WASHINGTON STATE MEDICAID CORE COMPANION GUIDE
3/2015 005010 Version 1.0 1
Washington State Medicaid
835 Health Care Payment/Advice
HIPAA Transaction Standard Companion Guide
Refers to the ASC X12N 835
(Version 005010X221A1)
CORE v5010 Companion Guide: Version 1.0
March 2015
WASHINGTON STATE MEDICAID CORE COMPANION GUIDE
3/2015 005010 Version 1.0 2
2015 WA State Medicaid Companion Guide Preface
WASHINGTON STATE MEDICAID CORE COMPANION GUIDE
3/2015 005010 Version 1.0 3
This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata
adopted under HIPAA clarifies and specifies the data content when exchanging electronically with
Washington State Medicaid. Transmissions based on this companion guide, used in tandem with
the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those
guides. This Companion Guide is intended to convey information that is within the framework of the
ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not
intended to convey information that in any way exceeds the requirements or usages of data
expressed in the Implementation Guides.
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Contents
1 INTRODUCTION ....................................................................................................... 6
1.1 SCOPE ......................................................................................................................... 6
1.2 OVERVIEW ................................................................................................................... 6
1.3 REFERENCES ............................................................................................................. 6
1.4 ADDITIONAL INFORMATION ....................................................................................... 7
1.4.1 Intended Users ............................................................................................ 7
1.4.2 Relationship to HIPAA Implementation Guides .................................................. 7
2 GETTING STARTED ................................................................................................. 7
2.1 WORKING WITH WASHINGTON STATE MEDICAID ................................................... 7
2.3 CERTIFICATION AND TESTING OVERVIEW .............................................................. 8
3 TESTING WITH THE PAYER .................................................................................... 9
4 CONNECTIVITY WITH THE PAYER/COMMUNICATIONS ...................................... 9
4.1 PROCESS FLOWS ....................................................................................................... 9
4.1.1 Provider One Web Portal ....................................................................................10
4.1.2 Secure File Transfer Protocol (SFTP) .................................................................13
4.1.3 Hypertext Transfer protocol (HTTP MIME + Multipart) ........................................14
4.1.4 Simple Object Access Protocol (SOAP + WSDL) ...............................................14
4.2 TRANSMISSION ADMINISTRATIVE PROCEDURES ................................................ 14
4.3 RE-TRANSMISSION PROCEDURE ........................................................................... 15
4.4 COMMUNICATION PROTOCOL SPECIFICATIONS .................................................. 15
4.5 PASSWORDS ............................................................................................................. 15
5 CONTACT INFORMATION ..................................................................................... 16
5.1 EDI CUSTOMER SERVICE AND TECHNICAL ASSISTANCE ................................... 16
5.2 PROVIDER SERVICE NUMBER ................................................................................ 16
5.3 APPLICABLE WEBSITES/E-MAIL .............................................................................. 16
6 CONTROL SEGMENTS/ENVELOPES ................................................................... 16
6.1 INTERCHANGE CONTROL STRUCTURE(ISA-IEA) .................................................. 16
6.2 FUNCTIONAL GROUP STRUCTURE (GS-GE ) ......................................................... 18
6.3 TRANSACTION SET HEADER/TRAILER (ST-SE ) .................................................... 18
7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS .................................. 18
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7.1 GENERAL INFORMATION ......................................................................................... 18
7.2 DATA FORMAT .......................................................................................................... 19
7.3 DATA INTERCHANGE CONVENTIONS ..................................................................... 19
7.4 REJECTED TRANSMISSIONS AND TRANSACTIONS .............................................. 20
8 ACKNOWLEDGEMENTS AND/OR REPORTS ...................................................... 20
9 TRADING PARTNER AGREEMENTS .................................................................... 20
10 TRANSACTION SPECIFIC INFORMATION ........................................................... 20
APPENDICES ............................................................................................................... 25
1 IMPLEMENTATION CHECKLIST ............................................................................... 25
2 BUSINESS SCENARIOS ............................................................................................ 25
3 TRANSMISSION EXAMPLES ..................................................................................... 25
4 FREQUENTLY ASKED QUESTIONS ......................................................................... 28
5 CHANGE SUMMARY.................................................................................................. 29
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1 INTRODUCTION
The Administrative Simplification provisions of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA, Title II) includes requirements that national standards be
established for electronic health care transactions, and national identifiers for providers, health
plans, and employers. This requires Washington State Health Care Authority (HCA) to adopt
standards to support the electronic exchange of administrative and financial health care
transactions between covered entities (health care providers, health plans, and healthcare
clearinghouses).
The intent of these standards is to improve the efficiency and effectiveness of the nation's
health care system by encouraging widespread use of electronic data interchange standards in
health care. The intent of the law is that all electronic transactions for which standards are
specified must be conducted according to the standards. These standards were developed by
processes that included significant public and private sector input.
1.1 SCOPE
Companion Guides are used to clarify the exchange of information on HIPAA transactions
between the HCA ProviderOne system and its trading partners. HCA defines trading partners as
covered entities that either submit or retrieve HIPAA batch transactions to and from
ProviderOne.
This Companion Guide provides information about the 835 healthcare payment advice file that
is specific to HCA and HCA trading partners. This Companion Guide is intended for trading
partner use in conjunction with the ASC X12 TR3 835 healthcare payment advice file version
005010X221A1. The ASC X12 TR3s that detail the full requirements for all HIPAA mandated
transactions are available at http://store.x12.org/store/.
1.2 OVERVIEW
The purpose of this document is to introduce and provide information about Washington State
Medicaid solution for receiving the 835 transaction. This document covers how Washington
State Medicaid will work with submitters, testing, connectivity, contact information, control
segments/envelopes, payer specific business rules and limitations, acknowledgements, and
trading partner agreements.
1.3 REFERENCES
The ASC X12 TR3s that detail the full requirements for all HIPAA mandated transactions
are available at http://store.x12.org/store/
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Washington State Medicaid’s companion guides and documentation on transactions for
Trading Partners is available for download via the web at
http://www.hca.wa.gov/medicaid/hipaa/Pages/index.aspx
The Council for Affordable Quality Healthcare (CAQH) launched the Committee on Operating
Rules for Information Exchange (CORE) with the vision of giving providers access to eligibility
and benefits information before or at the time of service using the electronic system of their
choice for any patient or health plan. http://www.caqh.org/
1.4 ADDITIONAL INFORMATION
1.4.1 Intended Users
Companion Guides are to be used by members/technical staff of trading partners who are
responsible for electronic transaction/file exchanges.
1.4.2 Relationship to HIPAA Implementation Guides
Companion Guides are intended to supplement the HIPAA Implementation Guides for each of
the HIPAA transactions. Rules for format, content, and field values can be found in the
Implementation Guides. This Companion Guide describes the technical interface environment
with HCA, including connectivity requirements and protocols, and electronic interchange
procedures. This guide also provides specific information on data elements and the values
required for transactions sent to or received from HCA.
Companion Guides are intended to supplement rather than replace the standard
Implementation Guide for each transaction set. The information in these documents is not
intended to:
ï‚· Modify the definition, data condition, or use of any data element or segment in the
standard Implementation Guides.
ï‚· Add any additional data elements or segments to the defined data set.
ï‚· Utilize any code or data values that are not valid in the standard Implementation Guides
ï‚· Change the meaning or intent of any implementation specifications in the standard
Implementation Guides
2 GETTING STARTED
2.1 Working With Washington State Medicaid
Email: hipaa-help@hca.wa.gov
ï‚· All emails result in the assignment of a Ticket Number for problem
tracking
Information required for initial email:
ï‚· Name
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ï‚· Phone Number
ï‚· Email Address
ï‚· 7 digit Provider One ID Number
ï‚· NPI
ï‚· HIPAA File Name
ï‚· Detailed Description of Issue
ï‚· HIPAA Transaction
Information required for follow up call(s):
ï‚· Assigned Ticket Number
2.2 TRADING PARTNER REGISTRATION
2.2.1 Provider One companion guides and trading partner enrollment package are
available for download via the web at
http://www.hca.wa.gov/medicaid/hipaa/Pages/index.aspx
2.2.2 The Trading Partner completes the Trading Partner Agreement (TPA) and
submits the signed agreement to HCA.
HCA HIPAA EDI Department
PO Box 45562
Olympia, WA 98504-5562
**For Questions call 1-800-562-3022 **
2.2.3 The trading partner is assigned a Submitter ID, Domain, Logon User ID and password.
2.3 CERTIFICATION AND TESTING OVERVIEW
All trading partners need to complete a TPA and successfully test the submission of
their HIPAA transactions before they are allowed to submit HIPAA production
transactions. Washington State Medicaid considers a trading partner ready to submit
HIPAA production transactions when they have received 999 for their submitted HIPAA
test transaction.
Trading partners should notify HCA using the contact information referenced in section
5 regarding their successful testing. HCA will then update the trading partners profile to
production ready. Once this is completed, trading partners can begin submitting HIPAA
production files.
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3 TESTING WITH THE PAYER
The trading partner can submit and retrieve all HIPPA test and production files through the
following methods.
ï‚· Provider One Web Portal
Test URL: https://www.waproviderone.org/edi
Production URL: https://www.waproviderone.org
ï‚· Secure File Transfer Protocol (SFTP)
URL: sftp://ftp.waproviderone.org/
ï‚· Hypertext Transfer protocol (HTTP MIME + Multipart )
BATCH (Test URL):
https://www.waproviderone.org/edi/erabatch-httpmultipart
BATCH (Production URL):
https://www.waproviderone.org/erabatch-httpmultipart
ï‚· Simple Object Access Protocol (SOAP + WSDL)
BATCH (Test URL):
https://www.waproviderone.org/edi/erabatch-soap
BATCH (Production URL):
https://www.waproviderone.org/erabatch-soap
These methods will be discussed in more detail in section 4.
4 CONNECTIVITY WITH THE PAYER/COMMUNICATIONS
4.1 Process Flows
When the trading partner request for 835 payment/advice by any one of the specified methods,
request will be validated using EDI validator, translated and will be processed. The positive
outcome will be 835 response.
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4.1.1 Provider One Web Portal
Log into the Provider One Portal, select the appropriate security profile and the following options will
be viewable to the user:
Scroll down to the HIPAA heading to manage the submission and retrieval of HIPAA transactions
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Select Retrieve HIPAA Batch Responses
In the HIPAA Response/Acknowledgement screen, the user can retrieve 835 files by following
these steps:
ï‚· Select 835 from the Transaction Type drop down menu
ï‚· There are 3 filter boxes available that contain the following filter criteria that you can use to
search for or narrow the search for the HIPAA 835 file
 File Name
 ProviderOne ID
 Response Date
ï‚· An example of a search would be ProviderOne ID %Your ProviderOne ID%
 The % are considered wildcard searches
 Example: %123456700%
ï‚· Another example of a search would involve using the Response Date.
 Example: 03012015 - 03182015
 Click on Go once you’ve entered all the necessary filters. Keep in mind you can enter up to
3 filters to refine the search of the HIPAA 835 transaction
ï‚· All the HIPAA transactions that match your search criteria will return on the page
ï‚· Click on the down arrow in the Response Date column to sort for the most current files to
least current files
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4.1.2 Secure File Transfer Protocol (SFTP)
Trading partners can email hipa[email protected] for information on establishing
connections through the SFTP server. Upon completion of set-up, they will receive additional
instructions on SFTP usage.
There are two categories of folders within a Trading Partner’s SFTP folders:
 TEST – Trading Partners should submit and receive their test files under this root
folder
 PROD – Trading Partners should submit and receive their production files under this
root folder
The following folders are available under the TEST/PROD folders within the SFTP root:
‘HIPAA_Inbound’ - This folder should be used to drop the HIPAA Inbound files that needs to
be submitted to HCA
‘HIPAA_Ack’ - Trading partner should look for acknowledgements to the files submitted in
this folder. TA1, 999 and custom report will be available for all the files submitted by the
Trading Partner
‘HIPAA_Outbound’ – HIPAA outbound transactions generated by HCA will be available in this
folder
‘HIPAA_Error’ – Any inbound file that is not processed, HIPAA compliant, or is not
recognized by ProviderOne will be moved to this folder
‘HIPAA Working’ – There is no functional use for this folder at this time.
‘HIPAA ReadMe’ – Important messages regarding password updates, outage information
and general SFTP messages will be available within this folder.
Folder structure will appear as:
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File Naming Convention
HIPAA 835 files are named:
For 835 Outbound transactions:
HIPAA.<TP ID>.<Provider NPI>.<date time stamp>.835.O.<out>
Example of file name: Hipaa.100005000.1003036195.10112013093528457.835.O.out
 <TP ID> is the Trading Partner ID
 <datetimestamp> is the date time stamp
 <Provider NPI> is the Provider NPI
4.1.3 Hypertext Transfer protocol (HTTP MIME + Multipart)
Trading Partners can send the 835 request [Batch] using HTTP MIME multipart Refer to the
example provided in Appendices 3: Transmission Examples.
4.1.4 Simple Object Access Protocol (SOAP + WSDL)
Trading Partners can send the 835 request [Batch] using SOAP WSDL Refer to the example
provided in Appendices 3: Transmission Examples.
4.2 TRANSMISSION ADMINISTRATIVE PROCEDURES
Trading partners can send 835 transaction to HCA using four methods:
ï‚· Provider One Web Portal
Test URL: https://www.waproviderone.org/edi
Production URL: https://www.waproviderone.org
ï‚· Secure File Transfer Protocol (SFTP)
URL: sftp://ftp.waproviderone.org/
ï‚· Hypertext Transfer protocol (HTTP MIME + Multipart )
BATCH (Test URL):
https://www.waproviderone.org/edi/erabatch-httpmultipart
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BATCH (Production URL):
https://www.waproviderone.org/erabatch-httpmultipart
ï‚· Simple Object Access Protocol (SOAP + WSDL)
BATCH (Test URL):
https://www.waproviderone.org/edi/erabatch-soap
BATCH (Production URL):
https://www.waproviderone.org/erabatch-soap
4.3 RE-TRANSMISSION PROCEDURE
HCA will validate all 835 transactions up to HIPAA validation levels 1 and 2. If a receiver
rejects any part of the transmission, they must reject the entire transmission. Data on
rejected 835 transmissions should not be used to update Trading Partner databases. HCA
transmits 835 Transactions within single functional groups, and in single ST-SE Segments.
4.4 COMMUNICATION PROTOCOL SPECIFICATIONS
Trading partners can submit HIPAA transactions to HCA using the following four methods:
ï‚§ï€ Secure File Transfer Protocol (SFTP)
ï‚§ï€ ProviderOne Web Portal
ï‚· Hypertext Transfer protocol (HTTP MIME + Multipart)
ï‚· Simple Object Access Protocol (SOAP + WSDL)
4.5 PASSWORDS
Washington State Medicaid requires every trading partner to have a valid login credentials to
retrieve 835 transactions through all four submission methods available.
If a user has forgotten their login credentials (login id and password) please use the email
below to have this information reset.
 SFTP – hipaa-help@hca.wa.gov
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 ProviderOne Web Portal – provideronesecurity@hca.wa.gov
 Hypertext Transfer Protocol (HTTP MIME + Multipart) – provideronesecurity@hca.wa.gov
 Simple Object Access Protocol (SOAP + WSDL) – provideronesecurity@hca.wa.gov
5 CONTACT INFORMATION
5.1 EDI CUSTOMER SERVICE AND TECHNICAL ASSISTANCE
Email: [email protected]ov
ï‚· All emails result in the assignment of a Ticket Number for problem tracking
ï‚· Information required for initial email:
 Name
 Phone Number
 Email Address
 7 digit ProviderOne ID Number
 NPI
 HIPAA File Name
 Detailed Description of Issue
 HIPAA Transaction
ï‚· Information required for follow up call(s):
 Assigned Ticket Number
5.2 PROVIDER SERVICE NUMBER
1-800-562-3022
5.3 APPLICABLE WEBSITES/E-MAIL
HIPAA website: http://www.hca.wa.gov/medicaid/hipaa/Pages/index.aspx
6 CONTROL SEGMENTS/ENVELOPES
6.1 Interchange Control Structure(ISA-IEA)
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Washington State Medicaid uses the below custom values for the ISA header of the 835
transaction request. The IEA segment does not require any custom values. In addition, refer
to the ASC X12 835 technical report type 3 guide.
835 ISA Segment Rules
Page
Loop
Segment
Data
Element
Element Name
Comments
Interchange Control Header
App B
Envelope
ISA
01
Authorization
Information
Qualifier
Receive 00
App B
Envelope
ISA
03
Security
Information
Qualifier
Receive 00
App B
Envelope
ISA
05
Interchange ID
Qualifier
Receive ZZ
App B
Envelope
ISA
06
Interchange
Sender ID
Receive 77045
followed by 10 Spaces
App B
Envelope
ISA
07
Interchange ID
Qualifier
Receive ZZ
App B
Envelope
ISA
08
Interchange
Receiver ID
Receive the 9 Digit
ProviderOne ID
followed by 6 Spaces
App B
Envelope
ISA
11
Repetition
Separator
Receive ^ for repetition
separator
App B
Envelope
ISA
16
Component
Element
Separator
Receive Value :
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6.2 Functional Group Structure (GS-GE )
Washington State Medicaid 835 transaction uses the below custom values of GS segment of
the 835 transaction request. GE segment does not require any custom values. In addition,
refer to the ASC X12 835 technical report type 3 guide.
Functional Group Header
App.C
Envelope
GS
02
Application
Sender’s Code
Receive the 9-digit
ProviderOne
Trading Partner ID
App.C
Envelope
GS
03
Application
Receiver’s
Code
Receive '77045'
6.3 Transaction Set Header/Trailer (ST-SE )
Washington State Medicaid 835 transaction does not expect any custom values for ST- SE
segment of 835 Request. In addition to this, refer to the ASC X12 835 technical report type 3
guide.
7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS
7.1 General Information
HIPAA standards are specified in the Implementation Guide for each mandated
transaction and modified by authorized Addenda. Currently, the 835 transaction has one
Addendum. This Addendum has been adopted as final and is incorporated into HCA
requirements.
An overview of requirements specific to each transaction can be found in the 835
Implementation Guide. Implementation Guides contain information related to:
ï‚· Format and content of interchanges and functional groups
ï‚· Format and content of the header, detailer and trailer segments
specific to the transaction
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ï‚· Code sets and values authorized for use in the transaction
ï‚· Allowed exceptions to specific transaction requirements
Transmission sizes are limited based on two factors:
ï‚· Number of Segments/Records allowed by HIPAA standards
ï‚· HCA file transfer limitations
HIPAA standards for the maximum file size of each transaction set are specified in the
835 Implementation Guide. The 835 Implementation Guide recommends a limit of 10,000
CLP Claim Payment Segments in 2100 Claim Payment Information Loop. ProviderOne
may exceed the recommended limit of 10,000 CLP (Claim Payment Information)
segments per ST-SE envelope in order to maintain the balancing requirement within 835.
HCA has no size limitations for postings to its FTP Server.
7.2 Data Format
Delimiters
The ProviderOne will use the following delimiters on outbound transactions:
ï‚· Data element separator, Asterisk, ( * )
ï‚· Sub-element Separator, Vertical Bar, ( : )
ï‚· Segment Terminator, Tilde, ( ~ )
ï‚· Repetition Separator, Caret, (^)
7.3 Data Interchange Conventions
HCA transmits 835 Transaction files with a single ISA/IEA and GS/GE envelope.
835 Transaction contains all the claims within one ST-SE segment within the same
GS/GE envelope.
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7.4 Rejected Transmissions and Transactions
HCA will validate all 835 transactions up to HIPAA validation levels 1 and 2. If a receiver
rejects any part of the transmission, they must reject the entire transmission. Data on rejected
835 transmissions should not be used to update Trading Partner databases. HCA transmits
835 Transactions within single functional groups, and in single ST-SE Segments.
8 ACKNOWLEDGEMENTS AND/OR REPORTS
N/A
9 TRADING PARTNER AGREEMENTS
Trading partner agreements are used to establish and document the relationship between
HCA and covered entities.
1. ProviderOne trading partner enrollment package is available for download via the web at
http://www.hca.wa.gov/medicaid/hipaa/Pages/index.aspx
2. The Trading Partner completes the Trading Partner Agreement and submits the signed
agreement to HCA.
Submit to:
HCA HIPAA EDI Department
PO Box 45562
Olympia, WA 98504-5562
For Questions call 1-800-562-3022
3. Once the agreement is processed the trading partner is assigned a Submitter ID, Domain,
Logon User ID and password.
10 TRANSACTION SPECIFIC INFORMATION
This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be
detailed with the use of a table. The tables contain a row for each segment that Washington State
Medicaid has something additional, over and above, the information in the IGs. That information
can:
1. Limit the repeat of loops, or segments
2. Limit the length of a simple data element
3. Specify a sub-set of the IGs internal code listings
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4. Clarify the use of loops, segments, composite and simple data elements
5. Any other information tied directly to a loop, segment, composite or simple data element
pertinent to trading electronically with Washington State Medicaid Health Plan
The following table specifies the columns and suggested use of the rows for the detailed description
of the transaction set companion guides.
Page
Loop
Segment
Data
Element
Element Name
Comments
Interchange Control Header
App B
Envelope
ISA
01
Authorization
Information
Qualifier
Receive 00
App B
Envelope
ISA
03
Security
Information
Qualifier
Receive 00
App B
Envelope
ISA
05
Interchange ID
Qualifier
Receive ZZ
App B
Envelope
ISA
06
Interchange
Sender ID
Receive 77045
followed by 10 Spaces
App B
Envelope
ISA
07
Interchange ID
Qualifier
Receive ZZ
App B
Envelope
ISA
08
Interchange
Receiver ID
Receive the 9 Digit
ProviderOne ID
followed by 6 Spaces
App B
Envelope
ISA
11
Repetition
Separator
Receive ^ for repetition
separator
App B
Envelope
ISA
16
Component
Element
Separator
Receive Value :
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Page
Loop
Segment
Data
Element
Element Name
Comments
Functional Group Header
App B
Envelope
GS
02
Application
Sender's Code
Receive 77045
App B
Envelope
GS
03
Application
Receiver's Code
Receive the 9 Digit
ProviderOne ID
Financial Information
74
Header
BPR
10
Originating
Company
Identifier
Receive 10 digit WA
State Payer Identifier
74
Header
BPR
11
Originating
Company
Supplemental
Code
Receive WA HCA
Re-association Trace Number
78
Header
TRN
03
Originating
Company
Identifier
Receive 10 digit WA
State Payer Identifier
78
Header
TRN
04
Reference
Identification
Receive WA HCA
Payer Identification
87
1000A
N1
02
Name
Receive WA State
HCA
88
1000A
N1
04
Identification
Code
Receive 10 digit WA
State Payer Identifier
Payer Address
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Page
Loop
Segment
Data
Element
Element Name
Comments
89
1000A
N3
01
Address
Information
Receive WA State
HCA
89
1000A
N3
02
Address
Information
Receive PO BOX
45500
Payer City, State, ZIP Code
90
1000A
N4
01
City Name
Receive Olympia
91
1000A
N4
02
State or Province
Code
Receive WA
91
1000A
N4
03
Postal Code
Receive 98504
Payer Business Contact Information
95
1000A
PER
02
Name
Receive WA State
HCA Provider
Relations
95
1000A
PER
04
Communication
Number
Receive 8005623022
Payer Technical Contact Information
98
1000A
PER
02
Name
Receive WA State
HCA Provider
Relations
98
1000A
PER
04
Communication
Number
Receive hipaa-
[email protected]a.gov
Header Number
111
2000
LX
01
Assigned Number
Receive HCA
Remittance Advice
(RA)
Number (Last six digits
only)
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Page
Loop
Segment
Data
Element
Element Name
Comments
Claim Payment Information
127
2100
CLP
07
Reference
Identification
Receive 18 digit HCA
Transaction Control
Number (TCN)
Patient Name
139
2100
NM1
09
Identification
Code
Receive ProviderOne
Client ID submitted on
claim
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APPENDICES
This section contains one or more appendices.
1 Implementation Checklist
This appendix contains all necessary steps for going live.
2 Business Scenarios
3 Transmission Examples
The following is an example of a Real time request message using the HTTP MIME Multipart
envelope method. The HTTP Header is shown in blue. The remainder of the request is the body of
the MIME Multipart message.
Sample HTTP Real-Time Request:
POST http://10.4.9.52:10819/erabatch-httpmultipart HTTP/1.1
Connection: close
Accept-Encoding: gzip,deflate
Content-Type: multipart/form-data; boundary="----=_Part_1_23716551.1385579913969"
MIME-Version: 1.0
Content-Length: 1707
Host: 10.4.9.52:10819
Connection: Keep-Alive
User-Agent: Apache-HttpClient/4.1.1 (java 1.5)
------=_Part_1_23716551.1385579913969
Content-Type: text/plain; charset=us-ascii
Content-Transfer-Encoding: 7bit
Content-Disposition: form-data; name="UserName"
supuser
------=_Part_1_23716551.1385579913969
Content-Type: text/plain; charset=us-ascii
Content-Transfer-Encoding: 7bit
Content-Disposition: form-data; name="Password"
HCA123$
------=_Part_1_23716551.1385579913969
Content-Type: text/plain; charset=us-ascii
Content-Transfer-Encoding: 7bit
Content-Disposition: form-data; name="PayloadType"
X12_835_Request_005010X221A1
------=_Part_1_23716551.1385579913969
Content-Type: text/plain; charset=us-ascii
Content-Transfer-Encoding: 7bit
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Content-Disposition: form-data; name="ProcessingMode"
Batch
------=_Part_1_23716551.1385579913969
Content-Type: text/plain; charset=us-ascii
Content-Transfer-Encoding: 7bit
Content-Disposition: form-data; name="PayloadID"
a10c42cf-c14b-4225-9495-62e27b3fb04a
------=_Part_1_23716551.1385579913969
Content-Type: text/plain; charset=us-ascii
Content-Transfer-Encoding: 7bit
Content-Disposition: form-data; name="TimeStamp"
2013-11-27T14:18:33Z
------=_Part_1_23716551.1385579913969
Content-Type: text/plain; charset=us-ascii
Content-Transfer-Encoding: 7bit
Content-Disposition: form-data; name="SenderID"
105410800
------=_Part_1_23716551.1385579913969
Content-Type: text/plain; charset=us-ascii
Content-Transfer-Encoding: 7bit
Content-Disposition: form-data; name="ReceiverID"
77045
------=_Part_1_23716551.1385579913969
Content-Type: text/plain; charset=us-ascii
Content-Transfer-Encoding: 7bit
Content-Disposition: form-data; name="CORERuleVersion"
2.2.0
------=_Part_1_23716551.1385579913969--
The following is an example of a Real time response message using the HTTP MIME Multipart
envelope method. The portion of the response below that is colored in blue is the HTTP Header.
The remainder of the response is the body of the MIME Multipart message.
Sample HTTP Real-Time Response
HTTP/1.1 200 OK
Date: Wed, 27 Nov 2013 19:17:58 GMT
Content-Type: multipart/form-data; boundary=AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME
Connection: close
Server: Jetty(7.5.4.v20111024)
--AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME
Content-Disposition: form-data; name="PayloadType"
Content-Type: text/plain; charset=US-ASCII
Content-Transfer-Encoding: 8bit
X12_835_Response_005010X221A1
--AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME
Content-Disposition: form-data; name="ProcessingMode"
Content-Type: text/plain; charset=US-ASCII
Content-Transfer-Encoding: 8bit
Batch
--AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME
Content-Disposition: form-data; name="PayloadID"
Content-Type: text/plain; charset=US-ASCII
WASHINGTON STATE MEDICAID CORE COMPANION GUIDE
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Content-Transfer-Encoding: 8bit
a10c42cf-c14b-4225-9495-62e27b3fb04a
--AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME
Content-Disposition: form-data; name="PayloadLength"
Content-Type: text/plain; charset=US-ASCII
Content-Transfer-Encoding: 8bit
40841
--AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME
Content-Disposition: form-data; name="TimeStamp"
Content-Type: text/plain; charset=US-ASCII
Content-Transfer-Encoding: 8bit
2013-11-27T11:18:16-08:00
--AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME
Content-Disposition: form-data; name="SenderID"
Content-Type: text/plain; charset=US-ASCII
Content-Transfer-Encoding: 8bit
77045
--AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME
Content-Disposition: form-data; name="ReceiverID"
Content-Type: text/plain; charset=US-ASCII
Content-Transfer-Encoding: 8bit
105410800
--AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME
Content-Disposition: form-data; name="CORERuleVersion"
Content-Type: text/plain; charset=US-ASCII
Content-Transfer-Encoding: 8bit
2.2.0
--AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME
Content-Disposition: form-data; name="CheckSum"
Content-Type: text/plain; charset=US-ASCII
Content-Transfer-Encoding: 8bit
1439E508B576D6BBD2B084CF0E7F8E0A9B2C9571
--AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME
Content-Disposition: form-data; name="Payload"
Content-Type: application/octet-stream
Content-Transfer-Encoding: binary
ISA*00* *00* *ZZ*77045 *ZZ*105410800
*131127*1112*^*00501*919673331*0*T*:~GS*HP*77045*105410800*20131127*1112*811981800*X*005010X22
A1~ST*835*293543000~BPR*H*0*C*NON************20130809~TRN*1*D3394844*1916001088*WA
--Sample Response only --
SE*17*293605000~GE*1*811988000~IEA*1*920293331~
--AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME
Content-Disposition: form-data; name="ErrorCode"
Content-Type: text/plain; charset=US-ASCII
Content-Transfer-Encoding: 8bit
Success
--AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME
Content-Disposition: form-data; name="ErrorMessage"
Content-Type: text/plain; charset=US-ASCII
Content-Transfer-Encoding: 8bit
--AanL9JT9i7wmEeNfzU3yyWYOoZOFd_tTAME--
Sample SOAP Real-Time Request
<soap:Envelope xmlns:soap="http://www.w3.org/2003/05/soap-envelope"
xmlns:cor="http://www.caqh.org/SOAP/WSDL/CORERule2.2.0.xsd">
<soap:Header>
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<wsse:Security soap:mustUnderstand="true" xmlns:wsse="http://docs.oasis-
open.org/wss/2004/01/oasis-200401-wss-wssecurity-secext-1.0.xsd">
<wsse:UsernameToken wsu:Id="UsernameToken-18430971" xmlns:wsu="http://docs.oasis-
open.org/wss/2004/01/oasis-200401-wss-wssecurity-utility-1.0.xsd">
<wsse:Username>supuser</wsse:Username>
<wsse:Password Type="http://docs.oasis-open.org/wss/2004/01/oasis-200401-wss-
username-token-profile-1.0#PasswordText">HCA123$</wsse:Password>
</wsse:UsernameToken>
</wsse:Security>
</soap:Header>
<soap:Body>
<cor:COREEnvelopeBatchResultsRetrievalRequest>
<PayloadType>X12_835_Request_005010X221A1</PayloadType>
<!--<PayloadType>X12_005010_Request_Batch_Results_271</PayloadType>-->
<ProcessingMode>Batch</ProcessingMode>
<PayloadID>0b3da023-6d89-4277-b9cc-a068c8a04faa</PayloadID>
<TimeStamp>${=new java.text.SimpleDateFormat("yyyy-MM-dd'T'HH:mm:ss'Z'").format(new
Date())}</TimeStamp>
<SenderID>201698800</SenderID>
<ReceiverID>77545</ReceiverID>
<CORERuleVersion>2.2.0</CORERuleVersion>
</cor:COREEnvelopeBatchResultsRetrievalRequest>
</soap:Body>
</soap:Envelope>
Sample SOAP Real-Time Response
<env:Envelope xmlns:env="http://www.w3.org/2003/05/soap-envelope">
<env:Header/>
<env:Body>
<core:COREEnvelopeBatchResultsRetrievalResponse
xmlns:core="http://www.caqh.org/SOAP/WSDL/CORERule2.2.0.xsd">
<PayloadType>X12_835_Response_005010X221A1</PayloadType>
<ProcessingMode>Batch</ProcessingMode>
<PayloadID>0b3da023-6d89-4277-b9cc-a068c8a04faa</PayloadID>
<PayloadLength>7969965</PayloadLength>
<TimeStamp>2013-11-27T10:52:17-08:00</TimeStamp>
<SenderID>77545</SenderID>
<ReceiverID>201698800</ReceiverID>
<CORERuleVersion>2.2.0</CORERuleVersion>
<CheckSum>795A01BD726E056C342FDE6CE3FC33E55C524328</CheckSum>
<Payload>
<xop:Include href="cid:638dbf78-f629-4143-a9ed-8dab8b8d4970@edifecs.com"
xmlns:xop="http://www.w3.org/2004/08/xop/include"/>
</Payload>
<ErrorCode>Success</ErrorCode>
<ErrorMessage/>
</core:COREEnvelopeBatchResultsRetrievalResponse>
</env:Body>
</env:Envelope>
4 Frequently Asked Questions
Refer CAQH CORE FAQ:
http://www.caqh.org/pdf/COREFAQsPartC.pdf
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5 Change Summary
Version
Date
Description of Changes
1.0
10-11-2013
Initial Draft
