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South Carolina EDI Technical Communications User's Manual

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EDI Gateway Technical
Communications User's
Manual
Version 3.8
August 2008

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Summary of Contents for South Carolina EDI

  • Page 1 EDI Gateway Technical Communications User’s Manual Version 3.8 August 2008...
  • Page 2 We publish this manual for informational use only. We periodically make changes to the information in this manual. We will incorporate these changes in new editions of this publication. EDI Gateway may make improvements and/or changes to this publication at any time. Page 1...
  • Page 3 If you have any questions or concerns with this manual, please contact edig.ops@PalmettoGBA.com. BlueChoice HealthPlan is a wholly owned subsidiary of BlueCross BlueShield of South Carolina. Both are independent licensees of the Blue Cross and Blue Shield Association. Page 2...

  • Page 4: Table Of Contents

    Claim Submission Summary Report..................42 Error Claim Summary Report ....................44 Additional Information for Trading Partners ................46 Glossary of Terms and Abbreviations ..................47 Appendix............................48 BlueCross EDIG Trading Partner Enrollment Form ASC X12N Transactions ......................49 Page 3 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 5: About Us / Introduction

    Companion Companies Companion Life Insurance Company EDI Gateway’s production environment is accessible 24 hours a day, seven days a week, with the exception of weekly maintenance performed Sundays between 3:00 p.m. – 10:00 p.m. EDI Gateway’s test environment is accessible Monday through Saturday 5:00 a.m. – 10:00 p.m.

  • Page 6: Trading Partner Enrollment

    Enter the name of the entity that will be submitting/receiving Trading Partner Name 1 2 3 electronic transactions with BlueCross EDIG. The Trading Partner ID is assigned by BlueCross EDIG to Trading Partner ID identify trading partners to our system. Page 5 BlueCross BlueShield of South Carolina EDI Gateway...
  • Page 7 After Hours Technical Contact. Mark yes (Y) or no (N) for each mode. If you mark yes, indicate Transaction Volume the average number of transactions you anticipate submitting Estimates each week. Page 6 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 8: Enrollment Testing Procedures

    Enrollment Testing Procedures There are fewer problems with trading partner exchange of electronic transactions in the production environment when you conduct testing. EDI Gateway requires trading partners test every transaction for every payer prior to approval for production status. This testing includes security validation, connectivity, compliance (for HIPAA X12N transactions) and front-end payer edits when available in the test environment.

  • Page 9: Payer Testing

    When test results have satisfied the test plan, we will change the trading partner’s submission status from test to production. At this time, the trading partner can begin to send production transaction data to EDIG. Page 8 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 10: Privacy

    EDIG and our trading partners are committed to protecting the privacy of patient information. When sending sensitive data (i.e., names, patient ID numbers, date of birth, etc.) via the Internet to EDIG Operations for research, please zip and password protect files. Page 9 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 11: Connectivity

    Technical Communications User’s Manual Connectivity Trading partners may choose to connect with EDI Gateway via dial-up (GP Net) interface, secure high-speed data transfer, SNA and IP access. Dial-up interfaces available are: • REDI (Asynchronous Dialup) • FTP (File Transfer Protocol Dialup) Secured high speed data transfer methods available are: •...

  • Page 12: Gp Net

    Technology Support Center. The GPNet asynchronous transmission is a dial-up connection. Depending on your operating system, your windows may display differently than those noted in the following figures. Page 11 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 13: Dial-Up Redi

    Verify that it is correct or use the dropdown arrow to select the correct modem. Figure 2 – Phone Number Message Box e) Click OK. Page 12 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 14: Server Connection Using Asynchronous Dial-Up

    2. Click on Dial Now. The Connect Message box will change to display Status information. After dialing completes, you are connected to the GPNet Gateway. (Figure 4) Figure 4 – Connection Message Box Page 13 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 15: Log In And User Validation

    3. The system will allow three invalid login attempts before it terminates the session. Also, the system will automatically log you off after approximately two minutes of inactivity. To change your password, please contact the BlueCross Technology Support Center at 1-800- 868-2505 or 1-803-736-5980. Page 14 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 16: Messages

    Main Menu From the Main Menu (Figure 7), you can either choose the number or the first letter of the action you want. Press ENTER Figure 7 – GPNet Main Menu Page 15 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 17: Upload A File

    24 hours before contacting the Technology Support Center. When the response file is available (listed in your Mailbox), return to the Main Menu and proceed to the Download option. Page 16 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 18: Download A Response

    If the file transfer fails, the “Transfer FAILED “ message will display. Files that have not been downloaded successfully will remain in the mailbox for 14 days before being purged. Page 17 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 19: List Files In Mailbox For X12 Transactions

    EDIG proprietary responses EDIG proprietary reports invalid file response MSG informational messages X12 responses (i.e. TA1, 997, 999) EDIG-generated sequential number for each file sent to a mailbox. Sequence Number Period Page 18 BlueCross BlueShield of South Carolina EDI Gateway...
  • Page 20 Sample Set 4: This is a file name when the file’s content is an informational message. Sample Set 5: If the file received is a HIPAA X12 835 transaction, the file description field will have the payer’s name (Example ‘BCBSSC’ for BlueCross remit files). Page 19 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 21: Dial-Up Ftp

    (Figure 14). In the first field type GPNet. Confirm that the appropriate modem for your system is chosen in the second field and then click Next. Figure 14 – Make New Connection Wizard 1 Page 20 BlueCross BlueShield of South Carolina EDI Gateway...
  • Page 22 Type in the GPNet router login and password (you will receive this information during connectivity testing) Note: The user name and password are case sensitive. Click Connect. Figure 18 – Connect to Window Page 21 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 23: Uploading Files Using Ftp

    Your local directory drive may be different from the example above. ftp> lcd d:/(the path name to the file on your local directory) e) Type put, your file name, and CUSTOMER_UPLD!FTP and then press ENTER ftp> put [YOURFILENAME] CUSTOMER_UPLD!FTP Page 22 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 24: Downloading Files Using Ftp

    “mget *” command, which will prompt you to confirm each file prior to the initiation of each file transfer – unless you have “prompt” turned off. Page 23 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 25: Secure File Transfer Protocol (Sftp)

    EDI Gateway processes. Trading partners should query the outbound directories to retrieve acknowledgement and response files. When you choose this connectivity option, EDI Gateway will request additional information from the trading partner such as source IP address and if you would like to test your connectivity setup.

  • Page 26: Connect Direct: Ndm

    BlueCross eServer dataset. Acknowledgement and response files will be returned from BlueCross' eServer to the trading partner. EDI files submitted through the SFTP, VPN and NDM communication methods can either be segmented (one segment per line) with a valid non-special character delimiter or a 1000 byte wrapped EDI format with each ISA starting in a new line.

  • Page 27: X12 Transactions

    Technical Communications User’s Manual X12 Transactions The EDI Gateway processes the following HIPAA transactions. ASC X12N transactions are version 4010A1. Transaction Description Health Care Eligibility and Benefit Inquiry Health Care Eligibility and Benefit Response Health Care Claim Status Request Health Care Claim Status Response...

  • Page 28: Edig Inbound Response Matrix

    Technical Communications User’s Manual EDIG Inbound Response Matrix The following table lists acknowledgement and response transactions returned to the trading partner when EDI Gateway receives HIPAA X12 transactions. Functional Payer Payer Interchange Transaction Set Implementation Trans- Group Appl. Acknowledge- Acknowledge-...
  • Page 29 ** Batch of many: All other record groupings. † HIPAA Implementation Guides are available that include format specifications for each transaction. You can get these guides from the Washington Publishing Company (WPC) Web site: www.wpc-edi.com/hipaa. Page 28 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 30: Edig Specifications For Enveloping X12 Transactions

    Technical Communications User’s Manual EDIG Specifications for Enveloping X12 Transactions X12 Inbound Transactions The following table lists envelope instructions for inbound (to EDI Gateway) HIPAA X12 transactions. Segment Data Element Description Identifier ISA01 Authorization Info Qualifier EDIG assigned Trading Partner ID...

  • Page 31: X12 Outbound Transactions

    Technical Communications User’s Manual X12 Outbound Transactions The following table lists envelope contents for outbound (from EDI Gateway) HIPAA X12 transactions. Segment Data Element Description Identifier ISA01 Authorization Info Qualifier Blanks ISA02 Authorization Information ISA03 Security Information Qualifier Blanks ISA04 Security Information 30 (qualifier indicating U.S.

  • Page 32: Edig Proprietary Claim Responses

    Claims Submission Summary Report and the Error Claim Summary Report. The Claims Submission Summary Report is a listing of what BlueCross EDI Gateway actually received from you and it indicates whether those claims passed the first set of front-end edits.
  • Page 33 PIC X(14) Loop 2010AB- FIRST-NAME NM104 Pay to provider middle initial PAY-TO-PROVIDER- PIC X(01) Loop 2010AB- MIDDLE-INITIAL NM105 Pay-To-Provider-Organization Redefines Pay-To-Provider-Individual Pay to provider identifier PAY-TO-PROVIDER- PIC X(25) Loop 2010AB- NM109 Page 32 BlueCross BlueShield of South Carolina EDI Gateway...
  • Page 34 Loop 2010CA- NM104 Patient middle initial PATIENT-MIDDLE- PIC X(01) Loop 2010CA- INITIAL NM105 Patient primary identification number PATIENT-ID-NUMBER PIC X(25) Loop 2010CA- NM109 Patient birthdate PATIENT-DATE-OF- PIC X(08) Loop 2010CA- BIRTH DMG02 Page 33 BlueCross BlueShield of South Carolina EDI Gateway...
  • Page 35 ACCEPT-CLAIM- PIC X(100) MESSAGE-LINE3 ACCEPT-CLAIM- PIC X(100) MESSAGE-LINE4 FILLER PIC X(536) End of Accept-Claim-Message FILLER PIC X(187) EDIG assigned; Value 0100 (01.00 Version 1) RESPONSE-FORMAT- PIC X(04) VERSION-CODE END of Layout Page 34 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 36: Claim Response Layout - Dental

    PIC X(01) Loop 1000A- INITIAL NM105 Submitter-Organization Redefines Submitter-Individual Trading Partner ID assigned by EDIG SUBMITTER-ID PIC X(25) ISA02 (GS02) Trading partner organization name SUBMITTER- PIC X(35) Loop 1000A- ORGANIZATION-NAME NM103 Page 35 BlueCross BlueShield of South Carolina EDI Gateway...
  • Page 37 Rendering provider last name RENDERING-PROVIDER- PIC X(20) Loop 2310B- LAST-NAME NM103 Rendering provider first name RENDERING-PROVIDER- PIC X(14) Loop 2310B- FIRST-NAME NM104 Rendering provider middle initial RENDERING-PROVIDER- PIC X(01) Loop 2310B- MIDDLE-INITIAL NM105 Page 36 BlueCross BlueShield of South Carolina EDI Gateway...
  • Page 38 Total claim charge amount TOTAL-CHARGES Loop 2300- 16(9)V99 CLM02 FILLER PIC X(20) Error-Claim-Message Occurs 8 Times Indexed By CLM-ERR-INDX. Segment Position Relative to ST SEGMENT-POSITION PIC 9(10) Hierarchical identification HL-ID PIC X(12) HL01 Page 37 BlueCross BlueShield of South Carolina EDI Gateway...
  • Page 39 PIC X(100) MESSAGE-LINE3 ACCEPT-CLAIM- PIC X(100) MESSAGE-LINE4 FILLER PIC X(536) End of Accept-Claim-Message FILLER PIC X(187) EDIG assigned; Value 0100 (01.00 Version 1) RESPONSE FORMAT PIC X(04) VERSION CODE END of Layout Page 38 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 40: Claim Response Layout - Institutional

    Trading Partner ID assigned by EDIG SUBMITTER-ID PIC X(25) ISA02 (GS02) Trading partner organization name SUBMITTER- PIC X(35) Loop 1000A- ORGANIZATION-NAME NM103 Payer-Data-Area Payer identifier PAYER-ID-CODE PIC X(25) Loop 2010BC- NM109 Page 39 BlueCross BlueShield of South Carolina EDI Gateway...
  • Page 41 Loop 2010CA- INITIAL NM105 Patient primary identification number PATIENT-ID-NBR PIC X(25) Loop 2010CA- NM109 Patient birthdate PATIENT-DATE-OF- PIC X(08) Loop 2010CA- BIRTH DMG02 Facility type code PATIENT-BILL-TYPE PIC X(03) Loop 2300- CLM05 Page 40 BlueCross BlueShield of South Carolina EDI Gateway...
  • Page 42 PIC X(100) MESSAGE-LINE3 ACCEPT-CLAIM- PIC X(100) MESSAGE-LINE4 FILLER PIC X(536) END of Accept-Claim-Message FILLER PIC X(187) EDIG assigned; Value 0100 (01.00 Version 1) RESPONSE FORMAT PIC X(04) VERSION CODE END of Layout Page 41 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 43: Claim Submission Summary Report

    Billing provider’s EIN or SSN Billing-Provider-ID BILLING PROVIDER Billing provider’s name Billing-Provider-Last-Name, Billing- (BILLING PROVIDER Provider-First-Name, Billing-Provider, NAME) Middle Initial or Billing Provider- Organization-Name Pay to provider’s EIN or SSN Pay-To-Provider-NBR PAY TO PROVIDER Page 42 BlueCross BlueShield of South Carolina EDI Gateway...
  • Page 44 Generated by EDIG to indicate Generated by BlueCross computer REJ/ACC claim forwarded to processor or system rejected back to trading partner with errors Code to indicate production (P) or Test/Prod-Indicator PROD/TEST test (T) claim Page 43 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 45: Error Claim Summary Report

    Date EDIG retrieved data from Entry-Date PROCESS DATE the Trading partners mailbox Trading Partner ID assigned by Trading Partner ID SUBMITTER ID EDIG Trading partner’s Name Submitter-Last-Name, Submitter-First- (NAME) Name, Submitter-Middle-Initial or Submitter-Organization-Name Page 44 BlueCross BlueShield of South Carolina EDI Gateway...
  • Page 46 Loop ID in error Loop-Identifier LOOP Loop-Repeat-Identifier REPEAT Segment in error Segment-Identifier Field in error Segment-Field-Identifier FIELD Segment-Repeat-Identifier REPEAT Code identifying the error Error-Code ERROR CODE Abbreviated error message Error-Description-Identifier DESCRIPTION description. Page 45 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 47: Additional Information For Trading Partners

    Additional Information for Trading Partners 1. Trading Partners should envelope (ISA-IEA) different transactions separately. 2. When preparing files for transmission to the EDI Gateway, please zip one file at a time and do not zip multiple files together. 3. Each file should contain only one transaction type (i.e. 837P, 837I, 270, etc).

  • Page 48: Glossary Of Terms And Abbreviations

    TCP tests for errors and requests retransmission if necessary, because IP does not. (www.techweb.com/enclyclopedia) TPA – Trading Partner Agreement, a contract between entities exchanging electronic transactions. Page 47 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 49: Appendix

    Technical Communications User’s Manual Appendix Page 48 BlueCross BlueShield of South Carolina EDI Gateway...

  • Page 50: Bluecross Edig Trading Partner Enrollment Form Asc X12N Transactions

    After Hours Technical Contact Information First / Last Name: E-mail: Telephone: ( Fax: ( ext. On Call Technical Contact Information First / Last Name: E-mail: Telephone: ( Fax: ( ext. Page 49 BlueCross BlueShield of South Carolina EDI Gateway...
  • Page 51 † Average number of transactions per week ** Yes / No If a vendor’s software is used to create ASC X12N transactions submitted to the EDI Gateway, please provide the vendor’s name and address below and list the transactions. Vendor’s Information Vendor’s Name:...
  • Page 52 First / Last Name: E-mail: Telephone: ( ext. Fax: ( Technical Contact Information First / Last Name: E-mail: Telephone: ( Fax: ( ext. First / Last Name: E-mail: Telephone: ( ext. Fax: ( Page 51 BlueCross BlueShield of South Carolina EDI Gateway...

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