New York State Department Of Health (NYS DOH)
ALL SUCHNew York StateDepartment of Health (NYS DOH)Office of Health Insurance Programs (OHIP)Standard Companion GuideTrading Partner InformationInstructions related to Transactionsbased on ASC X12 ImplementationGuides, version 5010Companion Guide Version Number: 3.1August 27, 2020
e M edN Y: TR AD IN G P AR TN ER IN FOR MA TION C O MP AN ION G UID EPrefaceCompanion Guides (CG) may contain two types of data, instructions for electroniccommunications with the publishing entity (Trading Partner Information) and supplementalinformation for creating transactions for the publishing entity while ensuring compliancewith the associated ASC X12 Implementation Guide (IG) (Transaction Instructions). Eitherthe Trading Partner Information component or the Transaction Instruction componentmust be included in every CG. The components may be published as separate documentsor as a single document.The Communications/Connectivity component is included in the CG when the publishingentity wants to convey the information needed to commence and maintain communicationexchange.The Transaction Instruction component is included in the CG when the publishing entitywants to clarify the IG instructions for submission of specific electronic transactions. TheTransaction Instruction component content is limited by ASCX12’s copyrights and FairUse statement.eMedNY TPI CG Version 3.1August 27, 2020Page 2 of 48
CONTENTSTrading Partner Information .61. Introduction . 61.1 Purpose .61.2 Scope .61.3 Overview .61.4 References .62. Getting Started . 82.1 Working Together .82.2 Trading Partner Registration .82.2.1 NYS Medicaid Program Enrollment . 82.2.2 Requirements for Electronic Data Interchange . 82.2.3 Supported Transactions . 102.3 Trading Partner Testing and Certification Process . 112.3.1 eMedNY Provider Test Environment (PTE). 112.3.2 PTE Enrollment and Support. 122.3.3 PTE Access Methods . 122.3.4 PTE Supported Transactions . 132.3.5 PTE Non-supported Transactions/Activities . 132.3.6 PTE Availability and Submission Cutoff Times . 132.3.7 PTE Synchronization to Production Environment . 132.3.8 PTE Financial Cycles. 143. Testing and Certification Requirements. 153.1 Testing Requirements . 153.1.1 X12 and NCPDP Transaction Versions and Dates . 153.1.2 PTE Limits. 153.1.3 Routing Test Files to PTE . 16eMedNY TPI CG Version 3.1August 27, 2020Page 3 of 48
3.1.4 PTE Response File Naming Conventions . 173.1.5 PTE Final Processing – EDI Response Files . 183.2 Certification Requirements . 194. Connectivity / Communications . 214.1 Process Flows . 214.1.1 ASC X12 EDI Validation (Batch File) . 224.1.2 ASC X12 EDI Validation (Real – Time) . 234.2 Transmission Administrative Procedures . 244.2.1 Re-transmission procedures . 244.3 Communication Protocols . 244.3.1 ePACES. 244.3.2 eMedNY eXchange . 254.3.3 FTP. 254.3.4 eMedNY File Transfer Service using SOAP . 254.3.5 CORE Web Services . 264.4 Security Protocols . 275. Contact information . 275.1 EDI Customer Service . 275.2 EDI Technical Assistance . 275.3 Provider Services . 275.4 Applicable websites / e-mail . 276. Control Segments / Envelopes . 296.1 ISA-IEA . 296.2 GS-GE . 296.3 ST-SE . 307. Acknowledgements and Reports . 307.1 ASC X12 Acknowledgments . 307.1.1 Production Response Files and Naming Conventions . 30eMedNY TPI CG Version 3.1August 27, 2020Page 4 of 48
7.1.2 Negative Interchange Acknowledgment (TA1) or Negative FileTransfer Status (F-File) . 327.1.3 Response Specific Information . 327.1.4 Pre-Adjudication Editing. 337.1.5 Responses to Other Batch Transaction Types . 347.2 Report Inventory . 347.2.1 Electronic Remittance Advice (ERA). 347.2.2 Remittance Advice Format . 357.2.3 Paper Remittance Sorts . 357.2.4 Delivery Options for Pended Claims . 367.2.5 Managed Care Organization Premium Payment . 378. Additional Trading Partner Information . 378.1 Implementation Checklist . 378.2 Trading Partner Agreement. 378.2.1 Batch Transaction Size Limitations . 388.3 Frequently Asked Questions . 388.4 Other Resources . 398.5 Examples . 398.5.1 Acknowledgments - Accepted . 398.5.2 Acknowledgments - Rejected . 408.5.3 EFT Notification Example (PTE) . 438.5.4 Paper Remittance Example (PTE). 449. Trading Partner Information Change Summary . 45eMedNY TPI CG Version 3.1August 27, 2020Page 5 of 48
Trading Partner Information1.Introduction0B1.1 Purpose9BThis document is intended to provide information from the author of this guide to tradingpartners to give them the information they need to exchange EDI data with the author.This includes information about registration, testing, support, and specific informationabout control record setup.1.2 Scope10BThis Trading Partner Information Companion Guide is intended as a resource to assistproviders, clearinghouses, service bureaus, and all other trading partners of the NewYork State Department of Health (NYS DOH) in successfully conducting Electronic DataInterchange (EDI) of administrative health care transactions. This document providesinstructions for enrolling as a NYS DOH Trading Partner, obtaining technical assistance,initiating and maintaining connectivity, sending and receiving files, testing, and otherrelated information. This document does not provide detailed data specifications, whichare published separately by the industry committees responsible for their creation andmaintenance.1.3 Overview1BThis guide provides communications-related information a Trading Partner needs toenroll as a Trading Partner, obtain support, format the ISA and GS envelopes, exchangetest and production transactions with NYS DOH.Providers who are not enrolled in NYS Medicaid cannot enroll as a Trading Partner untilregistered and credentialed with the NYS DOH. Please visit www.emedny.org or contactthe eMedNY Call Center at: 1-800-343-9000.1.4 R eferences12BFor billing instructions specific to practice or facility types, reference the NYS DOHProvider Manuals posted pxEligibility information, including Eligibility Benefits Descriptions, is published in theMEVS/DVS Provider Manual S/MEVS DVS Provider Manual (5010).pdfeMedNY TPI CG Version 3.1August 27, 2020Page 6 of 48
Related resources such as FAQs, Crosswalks, and the complete set of eMedNYCompanion Guides are provided at:https://www.emedny.org/HIPAA/5010/index.aspxThe eMedNY website also contains links to all forms and related information forenrollment as a Trading Partner of NYS DOH. The enrollment process is described indetail in the Provider Enrollment nt/index.aspxeMedNY TPI CG Version 3.1August 27, 2020Page 7 of 48
2.Getting Started1B2.1 W orking Together13BAll eMedNY support services can be accessed through the eMedNY Call Center bycalling (800) 343-9000.Technical assistance for HIPAA/EDI related issues can also be obtained by emailing:Privacy Issues:emedny HIPAA privacy and security@gdit.comConnectivity, other technical issues:emednyproviderservices@gdit.com2.2 T rading Partner Registration14B2.2.1 NYS Medicaid Program Enrollment36BNYS DOH requires any entity that wishes to exchange electronic data with NYSMedicaid to be enrolled in the NYS Medicaid Program.Medicaid Enrollment Forms and instructions are available index.aspxSuccessful enrollment is required before proceeding with Electronic DataInterchange (EDI).Important Note: Clearinghouses, Service Bureaus or any entity that intends toexchange electronic data with NYS Medicaid must be enrolled in the NYS MedicaidProgram.2.2.2 Requirements for Electronic Data Interchange37BAn Electronic Data Interchange (EDI) Trading Partner is any entity (provider, billingservice, software vendor, employer group, financial institution, etc.) that transmitselectronic data to or receives electronic data from another entity.For information about available eMedNY Access methods, refer to theCommunication Protocols in Section 4.3.Prior to establishing access with eMedNY the following requirements must besatisfied.Electronic Transmitter Identification NumbereMedNY TPI CG Version 3.1August 27, 2020Page 8 of 48
NYS DOH requires any entity that plans to exchange electronic data with NYSMedicaid obtain an Electronic Transmitter Identification Number (ETIN).There aretwo types of ETIN applications:Provider ETIN rollment/ProviderMaintForms/401101 ETINaPPL Provider Electronic Paper ETIN application.pdfService Bureau/BillingAgency ETIN Application:A service Bureau/Billing Agency ETIN Application is used only by entities who submittransactions on behalf of an enrolled NYS Medicaid lment/ProviderMaintForms/403101 ETINSBaP ETIN Service Bureau application.pdfAn ETIN is used to identify a submitter. An ETIN can also be used, in conjunctionwith a Provider ID, to set up electronic routing of Remittance Advices.Certification Statement for Existing ETINsA notarized Certification Statement must be submitted for each enrolled Provider IDand ETIN combination. The Certification Statement is packaged with the ETINApplication download and is also available as a standalone document ProviderMaintForms/490501 ETINCERT Certification Statement Cert Instructions for Existing ETINs.pdfNote: To add a provider to an existing ETIN only the Certification Statement isrequired.NYS DOH requires re-certification annually.Default ETIN Selection FormIn order to receive claims adjudication information in an Electronic RemittanceAdvice for Medicare crossover claims, claims that were submitted on paper, andState-submitted adjustments and voids, a Default ETIN must be designated. If thedefault ETIN option was not selected on the Electronic Remittance Request Form,this can be accomplished by filing the Default Electronic Transmitter IdentificationNumber (ETIN) Selection Form,available ProviderMaintForms/401103 ETINDFLT Default ETIN Selection Form.pdf.eMedNY TPI CG Version 3.1August 27, 2020Page 9 of 48
Only one Default ETIN is allowed for a provider. Electronic remittances reportingMedicare Crossover claims, paper claims, and State-submitted adjustments andvoids will be generated for the provider’s default ETIN only.Trading Partner AgreementAll Trading Partners must have a Trading Partner Agreement (TPA) on file.You may do so only after successful enrollment into the NYS Medicaid Program andupon receiving an ETIN. The TPA is available ProviderMaintForms/801101 TRDPRTaGR Trading Partner agreement.pdfInstitutional Provider Facility Affiliation of PractitionersInstitutional providers must provide the NPI of all affiliated practitioners who will bereported as the Attending Provider in 837 Institutional claims. Instructions areavailable at:https://npi.emedny.org/Facility/Requirements for Electronic Remittances and other reports are available in theReport Inventory, Section 7.2.2.2.3 Supported Transactions38BeMedNY supports the mandated version of all applicable HIPAA electronic healthcare transactions. The table below lists the inbound and possible outboundtransactions for the supported transaction types.As implied, “Direct Response(s)” are returned directly to the Trading Partner thatsubmitted the request. “Routed Response(s)” must be set up using appropriate formsavailable on:www.emedny.orgThe eMedNY Companion Guides (Transaction Instructions component), for ASC X12Version 5010 and NCPDP Version D.0/1.2, are published separately from thisdocument and are available index.aspxREQUEST270BATCHF-FILE; TA1; 999; 271REAL-TIMEGS99; TA1; 999; 271ROUTEDRESPONSE(S)BATCH ONLYN/A276F-FILE; TA1; 999; 277N/AN/ADIRECT RESPONSE(S)eMedNY TPI CG Version 3.1August 27, 2020Page 10 of 48
DIRECT RESPONSE(S)REQUEST278 DVSBATCHROUTEDRESPONSE(S)BATCH ONLYN/AN/AREAL-TIMEGS99; TA1; 999; 278DVS278 PAF-FILE; TA1; 999; 278PAGS99; TA1; 999; 278PAPA Rosters (PDF)834***F-FILE; TA1; 999N/AN/A837I*F-FILE; TA1; 999;277CAN/A837P**F-FILE; TA1; 999;277CAGS99; TA1; 999;U277835 & PendedClaims Reportor820 & Pend andDeny Report835 & PendedClaims Report837DF-FILE; TA1; 999;277CAN/A835 & PendedClaims ReportNCPDPF-FILE; NCPDP D.0 & 1.2GS99; NCPDP D.0835 & PendedClaims Report* 837I is also used for Managed Care Capitation Premium Billing.** 837P is also used for Non-Emergency Transportation Billing.*** See the MCE 834 Companion Guide at eMedNY.org for information aboutManaged Care enrollment, verification, and effectuation.IMPORTANT NOTES:eMedNY does not support blocked data formats. Trading partners must not includeCarriage Returns and/or Line Feeds in the inbound file.2.3 T rading Partner Testing and Certification Process15BTesters are responsible for the preservation, privacy, and security of data in theirpossession. While using production data that contains Protected Health Information(PHI) to conduct testing, the data must be guarded and disposed of appropriately.2.3.1 eMedNY Provider Test Environment (PTE)39BThe eMedNY Provider Testing Environment (PTE) is designed to enable NYSMedicaid trading partners to test batch and real-time EDI (Electronic DataInterchange) transactions using the same validation, adjudication logic, and methodsas the eMedNY production environment. Test transactions submitted to the eMedNYeMedNY TPI CG Version 3.1August 27, 2020Page 11 of 48
PTE undergo processes that verify and report on data structure and content to thesame degree of stringency as live transactions sent to the eMedNY productionenvironment, and receive, in most cases, the same system responses at each step.For similar inquiries, the response in the PTE may not be identical to the response inthe production environment. For example, edits involving duplicate and nearduplicate claims, or prior authorization submissions, are not applied in PTE, so as toallow for iterative testing. Also no claim, or authorization, requests are pended inPTE.2.3.2 PTE Enrollment and Support40BProvider ProfilesProvider profiles in the PTE are mirrored from the eMedNY production environment.Provider enrollment occurs in the production environment and there is no separateenrollment necessary for the PTE.eMedNY Provider SupportRefer to Contact Information, Section 5 in this guide.2.3.3 PTE Access Methods41BeMedNY PTE can be accessed using any of your existing eMedNY AccessMethods with a few exceptions (see below).Since existing access methods are being used for PTE access, it is critical the testindicator is valued in the inbound/outbound transactions.For ASC X12 transactions:“Test Indicator” in ISA15 is set to “T”For NCPDP Batch 1.2/D.0 transactions:File Type (702-MC) field in the NCPDP Batch Header is set to “T”No “Test” indicator has been defined for NCPDP real-time transactions. Pharmaciescan contact their Clearinghouses to arrange real-time testing.Important Note: If the appropriate indicator for a transaction is not set to Test, thetransactions will be processed through the production environment.PTE Access Exceptions (not supported):ePACESVeriFone POSAudio Response Unit (ARU)PapereMedNY TPI CG Version 3.1August 27, 2020Page 12 of 48
Note: Since these are internal applications maintained by eMedNY, end user testingis not necessary. User documentation has been modified for these select accessmethods. Anything sent as a test file through these three access methods will rejectwith a File Type Unknown message in either a TA1 or an F-File;CORE Web ServicesFile Transfer Service (FTS)Meds History Service (MHSNote: P TE Supported T
Aug 27, 2020 · This guide provides communications-related information a Trading Partner needs to enroll as a Trading Partner, obtain support, format the ISA and GS envelopes, exchange test and production transactions with NYS DOH. Providers who are not enrolled in NYS Medicaid cannot enroll as a Trading Partner
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