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United ConcordiaHIPAA TransactionStandard Companion GuideRefers to the Implementation Guides Basedon ASC X12 Implementation Guides,version 005010CORE v5010 Master Companion Guide TemplateOctober 2020

PrefaceThis Companion Guide to the v5010 ASC X12N Implementation Guides andassociated errata adopted under HIPAA clarifies and specifies the data content whenexchanging electronically with United Concordia. Transmissions based on thiscompanion guide, used in tandem with the v5010 ASC X12N ImplementationGuides, are compliant with both ASC X12 syntax and those guides. This CompanionGuide is intended to convey information that is within the framework of the ASCX12N Implementation Guides adopted for use under HIPAA. The Companion Guideis not intended to convey information that in any way exceeds the requirements orusages of data expressed in the Implementation Guides.October 2020 005010 v11.12

EDITOR’S NOTE: This page is blank because major sections of a book shouldbegin on a right-hand page.October 2020 005010 v11.13

Table of Contents1.Introduction . 51.1 Scope . 51.2 Overview . 51.3 References . 61.4 Additional Information . 72. Getting Started . 72.1 Working with United Concordia . 72.2 Trading Partner Registration . 82.3 Certification and Testing Overview . 103. Testing with the Payer . 104. Connectivity with the Payer/Communications . 114.1 Transmission Administrative Procedures . 114.2 Re-transmission procedures . 114.3 Communication Protocol Specifications . 114.4 Passwords . 155. Contact information . 155.1 EDI Customer Service . 155.2 EDI Technical Assistance . 155.3 Provider Service . 165.4 Applicable Websites/E-mail . 166. Control Segments/Envelopes . 166.1 ISA-IEA . 166.2 GS-GE . 206.3 ST-SE. 207. Payer Specific Business Rules and Limitations. 207.1 005010X224A2 Health Care Claim: Dental (837D) . 207.2 005010X214 Health Care Claim Acknowledgment (277CA) . 227.3 005010X221A1 Health Care Claim Payment/Advice (835) . 237.4 005010X212 Health Care Claim Status Request and Response (276/277) . 247.5 005010X279A1 Health Care Eligibility Benefit Inquiry andResponse (270/271) . 257.6 005010X231A1 Implementation Acknowledgment for Health Care Insurance(999) . 268. Acknowledgments and Reports . 288.1 Report Inventory . 288.2 ASC X12 Acknowledgments . 289. Trading Partner Agreements . 2910. Transaction Specific Information . 29005010X224A2 Health Care Claim: Dental (837D) . 30005010X214 Health Care Claim Acknowledgment (277CA) . 35005010X221A1 Health Care Claim Payment/ Advice (835) . 37005010X212 Health Care Claim Status Request and Response (276/277) . 39005010279A1 Health Care Eligibility Benefit Inquiry and Response (270/271) . 41005010X231A1 Implementation Acknowledgment for Health CareInsurance (999) . 45Appendices . 471. Checklist . 472. Business Scenarios . 473. Transmission Examples . 474. Frequently Asked Questions . 475. Change Summary . 476. United Concordia Business Edits . 47October 2020 005010 v11.14

1. Introduction1.1 ScopeThe Provider EDI Companion Guide addresses how Providers, ortheir business associates, conduct Dental Claim, ClaimAcknowledgment, Claim Payment Advice, Claim Status and EligibilityHIPAA standard electronic transactions with United Concordia. Thisguide also applies to the above referenced transactions that are beingtransmitted to United Concordia by a clearinghouse.An Electronic Data Interchange (EDI) Trading Partner is defined asany United Concordia customer (Provider, Billing Service, SoftwareVendor, etc.) that transmits to, or receives electronic data directlyfrom, United Concordia.United Concordia’s EDI transaction system supports transactionsadopted under the Health Insurance Portability and Accountability Actof 1996 (HIPAA) as well as additional supporting transactions asdescribed in this guide. United Concordia’s Dental Electronic Servicessupports transactions for multiple payers; each transaction chapterlists the supported payers for that transaction.1.2 OverviewThis Companion Guide includes information needed to commenceand maintain communication exchange with United Concordia. Thisinformation is organized in the sections listed below. Getting Started: This section includes information related tosystem operating hours, provider data services, and auditprocedures. It also contains a list of valid characters in text data.Information concerning Trading Partner registration and theTrading Partner testing process is also included in this section. Testing with the Payer: This section includes detailedtransaction testing information as well as other relevantinformation needed to complete transaction testing with UnitedConcordia. Connectivity with the Payer/Communications: This sectionincludes information on United Concordia’s transmissionprocedures as well as communication and security protocols. Contact Information: This section includes telephone and faxnumbers for United Concordia’s Dental Electronic Services.October 2020 005010 v11.15

Control Segments/Envelopes: This section contains informationneeded to create the ISA/IEA, GS/GE and ST/SE controlsegments for transactions to be submitted to United Concordia. Payer Specific Business Rules: This section containsinformation describing United Concordia’s business rules. Acknowledgments and Reports: This section containsinformation on all transaction acknowledgments sent by UnitedConcordia. These include the TA1, Health Care ClaimAcknowledgment (277CA) and the ImplementationAcknowledgment for Health Care Insurance (999). Trading Partner Agreements: This section contains generalinformation about and links to United Concordia’s tradingpartner agreements. Transaction Specific Information: This section describes howASC X12N Implementation Guides (IGs) adopted under HIPAAwill be detailed with the use of a table. The tables contain a rowfor each segment that United Concordia has somethingadditional, over and above, the information in the IGs.1.3 ReferencesTrading Partners must use the ASC X12 National ImplementationGuides adopted under the HIPAA Administrative SimplificationElectronic Transaction rule and United Concordia's EDI Companionguidelines for development of the EDI transactions. These documentsmay be accessed through United Concordia's EDI Trading -insurance/dentist/tradingpartners/Trading Partners must use the most current national standard codelists applicable to the EDI transactions. The code lists may beaccessed at the Washington Publishing Company website:http://www.wpc-edi.comThe applicable code lists and their respective X12 transactions are asfollows: Claim Adjustment Reason Codes and Remittance AdviceRemark Codes (ASC X12/005010X221A1 Health Care ClaimPayment/Advice (835)) Claim Status Category Codes and Claim Status Codes (ASCX12N/005010X212 Health Care Claim Status Request andResponse (276/277) and 005010X214 Health Care ClaimAcknowledgment (277CA))October 2020 005010 v11.16

Provider Taxonomy Codes (ASC X12N/005010X224A2 HealthCare Claim: Dental (837D)1.4 Additional InformationThere is no additional information at this time.2. Getting Started2.1 Working with United ConcordiaSystem Operating HoursUnited Concordia is available to handle EDI transactions 24 hours aday seven days a week, except during scheduled systemmaintenance periods.We strongly suggest that United Concordia EDI Trading Partnerstransmit any test data during the hours that United Concordia’s DentalElectronic Services support is available, Monday through Friday from8:00 AM ET to 5:00 PM ET.Audit ProceduresThe Trading Partner ensures that input documents and medicalrecords are available for every automated claim for audit purposes.United Concordia may require access to the records at any time.The Trading Partner’s automated claim input documents must be kepton file for a period of seven years after date of service for auditingpurposes. Microfilm/microfiche copies of Trading Partner documentsare acceptable. The Trading Partner, not his billing agent, is heldaccountable for accurate records.The audit consists of verifying a sample of automated claim inputagainst medical records. Retention of records may also be checked.Compliance to reporting requirements is sample checked to ensureproper coding technique is employed. Signature on file records mayalso be verified. In accordance with the Trading Partner Agreement,United Concordia may request, and the Trading Partner is obligated toprovide, access to the records at any time.Valid Characters in Text Data (AN, string data element type)For data elements that are type AN, "string", United Concordia canaccept characters from the basic and extended character sets with thefollowing exceptions:Character! October 2020 005010 v11.1NameExclamation pointGreater thanCaretPipeTildeHex value(21)(3E)(5E)(7C)(7E)7

These five characters are used by United Concordia for delimiters onoutgoing transactions and control characters for internal processingand therefore would cause problems if encountered in the transactiondata.As described in the X12 standards organization's Application ControlStructure document (X12.6), a string data element is a sequence ofcharacters from the basic or extended character sets and contains atleast one non-space character. The significant characters shall be leftjustified. Leading spaces, when they occur, are presumed to besignificant characters. In the actual data stream trailing spaces shouldbe suppressed. The representation for this data element type is AN.ConfidentialityUnited Concordia and its Trading Partners will comply with the privacystandards for all EDI transactions as outlined in the United ConcordiaEDI Trading Partner Agreement.Authorized Release of InformationWhen contacting Dental Electronic Services concerning any EDItransactions, you will be asked to confirm your Trading Partnerinformation.2.2 Trading Partner RegistrationAn EDI Trading Partner is any entity (provider, billing service, softwarevendor, employer group, financial institution, etc.) that transmitselectronic data to or receives electronic data from another entity.While United Concordia will accept HIPAA compliant transactionsfrom any covered entity, HIPAA security requirements dictate thatproper procedure be established in order to secure access to data. Asa result, United Concordia has a process in place to establish anElectronic Trading Partner relationship. That process has two aspects: A Trading Partner Agreement must be submitted whichestablishes the legal relationship and requirements. This isseparate from a participating provider agreement. Once the agreement is received, the Trading Partner will besent a logon ID and password combination for use whenaccessing United Concordia’s EDI system for submission orretrieval of transactions. This ID is also used within EDIInterchanges as the ID of the Trading Partner. Maintenance ofthe ID and password by the Trading Partner is detailed in thesecurity section of this document.Authorization ProcessNew Trading Partners wishing to submit EDI transactions must submita United Concordia EDI Trading Partner Agreement and EDIOctober 2020 005010 v11.18

Transaction Application to United Concordia’s Dental ElectronicServices.Both the United Concordia Trading Partner Agreement and EDITransaction Application can be found at the following nce/dentist/tradingpartners/Once these forms are completed they can be faxed to: 717-260-7131or mailed to:United ConcordiaDental Electronic Services4401 Deer Path RoadPO Box 69404Harrisburg, PA 17110These forms must be completed by an authorized representative ofthe organization.United Concordia may terminate the Trading Partner Agreement,without notice, if participant’s account is inactive for a period of six (6)consecutive months.Complete and accurate reporting of information will ensure that youragreement and form are processed in a timely manner. If you needassistance in completing the EDI Transaction Application contact yourcompany’s technical support area, your software vendor, or DentalElectronic Services.Upon completion of the authorization process, a Logon ID andPassword will be assigned to the Trading Partner. Dental ElectronicServices will authorize, in writing, the Trading Partner to submitproduction EDI transactions.Receiving ASC X12/005010X221A1 Health Care ClaimPayment/Advice (835) Transactions Generated from the PaymentCycle (Batch)If you are not currently receiving Health Care Claim Payment/Advice(835) remittance transactions generated from the payment cycle in abatch process and wish to, you will need to request ERA (835) bycontacting Dental Electronic Services or by going to the link below andcompleting an ERA Enrollment/Maintenance s/tradingpartner.htmlReporting Changes in StatusTrading Partners changing any of their Trading Partner informationmust inform Dental Electronic Services by completing a new TradingPartner EDI Transaction Application form and including all informationthat is to be updated. To access this form select this link:October 2020 005010 v11.19

entist/tradingpartners/2.3 Certification and Testing OverviewThis section provides a general overview of what to expect duringcertification and testing phases.Testing PolicyAll Trading Partners must be approved to submit 5010 transactions.To get started, you need a United Concordia Trading Partner ID. Thisrequires completion of the United Concordia EDI Trading PartnerAgreement and EDI Transaction Application as explained in section2.2.United Concordia Transactional TestingClaim TransactionsBatch:United Concordia allows Trading Partners to send claims transactionswith “test” indicated in the ISA15 element to our productionenvironment. A rejected 999 will be generated if the transaction fails.An accepted 999 will be generated for a compliant transaction.However, a 277CA will not be generated.Real-Time:United Concordia allows Trading Partners to send real-time claimtransactions with “test” indicated in the ISA15 element to ourproduction environment. A rejected 999 will be generated if thetransaction fails. If the transaction passes syntax; however, there is abusiness error a 277CA will be generated. If there is no businesserror, a “generic” flat file response is provided. The details of the Realtime claim response are outlined in the United Concordia Real Time837D Claim Submission Guide e/dentist/tradingpartners/Inquiry TransactionsUnited Concordia only conducts inquiry transactions in the “real-time”mode and does not allow Trading Partners to send test inquirytransactions to our production environment. A rejected 999 will begenerated for any transaction file that has “test” indicated in the ISA15element.3. Testing with the PayerFor Claims testing, the Trading Partners should submit a test filecontaining a minimum of 25 test claims. Test files should containclaims that accurately represent the type of claims that will besubmitted in production (ex. Taxonomy/specialty, member &October 2020 005010 v11.110

dependent claims). After a successful test file has been received theEDI Trading Partner will be moved to production. Any questions maybe directed to Dental Electronic Services at 800-633-5430.For 835s testing consists of setting up the ERA in the productionenvironment and making a production file available for retrieval. Tomake testing arrangements contact Dental Electronic Services at 800633-5430.4. Connectivity with the Payer/CommunicationsUnited Concordia offers its Trading Partners two types ofcommunication methods for transferring data electronically. Secure File Transfer Protocol (SFTP) through a secure Internetconnection (eDelivery) is available for transactions in batchmode. Hypertext Terminal Protocol Secure (HTTPS) through anInternet web service is available for transactions in real-timemode.4.1 Transmission Administrative ProceduresReal-Time Technical Connectivity SpecificationsUnited Concordia maintains separate specifications detailing thetechnical internet connectivity requirements for United Concordia’sreal-time processes. These connectivity specifications are located inthe Trading Partner section under “Access other important informationfor trading surance/dentist/tradingpartners/Real-Time Claim AdjudicationUnited Concordia has implemented real-time capability for claimadjudication.Real-Time Adjudication – allows providers to submit an electronicclaim that is adjudicated in real-time and receive a response at thepoint of service. This capability allows providers to accurately identifyand collect member responsibility based on the finalized claimadjudication results.4.2 Re-Transmission ProceduresUnited Concordia does not have specific re-transmission procedures.Submitters can retransmit files at their discretion.4.3 Communication Protocol Specifications InternetUnited Concordia offers two methods to utilize the Internet forconducting electronic business with United Concordia. The first issecured File Transfer Protocol (SFTP) through “eDelivery.” “eDelivery”is available for Trading Partners who submit or receive any HIPAA-October 2020 005010 v11.111

compliant EDI transactions in batch mode. The second Internet-basedservice offers “Real-Time” capability for the following real-timeenabled transactions: Health Care Eligibility Benefit Inquiry and Response (270/271)Health Care Claim Status Request and Response (276/277)Health Care Claim Adjudication (837D)Internet Secure File Transfer Protocol (SFTP) through “eDelivery”The United Concordia Secure FTP Server (“eDelivery”) provides anFTP service over an encrypted data session providing “on-the-wire”privacy during file exchanges. This service offers an Internetaccessible environment to provide the ability to exchange files withcustomers, providers, and business partners using a simple FTPprocess in an encrypted and private manner.Any state-of-the-art browser can be used to access the UnitedConcordia Secure FTP Server. Browsers must support strongencryption (128 bit) and must allow cookies for session trackingpurposes. Once the browser capabilities are confirmed, the followingare the general guidelines for exchanging files.1. Launch your web browser.2. Connect to the FTP servers at: https://ftp.highmark.com3. The server will prompt for an ID and Password. Use the ID/Password that United Concordia has provided you for accessingthis service. Enter the ID, tab to password field and enter thepassword, then hit enter or click on OK.4. The server will then place you in your individual file space onthe FTP server. No one else can see your space and youcannot access the space of others. You will not be able tochange out of your space.5. You will need to change into the directory for the type of file youare putting or getting from the server.6. By default, the file transfer mode will be binary and this mode isacceptable for all data types. However, you may changebetween ASCII and Binary file transfer modes by clicking the“Set ASCII”/”Set Binary” toggle button.7. Send United Concordia a file. The following is an example ofthe submission of an electronic claim transaction file:a. Click on the “hipaa-in” folder to change into thatdirectory.October 2020 005010 v11.112

b. Click on the browse button to select a file from yoursystem to send to United Concordia. This will pop open afile finder box listing the files available on your system.c. Select the file you wish to send to United Concordia andClick on OK.d. This will return you to the browser with the file name youselected in the filename window. Now click on the“Upload File” button to transfer the file to UnitedConcordia. Once completed, the file will appear in yourfile list.8. Retrieve a file from United Concordia. The following is anexample of retrieval of an Implementation Acknowledgment forHealth Care Insurance (999) file:a. Click on the “hipaa-out” directory.b. Your browser will list all the files available to you.c. Click on the “ack” directory.d. Click on the file you wish to download. Your browser willdownload the file. If your browser displays the fileinstead of downloading, click the browser back buttonand click on the tools next to the file you wish to receive.Select application/octet-stream. Your system may thenprompt you for a “Save As” file location window. Makethe selection appropriate for your system and click onsave to download the file.Internet/Real-Time (HTTPS- Hypertext Terminal Protocol Secure)United Concordia offers a Real-Time Web Service through a secureInternet connection (HTTPS) for our real-time enabled transactions:Real Time Transactions Health Care Eligibility Benefit Inquiry and Response (270/271) Claim Status Request/Response (276/277) Health Care Claim: Dental (837D)Real-time inquiry transactions utilize a CORE-compliant Web ServicesDescription Language (WSDL) Simple Object Access Protocol(SOAP). Whereas, Real-time claim transactions utilize a UnitedConcordia proprietary format SOAP. SOAP is a way for a programrunning in one kind of operating system to communicate with anotherOctober 2020 005010 v11.113

operating system by using Extensible Markup Language (XML) for theexchange of information over the Internet. Since the Internet is beingutilized to transport the data, encryption will be utilized to securemessages.This Real-Time Web Service is designed to support interoperablemachine-to-machine interaction over the Internet. In order to submitreal-time transactions you will need a computer, a web server, Internetaccess and the ability to submit and receive HIPAA-complianttransactions using SOAP.In order to take advantage of real-time transactions with UnitedConcordia, a Trading Partner will need to:Ensure that the EDI transaction software is programmed for UnitedConcordia’s real-time CORE-compliant or proprietary SOAPtransactions, as appropriate. For instructions on how to program forUnited Concordia’s real-time transactions, refer to the connectivityspecifications are located in the Trading Partner section under“Access other important information” for trading surance/dentist/tradingpartners/ Complete an EDI Transaction ApplicationSelect the real-time transaction option.o Include your email address.o Trading Partner must have a valid Internet enabled ‘V’Logon ID. Real-time can be used with any existing ‘V’Logon ID.o Download the Web Services Security Certificate asoutlined in appropriate Real-Time ConnectivitySpecification documents.Real-time transactions are designed to respond to individual end-userrequests for real-time enabled transactions.Inquiry TransactionsFor typical inquiry requests, the average response time should bewithin 15 seconds. Actual response time will be dependent upon realtime transaction activity.Claim AdjudicationReal-time claim adjudication is designed to provide real-timeprocessing. For typical claim requests, the average response timeshould be within 30 seconds. Actual response time will be dependentupon real-time transaction activity. Batched claim transmissionsOctober 2020 005010 v11.114

should not be submitted through the real-time process as they willreceive a rejected Implementation Acknowledgment for Health CareInsurance (999).4.4 PasswordsUnited Concordia’s Dental Electronic Services personnel will assignLogon IDs and Passwords to Trading Partners. EDI transactionssubmitted by unauthorized Trading Partners will not be accepted byour system.Trading Partners should protect password privacy by limitingknowledge of the password to key personnel. Passwords should bechanged regularly; upon initial usage and then periodically throughoutthe year. Also, the password should be changed if there are personnelchanges in the Trading Partner office, or at any time the TradingPartner deems necessary.Password requirements include: Password must be 8 characters in length. Password must contain a combination of both numeric andalpha characters. Password cannot contain the Logon ID. Password must be changed periodically5. Contact information5.1 EDI Customer ServiceContact information for Dental Electronic Services:TELEPHONE NUMBER: (800) 633-5430When contacting Dental Electronic Services, have your TradingPartner Number and Logon ID available. These numbers facilitate thehandling of your questions.Dental Electronic Services personnel are available for questions from8:00 a.m. to 5:00 p.m. ET, Monday through Friday.5.2 EDI Technical AssistanceContact information for Dental Electronic Services:TELEPHONE NUMBER: (800) 633-5430When contacting EDI Operations, have your Trading Partner Numberand Logon ID available. These numbers facilitate the handling of yourquestions.October 2020 005010 v11.115

EDI Operations personnel are available for questions from 8:00 a.m.to 5:00 p.m. ET, Monday through Friday.5.3 Provider ServiceIf providers have inquiries pertaining to United Concordia Dentalclaims they should be directed to contact the appropriate CustomerService Department.Inquiries pertaining to United Concordia Electronic Fund Transfers(EFT) should be directed to Dental Electronic Services at (800) 6335430.5.4 Applicable websites / e-mailEDI specifications, including this companion guide and instructionshow to program for United Concordia’s Real-Time transactions, canbe accessed online e/dentist/tradingpartners/6. Control Segments/EnvelopesInterchange Control (ISA/IEA) and Function Group (GS/GE)envelopes must be used as de

transmitted to United Concordia by a clearinghouse. An Electronic Data Interchange (EDI) Trading Partner is defined as any United Concordia customer (Provider, Billing Service, Software Vendor, etc.) that transmits to, or receives electronic data directly from, United Concordia. United

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