 Code BHT02 Transaction Set Purpose R 11 Code BHT03 Reference identification AN 1/ R Submitter Transaction Identifier. from the original 278 request. BHT04 Date DT R CCYYMMDD Transaction Set Creation Date DE Ref Last Updated: 7/25/2017 Page 35 of 61

39 Name/ Data Format Length BHT05 Time TM 4/8 337 R HHMM Transaction Set Creation Time BHT06 Transaction Type Code 2/2 640 S 18 = No further updates to follow 19 = Further updates to follow UMO ( 2000A) 2000A HL Hierarchical Level 2 R HL HL01 Hierarchical Number AN 1/ R 1 HL03 Hierarchical Level Code 1/2 735 R 20 = Information Source HL04 Hierarchical Child Code 1/1 736 R A NM1 Individual or 3 R NM1 Organizational Name NM101 Entity Identifier Code 2/3 98 R X3 = UMO NM102 Entity Type 1/ R 2 NM103 Name Last or AN 1/ R AHO MEDICA Organization Name NM104 Name First AN 1/ S NM105 Name Middle AN 1/25 Last Updated: 7/25/2017 Page 36 of 61 DE Ref

40 Name/ Data Format Length NM107 Name Suffix AN 1/ S NM108 Identification Code 1/2 66 R PI Payor Identification NM109 Identification Code AN 2/80 67 R _MMIS_4MOLINA uester ( 2000B) 2000B HL Hierarchical Level 2 R HL HL01 Hierarchical Number AN 1/ R 2 HL02 Hierarchical Parent AN 1/ R 1 Number HL03 Hierarchical Level Code 1/2 735 R 21=Information Receiver HL04 Hierarchical Child Code 1/1 736 R B NM1 Individual or Organizational Name 3 R NM1 - segment populated from uest NM101 Entity Identifier Code 2/3 98 R 1P=Provider, FA=Facility NM102 Entity Type R 1=Person, 2=Non-Person Entity NM103 Name Last or AN 1/ S Organization Name NM104 Name First AN 1/ S NM105 Name Middle AN 1/ S Use if NM104 is present and the Last Updated: 7/25/2017 Page 37 of 61 DE Ref

41 Name/ Data Format Length DE Ref middle name/initial of the person is known. NM107 Name Suffix AN 1/ S NM108 Identification Code 1/2 66 R 24=Employer s Identification Number XX = NPI NM109 Identification Code AN 2/80 67 R NPI or if provider is atypical, use EIN 2010B REF Reference Identification 3 S REF - segment populated from uest REF01 Reference Identification 2/3 128 R N5 REF02 Reference Identification AN 1/ R Medicaid assigned provider for the uesting Provider for Atypical providers only 2010CA AAA Subscriber uest 3 S AAA Validation AAA01 Yes/No Condition or R N = No Response Code AAA03 Reject Reason Code R AAA04 Follow-up Action Code R Last Updated: 7/25/2017 Page 38 of 61

42 Name/ Data Format Length Subscriber ( 2000C) 2000C HL Hierarchical Level 2 R HL HL01 Hierarchical Number AN 1/ R 3 HL02 Hierarchical Parent AN 1/ R 2 Number HL03 Hierarchical Level Code 1/2 735 R 22 = Subscriber HL04 Hierarchical Child Code R C NM1 Individual or 3 R NM1 - populated from uest Organizational Name NM101 Entity Identifier Code 2/3 98 R NM102 Entity Type R NM103 Name Last or Organization Name AN 1/ S NM104 Name First AN 1/ S NM105 Name Middle AN 1/ S NM106 Name Prefix AN 1/ S NM107 Name Suffix AN 1/ S DE Ref Last Updated: 7/25/2017 Page 39 of 61

43 Name/ Data Format Length Last Updated: 7/25/2017 Page 40 of 61 DE Ref NM108 Identification Code 1/2 66 R NM109 Identification Code AN 2/80 67 R 2010C AAA Subscriber uest 3 S AAA Validation AAA01 Yes/No Condition or R N = No Response Code AAA03 Reject Reason Code R AAA04 Follow-up Action Code R 2010C DMG Demographic Information 3 S DMG DMG01 Date Time Period Format 2/ R D8 DMG02 Date Time Period AN 1/ R DMG03 Gender Code S 2000E HL Hierarchical Level 2 R HL - populated from uest HL01 Hierarchical Number AN 1/ R 5 HL02 Hierarchical Parent AN 1/ R 4 Number

44 Name/ Data Format Length Last Updated: 7/25/2017 Page 41 of 61 DE Ref HL03 Hierarchical Level Code 1/2 735 R EV = Event HL04 Hierarchical Child Code R E TRN Patient Event Tracking 3 S TRN Number TRN01 Trace Type Code 1/2 481 R 1 TRN02 Reference Identification AN 1/ R TRN03 Originating Company AN R Identifier TRN04 Reference Identification AN 1/ S 2000E AAA Subscriber uest 3 S AAA Validation AAA01 Yes/No Condition or R N = No Response Code AAA03 Reject Reason Code R AAA04 Follow-up Action Code R 2000E UM Health Care Services 2 R UM Review Information UM01 uest Category Code 1/ R AR = Admission Review HS = Health Services Review

45 Name/ Data Format Length DE Ref UM02 Certification Type Code 1/ R I = Initial 3 = Cancel 4 = Extension UM03 Service Type Code 1/ R For Prior Authorizations, see UM03 Service Type PA Crosswalk in this guide UM04 Health Care Service C023 S Location Information UM04-1 Facility Code AN 1/ R Component Element 1 : Separator UM04-2 Facility Code 1/ R UM06 Level of Service Code 1/ S 2000E HCR Health Care Services 3 S HCR Review HCR01 Action Code 1/2 306 R HCR02 Reference Identification AN 1/ S HCR03 Industry Code AN 1/ S HCR04 Yes/No Condition or Response Code S Element Separator AN 1 ~ 2000E REF Reference Identification 3 S REF REF01 Reference Identification 2/3 128 R BB = Authorization Number Last Updated: 7/25/2017 Page 42 of 61

46 Name/ Data Format Length REF02 Reference Identification AN 1/ R Element Separator AN 1 ~ 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R 439 = Accident DTP02 Date Time Period Format 2/ R D8 = date expressed in format CCYYMMDD DTP03 Date Time Period AN 1/ R format = CCYYMMDD 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R 484 = Last Menstrual Period DTP02 Date Time Period Format 2/ R D8 = date expressed in format CCYYMMDD DTP03 Date Time Period AN 1/ R format = CCYYMMDD 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R ABC = Estimated Date of Birth DTP02 Date Time Period Format 2/ R D8 = date expressed in format CCYYMMDD DTP03 Date Time Period AN 1/ R format = CCYYMMDD DE Ref Last Updated: 7/25/2017 Page 43 of 61

47 Name/ Data Format Length 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R 431 = Onset of Current Symptoms or Illness DTP02 Date Time Period Format 2/ R D8 = date expressed in format CCYYMMDD DTP03 Date Time Period AN 1/ R format = CCYYMMDD 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R AAH = Event DTP02 Date Time Period Format DE Ref 2/ R D8 = date expressed in format CCYYMMDD RD8 = date expressed in format CCYYMMDD-CCYYMMDD DTP03 Date Time Period AN 1/ R format = CCYYMMDD if DTP02 = D8 format = CCYYMMDD- CCYYMMDD if DTP02 = RD8 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R 435 =Admission DTP02 Date Time Period Format 2/ R D8 = date expressed in format CCYYMMDD RD8 = date expressed in format CCYYMMDD-CCYYMMDD Last Updated: 7/25/2017 Page 44 of 61

48 Name/ Data Format Length DTP03 Date Time Period AN 1/ R format = CCYYMMDD if DTP02 = D8 format = CCYYMMDD- CCYYMMDD if DTP02 = RD8 2000E DTP Date or Time or Period 3 S DTP DTP01 Date/Time R 096 = Discharge DTP02 Date Time Period Format 2/ R D8 = date expressed in format CCYYMMDD DTP03 Date Time Period AN 1/ R format = CCYYMMDD 2000E HI Health Care Information 2 S HI Codes HI01 Health Care Code 4 C022 S Information Alias Diagnosis 1 HI01-1 Code List Code 1/ R BK (ICD-9) Principal Diagnosis ABK (ICD-10) Principal Diagnosis DE Ref BF (ICD-9) - Diagnosis ABF (ICD-10) - Diagnosis BJ (ICD-9) Admitting Diagnosis ABJ (ICD-10) Admitting Diagnosis Component Element 1 : Separator HI01-2 Industry Code AN 1/ R Diagnosis Code Last Updated: 7/25/2017 Page 45 of 61

49 Name/ Data Format Length DE Ref Component Element 1 : Separator HI01-3 Date Time Period Format 2/ S D8 = date expressed in format CCYYMMDD Component Element 1 : Separator HI01-4 Date Time Period AN 1/ S Diagnosis Date. Format date CCYYMMDD HI02 Health Care Code 4 C022 S Information Alias Diagnosis 2 HI02-1 Code List Code 1/ R BF (ICD-9) - Diagnosis ABF (ICD-10) - Diagnosis BJ (ICD-9) Admitting Diagnosis ABJ (ICD-10) Admitting Diagnosis Component Element 1 : Separator HI02-2 Industry Code AN 1/ R Diagnosis Code Component Element 1 : Separator HI02-3 Date Time Period Format 2/ S D8 = date expressed in format CCYYMMDD Component Element 1 : Separator HI02-4 Date Time Period AN 1/ S Diagnosis Date. Format date CCYYMMDD HI03 Health Care Code Information Alias Diagnosis 3 4 C022 S Last Updated: 7/25/2017 Page 46 of 61

50 Name/ Data Format Length HI03-1 Code List Code 1/ R BF (ICD-9) - Diagnosis ABF (ICD-10) - Diagnosis Component Element 1 : Separator HI03-2 Industry Code AN 1/ R Diagnosis Code Component Element 1 : Separator HI03-3 Date Time Period Format 2/ S D8 = date expressed in format CCYYMMDD Component Element 1 : Separator HI03-4 Date Time Period AN 1/ S Diagnosis Date. Format date CCYYMMDD Note: Can be up to 10 HI0x-1 thru HI0x-4 BF/ABF (Other Diagnosis Code) elements separated by * 2000E HSD Health Care Delivery 3 S HSD Services HSD01 Quantity S HSD02 Quantity R 1/ S HSD03 Unit or Basis for Measurement Code S HSD04 Sample Selection Modulus R 1/ S HSD05 Time Period 1/2 615 S HSD06 Number of Periods N0 1/3 616 S DE Ref Last Updated: 7/25/2017 Page 47 of 61

51 Name/ Data Format Length DE Ref HSD07 Ship/Delivery or Calendar Pattern Code 1/2 678 S HSD08 Ship/Delivery Pattern Time Code S 2000E CL1 Claim Codes 3 S CL101 Admission Type Code S CL102 Admission Source Code R S CL103 Patient Status Code ½ 1352 S CL104 Nursing Home Residential Status Code S 2000E CR1 Ambulance Certification 3 S CR1 CR103 Ambulance Transport Code R CR104 Ambulance Transport Reason Code R CR105 Unit or Basis for Measurement Code S CR106 Quantity R 1/ S Last Updated: 7/25/2017 Page 48 of 61

52 Name/ Data Format Length 2000E CR2 Chiropractic Certification 3 S CR2 CR201 Count N0 1/9 609 S CR202 Quantity R 1/ S CR203 Subluxation Level Code 2/ S CR204 Subluxation Level Code 2/ S Element Separator AN 1 ~ 2000E CR6 Home Health Care 3 S CR6 Certification CR601 Prognosis Code R CR602 Date DT R format CCYYMMDD CR603 Date Time Period Format 2/ S RD8 CR604 Date Time Period AN 1/ S format CCYYMMDD-CCYYMMDD CR607 Yes/No Condition or R W Response Code CR608 Certification Type Code R Element Separator AN 1 ~ 2010EA NM1 Individual or 3 R NM1 Organizational Name DE Ref Last Updated: 7/25/2017 Page 49 of 61

53 Name/ Data Format Length DE Ref NM101 Entity Identifier Code 2/3 98 R NM102 Entity Type R 1=Person, 2=Non-Person Entity NM103 Name Last or AN 1/ S Organization Name NM104 Name First AN 1/ S uired if NM102=1 & NM103 is present NM105 Name Middle AN 1/ S Only used if NM102=1 NM106 Name Prefix AN 1/ S NM107 Name Suffix AN 1/ S NM108 Identification Code 1/2 66 S 24=Employer s Identification Number (for atypical providers only) XX= National Provider Identifier NM109 Identification Code AN 2/80 67 S Enter NPI or if provider is atypical enter Employer Identification Number 2010EA REF Reference Information 3 S REF REF01 Reference Identification 2/3 128 R N5 = Provider Plan Network Identifier REF02 Reference Identification AN 1/ R Used for atypical providers only, to enter their assigned Provider Last Updated: 7/25/2017 Page 50 of 61

54 Name/ Data Format Length 2010EA AAA uest Validation 3 S AAA AAA01 Yes/No Condition or R N = No Response Code AAA03 Reject Reason Code R AAA04 Follow-up Action Code R 2010EB NM1 Individual or 3 R NM1 Organizational Name NM101 Entity Identifier Code 2/3 98 R NM102 Entity Type R 1=Person 2=Non-Person Entity NM103 Name Last or AN 1/ S Organization Name NM104 Name First AN 1/ S uired if NM102=1 & NM103 is present NM105 Name Middle AN 1/ S Only used if NM104 is valued and middle name/initial is known NM107 Name Suffix AN 1/ S NM108 Identification Code 1/2 66 S 24=Employer s Identification Last Updated: 7/25/2017 Page 51 of 61 DE Ref

55 Name/ Data Format Length Number (for atypical providers only) XX= National Provider Identifier NM109 Identification Code AN 2/80 67 S Enter NPI or if provider is atypical enter Employer Identification Number 2010EC NM1 Individual or 3 R NM1 Organizational Name NM101 Entity Identifier Code 2/3 98 R NM102 Entity Type R 2=Non-Person Entity NM103 Name Last or AN 1/ S Organization Name 2010EC AAA uest Validation 3 S AAA AAA01 Yes/No Condition or R N = No Response Code AAA03 Reject Reason Code R AAA04 Follow-up Action Code R Service ( 2000F) 2000F HL Hierarchical Level 2 R HL - populated from uest HL01 Hierarchical Number AN 1/ R 6 DE Ref Last Updated: 7/25/2017 Page 52 of 61

56 Name/ Data Format Length HL02 Hierarchical Parent AN 1/ R 5 Number HL03 Hierarchical Level Code 1/2 735 R SS=Services HL04 Hierarchical Child Code 1/1 736 R F AAA Service uest 3 S AAA Validation AAA01 Yes/No Condition or 1/ R N = No Response Code AAA03 Reject Reason Code R AAA04 Follow-up Action Code R 2000F HCR Health Care Services 3 S HCR Review HCR01 Action Code 1/2 306 R HCR02 Reference Identification AN 1/ S HCR03 Industry Code AN 1/ S HCR04 Yes/No Condition or Response Code S Element Separator AN 1 ~ 2000F DTP Date or Time or Period 3 S DTP - populated from uest Last Updated: 7/25/2017 Page 53 of 61 DE Ref

57 Name/ Data Format Length DTP01 Date/Time R Service DTP02 Date Time Period Format 2/ R D8 - CCYYMMDD RD8 - CCYYMMDD-CCYYMMDD DTP03 Date Time Period AN 1/ R CCYYMMDD if DTP02 = D8 CCYYMMDD-CCYYMMDD if DTP02 = RD8 2000F DTP Date or Time or Period 3 S DTP DTP01 Date/Time R Issue DTP02 Date Time Period Format 2/ R D8 - CCYYMMDD DTP03 Date Time Period AN 1/ R 2000F DTP Date or Time or Period 3 S DTP DTP01 Date/Time R Expiration DTP02 Date Time Period Format 2/ R D8 - CCYYMMDD DTP03 Date Time Period AN 1/ R 2000F DTP Date or Time or Period 3 S DTP DTP01 Date/Time R Effective DTP02 Date Time Period Format 2/ R D8 - CCYYMMDD RD8 CCYYMMDD-CCYYMMDD Last Updated: 7/25/2017 Page 54 of 61 DE Ref

58 Name/ Data Format Length Last Updated: 7/25/2017 Page 55 of 61 DE Ref DTP03 Date Time Period AN 1/ R CCYYMMDD if DTP02 = D8 CCYYMMDD-CCYYMMDD if DTP02 = RD8 2000F SV1 Professional Service 3 S SV1 SV101 Composite Medical C003 R Procedure Identifier SV101-1 Product/Service R HC = HCPCS Code SV101-2 Product/Service AN 1/ R SV101-3 Procedure Modifier AN S SV101-4 Procedure Modifier AN S SV101-5 Procedure Modifier AN S SV101-6 Procedure Modifier AN S SV101-7 Description AN 1/ S SV101-8 Product/Service AN 1/ S SV102 Monetary Amount R 1/ S SV103 Unit or Basis for S UN = Unit Measurement Code SV104 Quantity R 1/ S

59 Name/ Data Format Length SV111 Yes/No Condition or Response Code S N = No Y = Yes SV120 Level of Care Code S 2000F SV2 Institutional Service 3 S SV2 SV201 Product/Service AN 1/ S SV202 Composite Medical C003 S Procedure Identifier SV202-1 Product/Service R HC = HCPCS Code SV202-2 Product/Service AN 1/ R SV202-3 Procedure Modifier AN S DE Ref Last Updated: 7/25/2017 Page 56 of 61

60 Name/ Data Format Length DE Ref SV202-4 Procedure Modifier AN S SV202-5 Procedure Modifier AN S SV202-6 Procedure Modifier AN S SV202-7 Description AN 1/ S SV202-8 Product/Service AN 1/ S SV203 Monetary Amount R 1/ S SV204 Unit or Basis for Measurement Code S DA =Days UN = Unit SV205 Quantity R 1/ S SV206 Unit Rate R 1/ S SV210 Level of Care Code S 2000F SV3 Dental Service 3 S SV3 SV301 Composite Medical C003 R Procedure Identifier SV301-1 Product/Service R AD = American Dental Association Codes SV301-2 Product/Service AN 1/ R Last Updated: 7/25/2017 Page 57 of 61

61 Name/ Data Format Length DE Ref SV301-3 Procedure Modifier AN S SV301-4 Procedure Modifier AN S SV301-5 Procedure Modifier AN S SV301-6 Procedure Modifier AN S SV301-7 Description AN 1/ S SV301-8 Product/Service AN 1/ S SV302 Monetary Amount R 1/ S SV304 Oral Cavity Designation C006 S SV304-1 Oral Cavity Designation Code 1/ R SV304-2 Oral Cavity Designation Code 1/ S SV304-3 Oral Cavity Designation Code 1/ S SV304-4 Oral Cavity Designation Code 1/ S SV304-5 Oral Cavity Designation Code 1/ S Last Updated: 7/25/2017 Page 58 of 61

62 Name/ Data Format Length SV305 Prosthesis, Crown or Inlay Code S I = Initial Placement R = Replacement SV306 Quantity R 1/ R SV307 Description AN 1/ S 2000F TOO Tooth Identification 3 S TOO TOO01 Code List Code 1/ R JP = Universal National Tooth Designation System TOO02 Industry Code AN 1/ R TOO03 Tooth Surface C005 S TOO03-1 Tooth Surface Code 1/ R TOO03-2 Tooth Surface Code ½ 1369 S TOO03-3 Tooth Surface Code 1/ S TOO03-4 Tooth Surface Code 1/ S TOO03-5 Tooth Surface Code 1/ S Transaction Set Trailer TRAILER SE Transaction Set Trailer 2 R SE SE01 Number of Included s N0 1/10 96 R SE02 Transaction Set Control Number DE Ref AN 4/9 329 R must equal ST02 on transaction header Last Updated: 7/25/2017 Page 59 of 61

63 Name/ Data Format Length DE Ref Functional Group Trailer GE Functional Group Trailer 2 R GE GE01 Number of Transaction Sets Included N0 1/6 97 R GE02 Group Control Number N0 1/9 28 R Interchange Control Trailer IEA Interchange Control Trailer 3 R IEA IEA01 Number of Included Functional Groups N0 1/5 I16 R IEA02 Interchange Control Number N0 9 I12 R Last Updated: 7/25/2017 Page 60 of 61

64 Appendix A. Please see Appendix_A_Vendor_Specs-5010.docx. Last Updated: 7/25/2017 Page 61 of 61