Standard Companion Guide Trading Partner Information
Instructions Related to the X12 277 Health Care Claim Request for Additional Information Version 6020
Companion Guide Version Number: 6.0
Revised: October 2019
Preface
Companion Guides (CG) may contain two types of data, instructions for electronic communications with the publishing entity (Trading Partner Information) and supplemental information for creating transactions for the publishing entity while ensuring compliance with the associated ASC X12 Implementation Guide (IG) (transaction instructions). Either the Trading Partner Information component or the Transaction Instruction component must be included in every CG. The components may be published as separate documents or as a single document.
The Trading Partner Information component is included in the CG when the publishing entity wants to convey the information needed to commence and maintain communication exchange.
The Transaction Instruction component is included in the CG when the publishing entity wants to clarify the IG instructions for submission of specific electronic transactions.
The Transaction Instruction component content is limited by the ASC X12's copyrights and Fair Use statement.
Table of Contents
I. Introduction
1.1 Purpose
1.2 Scope
1.3 Overview
1.4 References
II. Getting Started
2.1 Working Together
2.2 Trading Partner Registration
2.3 Trading Partner Testing Process
2.4 Paper Letters
III. Response to the 277RFI Electronic Request
IV. Connectivity/Communications
4.1 Process Flows
4.2 Transmission Administrative Procedures
4.3 Communication Protocols
4.4 Security Protocols
V. Contact Information
5.1 EDI Customer Service Number
5.2 EDI Technical Assistance Number
5.3 Provider Services
5.4 Applicable Websites/Email
VI. Control Segments/Envelopes
6.1 ISA-IEA
6.2 GS-GE
6.3 Transaction Detail
VII. Additional Trading Partner Information
7.1 Implementation Checklist
7.2 Transmission Examples
7.3 Trading Partner Agreement
VIII. Trading Partner Information Change Summary
IX. Appendices
9.1 LOINC Codes
I. Introduction
1.1 Purpose
National Government Services is publishing this document which is intended to provide information to trading partners for implementation of the transactions and documents necessary to exchange Prior Authorization Request data electronically with NGS.
This CG clarifies, supplements and further defines specific data content requirements to be used in conjunction with, and not in place of, the ASCX12N TR3s for the X12 277 Health Care Claim Request for Additional Information (277RFI) v6020 Transaction.
The CG provides communication, connectivity and transaction specific information to NGS trading partners and serves as the authoritative source for NGS-specific EDI protocols.
Operational information regarding registration, testing, support and specific information about control record setup is also documented.
1.2 Scope
With this document, NGS EDI addresses how Part A and Part B providers or their business associates exchange the 277RFI v6020 to support the electronic request for additional information related to Medicare claims submitted to NGS.
This implementation is focusing on clinical reason codes. Providers may continue to receive additional development requests for nonclinical messages.
1.3 Overview
This CG includes information needed to commence and maintain communication exchange with NGS for the purpose of electronically submitting prior authorization requests with submission of unsolicited supporting documentation. In addition, this CG has been written to assist you in designing and implementing the associated transactions and documents to meet NGS processing standards. This information is organized in the sections listed below:
- Getting Started: This section includes information related to system operating hours. Information concerning Trading Partner registration is also included in this section.
- Testing Requirements: This section includes detailed transaction testing information needed to complete transaction testing with Medicare.
- Connectivity/Communications: This section includes information on NGS’ transmission procedures as well as communication and security protocols.
- Contact Information: This section includes EDI customer service, EDI technical assistance and applicable websites.
- Control Segments/Envelopes: This section contains information needed to receive the ISA/IEA, GS/GE and ST/SE control segments for transactions to be received by Medicare.
- Acknowledgments and Reports: This section contains information on all transaction acknowledgments sent by Medicare and report inventory.
- Additional Trading Partner Information: This section contains information related to implementation checklist, transmission examples, Trading Partner Agreements and other resources.
1.4 References
The following websites provide information for where to obtain documentation for the ASCX12 277 v6020 X313 transaction.
Resource: Washington Publishing Company
II. Getting Started
2.1 Working Together
NGS will work with providers directly through set-up, development, testing and production implementation of the electronic request for additional information.
Upon implementation, the NGS EDI help desk is the first point of contact for basic information and troubleshooting. An EDI email process is also accessible as a method of communicating with NGS. The email account is monitored by knowledgeable staff ready to assist you. When communicating via email, please exclude any PHI to ensure security is maintained. In addition to the NGS EDI help desk and email access, feel free to communicate via alternative methods (see section 5 below for contact information).
Specific information about the above-mentioned items can be found in the sections below.
2.2 Trading Partner Registration
The EDI electronic request for additional information is offered to providers that enroll for electronic claims with NGS. EDI Analysts will work directly with the provider to ensure all trading partner management activity is appropriately completed. As a reminder, providers are required to use a network service vendor to connect to the NGS EDI gateway.
2.3 Trading Partner Testing Process
Providers are not required to test 277 files.
2.4 Paper Letters
Providers who enroll for the 277RFI and receive the electronic transaction will not also receive the associated paper letter. However, providers who enroll for the 277RFI may continue to receive paper letters for messages that cannot be mapped to standard LOINC codes.
III. Response to the 277RFI Electronic Request
Providers can respond electronically using the X12 275 transaction with the embedded HL7 standard or they can respond by mail or fax as they currently respond. We accept documents via paper, fax, CD/DVD, electronic submission of medical documentation (esMD) and NGSConnex. Instructions for signing up for NGSConnex can be found on our website. If responding by way of paper, you must include the ICN/DCN, HICN/MBI and NPI on the documentation.
Medicare will accept clearly legible handwritten signatures, handwritten initials or electronic signatures. Rubber stamped signatures are not acceptable on any medical records except in accordance with the rehabilitation act of 1973. The author with a physical disability should submit proof of his/her inability to sign their signature due to their disability. Patient identification, date of service and provider of the service should be clearly identified in the submitted documentation. If the provider signature is not clearly legible, attach a signature log or key that includes the typed name of the provider with credentials, the signature, and the initials for each provider for which the records are requested. If you question the legibility of a signature, you should submit an attestation statement in your documentation response.
IV. Connectivity/Communications
4.1 Process Flows
- Additional information requests letters are generated, mapped to the 277RFI and delivered to trading partner mailboxes.
- Paper letters are not printed and mailed
- Trading partners download the transactions and translate for internal processing to respond to the request.
- Providers can use any of the current response methods to return the requested documentation.
- Part A and B providers can respond to the 277 electronically using the X12 275 transaction with the embedded HL7 supporting documentation. For further information please see the NGS 275 Claims Attachment Companion Guide located on the NGS Medicare website.
-
Conditions that cannot be mapped to LOINC codes will generate paper letters which will continue to the print and mail process.
- Part A providers will continue to have the ability to view ADR via the FISS DDE application.
4.2 Transmission Administrative Procedures
The NGS EDI Gateway is accessed through an NGS-approved NSV.
4.3 Communication Protocols
NGS supports Secured FTP (sFTP) protocol for all EDI file transfer activity with connectivity through an NGS-approved NSV.
For the implementation of the electronic request for additional information transaction, it is expected that providers can utilize their existing NSV connectivity to the NGS EDI Gateway. It is recommended that providers contact their NSV to discuss any impacts to their existing connection prior to initiating this transaction with NGS.
4.4 Security Protocols
Trading Partners who conduct business with NGS Medicare are subject to CMS security policies.
See the CMS IOM Publication 100-25, Information Security Acceptable Risk Safeguards Manual, Appendix A CMSR High Impact Level Data document (Section SA-9) located on the CMS website.
CMS’ information security policy strictly prohibits the sharing or loaning of Medicare assigned IDs and passwords. Users should take appropriate measures to prevent unauthorized disclosure or modification of assigned IDs and passwords. Violation of this policy will result in revocation of all methods of system access, including but not limited to EDI front-end access or EDC RACF user access. NGS is responsible for notifying all affected providers/suppliers as well as reporting the system revocation to CMS. See the Appendix A CMSR High Impact Level Data document (Section IA-2) located on the CMS website. The password length must be eight characters.
- Passwords must have at least one of these special characters; e.g. @, #, $.
- Passwords must start with a letter and must include at least one number
- You should choose passwords that are easy for you to remember but hard for others to guess. One of the easiest ways to choose a password is to use the first letters of a phrase you can easily remember. For example, “I like to go to the dollar theater” could translate to “IL2GTT$T.” Other examples of acceptable passwords include SPR1NG$4 and C@nad@01.
- Passwords are case-sensitive.
- You should never write down your passwords or share them with anyone.
- Use of previous 12 passwords is prohibited. Reset passwords cannot be the same as any of the previous 12 passwords.
- EDI submitter ID passwords will expire after 60 days.
-
EDI submitter IDs will suspend after 30 days of inactivity.
V. Contact Information
For EDI registration questions or technical questions related to the 277RFI transaction please use the following EDI contact information.
5.1 EDI Customer Service Number
- J6: 877-273-4334
- JK: 888-379-9132
Hours of Operation
Monday–Friday, 8:00 a.m.–5:00 p.m. ET
5.2 EDI Technical Assistance Number
- J6: 877-273-4334
- JK: 888-379-9132
Hours of Operation
Monday–Friday, 8:00 a.m.–5:00 p.m. ET
5.3 Provider Services
Questions related to claims and/or the associated request for additional information should be directed to the Provider Contact Center as follows:
- JK (CT, MA, ME, NH, NY, RI, VT):
- IVR: 877-567-7205
- Toll-Free Number: 888-855-4356
- TTY : 866-786-7155
- Hours available: 8:00 a.m.-4:00 p.m. ET
- Closed for training on the second and fourth Friday of the month from 12:00-4:00 p.m. ET
- J6 (IL, MN, WI):
- IVR: 877-309-4290
- Toll-Free Number: 877-702-0990
- TTY: 888-897-7523
- Hours available: 8:00 a.m.-4:00 p.m. CT
- Closed for training on the second and fourth Friday of the month from 11:00 a.m.-3:00 p.m. CT
5.4 Applicable Websites/Email
Questions directed to the EDI Help Desk can also be submitted via the EDI Email Inquiry Form found on the NGS website.
VI. Control Segments/Envelopes
Enveloping information must be as follows:
Interchange Control (ISA/IEA), Function Group (GS/GE), and Transaction (ST/SE) envelopes must be used as described in the standard implementation guides. Medicare’s expectations for inbound ISAs and a description of data on outbound ISAs are detailed in this chapter.
Delimiters – Outbound Transactions
NGS recommends the use of the following delimiters in all outbound transactions; trading partners/submitters should contact their local A/B MAC or CEDI for any deviations. Note that these characters will not be used in data elements within an ISA/IEA Interchange Envelope.
| Delimiter | Character Used | Dec Value | Hex Value |
|---|---|---|---|
| Data Element Separator | > | 62 | 3E |
| Repetition Separator | ^ | 94 | 5E |
| Component Element Separator | + | 43 | 2B |
| Segment Terminator | ~ | 126 | 7E |
Outbound Data Element Detail and Explanation
All data elements within the interchange envelop (ISA/IEA) must follow X12 syntax rules as defined within the adopted implementation guide.
6.1 ISA-IEA
| Reference | Name | Codes | Notes/Comments |
|---|---|---|---|
| ISA | Interchange Control Header | ||
| ISA01 | Authorization Information Qualifier | 00 | NGS will send the value of 00 |
| ISA02 | Authorization Information | NGS will send 10 blank spaces | |
| ISA03 | Security Information Qualifier | 00 | NGS will send the value of 00 |
| ISA04 | Security Information | NGS will send 10 blank spaces. | |
| ISA05 | Interchange ID Qualifier | ZZ | Sender ID Qualifier |
| ISA06 | Interchange Sender ID | NGS-specific number. These receiver IDs are also required in the GS02 and in Loop 2100A NM109. | |
| ISA07 | Interchange ID Qualifier | ZZ | Receiver ID Qualifier |
| ISA08 | Interchange Receiver ID | NGS assigned submitter ID. This is also required in the GS03 and in Loop 2100B NM109. | |
| ISA11 | Repetition Separator | Must be present | |
| ISA14 | Acknowledgement Requested | 0 | NGS will send code value 0. |
6.2 GS-GE
Functional group (GS-GE) codes are transaction specific. The following are NGS rules related to processing of the functional groups.
| Reference | Name | Codes | Notes/Comments |
|---|---|---|---|
| GS01 | Functional Identifier Code | HN | ID assigned to 277 health care claim request for additional information transaction. |
| GS02 | Application Sender Code | Sender ID NGS contractor code. | |
| GS03 | Application Receiver’s Code | Receiver ID submitter number assigned by NGS. | |
| GS08 | Version Identifier Code |
GS08 value will be 006020X313. |
6.3 Transaction Detail
| Reference | Name | Code | Notes/Comments |
|---|---|---|---|
| BHT01 | Hierachial Structure Code | 0085 |
Order of HL segements |
| BHT02 | Transaction Set Purpose Code | 48 | Suspended |
| BHT06 | Transaction Type Code | RQ | Request |
| 2100C NM102 |
Entity Type Qualifier | 2 | This value will be a 2 (nonperson entity) |
| 2100C NM109 |
Provider Identifier | This person will always be the billing provider NPI | |
| 2100D NM109 |
Patient Identification Number | (HICN/MBI) | Part B will include Xs in the first five positions as shown on the additional development letter. |
| 2200D TRN02 |
Patient Control Number | (ICN/DCN) |
This value will be the ICN/DCN of the claim. If responding electronically this value must be returned in the X12 275 transaction. |
| 2200D STC |
Claim Status Information Segement | This segment may be repeated to support multiple questions from the letter. | |
| 2200D STCC01-1 |
Health Care Claim Status Category Code | (Claim Status Request Category Codes) | |
|
2200D |
Health Care Claim Status Code |
(See Appendix A for the list of possible LOINC codes and descriptions) |
LOINC code that defines the information being requested. |
| 2200D STC01-4 |
Code List Qualifier Code | LOI |
Indicates STC01-2 is a LOINC code. |
| 2200D STC02 |
Status Information Effective Date |
(Date from the letter) | Date the additional development request was generated. |
|
2200D STC10-2 |
Health Care Claim Status Code |
(See Appendix A for the list of possible LOINC codes and descriptions) |
LOINC modifier codes which further define the request. |
|
2200D STC10-4 |
Code List Qualifier Code |
LOI |
Indicates STC10-2 is a LOINC code. |
|
2200D STC11-2 |
Health Care Claim Status Code |
(See Appendix A for the list of possible LOINC codes and descriptions) |
LOINC modifier codes which further define the request. |
|
2200D REF |
Provider’s Assigned Claim Identifier |
(Patient Account Number submitted on the claim) |
|
|
2200D REF |
Institutional Bill Type Identification |
(Type of Bill submitted on the claim) |
Part A only when submitted on the claim. |
|
2200D REF |
Medical Record Identification |
(Medical Record Number) |
Part A only when submitted on the claim. |
|
2200D REF |
Claim Identifier Number for Transmission Intermediaries |
N/A |
|
|
2200D REF |
Property and Casualty Claim Number |
This segment will not be included in the 277RFI transaction. |
|
|
2200D REF02 |
Case Reference Identifier |
(Case Reference Number) |
NGS Case reference number |
|
2200D REF |
Attachment Request Tracking Identifier |
This segment will not be included in the 277RFI transaction. |
|
|
2200D REF |
Prior Attachment Request Tracking Identifier |
This segment will not be included in the 277RFI transaction |
|
| 2200D DTP |
Service Date |
This segment will be available for Part A. For Part B, this segment may not be included in the 277RFI transaction if the date of service is not included on the additional development request. In addition, only the first date of service on the claim will be included. Note: The request is for the entire claim. |
|
|
2200D DTP03 |
Response Due Date |
This is the date that the response must be received by NGS. |
|
|
2210D PER02 |
Payer Contact |
(Payer Contact Name) |
If responding electronically, this information must be returned in the Loop 1000A PER segment of the 275 transaction. |
|
2210D N3 |
Payer Response Contact Address |
If responding by mail, the documentation should be mailed to this address |
|
|
2210D N4 |
Payer Response Contact City, State and ZIP |
If responding by mail, the documentation should be mailed to this address. |
|
|
2220D SVC Loop |
Service Line Information Loop |
This loop will not be included in the 277RFI transaction. All requests will be at the claim level. |
VII. Additional Trading Partner Information
While NGS EDI Gateway is available 24/7, NGS schedules regular maintenance for Sundays. Access to the EDI Gateway may be interrupted while maintenance is performed.
7.1 Implementation Checklist
-
Existing NGS trading partner with network service vendor connectivity and submitter ID established
-
Software to support the translation of the 277RFI v6020 transaction
-
Enroll for the 277RFI transaction
7.2 Transmission Examples
See appendix for example of the 277RFI.
7.3 Trading Partner Agreement
EDI trading partner agreements ensure the integrity of the electronic transaction process. The trading partner agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement.
For the purposes of the health care claim request for additional information initiative, the provider must be an active NGS EDI trading partner with an EDI enrollment agreement already on file.
VIII. Trading Partner Information Change Summary
| Version | Date | Section(s) Changed | Change Summary |
|---|---|---|---|
| 1.0 | All |
Initial Draft |
IX. Appendices
9.1 LOINC Codes
The following LOINC codes could possibly be included in the 277RFI transaction.
| LOINC Code | LOINC Code Description |
|---|---|
| 11503-0 | Medical Records |
| 18682-5 | Ambulance Claims Attachment |
| 53243-2 | Advanced Bene Notice |
| 11514-7 | Chiropractic Records Total Encounter |
| 18804-5 | Three months or fewer before start of date of services (LOINC modifier) |
| 18842-5 | Discharge Summary |
| 11485-0 | Anesthesia Records |
| 19002-5 | Physical Therapy Service Attachment |
| 18594-2 | Psychiatric Service Attachment |
| 11504-8 | Provider Unspecified Operation Note |
| 11526-1 | Pathology Study |
| 52035-3 | Home Health Claims |
| 18826-8 | Occupational Therapy Service Attachment |
| 11807-7 | 30 days before start date of service (LOINC modifier) |
| 11824-3 | Cardiac Service Attachment |
| 29206-0 | Speech Therapy Service Attachment |
Sample Part A 277RFI
ISA*00* *00* *ZZ*14011 *ZZ*TEST277RFI *180416*1316*^*00602*804040002*0*P*:~
GS*HN*14011*TEST277RFI*20180416*13164324*804040002*X*006020X313~
ST*277*000000001*006020X313~
BHT*0085*48*20180404*20180416*13164324*RQ~
HL*1**20*1~
NM1*PR*2*NATIONAL GOVERNMENT SERVICES*****PI*14011~
PER*IC**UR*NGSMEDICARE.COM~
HL*2*1*21*1~
NM1*41*2*277RFI TESTING TP ID*****46*TEST277RFI~
HL*3*2*19*1~
NM1*1P*2*RHODE ISLAND HOSPITAL*****XX*1222222222~
HL*4*3*PT~
NM1*QC*1*SMITH*MARY****MI*022333444A~
TRN*1*21877766666555RIA~
STC*R4:55555-5::LOI*20180322~
STC*R4:53243-2::LOI*20180322~
REF*BLT*131~
REF*EA*20001178380~
REF*3H*1401121807800147919RIA0PR~
DTP*472*RD8*20170823-20170828~
DTP*106*D8*20180506~
PWK*OZ~
PER*RE*MEDICAL REVIEW~
N3*CLAIMS-PART A/RHHI*P.O. BOX 7091~
N4*INDIANAPOLIS*IN*462077091~
SE*23*000000001~
GE*1*804040002~
IEA*1*804040002~
Sample Part B 277RFI File
ISA*00* *00* *ZZ*14312 *ZZ*TEST277RFI *180424*1143*^*00602*804180001*0*P*:~
GS*HN*14312*TEST277RFI*20180424*11433976*804180001*X*006020X313~
ST*277*000000001*006020X313~
BHT*0085*48*20180418*20180424*11433976*RQ~
HL*1**20*1~
NM1*PR*2*NATIONAL GOVERNMENT SERVICES*****PI*14312~
PER*IC**UR*NGSMEDICARE.COM~
HL*2*1*21*1~
NM1*41*2*277RFI TESTING TP ID*****46*TEST277RFI~
HL*3*2*19*1~
NM1*1P*2*DARTMOUTH-HITCHCOCK CLINIC*****XX*1223344444~
HL*4*3*PT~
NM1*QC*1*JONES*CHRISTINE*A***MI*XXXXX2222A~
TRN*1*22180890467404~
STC*R4:11503-3::LOI*20180403********R4:18804-5::LOI*R4:53243-2::LOI~
REF*X1*P842490201~
REF*3H*14312000002218089046740PR~
DTP*472*D8*20171103~
DTP*106*D8*20180518~
PWK*OZ~
PER*RE*CLAIMS PROCESSING DEPARTMENT~
N3*NATIONAL GOVERNMENT SERVICES INC*P.O. BOX 6474~
N4*INDIANAPOLIS*IN*462066474~
SE*22*000000001~
GE*1*804180001~
IEA*1*804180001~
Reviewed 9/23/2024