CONFIDENTIAL - NOT FOR CIRCULATION CONTRACT BETWEEN THE GEORGIA DEPARTMENT OF COMMUNITY HEALTH and PEACH STATE for PROVISION OF SERVICES TO GEORGIA HEALTHY FAMILIES

Exhibit 10.1

 

CONFIDENTIAL - NOT FOR CIRCULATION

 

CONTRACT BETWEEN

 

THE GEORGIA DEPARTMENT OF COMMUNITY

HEALTH

 

and

 

PEACH STATE

 

for

 

PROVISION OF SERVICES TO

 

GEORGIA HEALTHY FAMILIES

 

Contract No.: 0653

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TABLE OF CONTENTS

 

1.0		SCOPE OF SERVICE				1
		1.1		BACKGROUND		1
		1.2		ELIGIBILITY FOR GEORGIA CARES		2
		1.2.1		Medicaid		2
		1.2.2		PeachCare for Kids		3
		1.2.3		Exclusions		3
		1.3		SERVICE REGIONS		4
		1.4		DEFINITIONS		4
		1.5		ACRONYMS		17
2.0		DCH RESPONSIBILITIES				19
		2.1		GENERAL PROVISIONS		19
		2.2		LEGAL COMPLIANCE		19
		2.3		ELIGIBILITY AND ENROLLMENT		19
		2.4		DISENROLLMENT		22
		2.5		MEMBER SERVICES AND MARKETING		22
		2.6		COVERED SERVICES & SPECIAL COVERAGE PROVISIONS		23
		2.7		NETWORK		23
		2.8		QUALITY MONITORING		23
		2.9		COORDINATION WITH CONTRACTOR’S KEY STAFF		24
		2.10		FORMAT STANDARDS		24
		2.11		FINANCIAL MANAGEMENT		24
		2.12		INFORMATION SYSTEMS		25
		2.13		READINESS REVIEW		25
3.0		GENERAL CONTRACTOR RESPONSIBILITIES				26

 

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4.0		SPECIFIC CONTRACTOR RESPONSIBILITIES				27
		4.1		ENROLLMENT		27
		4.1.1		Enrollment Procedures		27
		4.1.2		Selection of a Primary Care Provider (PCP)		27
		4.1.3		Newborn Enrollment		28
		4.1.4		Reporting Requirements		29
		4.2		DISENROLLMENT		29
		4.2.1		Disenrollment Initiated by the Member		29
		4.2.2		Disenrollment Initiated by the Contractor		30
		4.2.3		Acceptable Reasons for Disenrollment Requests by Contractor		30
		4.2.4		Unacceptable Reasons for Disenrollment Requests by Contractor		31
		4.3		MEMBER SERVICES		32
		4.3.1		General Provisions		32
		4.3.2		Requirements for Written Materials		32
		4.3.3		Member Handbook Requirements		33
		4.3.4		Member Rights		36
		4.3.5		Provider Directory		37
		4.3.6		Member Identification (ID) Card		37
		4.3.7		Toll-free Telephone Hotline		38
		4.3.8		Internet Presence/Web Site		39
		4.3.9		Cultural Competency		40
		4.3.10		Translation Services		40
		4.3.11		Reporting Requirements		40
		4.4		MARKETING		41
		4.4.1		Prohibited Activities		41
		4.4.2		Allowable Activities		41
		4.4.3		State Approval of Materials		42

 

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		4.4.4		Provider Marketing Materials		42
		4.5		COVERED BENEFITS AND SERVICES		42
		4.5.1		Included Services		42
		4.5.2		Individuals with Disabilities Education Act (IDEA) Services		45
		4.5.3		Enhanced Services		45
		4.5.4		Medical Necessity		46
		4.5.5		Experimental, Investigational or Cosmetic Procedures		46
		4.5.6		Moral or Religious Objections		46
		4.6		SPECIAL COVERAGE PROVISIONS		47
		4.6.1		Emergency Services		47
		4.6.2		Post-Stabilization Services		49
		4.6.3		Urgent Care Services		50
		4.6.4		Family Planning Services		50
		4.6.5		Sterilizations, Hysterectomies and Abortions		51
		4.6.6		Pharmacy		53
		4.6.7		Immunizations		53
		4.6.8		Transportation		53
		4.6.9		Perinatal Services		54
		4.6.10		Parenting Education		55
		4.6.11		Mental Health and Substance Abuse		55
		4.6.12		Advance Directives		55
		4.6.13		▇▇▇▇▇▇ Care Forensic Exam		56
		4.6.14		Laboratory Services		56
		4.6.15		Member Cost-Sharing		56
		4.7		EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM: HEALTH CHECK		57
		4.7.1		General Provisions		57
		4.7.2		Outreach and Informing		57

 

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		4.7.3		Screening		58
		4.7.4		Tracking		60
		4.7.5		Diagnostic and Treatment Services		60
		4.7.6		Reporting Requirements		61
		4.8		PROVIDER NETWORK		61
		4.8.1		General Provisions		61
		4.8.2		Primary Care Providers (PCPs)		63
		4.8.3		Direct Access		65
		4.8.4		Significant Traditional Providers (STPs)		65
		4.8.5		Pharmacies		66
		4.8.6		Hospitals		66
		4.8.7		Laboratories		66
		4.8.8		Mental Health/Substance Abuse		66
		4.8.9		Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)		67
		4.8.10		Family Planning Clinics		67
		4.8.11		Nurse Practitioners Certified (NP-Cs) and Certified Nurse Midwives (CNMs)		67
		4.8.12		Geographic Access Requirements		67
		4.8.13		Waiting Maximums and Appointment Requirements		68
		4.8.14		Credentialing		69
		4.8.15		Mainstreaming		69
		4.8.16		Coordination Requirements		70
		4.8.17		Network Changes		70
		4.8.18		Out-of-Network Providers		71
		4.8.19		Reporting Requirements		72
		4.9		PROVIDER SERVICES		72
		4.9.1		General Provisions		72
		4.9.2		Provider Handbooks		72
		4.9.3		Education and Training		74

 

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		4.9.4		Provider Relations		74
		4.9.5		Toll-free Telephone Hotline		74
		4.9.6		Internet Presence/Web Site		75
		4.9.7		Provider Complaint System		76
		4.9.8		Reporting Requirements		77
		4.10		PROVIDER CONTRACTS AND PAYMENTS		78
		4.10.1		Provider Contracts		78
		4.10.2		Provider Termination		81
		4.10.3		Provider Insurance		82
		4.10.4		Provider Payment		83
		4.10.5		Reporting Requirements		83
		4.11		UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES		84
		4.11.1		Utilization Management		84
		4.11.2		Prior Authorization and Pre-Certification		85
		4.11.3		Referral Requirements		86
		4.11.4		Transition of Members		87
		4.11.5		Court-Ordered Evaluations and Services		87
		4.11.6		Second Opinions		87
		4.11.7		Care Coordination and Case Management		88
		4.11.8		Disease Management		89
		4.11.9		Discharge Planning		89
		4.11.10		Reporting Requirements		90
		4.12		QUALITY IMPROVEMENT		90
		4.12.1		General Provisions		90
		4.12.2		Quality Assessment Performance Improvement (QAPI) Program		90
		4.12.3		Performance Improvement Projects		91
		4.12.4		Practice Guidelines		93

 

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		4.12.5		Focused Studies		94
		4.12.6		Patient Safety Plan		94
		4.12.7		Performance Incentives		95
		4.12.8		External Quality Review		95
		4.12.9		Reporting Requirements		95
		4.13		FRAUD AND ABUSE		95
		4.13.1		Program Integrity		95
		4.13.2		Compliance Plan		96
		4.13.3		Coordination with DCH and Other Agencies		97
		4.13.4		Reporting Requirements		98
		4.14		INTERNAL GRIEVANCE SYSTEM		98
		4.14.1		General Requirements		98
		4.14.2		Grievance Process		99
		4.14.3		Proposed Action		100
		4.14.4		Appeal Process		102
		4.14.5		Notice of Adverse Action		103
		4.14.6		Administrative Law Hearing		104
		4.14.7		Continuation of Benefits while the Contractor Appeal and Administrative Law Hearing are Pending		105
		4.14.8		Reporting Requirements		106
		4.15		ADMINISTRATION AND MANAGEMENT		106
		4.15.1		General Provisions		106
		4.15.2		Place of Business and Hours of Operation		106
		4.15.3		Training		107
		4.15.4		Data Certification		107
		4.15.5		Implementation Plan		108
		4.16		CLAIMS MANAGEMENT		108
		4.16.1		General Provisions		108

 

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		4.16.2		Other Considerations		110
		4.16.3		Reporting Requirements		110
		4.17		INFORMATION MANAGEMENT AND SYSTEMS		110
		4.17.1		General Provisions		110
		4.17.2		Global System Architecture and Design Requirements		112
		4.17.3		Data and Document Management Requirements by Major Information Type		114
		4.17.4		System and Data Integration Requirements		114
		4.17.5		System Access Management and Information Accessibility Requirements		115
		4.17.6		Systems Availability and Performance Requirements		115
		4.17.7		System User and Technical Support Requirements		118
		4.17.8		System Change Management Requirements		120
		4.17.9		System Security and Information Confidentiality and Privacy Requirements		121
		4.17.10		Information Management Process and Information Systems Documentation Requirements		122
		4.17.11		Reporting Requirements		122
		4.18		REPORTING REQUIREMENTS		122
		4.18.1		General Procedures		122
		4.18.2		Weekly Reporting		123
		4.18.3		Monthly Reporting		124
		4.18.4		Quarterly Reporting		126
		4.18.5		Annual Reports		130
		4.18.6		Ad Hoc Reports		132
5.0		DELIVERABLES				134
		5.1		CONFIDENTIALITY		134
		5.2		NOTICE OF DISAPPROVAL		134
		5.3		RESUBMISSION WITH CORRECTIONS		135
		5.4		NOTICE OF APPROVAL/DISAPPROVAL OF RESUBMISSION		135
		5.5		DCH FAILS TO RESPOND		135

 

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		5.6		REPRESENTATIONS		135
		5.7		CONTRACT DELIVERABLES		136
		5.8		CONTRACT REPORTS		138
6.0		TERM OF CONTRACT				139
7.0		PAYMENT FOR SERVICES				139
8.0		FINANCIAL MANAGEMENT				142
		8.1		GENERAL PROVISIONS		142
		8.2		SOLVENCY AND RESERVES STANDARDS		142
		8.3		REINSURANCE		142
		8.4		THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS		142
		8.4.2		Cost Avoidance		143
		8.4.3		Compliance		144
		8.5		PHYSICIAN INCENTIVE PLAN		144
		8.6		REPORTING REQUIREMENTS		144
9.0		PAYMENT OF TAXES				148
10.0		RELATIONSHIP OF PARTIES				148
11.0		INSPECTION OF WORK				148
12.0		STATE PROPERTY				148
13.0		OWNERSHIP AND USE OF DATA/ UPGRADES				149
		13.1		OWNERSHIP AND USE OF DATA		149
		13.2		SOFTWARE AND OTHER UPGRADES		149
14.0		CONTRACTOR STAFFING				150
		14.1		STAFFING ASSIGNMENTS AND CREDENTIALS		150
		14.2		STAFFING CHANGES		151

 

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		14.3		CONTRACTOR’S FAILURE TO COMPLY		152
15.0		CRIMINAL BACKGROUND CHECKS				152
16.0		SUBCONTRACTS				152
		16.1		USE OF SUBCONTRACTORS		152
		16.2		COST OR PRICING BY SUBCONTRACTORS		153
17.0		LICENSE, CERTIFICATE, PERMIT REQUIREMENT				153
18.0		RISK OR LOSS AND REPRESENTATIONS				154
19.0		PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES				154
20.0		RECORDS REQUIREMENTS				155
		20.1		GENERAL PROVISIONS		155
		20.2		RECORDS RETENTION REQUIREMENTS		155
		20.3		ACCESS TO RECORDS		155
		20.4		MEDICAL RECORD REQUESTS		156
21.0		CONFIDENTIALITY REQUIREMENTS				156
		21.1		GENERAL CONFIDENTIALITY REQUIREMENTS		156
		21.2		HIPAA COMPLIANCE		157
22.0		TERMINATION OF CONTRACT				157
		22.1		GENERAL PROCEDURES		157
		22.2		TERMINATION BY DEFAULT		157
		22.3		TERMINATION FOR CONVENIENCE		158
		22.4		TERMINATION FOR INSOLVENCY OR BANKRUPTCY		158
		22.5		TERMINATION FOR INSUFFICIENT FUNDING		158
		22.6		TERMINATION PROCEDURES		159
		22.7		TERMINATION CLAIMS		160

 

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23.0		LIQUIDATED DAMAGES				161
		23.1		GENERAL PROVISIONS		161
		23.2		CATEGORY 1		161
		23.3		CATEGORY 2		162
		23.4		CATEGORY 3		163
		23.5		CATEGORY 4		164
		23.6		OTHER REMEDIES		166
		23.7		NOTICE OF REMEDIES		167
24.0		INDEMNIFICATION				167
25.0		INSURANCE				168
		25.1		INSURANCE OF CONTRACTOR		168
26.0		PAYMENT BOND & IRREVOCABLE LETTER OF CREDIT				169
27.0		COMPLIANCE WITH ALL LAWS				169
		27.1		NON-DISCRIMINATION		169
		27.2		DELIVERY OF SERVICE AND OTHER FEDERAL LAWS		170
		27.3		COST OF COMPLIANCE WITH APPLICABLE LAWS		171
		27.4		GENERAL COMPLIANCE		171
28.0		CONFLICT RESOLUTION				171
29.0		CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE				171
30.0		NOTICE				172
31.0		MISCELLANEOUS				173
		31.1		CHOICE OF LAW OR VENUE		173
		31.2		ATTORNEY’S FEES		173
		31.3		SURVIVABILITY		173
		31.4		DRUG-FREE WORKPLACE		173

 

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		31.5		CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER MATTERS		174
		31.6		WAIVER		174
		31.7		FORCE MAJEURE		174
		31.8		BINDING		174
		31.9		TIME IS OF THE ESSENCE		174
		31.10		AUTHORITY		174
		31.11		ETHICS IN PUBLIC CONTRACTING		175
		31.12		CONTRACT LANGUAGE INTERPRETATION		175
		31.13		ASSESSMENT OF FEES		175
		31.14		COOPERATION WITH OTHER CONTRACTORS		175
		31.15		SECTION TITLES NOT CONTROLLING		176
		31.16		LIMITATION OF LIABILITY/EXCEPTIONS		176
		31.17		COOPERATION WITH AUDITS		176
		31.18		HOMELAND SECURITY CONSIDERATIONS		176
		31.19		PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED		176
		31.20		OWNERSHIP AND FINANCIAL DISCLOSURE		177
32.0		AMENDMENT IN WRITING				177
33.0		CONTRACT ASSIGNMENT				178
34.0		SEVERABILITY				178
35.0		COMPLIANCE WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS (O.C.G.A. § 50-20-1 ET SEQ.)				178
36.0		ENTIRE AGREEMENT				178
ATTACHMENT A						181
		DRUG FREE WORKPLACE CERTIFICATE				181
ATTACHMENT B						183

 

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		CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER RESPONSIBILITY MATTERS		183
ATTACHMENT C				185
		NONPROFIT ORGANIZATION DISCLOSURE FORM		185
ATTACHMENT D				186
		CONFIDENTIALITY STATEMENT		186
ATTACHMENT E				187
		BUSINESS ASSOCIATE AGREEMENT		187
ATTACHMENT F				192
		VENDOR LOBBYLIST DISCLOSURE AND REGISTRATION CERTIFICATION FORM		192
ATTACHMENT G				194
		PAYMENT BOND AND		194
		IRREVOCABLE LETTER OF CREDIT		194
ATTACHMENT H				196
		CAPITATION PAYMENT		196
ATTACHMENT I				198
		NOTICE OF YOUR RIGHT TO A HEARING		198
ATTACHMENT J				199
		MAP OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS		199
ATTACHMENT K				200
		APPLICABLE CO-PAYMENTS		200
ATTACHMENT L				201
		INFORMATION MANAGEMENT AND SYSTEMS		201

 

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THIS CONTRACT, with an effective date of July 18, 2005 (hereinafter referred to as the “Effective Date”), is made and entered into by and between the Georgia Department of Community Health (hereinafter referred to as “DCH” or the “Department”) and Peach State (hereinafter referred to as the “Contractor”).

 

WHEREAS, DCH is responsible for Health Care policy, purchasing, planning and regulation pursuant to the Official Code of Georgia Annotated (O.C.G.A.) § 31-5A-4 et. seq.;

 

WHEREAS, DCH is the single State agency designated to administer medical assistance in Georgia under Title XIX of the Social Security Act of 1935, as amended, and O.C.G.A. §§ 49-4-140 et seq. (the “Medicaid Program”), and is charged with ensuring the appropriate delivery of Health Care services to Medicaid recipients and PeachCare for Kids Members;

 

WHEREAS, DCH has caused Request for Proposals Number ▇▇▇▇▇-▇▇▇-▇▇▇▇▇▇▇▇▇▇ (hereinafter the “RFP”) to be issued through Department of Administrative Service(s) (DOAS), which is expressly incorporated as if completely restated herein;

 

WHEREAS, DCH has received from Contractor a proposal in response to the RFP, “Contractor’s Proposal,” which is expressly incorporated as if completely restated herein; and,

 

WHEREAS, DCH accepts Contractor’s Proposal to provide various services for the Department.

 

NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises, covenants and agreements contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Department and the Contractor (each individually a “Party” and collectively the “Parties”) hereby agree as follows:

 

1.0	SCOPE OF SERVICE

 

1.0.1

The State of Georgia is implementing reforms to the Medicaid and PeachCare for Kids programs. These reforms will focus on system-wide improvements in performance and quality, will consolidate fragmented systems of care, and will control the currently unsustainable trend rate in Medicaid and PeachCare for Kids expenditures. The reforms will be implemented through a management of care approach to achieve the greatest value for the most efficient use of resources.

 

1.0.2

The Contractor shall assist the State of Georgia in this endeavor through the following tasks, obligations, and responsibilities.

 

1.1	BACKGROUND

 

1.1.1

Effective January 1, 2006 the Georgia Department of Community Health (DCH) will begin implementing Georgia Healthy Families (GHF). Scheduled for implementation over the course of the year, GHF will become a statewide, full-risk care management

 

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system for certain Medicaid adults and children and PeachCare for Kids children (pending legislative approval).

 

1.1.2

The GHF program is designed to:

 

1.1.2.1

Improve the Health Care status of the Member population;

 

1.1.2.2

Establish a “Provider Home” for Members through its use of assigned Primary Care Providers (PCPs);

 

1.1.2.3

Establish a climate of contractual accountability among the state, the care management organizations and the health care providers;

 

1.1.2.4

Slow the rate of expenditure growth in the Medicaid program; and

 

1.1.2.5

Expand and strengthen a sense of Member responsibility that leads to more appropriate utilization of the health care system.

 

1.2	ELIGIBILITY FOR GEORGIA CARES

 

1.2.1

Medicaid

 

1.1.2.1

The following Medicaid eligibility categories will be required to enroll in GHF.

 

1.2.1.1.1

Low Income Families – Adults and children who meet the standards of the old AFDC (Aid to Families with Dependent Children) program.

 

1.2.1.1.2

Transitional Medicaid – Former Low-Income Medicaid (LIM) families who are no longer eligible for LIM because their earned income exceeds the income limit.

 

1.2.1.1.3

Pregnant Women (Presumptive) – Pregnant women with family income at or below two hundred percent (200%) of the federal poverty level who receive temporary Medicaid under the Medicaid Presumptive Eligibility Program.

 

1.2.1.1.4

Pregnant Women (Right from the Start Medicaid - RSM) – Pregnant women with family income at or below two hundred percent (200%) of the federal poverty level who receive Medicaid through the RSM program.

 

1.2.1.1.5

Children (Right from the Start Medicaid - RSM) – Children less than nineteen (19) years of age whose family income is at or below the appropriate percentage of the federal poverty level for their age and family.

 

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1.2.1.1.6

Children (newborn) – A child born to a woman who is eligible for Medicaid on the day the child is born.

 

1.2.1.1.7

Women Eligible Due to Breast and Cervical Cancer – Women less than sixty-five (65) years of age who have been screened through Title XV Center for Disease Control (CDC) screening and have been diagnosed with breast or cervical cancer.

 

1.2.1.1.8

Refugees – Those individuals who have the required INS documentation showing they meet a status in one of these groups: refugees, asylees, Cuban parolees/Haitian entrants, Amerasians or human trafficking victims.

 

1.2.2

PeachCare for Kids

 

1.2.2.1

PeachCare for Kids – The State Children’s Health Insurance Program in Georgia. Children less than nineteen (19) years of age who have family income that is less than two hundred thirty-five percent (235%) of the federal poverty level, who are not eligible for Medicaid or any other health insurance program, and who cannot be covered by the State Health Benefit Plan.

 

1.2.3

Exclusions

 

1.2.3.1

The following recipients will be excluded from Enrollment in GHF, even if the recipient is otherwise eligible for GHF per section 1.2.1 and section 1.2.2.

 

1.2.3.1.1

Recipients eligible for Medicare;

 

1.2.3.1.2

Recipients that are Members of a Federally Recognized Indian Tribe;

 

1.2.3.1.3

Recipients that are eligible for Supplemental Security Income;

 

1.2.3.1.4

Children less than nineteen (19) years of age who are in ▇▇▇▇▇▇ care or other out-of-home placement;

 

1.2.3.1.5

Children less than nineteen (19) years of age who are receiving ▇▇▇▇▇▇ care or other adoption assistance under Title IV-E of the Social Security Act;

 

1.2.3.1.6

Children enrolled in the Children’s Medical Services program administered by the Georgia Division of Public Health;

 

1.2.3.1.7

Children enrolled in the Georgia Pediatric Program (▇▇▇▇);

 

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1.2.3.1.8

Children with severe emotional disturbance whose care is coordinated under the Multi-Agency Team for Children (MATCH) program; and

 

1.2.3.1.9

Recipients enrolled under group health plans for whom DCH provides payment for premiums, deductibles, coinsurance and other cost sharing, pursuant to Section 1906 of the Social Security Act.

 

1.3	SERVICE REGIONS

 

1.3.1

For the purposes of coordination and planning, DCH has divided the State, by county, into six (6) Service Regions. See Attachment J for a listing of the counties in each Service Region.

 

1.3.2

Members will choose or be assigned to a Care Management Organization (CMO) plan that is operating in the Service Region in which they reside.

 

1.4	DEFINITIONS

 

Whenever capitalized in this Contract, the following terms have the respective meaning set forth below, unless the context clearly requires otherwise.

 

Abandoned Call: A call in which the caller elects an option and is either not permitted access to that option or disconnects from the system.

 

Abuse: Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for Health Care. It also includes Member practices that result in unnecessary cost to the Medicaid program.

 

Administrative Law Hearing: The appeal process administered by the State in accordance with O.C.G.A. Title 50, Chapter 13 and as required by federal law, 42 CFR 200 et al, available to Members and Providers after they exhaust the Contractor’s Grievance System and Complaint Process.

 

Administrative Service(s): The Contractual obligations of the Contractor that include but may not be limited to Utilization Management, Credentialing Providers, network management, Quality improvement, marketing, Enrollment, Member services, Claims payment, management information Systems, financial management, and reporting.

 

Action: The denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service; the failure to provide services in a timely manner; or the failure of the CMO to act within the time frames provided in 42 CFR 438.408(b).

 

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Advance Directives: A written instruction, such as a living will or durable power of attorney for Health Care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of Health Care when the individual is incapacitated.

 

After-Hours: Provider office/visitation hours that extend beyond the normal business hours of Monday-Friday 9-5:30 and also extend to Saturday hours.

 

Agent: An entity that contracts with the State of Georgia to perform administrative functions, including but not limited to: fiscal agent activities; outreach, eligibility, and Enrollment activities; Systems and technical support; etc.

 

Appeal: A Member request for a review by the Contractor of a Proposed Action through the Contractor’s Internal Grievance System.

 

At Risk: Any service for which the Provider agrees to accept responsibility to provide, or arrange for, in exchange for the Capitation payment.

 

Authoritative Host: A system that contains the master or “authoritative” data for a particular data type, e.g. Member, Provider, CMO, etc. The Authoritative Host may feed data from its master data files to other systems in real time or in batch mode. Data in an Authoritative Host is expected to be up-to-date and reliable.

 

Authorized Representative: A person authorized by the Member in writing to make health-related decisions on behalf of a Member, including, but not limited to, Enrollment and Disenrollment decisions, filing Appeals and Grievances with the Contractor, and choice of a PCP.

 

Automatic Assignment (or Auto-Assignment): The Enrollment of an eligible person, for whom Enrollment is mandatory, in a CMO plan chosen by DCH or its Agent. Also the assignment of a new Member to a PCP chosen by the CMO Plan, pursuant to the provisions of this Contract.

 

Benefits: The Health Care services set forth in this Contract, for which the Contractor has agreed to provide, arrange, and be held fiscally responsible.

 

Blocked Call: A call that cannot be connected immediately because no circuit is available at the time the call arrives or the telephone system is programmed to block calls from entering the queue when the queue backs up beyond a defined threshold.

 

Business Days: Traditional workdays, including Monday, Tuesday, Wednesday, Thursday, and Friday. State Holidays are excluded.

 

Calendar Days: All seven days of the week.

 

Capitation: A Contractual agreement through which a Contractor agrees to provide specified Health Care services to Members for a fixed amount per month.

 

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Capitation Payment: A payment, fixed in advance, that DCH makes to a Contractor for each Member covered under a Contract for the provision of medical services. This payment is made regardless of whether the Member receives Covered Services or Benefits during the period covered by the payment.

 

Capitation Rate: The fixed monthly amount that the Contractor is prepaid by DCH for each Member to ensure that Covered Services and Benefits under this Contract are provided.

 

Capitated Service: Any Covered Service for which the Contractor receives an actuarially sound Capitation Payment.

 

Care Coordination: A set of Member-centered, goal-oriented, culturally relevant, and logical steps to assure that a Member receives needed services in a supportive, effective, efficient, timely, and cost-effective manner. Care Coordination is also referred to as care management.

 

Care Management Organization (CMO): An entity, that is organized for the purpose of providing Health Care and has a Health Maintenance Organization Certificate of Authority granted by the State of Georgia, which contracts with Providers and furnishes Health Care services on a prepaid, capitated basis to Members in a designated Service Region.

 

Centers for Medicare & Medicaid Services (CMS): The Agency within the U.S. Department of Health and Human Services with responsibility for the Medicare, Medicaid and the State Children’s Health Insurance Program.

 

Certified Nurse Midwife (CNM): A registered professional nurse who is legally authorized under State law to practice as a nurse-midwife, and has completed a program of study and clinical experience for nurse-midwives or equivalent.

 

Chronic Condition: Any ongoing physical, behavioral, or cognitive disorder, including chronic illnesses, impairments and disabilities. There is an expected duration of at least twelve (12) months with resulting functional limitations, reliance on compensatory mechanisms (medications, special diet, assistive device, etc) and service use or need beyond that which is normally considered routine.

 

Claim: A ▇▇▇▇ for services, a line item of services, or all services for one recipient within a ▇▇▇▇.

 

Claims Administrator: The entity engaged by DCH to provide Administrative Service(s) to the CMO Plans in connection with processing and adjudicating risk-based payment, and recording health benefit encounter Claims for Members.

 

Clean Claim: A claim received by the CMO for adjudication, in a nationally accepted format in compliance with standard coding guidelines and which requires no further information, adjustment, or alteration by the Provider of the services in order to be processed and paid by the CMO. The following exceptions apply to this definition: i. A Claim for payment of expenses incurred during a period of time for which premiums are delinquent; ii. A Claim for which Fraud is suspected; and iii. A Claim for which a Third Party Resource should be responsible.

 

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Cold-Call Marketing: Any unsolicited personal contact by the CMO Plan, with a potential Member, for the purposes of marketing.

 

Condition: A disease, illness, injury, disorder, of biological, cognitive, or psychological basis for which evaluation, monitoring and/or treatment are indicated.

 

Consecutive Enrollment Period: The consecutive twelve (12) month period beginning on the first day of Enrollment or the date the notice is sent, whichever is later. For Members that use their option to change CMO plans without cause during the first ninety (90) Calendar Days of Enrollment, the twelve-month consecutive Enrollment period will commence when the Member enrolls in the new CMO plan. This is not to be construed as a guarantee of eligibility during the consecutive Enrollment period.

 

Contested Claim: A Claim that is denied because the Claim is an ineligible Claim, the Claim submission is incomplete, the coding or other required information to be submitted is incorrect, the amount Claimed is in dispute, or the Claim requires special treatment.

 

Contract: The written agreement between the State and the Contractor; comprised of the Contract, any addenda, appendices, attachments, or amendments thereto.

 

Contract Award: The date upon which DCH issues the Apparent Successful Offeror Letters.

 

Contract Execution: The date upon which all parties have signed the Contract.

 

Contractor: The Care Management Organization with a valid Certificate of Authority in Georgia that contracts hereunder with the State for the provision of comprehensive Health Care services to Members on a prepaid, capitated basis.

 

Contractor’s Representative: The individual legally empowered to bind the Contractor, using his/her signature block, including his/her title. This individual will be considered the Contractor’s Representative during the life of any Contract entered into with the State unless amended in writing.

 

Co-payment: The part of the cost-sharing requirement for Members in which a fixed monetary amount is paid for certain services/items received from the Contractor’s Providers.

 

Corrective Action Plan: The detailed written plan required by DCH to correct or resolve a deficiency or event causing the assessment of a liquidated damage or sanction against the CMO.

 

Cost Avoidance: A method of paying Claims in which the Provider is not reimbursed until the Provider has demonstrated that all available health insurance has been exhausted.

 

Covered Services: Those Medically Necessary Health Care services provided to Members, the payment or indemnification of which is covered under this Contract.

 

Credentialing: The Contractor’s determination as to the qualifications and ascribed privileges of a specific Provider to render specific Health Care services.

 

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Critical Access Hospital (CAH): The facility located in the Primary Service Area that has been designated or is eligible for designation as a Critical Access Hospital by the State under the criteria for such hospitals as specifically set forth in 42 U.S.C.§ 1395i-4.

 

Cultural Competency: A set of interpersonal skills that allow individuals to increase their understanding, appreciation, acceptance, and respect for cultural differences and similarities within, among and between groups and the sensitivity to know how these differences influence relationships with Members. This requires a willingness and ability to draw on community-based values, traditions and customs, to devise strategies to better meet culturally diverse Member needs, and to work with knowledgeable persons of and from the community in developing focused interactions, communications, and other supports.

 

Deliverable: A document, manual or report submitted to DCH by the Contractor to fulfill requirements of this Contract.

 

Department of Community Health (DCH): The Agency in the State of Georgia responsible for oversight and administration of the Medicaid program, the PeachCare for Kids program, and the State Health Benefits Plan (SHBP).

 

Department of Insurance (DOI): The Agency in the State of Georgia responsible for licensing, overseeing, regulating, and certifying insuring entities.

 

Diagnostic Services: Any medical procedures or supplies recommended by a physician or other licensed medical practitioner, within the scope of his or her practice under State law, to enable him or her to identify the existence, nature or extent of illness, injury, or other health deviation in a Member.

 

Disenrollment: The removal of a Member from participation in the Contractor’s plan, but not necessarily from the Medicaid or PeachCare for Kids program.

 

Documented Attempt: A bona fide, or good faith, attempt to contract with a Provider. Such attempts may include written correspondence that outlines contracted negotiations between the parties, including rate and contract terms disclosure, as well as documented verbal conversations, to include date and time and parties involved.

 

Durable Medical Equipment (DME): Equipment, including assistive technology, which: a) can withstand repeated use; b) is used to service a health or functional purpose; c) is ordered by a qualified practitioner to address an illness, injury or disability; and d) is appropriate for use in the home, work place, or school.

 

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program: A Title XIX mandated program that covers screening and Diagnostic Services to determine physical and mental deficiencies in Members less than 21 years of age, and Health Care, treatment, and other measures to correct or ameliorate any deficiencies and Chronic Conditions discovered.

 

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Emergency Medical Condition: A medical Condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairments of bodily functions, or serious dysfunction of any bodily organ or part. An Emergency Medical Condition shall not be defined on the basis of lists of diagnoses or symptoms.

 

Emergency Services: Covered inpatient and outpatient services furnished by a qualified Provider that are needed to evaluate or stabilize an Emergency Medical Condition that is found to exist using the prudent layperson standard.

 

Encounter: For the purposes of this Contract, a Health Care encounter is defined as a distinct set of services provided to a Medicaid or PeachCare for Kids Member enrolled with a Contractor on the dates that the services were delivered.

 

Encounter Data: Health Care Encounter Data include: (i) All data captured during the course of a single Health Care encounter that specify the diagnoses, comorbidities, procedures (therapeutic, rehabilitative, maintenance, or palliative), Pharmaceuticals, medical devices and equipment associated with the Member receiving services during the Encounter; (ii) The identification of the Member receiving and the Provider(s) delivering the Health Care services during the single Encounter; and, (iii) A unique, i.e. unduplicated, identifier for the single Encounter.

 

Enrollee: See Member.

 

Enrollment: The process by which an individual eligible for Medicaid or PeachCare for Kids applies (whether voluntary or mandatory) to utilize the Contractor’s plan in lieu of fee for service and such application is approved by DCH or its Agent.

 

Enrollment Broker: The entity engaged by DCH to assist in outreach, education and Enrollment activities associated with the GHF program.

 

Enrollment Period: The twelve (12) month period commencing on the effective date of Enrollment.

 

External Quality Review (EQR): The analysis and evaluation by an external quality review organization of aggregated information on quality, timeliness, and access to the Health Care services that a CMO or its Subcontractors furnish to Members and to DCH.

 

External Quality Review Organization (EQRO): An organization that meets the competence and independence requirements set forth in 42 CFR 438.354 and performs external quality review, and other related activities.

 

Federal Financial Participation (FFP): The funding contribution that the federal government makes to the Georgia Medicaid and PeachCare for Kids programs.

 

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Federally Qualified Health Center (FQHC): An entity that provides outpatient health programs pursuant to Section 1905(1)(2)(B) of the Social Security Act.

 

Fee-for-Service (FFS): A method of reimbursement based on payment for specific services rendered to a Member.

 

Financial Relationship: A direct or indirect ownership or investment interest (including and option or nonvested interest) in any entity. This direct or indirect interest may be in the form of equity, debt, or other means and includes any indirect ownership or investment interest no matter how many levels removed from a direct interest, or a compensation arrangement with an entity.

 

Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit or financial gain to him/herself or some other person. It includes any act that constitutes Fraud under applicable federal or State law.

 

Grievance: An expression of dissatisfaction about any matter other than a Proposed Adverse Action.

 

Grievance System: The overall system that includes Grievances and Appeals at the Contractor level and access to the State Fair Hearing process (the State’s Administrative Law Review).

 

Health Care: Health Care means care, services, or supplies related to the health of an individual. Health Care includes, but is not limited to, the following: (i) Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental Condition, or functional status, of an individual or that affects the structure or function of the body; and (ii) Sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription.

 

Health Care Professional: A physician or other Health Care Professional, including but not limited to podiatrists, optometrists, chiropractors, psychologists, dentists, physician’s assistants, physical or occupational therapists and therapists assistants, speech-language pathologists, audiologists, registered or licensed practical nurses (including nurse practitioners, clinical nurse specialist, certified registered nurse anesthetists, and certified nurse midwives), licensed certified social workers, registered respiratory therapists, and certified respiratory therapy technicians licensed in the State of Georgia.

 

Health Check: The State of Georgia’s Early and Periodic Screening, Diagnostic, and Treatment program pursuant to Title XIX of the Social Security Act.

 

Health Insurance Portability and Accountability Act (HIPAA): A law enacted in 1996 by the Congress of the United States. When referenced in this Contract it includes all related rules, regulations and procedures.

 

Health Maintenance Organization: As used in Section 8.6 a Health Maintenance Organization is an entity, that is organized for the purpose of providing Health Care and has a Health Maintenance Organization Certificate of Authority granted by the State of Georgia, which contracts with

 

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Providers and furnishes Health Care services on a prepaid, capitated basis to Members in a designated Service Region.

 

Historical Provider Relationship: A Provider who has been the main source of Medicaid or PeachCare for Kids services for the Member during the previous year.

 

Immediately: Within twenty-four (24) hours.

 

In-Network Provider: A Provider that has entered into a Provider Contract with the Contractor to provide services.

 

Incentive Arrangement: Any mechanism under which a Contractor may receive additional funds over and above the Capitation rates, for exceeding targets specified in the Contract.

 

Incurred-But-Not-Reported (IBNR): Estimate of unpaid Claims liability, includes received but unpaid Claims.

 

Information: i. Structured Data: Data that adhere to specific properties and Validation criteria that are stored as fields in database records. Structured queries can be created and run against structured data, where specific data can be used as criteria for querying a larger data set; ii. Document: Information that does not meet the definition of structured data includes text, files, spreadsheets, electronic messages and images of forms and pictures.

 

Information System/Systems: A combination of computing hardware and software that is used in: (a) the capture, storage, manipulation, movement, control, display, interchange and/or transmission of information, i.e. structured data (which may include digitized audio and video) and documents; and/or (b) the processing of such information for the purposes of enabling and/or facilitating a business process or related transaction.

 

Insolvent: Unable to meet or discharge financial liabilities.

 

Limited-English-Proficient Population: Individuals with a primary language other than English who must communicate in that language if the individual is to have an equal opportunity to participate effectively in, and benefit from, any aid, service or benefit provided by the health Provider.

 

Mandatory Enrollment: The process whereby an individual eligible for Medicaid or PeachCare for Kids is required to enroll in a Contractor’s plan, unless otherwise exempted or excluded, to receive covered Medicaid or PeachCare for Kids services.

 

Marketing: Any communication from a CMO plan to any Medicaid or PeachCare for Kids eligible individual that can reasonably be interpreted as intended to influence the individual to enroll in that particular CMO plan, or not enroll in or disenroll from another CMO plan.

 

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Marketing Materials: Materials that are produced in any medium, by or on behalf of a CMO, and can reasonably be interpreted as intended to market to any Medicaid or PeachCare for Kids eligible individual.

 

Medicaid: The joint federal/state program of medical assistance established by Title XIX of the Social Security Act, which in Georgia is administered by DCH.

 

Medicaid Eligible: An individual eligible to receive services under the Medicaid Program but not necessarily enrolled in the Medicaid Program.

 

Medicaid Management Information System (MMIS): Computerized system used for the processing, collecting, analysis and reporting of Information needed to support Medicaid and SCHIP functions. The MMIS consists of all required subsystems as specified in the State Medicaid Manual.

 

Medical Director: The licensed physician designated by the Contractor to exercise general supervision over the provision of health service Benefits by the Contractor.

 

Medical Records: The complete, comprehensive records of a Member including, but not limited to, x-rays, laboratory tests, results, examinations and notes, accessible at the site of the Member’s participating Primary Care physician or Provider, that document all medical services received by the Member, including inpatient, ambulatory, ancillary, and emergency care, prepared in accordance with all applicable DCH rules and regulations, and signed by the medical professional rendering the services.

 

Medical Screening: An examination: i. provided on hospital property, and provided for that patient for whom it is requested or required, ii. performed within the capabilities of the hospital’s emergency room (ER) (including ancillary services routinely available to its ER) iii. the purpose of which is to determine if the patient has an Emergency Medical Condition, and iv. performed by a physician (M.D. or D.O.) and/or by a nurse practitioner, or physician assistant as permitted by State statutes and regulations and hospital bylaws.

 

Medically Necessary Services: Those services that meet the definition found in Section 4.5.

 

Member: A Medicaid or PeachCare for Kids recipient who is currently enrolled in a CMO plan.

 

National Committee for Quality Assurance (NCQA): An organization that sets standards, and evaluates and accredits health plans and other managed care organizations.

 

Non-Emergency Transportation (NET): A ride, or reimbursement for a ride, provided so that a Member with no other transportation resources can receive services from a medical provider. NET does not include transportation provided on an emergency basis, such as trips to the emergency room in life threatening situations.

 

Non-Institutional Claims: Claims submitted by a medical Provider other than a hospital, nursing facility, or intermediate care facility/mentally retarded (ICF/MR).

 

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Nurse Practitioner Certified (NP-C): A registered professional nurse who is licensed by the State of Georgia and meets the advanced educational and clinical practice requirements beyond the two or four years of basic nursing education required of all registered nurses.

 

Out-of-Network Provider: A Provider of services that does not have a Provider contract with the Contractor.

 

PeachCare for Kids: The State of Georgia’s State Children’s Health Insurance Program established pursuant to Title XXI of the Social Security Act.

 

Pharmacy Benefit Manager (PBM): An entity responsible for the provision and administration of pharmacy services.

 

Physician Incentive Plan: Any compensation arrangement between a Contractor and a physician or physician group that may directly have the effect of reducing or limiting services furnished to Members.

 

Post-Stabilization Services: Covered Services, related to an Emergency Medical Condition, that are provided after a Member is stabilized, in order to maintain the stabilized Condition, or to improve or resolve the Member’s Condition.

 

Potential Enrollee: See Potential Member.

 

Potential Member: A Medicaid or SCHIP recipient who is subject to mandatory Enrollment in a care management program but is not yet the Member of a specific CMO plan.

 

Pre-Certification: Review conducted prior to a Member’s admission, stay or other service or course of treatment in a hospital or other facility.

 

Prevalent Non-English Language: A language other than English, spoken by a significant number or percentage of potential Members and Members in the State.

 

Preventive Services: Services provided by a physician or other licensed health practitioner within the scope of his or her practice under State law to: prevent disease, disability, and other health Conditions or their progression; treat potential secondary Conditions before they happen or at an early remediable stage; prolong life; and promote physical and mental health and efficiency.

 

Primary Care: All Health Care services and laboratory services, including periodic examinations, preventive Health Care and counseling, immunizations, diagnosis and treatment of illness or injury, coordination of overall medical care, record maintenance, and initiation of Referrals to specialty Providers described in this Contract, and for maintaining continuity of patient care. These services are customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, or pediatrician, and may be furnished by a nurse practitioner to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them.

 

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Primary Care Provider (PCP): A licensed medical doctor (MD) or doctor of osteopathy (DO) or certain other licensed medical practitioner who, within the scope of practice and in accordance with State certification/licensure requirements, standards, and practices, is responsible for providing all required Primary Care services to Members. A PCP shall include general/family practitioners, pediatricians, internists, physician’s assistants, CNMs or NP-Cs, provided that the practitioner is able and willing to carry out all PCP responsibilities in accordance with these Contract provisions and licensure requirements.

 

Prior Authorization: (also known as “pre-authorization” or “prior approval”). Authorization granted in advance of the rendering of a service after appropriate medical review.

 

Proposed Action: The proposal of an action for the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service; the failure to provide services in a timely manner; or the failure of the CMO to act within the time frames provided in 42 CFR 438.408(b).

 

Provider: Any physician, hospital, facility, or other Health Care Professional who is licensed or otherwise authorized to provide Health Care services in the State or jurisdiction in which they are furnished.

 

Provider Complaint: A written expression by a Provider which indicates dissatisfaction or dispute with the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative functions, including a Proposed Action.

 

Provider Contract: Any written contract between the Contractor and a Provider that requires the Provider to perform specific parts of the Contractor’s obligations for the provision of Health Care services under this Contract.

 

Quality: The degree to which a CMO increases the likelihood of desired health outcomes of its Members through its structural and operational characteristics, and through the provision of health services that are consistent with current professional knowledge.

 

Referral: A request by a PCP for a Member to be evaluated and/or treated by a different physician, usually a specialist.

 

Referral Services: Those Health Care services provided by a health professional other than the Primary Care Provider and which are ordered and approved by the Primary Care Provider or the Contractor.

 

Reinsurance: An agreement whereby the Contractor transfers risk or liability for losses, in whole or in part, sustained under this Contract. A reinsurance agreement may also exist at the Provider level.

 

(Claims) Reprocessing: Upon determination of the need to correct the outcome of one or more claims processing transactions, the subsequent attempt to process a single claim or batch of claims.

 

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Remedy: The State’s means to enforce the terms of the Contract through performance guarantees and other actions.

 

Risk Contract: A Contract under which the Contractor assumes financial risk for the cost of the services covered under the Contract, and may incur a loss if the cost of providing services exceeds the payments made by DCH to the Contractor for services covered under the Contract.

 

Routine Care: Treatment of a Condition that would have no adverse effects if not treated within twenty-four (24) hours or could be treated in a less acute setting (e.g, physicians office) or by the patient.

 

Scope of Services: Those specific Health Care services for which a Provider has been credentialed, by the plan, to provide to Members.

 

Service Authorization: A Member’s request for the provision of a service.

 

Service Region: A geographic area comprised of those counties where the Contractor is responsible for providing adequate access to services and Providers.

 

Short Term: A period of thirty (30) Calendar Days or less.

 

Significant Traditional Providers: Those Providers that provided the top eighty percent (80%) of Medicaid encounters for the GMC-eligible population in the base year of 2004.

 

Span of Control: Information systems and telecommunications capabilities that the CMO itself operates or for which it is otherwise legally responsible according to the terms and Conditions of this Contract. The CMO span of control also includes Systems and telecommunications capabilities outsourced by the CMO.

 

State: The State of Georgia.

 

State Children’s Health Insurance Program (SCHIP): A joint federal-state Health Care program for targeted, low-income children, established pursuant to Title XXI of the Social Security Act. Georgia’s SCHIP program is called PeachCare for Kids.

 

State Fair Hearing: See Administrative Law Hearing.

 

Subcontract: Any written contract between the Contractor and a third party, including a Provider, to perform a specified part of the Contractor’s obligations under this Contract.

 

Subcontractor: Any third party who has a written Contract with the Contractor to perform a specified part of the Contractor’s obligations under this Contract.

 

Subcontractor Payments: Any amounts the Contractor pays a Provider or Subcontractor for services they furnish directly, plus amounts paid for administration and amounts paid (in whole or in part) based on use and costs of Referral Services (such as Withhold amounts, bonuses based on

 

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Referral levels, and any other compensation to the physician or physician group to influence the use for Referral Services). Bonuses and other compensation that are not based on Referral levels (such as bonuses based solely on quality of care furnished, patient satisfaction, and participation on committees) are not considered payments for purposes of Physician Incentive Plans.

 

System Access Device: A device used to access System functions; can be any one of the following devices if it and the System are so configured: i. Workstation (stationary or mobile computing device) ii. Network computer/”winterm” device, iii. “Point of Sale” device, iv. Phone, v. Multifunction communication and computing device, e.g. PDA.

 

System Unavailability: As measured within the Contractor’s information systems Span of Control, when a system user does not get the complete, correct full-screen response to an input command within three (3) minutes after depressing the “Enter” or other function key.

 

System Function Response Time: Based on the specific sub function being performed,

 

Record Search Time- the time elapsed after the search command is entered until the list of matching records begins to appear on the monitor.

 

Record Retrieval Time- the time elapsed after the retrieve command is entered until the record data begin to appear on the monitor.

 

Screen Edit Time- the time elapsed after the last field is filled on the screen with an enter command until all field entries are edited with the errors highlighted.

 

New Screen Page Time- the time elapsed from the time a new screen is requested until the data from that screen start to appear on the monitor.

 

Print Initiation Time- the elapsed time from the command to print a screen or report until it appears in the appropriate queue.

 

Confirmation of CMO Enrollment System Response Time - the elapsed time from the receipt of the transaction by the Contractor from the Provider and/or switch vendor until the Contractor hands-off a response to the Provider and/or switch vendor.

 

On-line Claims Adjudication Response Time- the elapsed time from the receipt of the transaction by the Contractor from the Provider and/or switch vendor until the Contractor hands-off a response to the Provider and/or switch vendor.

 

Systems: See Information Systems.

 

Telecommunication Device for the Deaf (TDD): Special telephony devices with keyboard attachments for use by individuals with hearing impairments who are unable to use conventional phones.

 

Third Party Resource: Any person, institution, corporation, insurance company, public, private or governmental entity who is or may be liable in Contract, tort, or otherwise by law or equity to pay all or part of the medical cost of injury, disease or disability of an applicant for or recipient of medical assistance.

 

Urgent Care: Medically Necessary treatment for an injury, illness, or another type of Condition (usually not life threatening) which should be treated within twenty-four (24) hours.

 

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Utilization: The rate patterns of service usage or types of service occurring within a specified time.

 

Utilization Management (UM): A service performed by the Contractor which seeks to assure that Covered Services provided to Members are in accordance with, and appropriate under, the standards and requirements established by the Contractor, or a similar program developed, established or administered by DCH.

 

Utilization Review (UR): Evaluation of the clinical necessity, appropriateness, efficacy, or efficiency of Health Care services, procedures or settings, and ambulatory review, prospective review, concurrent review, second opinions, care management, discharge planning, or retrospective review.

 

Validation: The review of information, data, and procedures to determine the extent to which they are accurate, reliable, free from bias and in accord with standards for data collection and analysis.

 

Week: The traditional seven-day week, Sunday through Saturday.

 

Withhold: A percentage of payments or set dollar amounts that a Contractor deducts from a practitioner’s service fee, Capitation, or salary payment, and that may or may not be returned to the physician, depending on specific predetermined factors.

 

Work Week: The traditional work week, Monday through Friday.

 

1.5

ACRONYMS

 

AFDC – Aid to Families with Dependent Children

 

AICPA – American Institute of Certified Public Accountants

 

CAH – Critical Access Hospital

 

CDC – Centers for Disease Control

 

CFR – Code of Federal Regulations

 

CMO – Care Management Organization

 

CMS – Centers for Medicare & Medicaid Services

 

CNM – Certified Nurse Midwives

 

CSB – Community Service Boards

 

DME – Durable Medical Equipment

 

DOI – Department of Insurance

 

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EB – Enrollment Broker

 

EPSDT – Early and Periodic Screening, Diagnostic, and Treatment

 

EQR – External Quality Review

 

EQRO – External Quality Review Organization

 

FFS – Fee-for-Service

 

FQHC – Federally Qualified Health Center

 

GHF – Georgia Cares

 

HHS – US Department of Health and Human Services

 

HIPAA – Health Insurance Portability and Accountability Act

 

HMO – Health Management Organization

 

IBNR – Incurred-But-Not-Reported

 

INS – U.S. Immigration and Naturalization Services

 

LIM – Low-Income Medicaid

 

MMIS – Medicaid Management Information System

 

NAIC – National Association of Insurance Commissioners

 

NCQA – National Committee for Quality Assurance

 

NET – Non-Emergency Transportation

 

NP-C – Certified Nurse Practitioners

 

NPI – National Provider Identifier

 

PBM – Pharmacy Benefit Manager

 

PCP – Primary Care Provider

 

QAPI – Quality Assessment Performance Improvement

 

RHC – Rural Health Clinic

 

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RSM – Right from the Start Medicaid

 

SCHIP – State Children’s Health Insurance Program

 

SSA – Social Security Act

 

TANF – Temporary Assistance for Needy Families

 

TDD – Telecommunication Device for the Deaf

 

UM – Utilization Management

 

UPIN – Unique Physician Identifier Number

 

UR – Utilization Review

 

2.0	DCH RESPONSIBILITIES

 

2.1	GENERAL PROVISIONS

 

2.1.1

DCH will be responsible for administering the GHF program. The agency will administer Contracts, monitor Contractor performance, and provide oversight in all aspects of the Contractor’ operations. Specifically, DCH will perform the following activities:

 

2.2	LEGAL COMPLIANCE

 

2.2.1

DCH will comply with, and will monitor the Contractor’s compliance with, all applicable State and federal laws and regulations.

 

2.3	ELIGIBILITY AND ENROLLMENT

 

2.3.1

The State of Georgia has the sole authority for determining eligibility for the Medicaid program and whether Medicaid beneficiaries are eligible for Enrollment in GHF. DCH or its Agent will determine eligibility for PeachCare for Kids and will collect applicable premiums. DCH or its agent will continue responsibility for the electronic eligibility verification system (EVS).

 

2.3.2

DCH or its Agent will review the Medicaid Management Information System (MMIS) file daily and send written notification and information within two (2) Business Days to all Members who are determined eligible for GHF. A Member shall have thirty (30) Calendar Days to select a CMO plan and a PCP. DCH or its Agent will issue a monthly notice of all Enrollments to the CMO plan.

 

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2.3.3

At the time of CMO plan selection the Member will also sign an acknowledgement of receipt of the Member Roles and Responsibilities document.

 

2.3.4

If the Member does not choose a CMO plan within thirty (30) Calendar Days of being deemed eligible for GHF, DCH or its Agent will Auto-Assign the individual to a CMO plan using the following algorithm:

 

2.3.4.1

If an immediate family member(s) of the Member is already enrolled in one CMO plan, the Member will be Auto-Assigned to that plan;

 

2.3.4.2

If there are no immediate family members already enrolled and the Member has a Historical Provider Relationship with a Provider, the Member will be Auto-Assigned to the CMO plan where the Provider is contracted;

 

2.3.4.3

If the Member does not have a Historical Provider Relationship with a Provider in any CMO plan, or the Provider contracts with all plans, the Member will be Auto-Assigned to the CMO plan that has the lowest capitated rates in the Service Region.

 

2.3.5

Enrollment, whether chosen or Auto-Assigned, will be effective at 12:01 a.m. on the first (1st) Calendar Day of the month following the Member selection or Auto-Assignment, for those Members assigned on or between the first (1st) and twenty-fourth (24th) Calendar Day of the month. For those Members assigned on or between the twenty-fifth (25th) and thirty-first (31st) Calendar Day of the month, Enrollment will be effective at 12:01 a.m. on the first (1st) Calendar Day of the second (2nd) month after assignment.

 

2.3.6

In the future, at a date to be determined by DCH, DCH or its Agent may include quality measures in the Auto-Assignment algorithm. Members will be Auto-Assigned to those plans that have higher scores on quality measures to be defined by DCH. This factor will be applied after determining that there are no Historical Provider Relationships, but prior to utilizing the lowest Capitation rates criteria.

 

2.3.7

In the ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ will limit enrollment in a single plan to no more than forty percent (40%) of total GCS eligible lives in the Service Region. Members will not be Auto-Assigned to that CMO plan unless a family member is enrolled in the CMO plan or a Historical Provider Relationship exists with a Provider that does not participate in any other CMO plan in the Atlanta Service Region. DCH may, at its sole discretion, elect to modify this threshold for reasons it deems necessary and proper.

 

2.3.8

In the five (5) Service Regions other than Atlanta DCH will limit Enrollment in a single plan to no more than sixty-five percent (65%) of total GHF eligible lives in the Service Region. Members will not be Auto-Assigned to that CMO plan unless a family member is enrolled in the CMO plan or a Historical Provider Relationship exists with a Provider that does not participate in any other CMO plan in the Service

 

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Region. Enrollment limits will be figured once per quarter at the beginning of each quarter.

 

2.3.9

DCH or its Agent will have five (5) Business Days to notify Members and the CMO plan of the Auto-Assignment. Notice to the Member will be made in writing and sent via surface mail. Notice to the CMO plan will be made via file transfer.

 

2.3.10

DCH or its Agent will be responsible for the consecutive Enrollment period and re-Enrollment functions.

 

2.3.11

Conditioned on continued eligibility, all Members will be enrolled in a CMO plan for a period of twelve (12) consecutive months. This consecutive Enrollment period will commence on the first (1st) day of Enrollment or upon the date the notice is sent, whichever is later. If a Member disenrolls from one CMO plan and enrolls in a different CMO plan, consecutive Enrollment period will begin on the effective date of Enrollment in the second (2nd) CMO plan.

 

2.3.12

DCH or its Agent will automatically enroll a Member into the CMO plan in which he or she was most recently enrolled if the Member has a temporary loss of eligibility, defined as less than sixty (60) Calendar Days. In this circumstance the consecutive Enrollment period will continue as though there has been no break in eligibility, keeping the original twelve (12) month period.

 

2.3.13

DCH or its Agent will notify Members at least once every twelve (12) months, and at least sixty (60) Calendar Days prior to the date upon which the consecutive Enrollment period ends (the annual Enrollment opportunity), that they have the opportunity to switch CMO plans. Members who do not make a choice will be deemed to have chosen to remain with their current CMO plan.

 

2.3.14

In the event a temporary loss of eligibility has caused the Member to miss the annual Enrollment opportunity, DCH or its Agent will enroll the Member in the CMO plan in which he or she was enrolled prior to the loss of eligibility. The Member will have ninety (90) Calendar Days to disenroll without cause as described in Section 4.2.1.

 

2.3.15

In accordance with current operations, the State will issue a Medicaid number to a newborn upon notification from the Contractor, the hospital, or other authorized Medicaid provider.

 

2.3.16

Upon notification from a CMO plan that a Member is an expectant mother, DCH or its Agent shall mail a newborn enrollment packet to the expectant mother. This packet shall include information that the newborn will be Auto-Assigned to the mother’s CMO plan and that she may, if she wants, select a PCP for her newborn prior to the birth by contacting her CMO plan. The mother shall have ninety (90) Calendar Days from the day a Medicaid number was assigned to her newborn to choose a different CMO plan.

 

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2.4	DISENROLLMENT

 

2.4.1

DCH or its Agent will process all CMO plan Disenrollments. This includes Disenrollments due to non-payment of the PeachCare for Kids premiums, loss of eligibility for GHF due to other reasons, and all Disenrollment requests Members or CMO plans submit via telephone, surface mail, internet, facsimile, and in person.

 

2.4.2

DCH or its Agent will make final determinations about granting Disenrollment requests and will notify the CMO plan via file transfer and the Member via surface mail of any Disenrollment decision within five (5) Calendar Days of making the final determination

 

2.4.3

Whether requested by the Member or the Contractor the following are the Disenrollment timeframes:

 

2.4.3.1

If the Disenrollment request was date stamped received by DCH on or between the first (1st) and fifteenth (15th) Calendar Day of the month, the Disenrollment will be effective at midnight the first (1st) day of the month following the month in which the request was filed; and

 

2.4.3.2

If the Disenrollment request was date stamped received by DCH on or between the sixteenth (16th) and thirty-first (31st) Calendar Day of the month, the Disenrollment will be effective at midnight the first (1st) day of the second (2nd) month following the month in which the request was filed.

 

2.4.4

If DCH or its Agent fails to make a determination, the date of Disenrollment will be deemed effective on the first (1st) day of the second (2nd) month.

 

2.4.5

When Disenrollment is necessary due to a change in eligibility category, or eligibility for GHF, the Member will be disenrolled according to the timeframes identified in Section 2.4.3.

 

2.4.6

When disenrollment is necessary because a Member loses Medicaid or PeachCare for Kids eligibility (for example, he or she has died, been incarcerated, or moved out-of-state) disenrollment shall be immediate.

 

2.5	MEMBER SERVICES AND MARKETING

 

2.5.1

DCH will provide to the Contractor its methodology for identifying the prevalent non-English languages spoken. For the purposes of this Section, prevalent means a non-English language spoken by a significant number or percentage of Medicaid and PeachCare for Kids eligible individuals in the State.

 

2.5.2

DCH will review and prior approve all marketing materials.

 

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2.6	COVERED SERVICES & SPECIAL COVERAGE PROVISIONS

 

2.6.1

DCH will use submitted Encounter Data, and other data sources, to determine Contractor compliance with federal requirements that eligible Members under the age of twenty-one (21) receive periodic screens and preventive/well child visits in accordance with the specified periodicity schedule. DCH will use the participant ratio as calculated using the CMS 416 methodology for measuring the Contractor’s performance.

 

2.7

NETWORK

 

2.7.1

DCH will provide to the Contractor up-to-date changes to the State’s list of excluded Providers, as well as any additional information that will affect the Contractor’s Provider network.

 

2.7.2

DCH will consider all Contractor’s requests to waive network geographic access requirements in rural areas. All such requests shall be submitted in writing.

 

2.7.3

DCH will provide the State’s Provider Credentialing policies to the Contractor upon award of this Contract.

 

2.8	QUALITY MONITORING

 

2.8.1

DCH will have a written strategy for assessing and improving the quality of services provided by the Contractor. In accordance with 42 CFR 438.204 this strategy will, at a minimum, monitor:

 

2.8.1.1

The availability of services;

 

2.8.1.2

The adequacy of the Contractor’s capacity and services;

 

2.8.1.3

The Contractor’s coordination and continuity of care for Members;

 

2.8.1.4

The coverage and authorization of services;

 

2.8.1.5

The Contractor’s policies and procedures for selection and retention of Providers;

 

2.8.1.6

The Contractor’s compliance with Member information requirements in accordance with 42 CFR 43 8.10;

 

2.8.1.7

The Contractor’s compliance with State and federal privacy laws and regulations relative to Member’s confidentiality;

 

2.8.1.8

The Contractor’s compliance with Member Enrollment and Disenrollment requirements and limitations;

 

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2.8.1.9

The Contractor’s Grievance System;

 

2.8.1.10

The Contractor’s oversight of all Subcontractor relationships and delegations;

 

2.8.1.11

The Contractor’s adoption of practice guidelines, including the dissemination of the guidelines to Providers and Providers’ application of them;

 

2.8.1.12

The Contractor’s quality assessment and performance improvement program; and

 

2.8.1.13

The Contractor’s health information systems.

 

2.9	COORDINATION WITH CONTRACTOR’S KEY STAFF

 

2.9.1

DCH will make diligent good faith efforts to facilitate effective and continuous communication and coordination with the Contractor in all areas of GHF operations.

 

2.9.2

Specifically, DCH will designate individuals within the department who will serve as a liaison to the corresponding individual on the Contractor’s staff, including:

 

2.9.2.1

A program integrity staff Member;

 

2.9.2.2

A quality oversight staff Member;

 

2.9.2.3

A Grievance System staff Member who will also ensure that the State Administrative Law Hearing process is consistent with the Rules of the Office of the State Administrative Hearings Chapter 616-1-2 and with any other applicable rule, regulation, or procedure whether State or federal;

 

2.9.2.4

An information systems coordinator; and

 

2.9.2.5

A vendor management staff Member.

 

2.10	FORMAT STANDARDS

 

2.10.1

DCH will provide to the Contractor its standards for formatting all Reports requested of the Contractor. DCH will require that all Reports be submitted electronically.

 

2.11	FINANCIAL MANAGEMENT

 

2.11.1

In order to facilitate the Contractor’s efforts in using Cost Avoidance processes to ensure that primary payments from the liable third party are identified and collected to offset medical expenses, DCH will include information about known Third Party Resources on the electronic Enrollment data given to the Contractor.

 

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2.11.2

DCH will monitor Contractor compliance with federal and State physician incentive plan rules and regulations.

 

2.12	INFORMATION SYSTEMS

 

2.12.1

DCH will supply the following information to the Contractor:

 

2.12.1.1

Application and database design and development requirements (standards) that are specific to the State of Georgia.

 

2.12.1.2

Networking and data communications requirements (standards) that are specific to the State of Georgia.

 

2.12.1.3

Specific information for integrity controls and audit trail requirements.

 

2.12.1.4

State web portal (▇▇▇▇▇▇▇.▇▇▇) integration standards and design guidelines.

 

2.12.1.5

Specifications for data files to be transmitted by the Contractor to DCH and/or its agents.

 

2.12.1.6

Specifications for point-to-point, uni-directional or bi-directional interfaces between Contractor and DCH systems.

 

2.13	READINESS REVIEW

 

2.13.1

DCH will conduct a readiness review of each CMO plan that will include, at a minimum, one (1) on-site review. This review shall be conducted ninety (90) to one hundred twenty (120) days prior to Enrollment of Medicaid/PeachCare for Kids recipients in the CMO plan, and at other times during the Contract period at the discretion of DCH. DCH will conduct the readiness review to provide assurances that the Contractor is able and prepared to perform all administrative functions and to provide high-quality services to Members.

 

2.13.2

Specifically, DCH’s review will document the status of the Contractor with respect to meeting program standards set forth in this Contract, as well as any goals established by the Contractor. A multidisciplinary team appointed by DCH will conduct the readiness review. The scope of the readiness review will include, but not be limited to, review and/or verification of:

 

2.13.2.1

Network Provider composition and access;

 

2.13.2.2

Staff;

 

2.13.2.3

Marketing materials;

 

2.13.2.4

Content of Provider agreements;

 

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2.13.2.5

EPSDT plan;

 

2.13.2.6

Member services capability;

 

2.13.2.7

Comprehensiveness of quality and Utilization Management strategies;

 

2.13.2.8

Policies and procedures for the Grievance System and Complaint System;

 

2.13.2.9

Financial solvency;

 

2.13.2.10

Contractor litigation history, current litigation, audits and other government investigations both in Georgia and in other states; and

 

2.13.2.11

Information systems’ Claims payment system performance and interfacing capabilities.

 

2.13.3

The readiness review may assess the Contractor’s ability to meet any requirements set forth in this Contract and the documents referenced herein.

 

2.13.4

Members may not be enrolled in a CMO plan until DCH has determined that the Contractor is capable of meeting these standards. A Contractor’s failure to pass the readiness review within one hundred twenty (120) Calendar Days of Contract Award may result in immediate Contract termination.

 

2.13.5

DCH will provide the Contractor with a summary of the findings as well as areas requiring remedial action.

 

3.0	GENERAL CONTRACTOR RESPONSIBILITIES

 

3.1	The Contractor shall immediately notify DCH of any of the following:

 

3.1.1

Change in business address, telephone number, facsimile number, and e-mail address;

 

3.1.2

Change in corporate status or nature;

 

3.1.3

Change in business location;

 

3.1.4

Change in solvency;

 

3.1.5

Change in corporate officers, executive employees, or corporate structure;

 

3.1.6

Change in ownership, including but not limited to the new owner’s legal name, business address, telephone number, facsimile number, and e-mail address;

 

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3.1.7

Change in incorporation status; or

 

3.1.8

Change in federal employee identification number or federal tax identification number.

 

3.2	The Contractor shall not make any changes to any of the requirements herein, without explicit written approval from Commissioner of DCH, or his or her designee.

 

4.0	SPECIFIC CONTRACTOR RESPONSIBILITIES

 

The Contractor shall complete the following actions, tasks, obligations, and responsibilities:

 

4.1	ENROLLMENT

 

4.1.1

Enrollment Procedures

 

4.1.1.1

DCH or its Agent is responsible for Enrollment, including auto-assignment of a CMO plan; Disenrollment; education; and outreach activities. The Contractor shall coordinate with DCH and its Agent as necessary for all Enrollment and Disenrollment functions.

 

4.1.1.2

DCH or its Agent will make every effort to ensure that recipients ineligible for Enrollment in GHF are not be enrolled in GHF. However, to ensure that such recipients are not enrolled in GHF, the Contractor shall assist DCH or its Agent in the identification of recipients that are ineligible for Enrollment in GHF, as discussed in Section 1.2.3, should such recipients inadvertently become enrolled in GHF. The Contractor shall assist DCH or its Agent in the identification of recipients that become ineligible for Medicaid (for example, those who have died, been incarcerated, or moved out-of-state).

 

4.1.1.3

The Contractor shall accept all individuals without restrictions. The Contractor shall not discriminate against individuals on the basis of religion, gender, race, color, or national origin, and will not use any policy or practice that has the effect of discriminating on the basis of religion, gender, race, color, or national origin or on the basis of health, health status, pre-existing Condition, or need for Health Care services.

 

4.1.2

Selection of a Primary Care Provider (PCP)

 

4.1.2.1

At the time of plan selection, Members, with counseling and assistance from DCH or its Agent, will choose an In-Network PCP. If a Member fails to select a PCP, or if the Member has been Auto-Assigned to the CMO plan, the Contractor shall Auto-Assign Members to a PCP based on the following algorithm:

 

4.1.2.1.1

Assignment shall be made to a Provider with whom, based on FFS Claims history, the Member has a Historical Provider Relationship, provided that the geographic access requirements in 4.8.12 are met;

 

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4.1.2.1.2

If there is no Historical Provider Relationship the Member shall be Auto-Assigned to a Provider who is the assigned PCP for an immediate family member enrolled in the CMO plan, if the Provider is an appropriate Provider based on the age and gender of the Member;

 

4.1.2.1.3

If other immediate family members do not have an assigned PCP, Auto-Assignment shall be made to a Provider with whom a family member has a Historical Provider Relationship; if the Provider is an appropriate Provider based on the age and gender of the Member; and

 

4.1.2.1.4

If there is no Member or immediate family member historical usage Members shall be Auto-Assigned to a PCP, using an algorithm developed by the Contractor, based on the age and sex of the Member, and geographic proximity.

 

4.1.2.2

PCP assignment shall be effective immediately. The Contractor shall notify the Member via surface mail of their Auto-Assigned PCP within ten (10) Calendar Days of Auto-Assignment.

 

4.1.2.3

The Contractor shall submit its PCP Auto-Assignment Policies and Procedures to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

4.1.3

Newborn Enrollment

 

4.1.3.1

All newborns shall be Auto-Assigned by DCH or its Agent to the mother’s CMO plan.

 

4.1.3.2

The Contractor shall be responsible for notifying DCH or its Agent of any Members who are expectant mothers at least sixty (60) Calendar Days prior to the expected date of delivery. In the event a woman does not enroll in the CMO plan until she is already within sixty (60) Calendar Days of her expectant due date the Contractor shall notify DCH or its agent immediately.

 

4.1.3.3

During this sixty (60) Calendar Day period prior to the birth, the Contractor shall provide assistance to any expectant mother who contacts them wishing to make a PCP selection for her newborn and record that selection.

 

4.1.3.4

Within twenty-four (24) hours of the birth, the Contractor shall ensure the submission of a newborn notification form to DCH or its agent. If the mother has made a PCP selection, this information shall be included in the newborn

 

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notification form. If the mother has not made a PCP selection, the Contractor shall Auto-Assign the newborn to a PCP within two (2) Business Days of the birth. Auto-Assignment shall be made using the algorithm described in Section 4.1.2.1. Notice of the PCP Auto-Assignment shall be mailed to the mother within twenty-four (24) hours.

 

4.1.4

Reporting Requirements

 

4.1.4.1

The Contractor shall submit to DCH weekly Member Information Reports as described in Section 4.18.2.1.

 

4.1.4.2

The Contractor shall submit to DCH monthly Eligibility and Enrollment Reconciliation Reports as described in Section 4.18.3.1.

 

4.2	DISENROLLMENT

 

4.2.1

Disenrollment Initiated by the Member

 

4.2.1.1

A Member may request Disenrollment from a CMO plan without cause during the ninety (90) Calendar Days following the date of the Member’s initial Enrollment with the CMO plan or the date DCH or its Agent sends the Member notice of the Enrollment, whichever is later. A Member may request Disenrollment without cause every twelve (12) months thereafter.

 

4.2.1.2

A Member may request Disenrollment from a CMO plan for cause at any time. The following constitute cause for Disenrollment by the Member:

 

4.2.1.2.1

The Member moves out of the CMO plan’s Service Region;

 

4.2.1.2.2

The CMO plan does not, because of moral or religious objections, provide the Covered Service the Member seeks;

 

4.2.1.2.3

The Member needs related services to be performed at the same time and not all related services are available within the network. The Member’s Provider or another Provider have determined that receiving service separately would subject the Member to unnecessary risk;

 

4.2.1.2.4

The Member requests to be assigned to the same CMO plan as family members; and

 

4.2.1.2.5

The Member’s Medicaid eligibility category changes to a category ineligible for GHF, and/or the Member otherwise becomes ineligible to participate in GHF.

 

4.2.1.2.6

Other reasons, per 42 CFR 438.56(d)(2), include, but are not limited to, poor quality of care, lack of access to services covered under the

 

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Contract, or lack of Providers experienced in dealing with the Member’s Health Care needs. DCH or its Agent shall make determination of these reasons.

 

4.2.1.3

The Contractor shall provide assistance to Members seeking to disenroll. This assistance shall consist of providing the forms to the Member and referring the Member to DCH or its Agent who will make Disenrollment determinations.

 

4.2.2

Disenrollment Initiated by the Contractor

 

4.2.2.1

The Contractor shall complete all Disenrollment paperwork for Members it is seeking to disenroll.

 

4.2.2.2

The Contractor shall notify DCH or its Agent upon identification of a Member who it knows or believes meets the criteria for Disenrollment, as defined in Section 4.2.3.1.

 

4.2.2.3

Prior to requesting Disenrollment of a Member for reasons described in Sections 4.2.3.1.1, 4.2.3.1.2, and 4.2.3.1.3 the Contractor shall document at least three (3) interventions over a period of ninety (90) Calendar Days that occurred through treatment, case management, and Care Coordination to resolve any difficulty leading to the request. The Contractor shall provide at least one (1) written warning to the Member, certified return receipt requested, regarding implications of his or her actions. DCH recommends that this notice be delivered within ten (10) Business Days of the Member’s action.

 

4.2.2.4

If the Member has demonstrated abusive or threatening behavior as defined by DCH, only one (1) written attempt to resolve the difficulty is required.

 

4.2.2.5

The Contractor shall cite to DCH or its Agent at least one (1) acceptable reason for Disenrollment outlined in Section 4.2.3 before requesting Disenrollment of the Member.

 

4.2.2.6

The Contractor shall submit Disenrollment requests to DCH or its Agent and the Contractor shall honor all Disenrollment determinations made by DCH or its Agent. DCH’s decision on the matter shall be final, conclusive and not subject to appeal.

 

4.2.3

Acceptable Reasons for Disenrollment Requests by Contractor

 

4.2.3.1

The Contractor may request Disenrollment if:

 

4.2.3.1.1

The Member’s continued Enrollment in the CMO plan seriously impairs the ability to furnish services to either this particular Member or other Members;

 

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4.2.3.1.2

The Member demonstrates a pattern of disruptive or abusive behavior that could be construed as non-compliant and is not caused by a presenting illness;

 

4.2.3.1.3

The Member’s Utilization of services is Fraudulent or abusive;

 

4.2.3.1.4

The Member has moved out of the Service Region;

 

4.2.3.1.5

The Member is placed in a long-term care nursing facility, State institution, or intermediate care facility for the mentally retarded;

 

4.2.3.1.6

The Member’s Medicaid eligibility category changes to a category ineligible for GHF, and/or the Member otherwise becomes ineligible to participate in GHF;

 

4.2.3.1.7

The Member has any other condition as so defined by DCH; or

 

4.2.3.1.8

The Member has died, been incarcerated, or moved out of State, thereby making them ineligible for Medicaid.

 

4.2.4

Unacceptable Reasons for Disenrollment Requests by Contractor

 

4.2.4.1

The Contractor shall not request Disenrollment of a Member for discriminating reasons, including:

 

4.2.4.1.1

Adverse changes in a Member’s health status;

 

4.2.4.1.2

Missed appointments;

 

4.2.4.1.3

Utilization of medical services;

 

4.2.4.1.4

Diminished mental capacity;

 

4.2.4.1.5

Pre-existing medical condition; or

 

4.2.4.1.6

Uncooperative or disruptive behavior resulting from his or her special needs.

 

4.2.4.2

The Contractor shall not request Disenrollment because of the Member’s attempt to exercise his or her rights under the Grievance System.

 

4.2.4.3

The request of one PCP to have a Member assigned to a different Provider shall not be sufficient cause for the Contractor to request that the Member be disenrolled from the plan. Rather, the Contractor shall utilize its PCP assignment process to assign the Member to a different and available PCP.

 

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4.3	MEMBER SERVICES

 

4.3.1

General Provisions

 

4.3.1.1

The Contractor shall ensure that Members are aware of their rights and responsibilities, the role of PCPs, how to obtain care, what to do in an emergency or urgent medical situation, how to request a Grievance, Appeal, or Administrative Law Hearings, and how to report suspected Fraud and Abuse. The Contractor shall convey this information via written materials and via telephone, internet, and face-to-face communications which allow the Members to submit questions and receive responses from the Contractor.

 

4.3.2

Requirements for Written Materials

 

4.3.2.1

The Contractor shall make all written materials available in alternative formats and in a manner that takes into consideration the Member’s special needs, including those who are visually impaired or have limited reading proficiency. The Contractor shall notify all Members and Potential Members that information is available in alternative formats and how to access those formats.

 

4.3.2.2

The Contractor shall make all written information available in English, Spanish and all other prevalent non-English languages, as defined by DCH. For the purposes of this Contract, prevalent means a non-English language spoken by a significant number or percentage of Medicaid and PeachCare for Kids eligible individuals in the State.

 

4.3.2.3

All written materials distributed to Members shall include a language block, printed in Spanish and all other prevalent non-English languages, that informs the Member that the document contains important information and directs the Member to call the Contractor to request the document in an alternative language or to have it orally translated.

 

4.3.2.4

All written materials shall be worded such that they are understandable to a person who reads at the fifth (5th) grade level. Suggested reference materials to determine whether this requirement is being met are:

 

4.3.2.4.1

Fry Readability Index;

 

4.3.2.4.2

PROSE The Readability Analyst (software developed by Education Activities, Inc.);

 

4.3.2.4.3

Gunning FOG Index;

 

4.3.2.4.4

▇▇▇▇▇▇▇▇▇▇ SMOG Index;

 

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4.3.2.4.5

The ▇▇▇▇▇▇-▇▇▇▇▇▇▇ Index; or

 

4.3.2.4.6

Other word processing software approved by DCH.

 

4.3.2.5

The Contractor shall provide written notice to DCH of any changes to any written materials provided to the Members. Written notice shall be provided at least thirty (30) Calendar Days before the effective date of the change.

 

4.3.2.6

All written materials, including information for the Web site, must be submitted to DCH for approval before being distributed.

 

4.3.3

Member Handbook Requirements

 

4.3.3.1

The Contractor shall mail to all newly enrolled Members a Member Handbook within ten (10) Calendar Days of receiving the notice of enrollment from DCH or its Agent. The Contractor shall mail to all enrolled Members a Member Handbook at least annually thereafter.

 

4.3.3.2

Pursuant to the requirements set forth in 42 CFR 438.10, the Member Handbook shall include, but not be limited to:

 

4.3.3.2.1

A table of contents;

 

4.3.3.2.2

Information about the roles and responsibilities of the Member (this information to be supplied by DCH);

 

4.3.3.2.3

Information about the role of the PCP;

 

4.3.3.2.4

Information about choosing a PCP;

 

4.3.3.2.5

Information about what to do when family size changes;

 

4.3.3.2.6

Appointment procedures;

 

4.3.3.2.7

Information on Benefits and services, including a description of all available GHF Benefits and services;

 

4.3.3.2.8

Information on how to access services, including Health Check services, non-emergency transportation (NET) services, and maternity and family planning services;

 

4.3.3.2.9

An explanation of any service limitations or exclusions from coverage;

 

4.3.3.2.10

A notice stating that the Contractor shall be liable only for those services authorized by the Contractor;

 

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4.3.3.2.11

Information on where and how Members may access Benefits not available from or not covered by the Contractor;

 

4.3.3.2.12

The Medical Necessity definition used in determining whether services will be covered;

 

4.3.3.2.13

A description of all pre-certification, prior authorization or other requirements for treatments and services;

 

4.3.3.2.14

The policy on Referrals for specialty care and for other Covered Services not furnished by the Member’s PCP;

 

4.3.3.2.15

Information on how to obtain services when the Member is out of the Service Region and for after-hours coverage;

 

4.3.3.2.16

Cost-sharing;

 

4.3.3.2.17

The geographic boundaries of the Service Regions;

 

4.3.3.2.18

Notice of all appropriate mailing addresses and telephone numbers to be utilized by Members seeking information or authorization, including an inclusion of the Contractor’s toll-free telephone line and Web site;

 

4.3.3.2.19

A description of Utilization Review policies and procedures used by the Contractor;

 

4.3.3.2.20

A description of Member rights and responsibilities as described in Section 4.3.4;

 

4.3.3.2.21

The policies and procedures for Disenrollment;

 

4.3.3.2.22

Information on Advance Directives;

 

4.3.3.2.23

A statement that additional information, including information on the structure and operation of the CMO plan and physician incentive plans, shall be made available upon request;

 

4.3.3.2.24

Information on the extent to which, and how, after-hours and emergency coverage are provided, including the following:

 

i.

What constitutes an Urgent and Emergency Medical Condition, Emergency Services, and Post-Stabilization Services;

 

ii.

The fact that Prior Authorization is not required for Emergency Services;

 

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iii.

The process and procedures for obtaining Emergency Services, including the use of the 911 telephone systems or its local equivalent;

 

iv.

The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Services covered herein; and

 

v.

The fact that a Member has a right to use any hospital or other setting for Emergency Services;

 

4.3.3.2.25

Information on the Grievance Systems policies and procedures, as described in Section 4.14 of this Contract. This description must include the following:

 

i.

The right to file a Grievance and Appeal with the Contractor;

 

ii.

The requirements and timeframes for filing a Grievance or Appeal with the Contractor;

 

iii.

The availability of assistance in filing a Grievance or Appeal with the Contractor;

 

iv.

The toll-free numbers that the Member can use to file a Grievance or an Appeal with the Contractor by phone;

 

v.

The right to a State Administrative Law Hearing, the method for obtaining a hearing, and the rules that govern representation at the hearing;

 

vi.

Notice that if the Member files an Appeal or a request for a State Administrative Law Hearing within the timeframes specified for filing, the Member may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Member; and

 

vii.

Any Appeal rights that the State chooses to make available to Providers to challenge the failure of the Contractor to cover a service.

 

4.3.3.3

The Member Handbook shall be submitted to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

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4.3.4

Member Rights

 

4.3.4.1

The Contractor shall have written policies and procedures regarding the rights of Members and shall comply with any applicable federal and State laws and regulations that pertain to Member rights. These rights shall be included in the Member Handbook. At a minimum, said policies and procedures shall specify the Member’s right to:

 

4.3.4.1.1

Receive information pursuant to 42 CFR 438.10;

 

4.3.4.1.2

Be treated with respect and with due consideration for the Member’s dignity and privacy;

 

4.3.4.1.3

Have all records and medical and personal information remain confidential;

 

4.3.4.1.4

Receive information on available treatment options and alternatives, presented in a manner appropriate to the Member’s Condition and ability to understand;

 

4.3.4.1.5

Participate in decisions regarding his or her Health Care, including the right to refuse treatment;

 

4.3.4.1.6

Be free from any form of restraint or seclusion as a means of coercion, discipline, convenience or retaliation, as specified in other federal regulations on the use of restraints and seclusion;

 

4.3.4.1.7

Request and receive a copy of his or her Medical Records pursuant to 45 CFR 160 and 164, subparts A and E, and request to amend or correct the record as specified in 45 CFR 164.524 and 164.526;

 

4.3.4.1.8

Be furnished Health Care services in accordance with 42 CFR 438.206 through 438.210;

 

4.3.4.1.9

Freely exercise his or her rights, including those related to filing a Grievance or Appeal, and that the exercise of these rights will not adversely affect the way the Member is treated;

 

4.3.4.1.10

Not be held liable for the Contractor’s debts in the event of insolvency; not be held liable for the Covered Services provided to the Member for which DCH does not pay the Contractor; not be held liable for Covered Services provided to the Member for which DCH or the CMO plan does not pay the Health Care Provider that furnishes the services; and not be held liable for payments of Covered Services furnished under a contract, Referral, or other arrangement to the extent that those payments are in excess of amount the Member would owe if the Contractor provided the services directly; and

 

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4.3.4.1.11

Only be responsible for cost sharing in accordance with 42 CFR 447.50 through 42 CFR 447.60 and Attachment K of this Contract.

 

4.3.5

Provider Directory

 

4.3.5.1

The Contractor shall mail via surface mail a Provider Directory to all new Members within ten (10) Calendar Days of receiving the notice of Enrollment from DCH or the State’s Agent.

 

4.3.5.2

The Provider Directory shall include names, locations, office hours, telephone numbers of, and non-English languages spoken by, current Contracted Providers. This includes, at a minimum, information on PCPs, specialists, dentists, pharmacists, FQHCs and RHCs, mental health and substance abuse Providers, and hospitals. The Provider Directory shall also identify Providers that are not accepting new patients.

 

4.3.5.3

The Contractor shall submit the Provider Directory to DCH for review and prior approval within sixty (60) Calendar Days of Contract Award.

 

4.3.5.4

The Contractor shall up-date and amend the Provider Directory on its Web site within five (5) Business Days of any changes, produce and distribute quarterly up-dates to all Members, and re-print the Provider Directory and distribute to all Members at least once per year.

 

4.3.5.5

At least once per month, the Contractor shall submit to DCH and its Agent any changes and edits to the Provider Directory. Such changes shall be submitted electronically in a format to be determined by DCH.

 

4.3.6

Member Identification (ID) Card

 

4.3.6.1

The Contractor shall mail via surface mail a Member ID Card to all new Members according to the following timeframes:

 

4.3.6.1.1

Within ten (10) Calendar Days of receiving the notice of Enrollment from DCH or the Agent for Members who have selected a CMO plan and a PCP;

 

4.3.6.1.2

Within ten (10) Calendar Days of PCP assignment or selection for Members that are Auto-Assigned to the CMO plan.

 

4.3.6.2

The Member ID Card must, at a minimum, include the following information:

 

4.3.6.2.1

The Member’s name;

 

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4.3.6.2.2

The Member’s Medicaid or PeachCare for Kids identification number;

 

4.3.6.2.3

The PCP’s name, address, and telephone numbers (including after-hours number if different from business hours number);

 

4.3.6.2.4

The name and telephone number(s) of the Contractor;

 

4.3.6.2.5

The Contractor’s twenty-four (24) hour, seven (7) day a week toll-free Member services telephone number; and

 

4.3.6.2.6

Instructions for emergencies.

 

4.3.6.3

The Contractor shall reissue the Member ID Card within ten (10) Calendar Days of notice if a Member reports a lost card, there is a Member name change, the PCP changes, or for any other reason that results in a change to the information disclosed on the Member ID Card.

 

4.3.6.4

The Contractor shall submit a front and back sample Member ID Card to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

4.3.7

Toll-free Telephone Hotline

 

4.3.7.1

The Contractor shall operate a toll-free telephone hotline to respond to Member questions, comments and inquiries.

 

4.3.7.2

The Contractor shall develop Telephone Hotline Policies and Procedures, that address staffing, personnel, hours of operation, access and response standards, monitoring of calls via recording or other means, and compliance with standards.

 

4.3.7.3

The Contractor shall submit these Telephone Hotline Policies and Procedures, including performance standards pursuant to Section 4.3.7.7, to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

4.3.7.4

The telephone hotline shall handle calls from non-English speaking callers, as well as calls from Members who are hearing impaired.

 

4.3.7.5

The Contractor’s call center systems shall have the capability to track call management metrics identified in Attachment L.

 

4.3.7.6

The telephone hotline shall be fully staffed between the hours of 7:00 a.m. and 7:00 p.m. EST, Monday through Friday, excluding State holidays. The telephone hotline staff shall be trained to respond to Member questions in all

 

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areas, including, but not limited to, Covered Services, the Provider network, and non-emergency transportation (NET).

 

4.3.7.7

The Contractor shall develop performance standards and monitor Telephone Hotline performance by recording calls and employing other monitoring activities. At a minimum, the standards shall require that, on a monthly basis, eighty percent (80%) of calls are answered by a person within thirty (30) seconds, the Blocked Call rate does not exceed one percent (1%), and the rate of Abandoned Calls does not exceed five percent (5%).

 

4.3.7.8

The Contractor shall have an automated system available between the hours of 7:00 p.m. and 7:00 a.m. EST Monday through Friday and at all hours on weekends and holidays. This automated system must provide callers with operating instructions on what to do in case of an emergency and shall include, at a minimum, a voice mailbox for callers to leave messages. The Contractor shall ensure that the voice mailbox has adequate capacity to receive all messages. A Contractor’s Representative shall return messages on the next Business Day.

 

4.3.7.9

The Contractor shall develop Call Center Quality Criteria and Protocols to measure and monitor the accuracy of responses and phone etiquette as it relates to the Toll-free Telephone Hotline. The Contractor shall submit the Call Center Quality Criteria and Protocols to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

4.3.8

Internet Presence/Web Site

 

4.3.8.1

The Contractor shall provide general and up-to-date information about the CMO plan’s program, its Provider network, its customer services, and its Grievance and Appeals Systems on its Web site.

 

4.3.8.2

The Contractor shall maintain a Member portal that allows Members to access a searchable Provider Directory that shall be updated within five (5) Business Days upon changes to the Provider network.

 

4.3.8.3

The Web site must have the capability for Members to submit questions and comments to the Contractor and receive responses.

 

4.3.8.4

The Web site must comply with the marketing policies and procedures and with requirements for written materials described in this Contract and must be consistent with applicable State and federal laws.

 

4.3.8.5

In addition to the specific requirements outlined above, the Contractor’s Web site shall be functionally equivalent, with respect to functions described in this Contract, to the Web site maintained by the State’s Medicaid fiscal agent (▇▇▇.▇▇▇.▇▇▇▇▇▇▇.▇▇▇).

 

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4.3.8.6

The Contractor shall submit Web site screenshots to DCH for review and approval sixty (60) Calendar Days prior to implementation of GHF.

 

4.3.9

Cultural Competency

 

4.3.9.1

In accordance with 42 CFR 438.206, the Contractor shall have a comprehensive written Cultural Competency Plan describing how the Contractor will ensure that services are provided in a culturally competent manner to all Members, including those with limited English proficiency. The Cultural Competency Plan must describe how the Providers, individuals and systems within the CMO plan will effectively provide services to people of all cultures, races, ethnic backgrounds and religions in a manner that recognizes, values, affirms and respects the worth of the individual Members and protects and preserves the dignity of each.

 

4.3.9.2

The Contractor shall submit the Cultural Competency Plan to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

4.3.9.3

The Contractor may distribute a summary of the Cultural Competency Plan to the In-Network Providers if the summary includes information on how the Provider may access the full Cultural Competency Plan on the Web site. This summary shall also detail how the Provider can request a hard-copy from the CMO at no charge to the Provider.

 

4.3.10

Translation Services

 

4.3.10.1

The Contractor is required to provide oral translation services of information to any Member who speaks any non-English language regardless of whether a Member speaks a language that meets the threshold of a Prevalent Non-English Language. The Contractor is required to notify its Members of the availability of oral interpretation services and to inform them of how to access oral interpretation services. There shall be no charge to the Member for translation services.

 

4.3.11

Reporting Requirements

 

4.3.11.1

The Contractor shall submit weekly Telephone and Internet Activity Reports to DCH as described in Section 4.18.2.2.

 

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4.4

MARKETING

 

4.4.1

Prohibited Activities

 

4.4.1.1

The Contractor is prohibited from engaging in the following activities:

 

4.4.1.1.1

Directly or indirectly engaging in door-to-door, telephone, or other Cold-Call Marketing activities to Potential Members;

 

4.4.1.1.2

Offering any favors, inducements or gifts, promotions, and/or other insurance products that are designed to induce Enrollment in the Contractor’s plan, and that are not health related and/or worth more than $5.00 cash;

 

4.4.1.1.3

Distributing plans and materials that contain statements that DCH determines are inaccurate, false, or misleading. Statements considered false or misleading include, but are not limited to, any assertion or statement (whether written or oral) that the recipient must enroll in the Contractor’s plan in order to obtain Benefits or in order to not lose Benefits or that the Contractor’s plan is endorsed by the federal or State government, or similar entity; and

 

4.4.1.1.4

Distributing materials that, according to DCH, mislead or falsely describe the Contractor’s Provider network, the participation or availability of network Providers, the qualifications and skills of network Providers (including their bilingual skills); or the hours and location of network services.

 

4.4.2

Allowable Activities

 

4.4.2.1

The Contractor shall be permitted to perform the following marketing activities:

 

4.4.2.1.1

Distribute general information through mass media (i.e. newspapers, magazines and other periodicals, radio, television, the Internet, public transportation advertising, and other media outlets);

 

4.4.2.1.2

Make telephone calls, mailings and home visits only to Members currently enrolled in the Contractor’s plan, for the sole purpose of educating them about services offered by or available through the Contractor;

 

4.4.2.1.3

Distribute brochures and display posters at Provider offices and clinics that inform patients that the clinic or Provider is part of the CMO plan’s Provider network, provided that all CMO plans in which the Provider participates have an equal opportunity to be represented; and

 

4.4.2.1.4

Attend activities that benefit the entire community such as health fairs or other health education and promotion activities.

 

4.4.2.2

If the Contractor performs an allowable activity, the Contractor shall conduct these activities in the entire Service Region as defined by this Contract.

 

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4.4.2.3

All materials shall be in compliance with the information requirements in 42 CFR 438.10 and detailed in Section 4.3.2 of this Contract.

 

4.4.3

State Approval of Materials

 

4.4.3.1

The Contractor shall submit a detailed description of its Marketing Plan and copies of all Marketing Materials (written and oral) it or its Subcontractors plan to distribute to DCH for review and approval within sixty (60) Calendar Days of Contract Award. This requirement includes, but is not limited to posters, brochures, Web sites, and any materials that contain statements regarding the benefit package and Provider network-related materials. Neither the Contractor nor its Subcontractors shall distribute any marketing materials without prior, written approval from DCH.

 

4.4.3.2

The Contractor shall submit any changes to previously approved marketing materials and receive approval from DCH of the changes before distribution.

 

4.4.4

Provider Marketing Materials

 

4.4.4.1

The Contractor shall collect from its Providers any Marketing Materials they intend to distribute and submit these to DCH for review and approval prior to distribution.

 

4.5	COVERED BENEFITS AND SERVICES

 

4.5.1

Included Services

 

4.5.1.1

The Contractor shall at a minimum provide Medically Necessary services and Benefits as outlined below, and pursuant to the Georgia State Medicaid Plan, and the Georgia Medicaid Policies and Procedures Manual. Such Medically Necessary services shall be furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to recipients under Fee-for-Service Medicaid. The Contractor may not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of the diagnosis, type of illness or Condition.

 

4.5.1.2

 

 

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4.5.2

Individuals with Disabilities Education Act (IDEA) Services

 

4.5.2.1

For Members up to and including age three (3), the Contractor shall be responsible for Medically Necessary IDEA services provided pursuant to an Individualized Family Service Plan (IFSP) or Individualized Service Plan (IEP).

 

4.5.2.2

For Members age four (4) and older, the Contractor shall not be responsible for Medically Necessary IDEA services provided pursuant to an IEP or IFSP. Such services shall remain in FFS Medicaid.

 

4.5.3

Enhanced Services

 

4.5.3.1

In addition to the Covered Services provided above, the Contractor shall do the following:

 

4.5.3.1.1

Place strong emphasis on programs to enhance the general health and well-being of Members;

 

4.5.3.1.2

Make health promotion materials available to Members;

 

4.5.3.1.3

Participate in community-sponsored health fairs; and

 

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4.5.3.1.4

Provide education to Members, families and other Health Care Providers about early intervention and management strategies for various illnesses.

 

4.5.3.2

The Contractor shall not charge a Member for participating in health education services that are defined as either enhanced or Covered Services.

 

4.5.4

Medical Necessity

 

4.5.4.1

Based upon generally accepted medical practices in light of Conditions at the time of treatment, Medically Necessary services are those that are:

 

4.5.4.1.1

Appropriate and consistent with the diagnosis of the treating Provider and the omission of which could adversely affect the eligible Member’s medical Condition;

 

4.5.4.1.2

Compatible with the standards of acceptable medical practice in the community;

 

4.5.4.1.3

Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms;

 

4.5.4.1.4

Not provided solely for the convenience of the Member or the convenience of the Health Care Provider or hospital; and

 

4.5.4.1.5

Not primarily custodial care unless custodial care is a covered service or benefit under the Members evidence of coverage.

 

4.5.4.2

There must be no other effective and more conservative or substantially less costly treatment, service and setting available.

 

4.5.5

Experimental, Investigational or Cosmetic Procedures

 

4.5.5.1

Pursuant to the Georgia State Medicaid Plan and the Georgia Medicaid Policies and Procedures Manual, in no instance shall the Contractor cover experimental, investigational or cosmetic procedures.

 

4.5.6

Moral or Religious Objections

 

4.5.6.1

The Contractor is required to provide and reimburse for all Covered Services. If, during the course of the Contract period, pursuant to 42 CFR 438.102, the Contractor elects not to provide, reimburse for, or provide coverage of a counseling or Referral service because of an objection on moral or religious grounds, the Contractor shall notify:

 

4.5.6.1.1

DCH within one hundred and twenty (120) Calendar Days prior to adopting the policy with respect to any service;

 

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4.5.6.1.2

Members within ninety (90) Calendar Days after adopting the policy with respect to any service; and

 

4.5.6.1.3

Members and Potential Members before and during Enrollment.

 

4.5.6.2

The Contractor acknowledges that such objection will be grounds for recalculation of rates paid to the Contractor.

 

4.6	SPECIAL COVERAGE PROVISIONS

 

4.6.1

Emergency Services

 

4.6.1.1

Emergency Services shall be available twenty-four (24) hours a day, seven (7) Days a week to treat an Emergency Medical Condition.

 

4.6.1.2

An Emergency Medical Condition shall not be defined or limited based on a list of diagnoses or symptoms. An Emergency Medical Condition is a medical or mental health Condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:

 

4.6.1.2.1

Placing the physical or mental health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

 

4.6.1.2.2

Serious impairment to bodily functions;

 

4.6.1.2.3

Serious dysfunction of any bodily organ or part;

 

4.6.1.2.4

Serious harm to self or others due to an alcohol or drug abuse emergency;

 

4.6.1.2.5

Injury to self or bodily harm to others; or

 

4.6.1.2.6

With respect to a pregnant woman having contractions: (i) that there is adequate time to effect a safe transfer to another hospital before delivery, or (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.

 

4.6.1.3

The Contractor shall provide payment for Emergency Services when furnished by a qualified Provider, regardless of whether that Provider is in the Contractor’s network. These services shall not be subject to prior

 

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authorization requirements. The Contractor shall be required to pay for all Emergency Services that are Medically Necessary until the Member is stabilized. The Contractor shall also pay for any screening examination services conducted to determine whether an Emergency Medical Condition exists.

 

4.6.1.4

The Contractor shall base coverage decisions for Emergency Services on the severity of the symptoms at the time of presentation and shall cover Emergency Services when the presenting symptoms are of sufficient severity to constitute an Emergency Medical Condition in the judgment of a prudent layperson.

 

4.6.1.5

The attending emergency room physician, or the Provider actually treating the Member, is responsible for determining when the Member is sufficiently stabilized for transfer or discharge, and that determination is binding on the Contractor, who shall be responsible for coverage and payment. The Contractor, however, may establish arrangements with a hospital whereby the Contractor may send one of its own physicians with appropriate emergency room privileges to assume the attending physician’s responsibilities to stabilize, treat, and transfer the Member, provided that such arrangement does not delay the provision of Emergency Services.

 

4.6.1.6

The Contractor shall not retroactively deny a Claim for an emergency screening examination because the Condition, which appeared to be an Emergency Medical Condition under the prudent layperson standard, turned out to be non-emergency in nature. If an emergency screening examination leads to a clinical determination by the examining physician that an actual Emergency Medical Condition does not exist, then the determining factor for payment liability shall be whether the Member had acute symptoms of sufficient severity at the time of presentation. In this case, the Contractor shall pay for all screening and care services provided. Payment shall be at either the rate negotiated under the Provider Contract, or the rate paid by DCH under the Fee for Service Medicaid program.

 

4.6.1.7

The Contractor may establish guidelines and timelines for submittal of notification regarding provision of emergency services, but, the Contractor shall not refuse to cover an Emergency Service based on the emergency room Provider, hospital, or fiscal agent’s failure to notify the Member’s PCP, CMO plan representative, or DCH of the Member’s screening and treatment within said timeframes.

 

4.6.1.8

When a representative of the Contractor instructs the Member to seek Emergency Services the Contractor shall be responsible for payment for the Medical Screening examination and for other Medically Necessary Emergency Services, without regard to whether the Condition meets the prudent layperson standard.

 

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4.6.1.9

The Member who has an Emergency Medical Condition shall not be held liable for payment of subsequent screening and treatment needed to diagnose the specific Condition or stabilize the patient.

 

4.6.1.10

Once the Member’s Condition is stabilized, the Contractor may require Pre-Certification for hospital admission or Prior Authorization for follow-up care.

 

4.6.2

Post-Stabilization Services

 

4.6.2.1

The Contractor shall be responsible for providing Post-Stabilization care services twenty-four (24) hours a day, seven (7) days a week, both inpatient and outpatient, related to an Emergency Medical Condition, that are provided after a Member is stabilized in order to maintain the stabilized Condition, or, pursuant to 42 CFR 438.114(e), to improve or resolve the Member’s Condition.

 

4.6.2.2

The Contractor shall be responsible for payment for Post-Stabilization Services that are Prior Authorized or Pre-Certified by an In-Network Provider or organization representative, regardless of whether they are provided within or outside the Contractor’s network of Providers.

 

4.6.2.3

The Contractor is financially responsible for Post-Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network that are administered to maintain the Member’s stabilized Condition for one (1) hour while awaiting response on a Pre-Certification or Prior Authorization request.

 

4.6.2.4

The Contractor is financially responsible for Post-Stabilization Services obtained from any Provider, regardless of whether they are within or outside the Contractor’s Provider network, that are not prior authorized by a CMO plan Provider or organization representative but are administered to maintain, improve or resolve the Member’s stabilized Condition if:

 

4.6.2.4.1

The Contractor does not respond to the Provider’s request for pre-certification or prior authorization within one (1) hour;

 

4.6.2.4.2

The Contractor cannot be contacted; or

 

4.6.2.4.3

The Contractor’s Representative and the attending physician cannot reach an agreement concerning the Member’s care and a CMO plan physician is not available for consultation. In this situation the Contractor shall give the treating physician the opportunity to consult with an In-Network physician and the treating physician may continue with care of the Member until a CMO plan physician is reached or one of the criteria in Section 4.6.2.5 are met.

 

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4.6.2.5

The Contractor’s financial responsibility for Post-Stabilization Services it has not approved will end when:

 

4.6.2.5.1

An In-Network Provider with privileges at the treating hospital assumes responsibility for the Member’s care;

 

4.6.2.5.2

An In-Network Provider assumes responsibility for the Member’s care through transfer;

 

4.6.2.5.3

The Contractor’s Representative and the treating physician reach an agreement concerning the Member’s care; or

 

4.6.2.5.4

The Member is discharged.

 

4.6.2.6

In the event the Member receives Post-Stabilization Services from a Provider outside the Contractor’s network, the Contractor is prohibited from charging the Member more than he or she would be charged if he or she had obtained the services through an In-Network Provider.

 

4.6.3

Urgent Care Services

 

4.6.3.1

The Contractor shall provide Urgent Care services as necessary. Such services shall not be subject to Prior Authorization or Pre-Certification.

 

4.6.4

Family Planning Services

 

4.6.4.1

The Contractor shall provide access to family planning services within the network. In meeting this obligation, the Contractor shall make a reasonable effort to contract with all family planning clinics, including those funded by Title X of the Public Health Services Act, for the provision of family planning services. The Contractor shall verify its efforts to contract with Title X Clinics by maintaining records of communication. The Contractor shall not limit Members’ freedom of choice for family planning services to In-Network Providers and the Contractor shall cover services provided by any qualified Provider regardless of whether the Provider is In-Network. The Contractor shall not require a Referral if a Member chooses to receive family planning services and supplies from outside of the network.

 

4.6.4.2

The Contractor shall inform Members of the availability of family planning services and must provide services to Members wishing to prevent pregnancies, plan the number of pregnancies, plan the spacing between pregnancies, or obtain confirmation of pregnancy.

 

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4.6.4.3

Family planning services and supplies include at a minimum:

 

4.6.4.3.1

Education and counseling necessary to make informed choices and understand contraceptive methods;

 

4.6.4.3.2

Initial and annual complete physical examinations;

 

4.6.4.3.3

Follow-up, brief and comprehensive visits;

 

4.6.4.3.4

Pregnancy testing;

 

4.6.4.3.5

Contraceptive supplies and follow-up care;

 

4.6.4.3.6

Diagnosis and treatment of sexually transmitted diseases; and

 

4.6.4.3.7

Infertility assessment.

 

4.6.4.4

The Contractor shall furnish all services on a voluntary and confidential basis, even if the Member is less than eighteen (18) years of age.

 

4.6.5

Sterilizations, Hysterectomies and Abortions

 

4.6.5.1

In compliance with federal regulations, the Contractor shall cover sterilizations, hysterectomies, and abortions only if all of the following requirements are met:

 

4.6.5.1.1

The Member is at least twenty-one (21) years of age at the time consent is obtained;

 

4.6.5.1.2

The Member is mentally competent;

 

4.6.5.1.3

The Member voluntarily gives informed consent in accordance with the State Policies and Procedures for Family Planning Clinic Services. This includes the completion of all applicable documentation;

 

4.6.5.1.4

At least thirty (30) Calendar Days, but not more than one hundred and eighty (180) Calendar Days, have passed between the date of informed consent and the date of sterilization, except in the case of premature delivery or emergency abdominal surgery. A Member may consent to be sterilized at the time of premature delivery or emergency abdominal surgery, if at least seventy-two (72) hours have passed since informed consent for sterilization was signed. In the case of premature delivery, the informed consent must have been given at least thirty (30) Calendar Days before the expected date of delivery (the expected date of delivery must be provided on the consent form);

 

4.6.5.1.5

An interpreter is provided when language barriers exist. Arrangements are to be made to effectively communicate the required information to

 

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a Member who is visually impaired, hearing impaired or otherwise disabled; and

 

4.6.5.1.6

The Member is not institutionalized in a correctional facility, mental hospital or other rehabilitative facility.

 

4.6.5.2

A hysterectomy shall be considered a Covered Service only if the following additional requirements are met:

 

4.6.5.2.1

The Member must be informed orally and in writing that the hysterectomy will render the individual permanently incapable of reproducing (this is not applicable if the individual was sterile prior to the hysterectomy or in the case of an emergency hysterectomy); and

 

4.6.5.2.2

The Member must sign and date a “Patient’s Acknowledgement of Prior Receipt of Hysterectomy Information” form prior to the Hysterectomy. Informed consent must be obtained regardless of diagnosis or age.

 

4.6.5.3

Regardless of whether the requirements listed above are met, a hysterectomy shall not be covered under the following circumstances:

 

4.6.5.3.1

If it is performed solely for the purpose of rendering a Member permanently incapable of reproducing;

 

4.6.5.3.2

If there is more than one (1) purpose for performing the hysterectomy, but the primary purpose was to render the Member permanently incapable of reproducing; or

 

4.6.5.3.3

If it is performed for the purpose of cancer prophylaxis.

 

4.6.5.4

Abortions or abortion-related services performed for family planning purposes are not Covered Services. Abortions are Covered Services if a Provider certifies that the abortion is medically necessary to save the life of the mother or if pregnancy is the result of rape or incest. The Contractor shall cover treatment of medical complications occurring as a result of an elective abortion and treatments for spontaneous, incomplete, or threatened abortions and for ectopic pregnancies.

 

4.6.5.5

The Contractor shall maintain documentation of all sterilizations, hysterectomies and abortions and provide documentation to DCH upon the request of DCH.

 

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4.6.6

Pharmacy

 

4.6.6.1

The Contractor shall provide pharmacy services either directly or through a Pharmacy Benefits Manager (PBM). The Contractor or its PBM may establish a drug formulary if the following minimum requirements are met:

 

4.6.6.1.1

Drugs from each specific therapeutic drug class are included and are sufficient in amount, duration, and scope to meet Members’ medical needs;

 

4.6.6.1.2

The only excluded drug categories are those permitted under section 1927(d) of the Social Security Act;

 

4.6.6.1.3

A Pharmacy & Therapeutics Committee makes the formulary decisions; and

 

4.6.6.1.4

Over-the-counter medications specified in the Georgia State Medicaid Plan are included in the formulary.

 

4.6.6.2

The Contractor shall provide the formulary to DCH upon the request of DCH.

 

4.6.6.3

If the Contractor chooses to implement a mail-order pharmacy program, any such program must be accordance with State and federal law.

 

4.6.7

Immunizations

 

4.6.7.1

The Contractor shall provide all Members under twenty-one (21) years of age with all vaccines and immunizations in accordance with the Advisory Committee on Immunization Practices (ACIP) guidelines.

 

4.6.7.2

The Contractor shall ensure that all Providers use vaccines available free under the Vaccine for Children (VFC) program for Medicaid children eighteen (18) years old and younger. Immunizations shall be given in conjunction with Well-Child/Health Check care.

 

4.6.7.3

The Contractor shall provide all adult immunizations specified in the Georgia Medicaid Policies and Procedures Manual.

 

4.6.7.4

The Contractor shall report all immunizations to the Georgia Registry of Immunization Transactions and Services (GRITS) in a format to be determined by DCH.

 

4.6.8

Transportation

 

4.6.8.1

The Contractor shall provide emergency transportation and shall not retroactively deny a Claim for emergency transportation to an emergency Provider because the Condition, which appeared to be an Emergency Medical

 

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Condition under the prudent layperson standard, turned out to be non-emergency in nature.

 

4.6.8.2

The Contractor is not responsible for providing non-emergency transportation (NET) but the Contractor shall coordinate with the NET vendors for services required by Members.

 

4.6.9

Perinatal Services

 

4.6.9.1

The Contractor shall ensure that appropriate perinatal care is provided to women and newborn Members. The Contractor shall have adequate capacity such that any new Member who is pregnant is able to have an initial visit with her Provider within fourteen (14) Calendar Days of Enrollment. The Contractor shall have in place a system that provides, at a minimum, the following services:

 

4.6.9.1.1

Pregnancy planning and perinatal health promotion and education for reproductive-age women;

 

4.6.9.1.2

Perinatal risk assessment of non-pregnant women, pregnant and post-partum women, and newborns and children up to five (5) months of age;

 

4.6.9.1.3

Childbirth education classes to all pregnant Members and their chosen partner. Through these classes expectant parents shall be encouraged to prepare themselves physically, emotionally, and intellectually for the childbirth experience. The classes shall be offered at times convenient to the population served, in locations that are accessible, convenient and comfortable. Classes shall be offered in languages spoken by the Members.

 

4.6.9.1.4

Access to appropriate levels of care based on risk assessment, including emergency care;

 

4.6.9.1.5

Transfer and care of pregnant women, newborns, and infants to tertiary care facilities when necessary;

 

4.6.9.1.6

Availability and accessibility of OB/GYNs, anesthesiologists, and neonatologists capable of dealing with complicated perinatal problems; and

 

4.6.9.1.7

Availability and accessibility of appropriate outpatient and inpatient facilities capable of dealing with complicated perinatal problems.

 

4.6.9.2

The Contractor shall provide inpatient care and professional services relating to labor and delivery for its pregnant/delivering Members, and neonatal care

 

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for its newborn Members at the time of delivery and for up to forty-eight (48) hours following an uncomplicated vaginal delivery and ninety-six (96) hours following an uncomplicated Caesarean delivery.

 

4.6.10

Parenting Education

 

4.6.10.1

In addition to individual parent education and anticipatory guidance to parents and guardians at preventive pediatric visits and Health Check screens, the Contractor shall offer or arrange for parenting skills education to expectant and new parents, at no cost to the Member.

 

4.6.10.2

The Contractor agrees to create effective ways to deliver this education, whether through classes, as a component of post-partum home visiting, or other such means. The educational efforts shall include topics such as bathing, feeding (including breast feeding), injury prevention, sleeping, illness, when to call the doctor, when to use the emergency room, etc. The classes shall be offered at times convenient to the population served, and in locations that are accessible, convenient and comfortable. Classes shall be offered in languages spoken by the Members.

 

4.6.11

Mental Health and Substance Abuse

 

4.6.11.1

The Contractor shall have written Mental Health and Substance Abuse Policies and Procedures that explain how they will arrange or provide for covered mental health and substance abuse services. Such policies and procedures shall include Advance Directives. The Contractor shall assure timely delivery of mental health and substance abuse services and coordination with other acute care services.

 

4.6.11.2

Mental Health and Substance Abuse Policies and Procedures shall be submitted to DCH for approval within sixty (60) Calendar Days of Contract Award.

 

4.6.11.3

The Contractor shall permit Members to self-refer to an In-Network Provider for an initial mental health or substance abuse visit but prior authorization may be required for subsequent visits.

 

4.6.12

Advance Directives

 

4.6.12.1

In compliance with 42 CFR 438.6 (i) (1)-(2) and 42 CFR 422.128, the Contractor shall maintain written policies and procedures for Advance Directives, including mental health advance directives. Such Advance Directives shall be included in each Member’s medical record. The Contractor shall provide these policies to all Members eighteen (18) years of age and older and shall advise Members of:

 

4.6.12.1.1

Their rights under the law of the State of Georgia, including the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives; and

 

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4.6.12.1.2

The Contractor’s written policies respecting the implementation of those rights, including a statement of any limitation regarding the implementation of Advance Directives as a matter of conscience.

 

4.6.12.2

The information must include a description of State law and must reflect changes in State laws as soon as possible, but no later than ninety (90) Calendar Days after the effective change.

 

4.6.12.3

The Contractor’s information must inform Members that complaints may be filed with the State’s Survey and Certification Agency.

 

4.6.12.4

The Contractor shall educate its staff about its policies and procedures on Advance Directives, situations in which Advance Directives may be of benefit to Members, and their responsibility to educate Members about this tool and assist them to make use of it.

 

4.6.12.5

The Contractor shall educate Members about their ability to direct their care using this mechanism and shall specifically designate which staff Members and/or network Providers are responsible for providing this education.

 

4.6.13

▇▇▇▇▇▇ Care Forensic Exam

 

4.6.13.1

The Contractor shall provide a forensic examination to a Member that is less than eighteen (18) years of age that is placed outside the home in State custody. Such exam shall be in accordance with State law and regulations.

 

4.6.14

Laboratory Services

 

4.6.14.1

The Contractor shall require all network laboratories to automatically report the Glomerular Filtration Rate (GFR) on any serum creatinine tests ordered by In-Network Providers.

 

4.6.15

Member Cost-Sharing

 

4.6.15.1

The Contractor shall ensure that Providers collect Member co-payments as specified in Attachment K.

 

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4.7	EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM: HEALTH CHECK

 

4.7.1

General Provisions

 

4.7.1.1

The Contractor shall provide EPSDT services (called Health Check services) to Medicaid children less than twenty-one (21) years of age and PeachCare for Kids children less than age nineteen (19) years of age (hereafter referred to as Health Check eligible children), in compliance with all requirements found below.

 

4.7.1.2

The Contractor shall comply with sections 1902(a)(43) and 1905(a)(4)(B) and 1905(r) of the Social Security Act and federal regulations at 42 CFR 441.50 that require EPSDT services to include outreach and informing, screening, tracking, and, diagnostic and treatment services. The Contractor shall comply with all Health Check requirements pursuant to the Georgia Medicaid Policies and Procedures Manual.

 

4.7.1.3

The Contractor shall develop an EPSDT Plan that includes written policies and procedures for conducting outreach, informing, tracking, and follow-up to ensure compliance with the Health Check periodicity schedules. The EPSDT Plan shall emphasize outreach and compliance monitoring for children and adolescents (young adults), taking into account the multi-lingual, multi cultural nature of the GHF population, as well as other unique characteristics of this population. The plan shall include procedures for follow-up of missed appointments, including missed Referral appointments for problems identified through Health Check screens and exams. The plan shall also include procedures for referral, tracking and follow up for annual dental examinations and visits. The Contractor shall submit its EPSDT Plan to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

4.7.2

Outreach and Informing

 

4.7.2.1

The Contractor’s Health Check outreach and informing process shall include:

 

4.7.2.1.1

The importance of preventive care;

 

4.7.2.1.2

The periodicity schedule and the depth and breadth of services;

 

4.7.2.1.3

How and where to access services, including necessary transportation and scheduling services; and

 

4.7.2.1.4

A statement that services are provided without cost.

 

4.7.2.2

The Contractor shall inform its newly enrolled families with Health Check eligible children about the Health Check program within sixty (60) Calendar

 

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Days of Enrollment with the plan. This requirement includes informing pregnant women and new mothers, either before or within seven (7) days after the birth of their children, that Health Check services are available.

 

4.7.2.3

The Contractor shall provide written notification to its families with Health Check eligible children when appropriate periodic assessments or needed services are due. The Contractor shall coordinate appointments for care. The Contractor shall follow up with families with Health Check eligible children that have failed to access Health Check screens and services after one hundred and twenty (120) Calendar Days of Enrollment in the CMO plan.

 

4.7.2.4

The Contractor shall provide to each PCP, on a monthly basis, a list of the PCP’s Health Check eligible children that have not had an encounter during the initial one hundred and twenty (120) Calendar Days of CMO plan Enrollment, and/or are not in compliance with the Health Check periodicity schedule. The Contractor and/or the PCP shall contact the Members’ parents or guardians to schedule an appointment.

 

4.7.2.5

Informing may be oral (on the telephone, face-to-face, or films/tapes) or written and may be done by Contractor personnel or Health Care Providers. All outreach and informing shall be documented and shall be conducted in non-technical language at or below a fifth (5th) grade reading level. The Contractor shall use accepted methods for informing persons who are blind or deaf, or cannot read or understand the English language, in accordance with Section 4.3.2 of this Contract.

 

4.7.2.6

The Contractor may provide nominal, non-cash incentives to Members to motivate compliance with periodicity schedules.

 

4.7.3

Screening

 

4.7.3.1

The Contractor is responsible for periodic screens in accordance with the State’s periodicity schedule. Such screens must include all of the following:

 

4.7.3.1.1

A comprehensive health and developmental history;

 

4.7.3.1.2

Developmental assessment, including mental, emotional, and behavioral health development;

 

4.7.3.1.3

Measurements (including head circumference for infants);

 

4.7.3.1.4

An assessment of nutritional status;

 

4.7.3.1.5

A comprehensive unclothed physical exam;

 

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4.7.3.1.6

Immunizations according to the Advisory Committee of Immunization Practices (ACIP);

 

4.7.3.1.7

Certain laboratory tests (including the federally required blood lead screening);

 

4.7.3.1.8

Anticipatory guidance and health education;

 

4.7.3.1.9

Vision screening;

 

4.7.3.1.10

Tuberculosis and lead risk screening;

 

4.7.3.1.11

Hearing screening; and

 

4.7.3.1.12

Dental and oral health assessment.

 

4.7.3.2

Lead screening is a required component of a Health Check screen and the Contractor shall implement a screening program for the presence of lead toxicity. The screening program shall consist of two (2) parts: verbal risk assessment (from thirty-six (36) to seventy-two (72) months of age), and blood lead screening. Regardless of risk, the Contractor shall provide for a blood lead screening test for all Health Check eligible children at twelve (12) and twenty-four (24) months of age. Children between twenty-four (24) months of age and seventy-two (72) months of age should receive a blood lead screening test if there is no record of a previous test.

 

4.7.3.3

The Contractor shall have a lead case management program for Health Check eligibles and their households when there is a positive blood lead test equal to or greater than ten (10) micrograms per deciliter. The lead case management program shall include education, a written case management plan that includes all necessary referrals, coordination with other specific agencies, and aggressive pursuit of non-compliance with follow-up tests and appointments.

 

4.7.3.4

The Contractor shall have procedures for Referral to and follow up with oral health professionals, including annual dental examinations and services by an oral health professional.

 

4.7.3.5

The Contractor shall provide inter-periodic screens, which are screens that occur between the complete periodic screens and are Medically Necessary to determine the existence of suspected physical or mental illnesses or Conditions. This includes at a minimum vision, hearing and dental services.

 

4.7.3.6

The Contractor shall provide Referrals for further diagnostic and/or treatment services to correct or ameliorate defects, and physical and mental illnesses and Conditions discovered by the Health Check screens. Referral and follow up

 

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may be made to the Provider conducting the screening or to another Provider, as appropriate.

 

4.7.3.7

The Contractor shall provide an initial health and screening visit to all newly enrolled GHF Health Check eligible children within ninety (90) Calendar Days and within twenty-four (24) hours of birth to all newborns.

 

4.7.3.8

Minimum Contractor compliance with the Health Check screening requirements, including blood lead screening and annual dental examinations and services, is an eighty percent (80%) screening rate, using the methodology prescribed by CMS to determine the screening rate.

 

4.7.4

Tracking

 

4.7.4.1

The Contractor shall establish a tracking system that provides information on compliance with Health Check requirements. This system shall track, at a minimum, the following areas:

 

4.7.4.1.1

Initial newborn Health Check visit occurring in the hospital;

 

4.7.4.1.2

Periodic and preventive/well child screens and visits as prescribed by the periodicity schedule;

 

4.7.4.1.3

Diagnostic and treatment services, including Referrals;

 

4.7.4.1.4

Immunizations, lead, tuberculosis and dental services; and

 

4.7.4.1.5

A reminder/notification system.

 

4.7.4.2

All information generated and maintained in the tracking system shall be consistent with Encounter Data requirements as specified elsewhere herein.

 

4.7.5

Diagnostic and Treatment Services

 

4.7.5.1

If a suspected problem is detected by a screening examination as described above, the child shall be evaluated as necessary for further diagnosis. This diagnosis is used to determine treatment needs.

 

4.7.5.2

Health Check requires coverage for all follow-up diagnostic and treatment services deemed Medically Necessary to ameliorate or correct a problem discovered during a Health Check screen. Such Medically Necessary diagnostic and treatment services must be provided regardless of whether such services are covered by the State Medicaid Plan, as long as they are Medicaid-Covered Services as defined in Title XIX of the Social Security Act. The Contractor shall provide Medically Necessary, Medicaid-covered diagnostic and treatment services, either directly or by Referral.

 

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4.7.6

Reporting Requirements

 

4.7.6.1

The Contractor shall submit to DCH quarterly Health Check Reports as described in Section 4.18.4.1. The Contractor shall report Health Check visits in accordance with the appropriate codes specified in the appropriate Provider Handbooks.

 

4.8	PROVIDER NETWORK

 

4.8.1

General Provisions

 

4.8.1.1

The Contractor is solely responsible for providing a network of physicians, pharmacies, hospitals, and other health care Providers through whom it provides the items and services included in Covered Services.

 

4.8.1.2

The Contractor shall ensure that its network of Providers is adequate to assure access to all Covered Services, and that all Providers are appropriately credentialed, maintain current licenses, and have appropriate locations to provide the Covered Services.

 

4.8.1.3

The Contractor shall not include any Providers who have been excluded from participation by the Department of Health and Human Services, Office of Inspector General, or who are on the State’s list of excluded Providers. The Contractor is responsible for routinely checking the exclusions list and shall immediately terminate any Provider found to be excluded and notify the Member per the requirements outlined in this Contract.

 

4.8.1.4

The Contractor shall require that each Provider have a unique physician identifier number (UPIN). Effective May 23, 2007, in accordance with 45 CFR 160.103, the Contractor shall require that each Provider have a national Provider identifier (NPI).

 

4.8.1.5

The Contractor shall have written Selection and Retention Policies and Procedures. These policies shall be submitted to DCH for review and approval within sixty (60) Calendar Days of Contract Award. In selecting and retaining Providers in its network the Contractor shall consider the following:

 

4.8.1.5.1

The anticipated GHF Enrollment;

 

4.8.1.5.2

The expected Utilization of services, taking into consideration the characteristics and Health Care needs of its Members;

 

4.8.1.5.3

The numbers and types (in terms of training, experience and specialization) of Providers required to furnish the Covered Services;

 

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4.8.1.5.4

The numbers of network Providers who are not accepting new GHF patients; and

 

4.8.1.5.5

The geographic location of Providers and Members, considering distance, travel time, the means of transportation ordinarily used by Members, and whether the location provides physical access for Members with disabilities.

 

4.8.1.6

If the Contractor declines to include individual Providers or groups of Providers in its network, the Contractor shall give the affected Providers written notice of the reason(s) for the decision.

 

4.8.1.7

These provisions shall not be construed to:

 

4.8.1.7.1

Require the Contractor to contract with Providers beyond the number necessary to meet the needs of its Members;

 

4.8.1.7.2

Preclude the Contractor from establishing measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to Members.

 

4.8.1.8

The Contractor shall ensure that all network Providers have knowingly and willfully agreed to participate in the Contractor’s network. The Contractor shall be prohibited from acquiring established networks without contacting each individual Provider to ensure knowledge of the requirements of this Contract and the Provider’s complete understanding and agreement to fulfill all terms of the Provider Contract, as outlined in section 4.10. DCH reserves the right to confirm and validate, through both the collection of information and documentation from the Contractor and on-site visits to network Providers, the existence of a direct relationship between the Contractor and the network Providers.

 

4.8.1.9

The Contractor shall submit an up-dated version of the Provider Network Listing spreadsheet for all requested Provider types (as outlined under Required Attachments in 5.1.2.8 in the RPP), and include any Provider Letters of Intent or executed Signature Pages of Provider Contracts not previously submitted (as part of the RFP response) to DCH within sixty (60) Calendar Days of Contract Award.

 

4.8.1.10

The Contractor shall submit a final copy of the Provider Network Listing spreadsheet for all requested Provider types (as outlined under Required Attachments in 5.1.2.8 in the RFP), Signature Pages for all Provider Contracts, and written acknowledgements from all Providers part of a PHO, IPA, or other network stating that they know they are in the CMO’s network, know they are accepting Medicaid patients, and that they are accepting the

 

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terms and conditions. These shall all be submitted to DCH ninety (90) Calendar Days prior to implementation of GHF in that Service Region.

 

4.8.2

Primary Care Providers (PCPs)

 

4.8.2.1

The Contractor shall offer its Members freedom of choice in selecting a PCP. The Contractor shall have written PCP Selection Policies and Procedures describing how Members select their PCP.

 

4.8.2.2

The Contractor shall submit these PCP Selection Policies and Procedures policies to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

4.8.2.3

PCP assignment policies shall be in accordance with Section 4.1.2 of this Contract.

 

4.8.2.4

The Contractor may require that Members are assigned to the same PCP for a period of up to six (6) months. In the event the Contractor requires that Members are assigned to the same PCP for a period of six (6) months or less, the following exceptions shall be made:

 

4.8.2.4.1

Members shall be allowed to change PCPs without cause during the first ninety (90) Calendar Days following PCP selection;

 

4.8.2.4.2

Members shall be allowed to change PCPs with cause at anytime. The following constitute cause for change:

 

i.

The PCP no longer meets the geographic access standards as defined in Section 4.8.12;

 

ii.

The PCP does not, because of moral or religious objections, provide the Covered Service(s) the Member seeks; and

 

iii.

The Member requests to be assigned to the same PCP as other family members.

 

4.8.2.4.3

Members shall be allowed to change PCPs every six (6) months.

 

4.8.2.5

The PCP is responsible for supervising, coordinating, and providing all Primary Care to each assigned Member. In addition, the PCP is responsible for coordinating and/or initiating Referrals for specialty care (both in and out of network), maintaining continuity of each Member’s Health Care and maintaining the Member’s Medical Record, which includes documentation of all services provided by the PCP as well as any specialty services. The Contractor shall require that PCPs fulfill these responsibilities for all Members.

 

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4.8.2.6

The Contractor shall include in its network as PCPs the following:

 

4.8.2.6.1

Physicians who routinely provide Primary Care services in the areas of:

 

i.

Family Practice;

 

ii.

General Practice;

 

iii.

Pediatrics; or

 

iv.

Internal Medicine.

 

4.8.2.6.2

Nurse Practitioners Certified (NP-C) specializing in:

 

i.

Family Practice; or

 

ii.

Pediatrics.

 

4.8.2.7

NP-Cs in independent practice must also have a current collaborative agreement with a licensed physician who has hospital admitting privileges.

 

4.8.2.8

FQHCs and RHCs may be included as PCPs. The Contractor shall maintain an accurate list of all Providers rendering care at these facilities.

 

4.8.2.9

Primary Care Public Health Department Clinics and Primary Care Hospital Outpatient Clinics may be included as PCPs if they agree to the requirements of the PCP role, including the following conditions:

 

4.8.2.9.1

The practice must routinely deliver Primary Care as defined by the majority of the practice devoted to providing continuing comprehensive and coordinated medical care to a population undifferentiated by disease or organ system. If deemed necessary, a Medical Record audit of the practice will be performed. Any exceptions to this requirement will be considered on a case-by-case basis.

 

4.8.2.9.2

Any Referrals for specialty care to other Providers of the same practice may be reviewed for appropriateness.

 

4.8.2.10

Physician’s assistants (PAs) may participate as a PCP as a Member of a physician’s practice.

 

4.8.2.11

The Contractor may allow female Members to select a gynecologist or obstetrician-gynecologist (OB-GYN) as their Primary Care Provider.

 

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4.8.2.12

The Contractor may allow Members with Chronic Conditions to select a specialist with whom he or she has an on-going relationship to serve as a PCP.

 

4.8.3

Direct Access

 

4.8.3.1

The Contractor shall provide female Members with direct in-network access to a women’s health specialist for covered care necessary to provide her routine and preventive Health Care services. This is in addition to the Member’s designated source of Primary Care if that Provider is not a women’s health specialist.

 

4.8.3.2

The Contractor shall have a process in place that ensures that Members determined to need a course of treatment or regular care monitoring have direct access to a specialist as appropriate for the Member’s condition and identified needs. The Medical Director shall be responsible for over-seeing this process.

 

4.8.3.3

The Contractor shall ensure that Members who are determined to need a course of treatment or regular care monitoring have a treatment plan. This treatment plan shall be developed by the Member’s PCP with Member participation, and in consultation with any specialists caring for the Member. This treatment plan shall be approved in a timely manner by the Medical Director and in accord with any applicable State quality assurance and utilization review standards.

 

4.8.4

Significant Traditional Providers (STPs)

 

4.8.4.1

The Contractor shall include in its network all STPs in its Service Region for the first two (2) years of operation under this Contract, provided that the STP:

 

4.8.4.1.1

Agrees to participate as an In-Network Provider and abide by the provisions of the Provider Contract as discussed in Section 4.10.

 

4.8.4.1.2

Agrees to accept the Contractor’s Provider reimbursement rate for the Provider Type/Class; and

 

4.8.4.1.3

Meets the Contractor’s credentialing requirements as established pursuant to Section 4.8.13.

 

4.8.4.2

Provider types/classes eligible for participation as a STP are:

 

4.8.4.2.1

PCPs (as defined in Section 4.8.2.6);

 

4.8.4.2.2

OB-GYNs;

 

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4.8.4.2.3

Behavioral Health Providers;

 

4.8.4.2.4

Oral Health Providers;

 

4.8.4.2.5

Pharmacies; and

 

4.8.4.2.6

Hospitals.

 

4.8.4.3

The Contractor shall maintain copies of all letters and other correspondence related to its efforts to include STPs in its network. This documentation shall be provided to DCH upon request.

 

4.8.5

Pharmacies

 

4.8.5.1

The Contractor shall maintain a comprehensive Provider network of pharmacies that ensures pharmacies are available and accessible to all Members.

 

4.8.6

Hospitals

 

4.8.6.1

The Contractor shall have a comprehensive Provider network of hospitals such that they are available and accessible to all Members. This includes, but is not limited to tertiary care facilities and facilities with neo-natal, intensive care, burn, and trauma units.

 

4.8.6.2

The Contractor shall include in its network Critical Access Hospitals (CAHs) that are located in its Service Region.

 

4.8.6.3

The Contractor shall maintain copies of all letters and other correspondence related to its efforts to include CAHs in its network. This documentation shall be provided to DCH upon request.

 

4.8.7

Laboratories

 

4.8.7.1

The Contractor shall maintain a comprehensive Provider network of laboratories that ensures laboratories are accessible to all Members. The Contractor shall ensure that all laboratory testing sites providing services under this contract have either a clinical laboratory (CLIA) certificate or a waiver of a certificate of registration, along with a CLIA number, pursuant to 42 CFR 493.3.

 

4.8.8

Mental Health/Substance Abuse

 

4.8.8.1

The Contractor shall include in its network Community Service Boards (CSBs) that meet the requirements and are located in its Service Region.

 

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4.8.8.2

The Contractor shall maintain copies of all letters and other correspondence related to the inclusion of CSBs in its network. This documentation shall be provided to DCH upon request.

 

4.8.9

Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

 

4.8.9.1

The Contractor shall include in its Provider network all FQHCs and RHCs in its Service Region.

 

4.8.9.2

The Contractor shall maintain copies of all letters and other correspondence related to its efforts to include FQHCs and RHCs in its network. This documentation shall be provided to DCH upon request.

 

4.8.10

Family Planning Clinics

 

4.8.10.1

The Contractor shall make a reasonable effort to subcontract with all family planning clinics, including those funded by Title X of the Public Health Services Act.

 

4.8.10.2

The Contractor shall maintain copies of all letters and other correspondence related to its efforts to include Title X Clinics in its network. This documentation shall be provided to DCH upon request.

 

4.8.11

Nurse Practitioners Certified (NP-Cs) and Certified Nurse Midwives (CNMs)

 

4.8.11.1

The Contractor shall ensure that Members have appropriate access to NP-Cs and CNMs, through either Provider contracts or Referrals. This provision shall in no way be interpreted as requiring the Contractor to provide any services that are not Covered Services.

 

4.8.12

Geographic Access Requirements

 

4.8.12.1

In addition to maintaining in its network a sufficient number of Providers to provide all services to its Members, the Contractor shall meet the following geographic access standards for all Members:

 

		Urban		Rural
PCPs		Two (2) within eight (8) miles		Two (2) within fifteen (15) miles
Specialists		One (1) within thirty (30) minutes or thirty (30) miles		One within forty-five (45) minutes or forty-five (45) miles
Dental Providers		One (1) within thirty (30) minutes or thirty (30) miles		One within forty-five (45) minutes or forty-five (45) miles

 

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		Urban		Rural
Hospitals		One (1) within thirty (30) minutes or thirty (30) miles		One within forty-five (45) minutes or forty-five (45) miles
Mental Health Providers		One (1) within thirty (30) minutes or thirty (30) miles		One within forty-five (45) minutes or forty-five (45) miles
Pharmacies		One (1) twenty-four (24) hours a day, seven (7) days a week within fifteen (15) minutes or fifteen (15) miles		One (1) twenty-four (24) hours a day, seven (7) days a week within thirty (30) minutes or thirty (30) miles

 

4.8.12.2

All travel times are maximums for the amount of time it takes a Member, using usual travel means in a direct route to travel from their home to the Provider. DCH recognizes that transportation with NET vendors may not always follow direct routes due to multiple passengers.

 

4.8.13

Waiting Maximums and Appointment Requirements

 

4.8.13.1

The Contractor shall require that all network Providers offer hours of operation that are no less than the hours of operation offered to commercial and Fee-for-Service patients. The Contractor shall encourage its PCPs to offer After-Hours office care in the evenings and on week-ends.

 

4.8.13.2

Office wait times for appointments shall not exceed one (1) hour.

 

4.8.13.3

The Contractor shall have in its network the capacity to ensure that waiting times for appointments do not exceed the following:

 

PCPs (routine visits)		21 Calendar Days
PCP (adult sick visit)		72 hours
PCP (pediatric sick visit)		24 hours
Specialist		30 Calendar Days
Dental Providers		30 Calendar Days
Non-emergency hospital stays		30 Calendar Days
Mental health Providers		14 Calendar Days
Urgent Care Providers		24 hours
Emergency Providers		immediately (24 hours a day, 7 days a week) and without prior authorization

 

4.8.13.4

The Contractor shall provide adequate capacity for initial visits for pregnant women within fourteen (14) Calendar Days and visits for Health Check eligible children within ninety (90) Calendar Days of Enrollment into the CMO plan.

 

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4.8.13.5

The Contractor shall take corrective action if there is a failure to comply with these waiting times.

 

4.8.14

Credentialing

 

4.8.14.1

The Contractor shall maintain written policies and procedures for the Credentialing and Re-Credentialing of network Providers, using standards established by National Committee Quality Assurance (NCQA), Joint Commission on Accreditation Healthcare Organization (JCAHO), or American Accreditation Healthcare Commission/URAC. At a minimum the Contractor shall require that each Provider be credentialed in accordance with State law. The Contractor may impose more stringent Credentialing criteria than the State requires.

 

4.8.14.2

Such policies and procedures shall include: the verification of the existence and maintenance of credentials, licenses, certificates, and insurance coverage of each Provider from a primary source; a methodology and process for Re-Credentialing Providers; a description of the initial quality assessment of private practitioner offices and other patient care settings; and procedures for disciplinary action, such as reducing, suspending, or terminating Provider privileges.

 

4.8.14.3

Upon the request of DCH, The Contractor shall make available all licenses, insurance certificates, and other documents of network Providers.

 

4.8.13.4

The Contractor shall submit its Provider Credentialing and re-Credentialing Policies and Procedures to DCH within sixty (60) Calendar Days of Contract Award.

 

4.8.15

Mainstreaming

 

4.8.15.1

The Contractor shall ensure that all In-Network Providers accept Members for treatment, unless they have a full panel and are accepting no new GHF or commercial patients. The Contractor shall also ensure that In-Network Providers do not intentionally segregate Members in any way from other persons receiving services.

 

4.8.15.2

The Contractor shall ensure that Members are provided services without regard to race, color, creed, sex, religion, age, national origin, ancestry, marital status, sexual preference, health status, income status, or physical or mental disability.

 

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4.8.16

Coordination Requirements

 

4.8.16.1

The Contractor shall coordinate with all divisions within DCH, as well as with other State agencies, and with other CMO plans operating within the same Service Region.

 

4.8.16.2

The Contractor shall also coordinate with local education agencies in the Referral and provision of children’s intervention services provided through the school to ensure Medical Necessity and prevent duplication of services.

 

4.8.16.3

The Contractor shall coordinate the services furnished to its Members with the service the Member receives outside the CMO plan, including services received through any other managed care entity.

 

4.8.16.4

The Contractor shall coordinate with all NET vendors.

 

4.8.16.5

DCH strongly encourages the Contractor to Contract with Providers of essential community services who would normally Contract with the State as well as other public agencies and with non-profit organizations that have maintained a historical base in the community.

 

4.8.16.6

The Contractor shall implement procedures to ensure that in the process of coordinating care each Member’s privacy is protected consistent with the confidentiality requirements in 45 CFR 160 and 45 CFR 164.

 

4.8.17

Network Changes

 

4.8.17.1

The Contractor shall notify DCH within seven (7) Business Days of any significant changes to the Provider network or, if applicable, to any Subcontractors’ Provider network. A significant change is defined as:

 

4.8.17.1.1

A decrease in the total number of PCPs by more than five percent (5%);

 

4.8.17.1.2

A loss of all Providers in a specific specialty where another Provider in that specialty is not available within sixty (60) miles;

 

4.8.17.1.3

A loss of a hospital in an area where another CMO plan hospital of equal service ability is not available within thirty (30) miles; or

 

4.8.17.1.4

Other adverse changes to the composition of the network which impair or deny the Members’ adequate access to In-Network Providers.

 

4.8.17.2

The Contractor shall have procedures to address changes in the health plan Provider network that negatively affect the ability of Members to access services, including access to a culturally diverse Provider network. Significant changes in network composition that negatively impact Member

 

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access to services may be grounds for Contract termination or State determined remedies.

 

4.8.17.3

If a PCP ceases participation in the Contractor’s Provider network the Contractor shall send written notice to the Members who have chosen the Provider as their PCP. This notice shall be issued no less than thirty (30) Calendar Days prior to the effective date of the termination and no more than ten (10) Calendar Days after receipt or issuance of the termination notice.

 

4.8.17.4

If a Member is in a prior authorized ongoing course of treatment with any other participating Provider who becomes unavailable to continue to provide services, the Contractor shall notify the Member in writing within ten (10) Calendar Days from the date the Contractor becomes aware of such unavailability.

 

4.8.17.5

These requirements to provide notice prior to the effective dates of termination shall be waived in instances where a Provider becomes physically unable to care for Members due to illness, a Provider dies, the Provider moves from the Service Region and fails to notify the Contractor, or when a Provider fails Credentialing. Under these circumstances notice shall be issued immediately upon the Contractor becoming aware of the circumstances.

 

4.8.18

Out-of-Network Providers

 

4.8.18.1

If the Contractor’s network is unable to provide Medically Necessary Covered Services to a particular Member, the Contractor shall adequately and timely cover these services Out-of-Network for the Member.

 

4.8.18.2

The Contractor shall coordinate with Out-of-Network Providers regarding payment. For payment to Out-of-Network, or non-participating Providers, the following guidelines apply:

 

4.8.18.2.1

If the Contractor offers the service through an In-Network Provider(s), and the Member chooses to access the service (i.e., it is not an emergency) from an Out-of-Network Provider, the Contractor is not responsible for payment.

 

4.8.18.2.2

If the service is not available from an In-Network Provider, but the Contractor has three (3) Documented Attempts to contract with the Provider, the Contractor is not required to pay more than Medicaid FFS rates for the applicable service, less ten percent (10%).

 

4.8.18.2.3

If the service is available from an In-Network Provider, but the service meets the Emergency Medical Condition standard, and the Contractor has three (3) Documented Attempts to contract with the Provider, the

 

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Contractor is not required to pay more than Medicaid FFS rates for the applicable service, less ten percent (10%).

 

4.8.18.2.4

If the service is not available from an In-Network Provider and the Member requires the service and is referred for treatment to an Out-of-Network Provider, the payment amount is a matter between the CMO and the Out-of-Network Provider.

 

4.8.18.3

In the event that needed services are not available from an In-Network Provider and the Member must receive services from an Out-of-Network Provider, the Contractor is prohibited from charging the Member more than it would have if the services were furnished within the network.

 

4.8.19

Reporting Requirements

 

4.8.19.1

The Contractor shall submit to DCH Provider Network Adequacy and Capacity Reports, as described in Section 4.18.6.2.

 

4.8.19.2

The Contractor shall submit to DCH quarterly Timely Access Reports as described in Section 4.18.4.2.

 

4.9	PROVIDER SERVICES

 

4.9.1

General Provisions

 

4.9.1.1

The Contractor shall provide information to all Providers about GHF in order to operate in full compliance with the GHF Contract and all applicable federal and State regulations.

 

4.9.1.2

The Contractor shall monitor Provider knowledge and understanding of Provider requirements, and take corrective actions to ensure compliance with such requirements.

 

4.9.1.3

The Contractor shall submit to DCH for review and prior approval all materials and information to be distributed and/or made available.

 

4.9.1.4

All Provider Handbooks and bulletins must be in compliance with State and federal laws.

 

4.9.2

Provider Handbooks

 

4.9.2.1

The Contractor shall issue a Provider Handbook to all network Providers at the time the Provider Contract is signed. The Contractor may choose not to distribute the Provider Handbook via mail, provided it submits a written notification to all Providers that explains how to obtain the Provider Handbook from the CMO’s Web site. This notification shall also detail how

 

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the Provider can request a hard-copy from the CMO at no charge to the Provider. All Provider Handbooks and bulletins shall be in compliance with State and federal laws. The Provider Handbook shall serve as a source of information regarding GHF Covered Services, policies and procedures, statutes, regulations, telephone access and special requirements to ensure all Contract requirements are being met. At a minimum the Provider Handbook shall include the following information:

 

4.9.2.1.1

Description of the GHF;

 

4.9.2.1.2

Covered Services;

 

4.9.2.1.3

Emergency Service responsibilities;

 

4.9.2.1.4

Health Check/EPSDT program services and standards;

 

4.9.2.1.5

Policies and procedures of the Provider complaint system;

 

4.9.2.1.6

Information on the Member Grievance System, including the Member’s right to a State Administrative Law Hearing, the timeframes and requirements, the availability of assistance in filing, the toll-free numbers and the Member’s right to request continuation of Benefits while utilizing the Grievance System;

 

4.9.2.1.7

Medical Necessity standards and practice guidelines;

 

4.9.2.1.8

Practice protocols, including guidelines pertaining to the treatment of chronic and complex Conditions;

 

4.9.2.1.9

PCP responsibilities;

 

4.9.2.1.10

Other Provider or Subcontractor responsibilities;

 

4.9.2.1.11

Prior Authorization, Pre-Certification, and Referral procedures;

 

4.9.2.1.12

Protocol for Encounter Data element reporting/records;

 

4.9.2.1.13

Medical Records standard;

 

4.9.2.1.14

Claims submission protocols and standards, including instructions and all information necessary for a clean or complete Claim;

 

4.9.2.1.15

Payment policies;

 

4.9.2.1.16

The Contractor’s Cultural Competency Plan; and

 

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4.9.2.1.17

Member rights and responsibilities.

 

4.9.2.2

The Contractor shall disseminate bulletins as needed to incorporate any needed changes to the Provider Handbook.

 

4.9.2.3

The Contractor shall submit the Provider Handbook to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

4.9.3

Education and Training

 

4.9.3.1

The Contractor shall provide training to all Providers and their staff regarding the requirements of the Contract and special needs of Members. The Contractor shall conduct initial training within thirty (30) Calendar Days of placing a newly Contracted Provider on active status. The Contractor shall also conduct ongoing training as deemed necessary by the Contractor or DCH in order to ensure compliance with program standards and the GHF Contract.

 

4.9.3.2

The Contractor shall submit the Provider Training Manual and Training Schedule to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

4.9.4

Provider Relations

 

4.9.4.1

The Contractor shall establish and maintain a formal Provider relations function to timely and adequately respond to inquiries, questions and concerns from network Providers. The Contractor shall implement policies addressing the compliance of Providers with the requirements of GHF, institute a mechanism for Provider dispute resolution and execute a formal system of terminating Providers from the network.

 

4.9.4.2

The Contractor shall provide for a Provider Relations Liaison to carry out the Provider relations functions. There shall be at least one (1) Provider Relations Liaison in each Service Region.

 

4.9.5

Toll-free Telephone Hotline

 

4.9.5.1

The Contractor shall operate a toll-free telephone hotline to respond to Provider questions, comments and inquiries.

 

4.9.5.2

The Contractor shall develop Telephone Hotline Policies and Procedures that address staffing, personnel, hours of operation, access and response standards, monitoring of calls via recording or other means, and compliance with standards.

 

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4.9.5.3

The Contractor shall submit these Telephone Hotline Policies and Procedures, including performance standards, to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

4.9.5.4

The Contractor’s call center systems shall have the capability to track call management metrics identified in Attachment L.

 

4.9.5.5

Pursuant to OCGA 30-20A-7.1, the telephone hotline shall be staffed twenty-four (24) hours a day, seven (7) days a week to respond to Prior Authorization and Pre-certification requests. This telephone hotline shall have staff to respond to Provider questions in all other areas, including the Provider complaint system, Provider responsibilities, etc. between the hours of 7:00am and 7:00pm EST Monday through Friday, excluding State holidays.

 

4.9.5.6

The Contractor shall develop performance standards and monitor Telephone Hotline performance by recording calls and employing other monitoring activities. At a minimum, the standards shall require that, on a monthly basis, eighty percent (80%) of calls are answered by a person within thirty (30) seconds, the Blocked Call rate does not exceed one percent (1%), and the rate of Abandoned Calls does not exceed five percent (5%).

 

4.9.5.7

The Contractor shall insure that after regular business hours the non-Prior Authorization/Pre-certification line is answered by an automated system with the capability to provide callers with operating hours information and instructions on how to verify Enrollment for a Member with an Emergency or Urgent Medical Condition. The requirement that the Contractor shall provide information to Providers on how to verify Enrollment for a Member with an Emergency or Urgent Medical Condition shall not be construed to mean that the Provider must obtain verification before providing Emergency Services.

 

4.9.5.8

The Contractor shall develop Call Center Quality Criteria and Protocols to measure and monitor the accuracy of responses and phone etiquette as it relates to the Toll-free Telephone Hotline. The Contractor shall submit the Call Center Quality Criteria and Protocols to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

4.9.6

Internet Presence/Web Site

 

4.9.6.1

The Contractor shall dedicate a section of its Web Site to Provider services and provide at a minimum, the capability for Providers to make inquiries and receive responses through the Medicaid fiscal agent Web Site, (▇▇▇.▇▇▇.▇▇▇▇▇▇▇.▇▇▇).

 

4.9.6.2

In addition to the specific requirements outlined above, the Contractor’s Web Site shall be functionally equivalent, with respect to functions described in

 

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this Contract, to the Web Site maintained by the State’s Medicaid fiscal agent (www, ghp. georgia. gov).

 

4.9.6.3

The Contractor shall submit Web site screenshots to DCH for review and approval sixty (60) Calendar Days prior to implementation of GHF.

 

4.9.7

Provider Complaint System

 

4.9.7.1

The Contractor shall establish a Provider Complaint system that permits a Provider to dispute the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative functions, including Proposed Actions.

 

4.9.7.2

The Contractor shall submit its Provider Complaint System Policies and Procedures to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

4.9.7.3

The Contractor shall include its Provider Complaint System Policies and Procedures in its Provider Handbook that is distributed to all network Providers. This information shall include, but not be limited to, specific instructions regarding how to contact the Contractor’s Provider services to file a Provider complaint and which individual(s) have the authority to review a Provider complaint.

 

4.9.7.4

The Contractor shall distribute the Provider Complaint System Policies and Procedures to Out-of-Network Providers with the remittance advice of the processed Claim. The Contractor may distribute a summary of these Policies and Procedures if the summary includes information on how the Provider may access the full Policies and Procedures on the Web site. This summary shall also detail how the Provider can request a hard-copy from the CMO at no charge to the Provider.

 

4.9.7.5

As a part of the Provider Complaint System, the Contractor shall:

 

4.9.7.5.1

Allow Providers forty-five (45) Calendar Days to file a written complaint;

 

4.9.7.5.2

Require that Providers exhaust the Contractor’s internal Provider Complaint process prior to requesting an Administrative Law Hearing (State Fair Hearing);

 

4.9.7.5.3

Have dedicated staff for Providers to contact via telephone, electronic mail, or in person, to ask questions, file a Provider Complaint and resolve problems;

 

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4.9.7.5.4

Identify a staff person specifically designated to receive and process Provider Complaints;

 

4.9.7.5.5

Thoroughly investigate each GHF Provider Complaint using applicable statutory, regulatory, and Contractual provisions, collecting all pertinent facts from all parties and applying the Contractor’s written policies and procedures; and

 

4.9.7.5.6

Ensure that CMO plan executives with the authority to require corrective action are involved in the Provider Complaint process.

 

4.9.7.6

In the event the outcome of the review of the Provider Complaint is adverse to the Provider, the Contractor shall provide a written Notice of Adverse Action to the Provider. The Notice of Adverse Action shall state that Providers may request an Administrative Law Hearing in accordance with OCGA § 49-4-153.

 

4.9.7.7

The Contractor shall notify the Providers that a request for an Administrative Law Hearing must include the following information:

 

4.9.7.7.1

A clear expression by the Provider that he/she wishes to present his/her case to an Administrative Law Judge;

 

4.9.7.7.2

Identification of the Action being appealed and the issues that will be addressed at the hearing;

 

4.9.7.7.3

A specific statement of why the Provider believes the Contractor’s Action is wrong; and

 

4.9.7.7.4

A statement of the relief sought.

 

4.9.7.8

The Contractor shall include with the Notice of Adverse Action the following address where a request for an Administrative Law Hearing can be sent:

 

		Department of Community Health
		Legal Services Section
		Division of Medical Assistance
		▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇-▇▇▇▇ ▇▇▇▇▇
		▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇

 

4.9.8

Reporting Requirements

 

4.9.8.1

The Contractor shall submit to DCH weekly Telephone Activity Reports as described in Section 4.18.2.2.

 

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4.9.8.2

The Contractor shall submit to DCH quarterly Provider Complaints Reports as described in 4.18.4.3.

 

4.10	PROVIDER CONTRACTS AND PAYMENTS

 

4.10.1

Provider Contracts

 

4.10.1.1

The Contractor shall comply with all DCH procedures for contract review and approval submission. Memoranda of Agreement (MOA) shall not be permitted. Letters of Intent shall only be permitted in accordance with Section 4.8.1.9.

 

4.10.1.2

The Contractor shall submit to DCH for review and approval a model for each type of Provider Contract within sixty (60) Calendar Days of Contract Award.

 

4.10.1.3

Any significant changes to the model Provider Contract shall be submitted to DCH for review and approval no later than thirty (30) Calendar Days prior to the Enrollment of Members into the CMO plan.

 

4.10.1.4

Upon request, the Contractor shall provide DCH with free copies of all executed Provider Contracts.

 

4.10.1.5

In addition to addressing the CMO plan licensure requirements, the Contractor’s Provider Contracts shall:

 

4.10.1.5.1

Prohibit the Provider from seeking payment from the Member for any Covered Services provided to the Member within the terms of the Contract and require the Provider to look solely to the Contractor for compensation for services rendered, with the exception of nominal cost sharing pursuant to the Georgia State Medicaid Plan, the Georgia State Medicaid Policies and Procedures Manual, and the GHF Contract;

 

4.10.1.5.2

Require the Provider to cooperate with the Contractor’s quality improvement and Utilization Review and management activities;

 

4.10.1.5.3

Include provisions for the immediate transfer to another PCP or Contractor if the Member’s health or safety is in jeopardy;

 

4.10.1.5.4

Not prohibit a Provider from discussing treatment or non-treatment options with Members that may not reflect the Contractor’s position or may not be covered by the Contractor;

 

4.10.1.5.5

Not prohibit a Provider from acting within the lawful scope of practice, from advising or advocating on behalf of a Member for the

 

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Member’s health status, medical care, or treatment or non-treatment options, including any alternative treatments that might be self-administered;

 

4.10.1.5.6

Not prohibit a Provider from advocating on behalf of the Member in any Grievance System or Utilization Review process, or individual authorization process to obtain necessary Health Care services;

 

4.10.1.5.7

Require Providers to meet appointment waiting time standards pursuant to Section 4.8.12.3 of this Contract;

 

4.10.1.5.8

Provide for continuity of treatment in the event a Provider’s participation terminates during the course of a Member’s treatment by that Provider;

 

4.10.1.5.9

Prohibit discrimination with respect to participation, reimbursement, or indemnification of any Provider who is acting within the scope of his or her license or certification under applicable State law, solely on the basis of such license or certification. This provision should not be construed as any willing provider law, as it does not prohibit Contractors from limiting Provider participation to the extent necessary to meet the needs of the Members. Additionally, this provision shall not preclude the Contractor from using different reimbursement amounts for different specialties or for different practitioners in the same specialty. This provision also does not interfere with measures established by the Contractor that are designed to maintain Quality and control costs;

 

4.10.1.5.10

Prohibit discrimination against Providers serving high-risk populations or those that specialize in Conditions requiring costly treatments;

 

4.10.1.5.11

Specify that CMS and DCH will have the right to inspect, evaluate, and audit any pertinent books, financial records, documents, papers, and records of any Provider involving financial transactions related to the GHF Contract;

 

4.10.1.5.12

Specify Covered Services and populations;

 

4.10.1.5.13

Require Provider submission of complete and timely Encounter Data, pursuant to Section 4.17 of the GHF Contract;

 

4.10.1.5.14

Include the definition and standards for Medical Necessity, pursuant to the definition in Section 4.5.4 of this Contract;

 

4.10.1.5.15

Specify rates of payment. The Contractor ensures that Providers will accept such payment as payment in full for Covered Services provided

 

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to Members, as deemed Medically Necessary and appropriate under the Contractor’s Quality Improvement and Utilization Management program, less any applicable Member cost sharing pursuant to the GHF Contract;

 

4.10.1.5.16

Provide for timely payment to all Providers for Covered Services to Members. Pursuant to the Georgia Prompt Payment Requirements timely payment is defined as fifteen (15) Calendar Days for a Clean Claim;

 

4.10.1.5.17

Specify acceptable billing and coding requirements;

 

4.10.1.5.18

Require that Providers comply with the Contractor’s Cultural Competency plan;

 

4.10.1.5.19

Require that any marketing materials developed and distributed by Providers be submitted to the Contractor to submit to DCH for approval;

 

4.10.1.5.20

Specify that in the case of newborns the Contractor shall be responsible for any payment owed to Providers for services rendered prior to the newborn’s Enrollment with the Contractor;

 

4.10.1.5.21

Specify that the Contractor shall not be responsible for any payments owed to Providers for services rendered prior to a Member’s Enrollment with the Contractor, even if the services fell within the established period of retroactive eligibility;

 

4.10.1.5.22

Comply with 42 CFR 434 and 42 CFR 438.6;

 

4.10.1.5.23

Require Providers to collect Member co-payments as specified in Attachment K;

 

4.10.1.5.24

Not employ or subcontract with individuals on the State or Federal Exclusions list;

 

4.10.1.5.25

Prohibit Providers from making Referrals for designated health services to Health Care entities with which the Provider or a Member of the Provider’s family has a Financial Relationship.

 

4.10.1.5.26

Require Providers of transitioning Members to cooperate in all respects with Providers of other CMO plans to assure maximum health outcomes for Members;

 

4.10.1.5.27

Not require that Providers sign exclusive Provider Contracts with the Contractor if the Provider is an STP, CAH, FQHC, or RHC;

 

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4.10.1.5.28

Contain a provision stating that in the event DCH is due funds from a Provider, the Contractor shall reduce payment by one hundred percent (100%) to that Provider until such time as the amount owed to DCH is recovered; and

 

4.10.1.5.29

Contain a provision giving notice that the Contractor’s negotiated rates with Providers shall be adjusted in the event the Commissioner of DCH directs the Contractor to make such adjustments in order to reflect budgetary changes to the Medical Assistance program.

 

4.10.2

Provider Termination

 

4.10.2.1

The Contractor shall comply with all State and federal laws regarding Provider termination. In its Provider Contracts the Contractor shall:

 

4.10.2.1.1

Specify that in addition to any other right to terminate the Provider Contract, and notwithstanding any other provision of this Contract, DCH may request Provider termination immediately, or the Contractor may immediately terminate on its own, a Provider’s participation under the Provider Contract if a Provider fails to abide by the terms and conditions of the Provider Contract, as determined by DCH, or, in the sole discretion of DCH, fails to come into compliance within fifteen (15) Calendar Days after a receipt of notice from the Contractor specifying such failure and requesting such Provider to abide by the terms and conditions hereof;

 

4.10.2.1.2

Specify that any Provider whose participation is terminated under the Provider Contract for any reason shall utilize the applicable appeals procedures outlined in the Provider Contract. No additional or separate right of appeal to DCH or the Contractor is created as a result of the Contractor’s act of terminating, or decision to terminate any Provider under this Contract. Notwithstanding the termination of the Provider Contract with respect to any particular Provider, this Contract shall remain in full force and effect with respect to all other Providers;

 

4.10.2.2

The Contractor shall notify DCH at least forty-five (45) Calendar Days prior to the effective date of the suspension, termination, or withdrawal of a Provider from participation in the Contractor’s network. If the termination was “for cause” the Contractor shall provide to DCH the reasons for termination; and

 

4.10.2.3

The Contractor shall notify the Members pursuant to Section 4.8.17.3 and Section 4.8.17.4 of this Contract.

 

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4.10.3

Provider Insurance

 

4.10.3.1

The Contractor shall require each Provider (with the exception of 4.10.3.2 below, and FQHC’s that are section 330 grantees) to maintain, throughout the terms of the Contract, at its own expense, professional and comprehensive general liability, and medical malpractice, insurance. Such comprehensive general liability policy of insurance shall provide coverage in an amount established by the Contractor pursuant to its written Contract with the Provider. Such professional liability policy of insurance shall provide a minimum coverage in the amount of one million dollars ($1,000,000) per occurrence, and three million dollars ($3,000,000) annual aggregate. Providers may be allowed to self-insure if the Provider establishes an appropriate actuarially determined reserve. DCH reserves the right to waive this requirement if necessary for business need.

 

4.10.3.2

The Contractor shall require allied mental health professionals to maintain, throughout the terms of the Contract, professional and comprehensive general liability, and medical malpractice, insurance. Such comprehensive general liability policy of insurance shall provide coverage in an amount established by the Contractor pursuant to its written Contract with Provider. Such professional liability policy of insurance shall provide a minimum coverage in the amount of one million dollars ($1,000,000) per occurrence, and one million dollars ($1,000,000) annual aggregate. These providers may also be allowed to self insure if the Provider establishes an appropriate actuarially determined reserve.

 

4.10.3.3

In the event any such insurance is proposed to be reduced, terminated or canceled for any reason, the Contractor shall provide to DCH and Department of Insurance (DOI) at least thirty (30) Calendar Days prior written notice of such reduction, termination or cancellation. Prior to the reduction, expiration and/or cancellation of any insurance policy required hereunder, the Contractor shall require the Provider to secure replacement coverage upon the same terms and provisions so as to ensure no lapse in coverage, and shall furnish DCH and DOI with a Certificate of Insurance indicating the receipt of the required coverage at the request of DCH or DOI.

 

4.10.3.4

The Contractor shall require Providers to maintain insurance coverage (including, if necessary, extended coverage or tail insurance) sufficient to insure against claims arising at any time during the term of the GHF Contract, even though asserted after the termination of the GHF Contract. DCH or DOI, at its discretion, may request that the Contractor immediately terminate the Provider from participation in the program upon the Provider’s failure to abide by these provisions. The provisions of this Section shall survive the expiration or termination of the GHF Contract for any reason.

 

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4.10.4

Provider Payment

 

4.10.4.1

With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including any Providers that may be paid a Capitation Payment.

 

4.10.4.2

The Contractor shall be responsible for issuing to Provider IRS Form 1099s in accordance with all federal laws, regulations and guidelines.

 

4.10.4.3

When the Contractor negotiates a contract with a Critical Access Hospital (CAH), pursuant to Section 4.8.6 of the GHF Contract, the Contractor shall pay the CAH a payment rate based on allowable costs incurred by the CAH, in accordance with the Georgia Medicaid Policies and Procedures Manual.

 

4.10.4.4

When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor shall pay the FQHC/RHC rates that are comparable to rates paid to other similar Providers providing similar services.

 

4.10.4.5

Upon receipt of notice from DCH that it is due funds from a Provider, the Contractor shall reduce payment to the Provider for all claims submitted by that Provider by one hundred percent (100%), or such other amount as DCH may elect, until such time as the amount owed to DCH is recovered. The Contractor shall promptly remit any such funds recovered to DCH in the manner specified by the DCH. To that end, the Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.

 

4.10.4.6

The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes to the Medical Assistance program, as directed by the Commissioner of DCH, to the extent such adjustments can be made within funds appropriated to DCH and available for payment to the Contractor. The Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.

 

4.10.5

Reporting Requirements

 

4.10.5.1

The Contractor shall submit a quarterly FQHC Report as described in Section 4.18.4.4.

 

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4.11	UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES

 

4.11.1

Utilization Management

 

4.11.1.1

The Contractor shall provide assistance to Members and Providers to ensure the appropriate Utilization of resources, using the following program components: Prior Authorization and Pre-Certification, prospective review, concurrent review, retrospective review, ambulatory review, second opinion, discharge planning and case management. Specifically, the Contractor shall have written Utilization Management Policies and Procedures that:

 

4.11.1.1.1

Include protocols and criteria for evaluating Medical Necessity, authorizing services, and detecting and addressing over-Utilization and under-Utilization. Such protocols and criteria shall comply with federal and State laws and regulations.

 

4.11.1.1.2

Address which services require PCP Referral; which services require Prior-Authorization and how requests for initial and continuing services are processed, and which services will be subject to concurrent, retrospective or prospective review.

 

4.11.1.1.3

Describe mechanisms in place that ensure consistent application of review criteria for authorization decisions.

 

4.11.1.1.4

Require that all Medical Necessity determinations are made in accordance with DCH’s Medical Necessity definition as stated in Section 4.5.4.

 

4.11.1.2

The Contractor shall submit the Utilization Management Policies and Procedures to DCH for review and prior approval within sixty (60) Calendar Days of Contract Award.

 

4.11.1.3

Network Providers may participate in Utilization Review activities in their own Service Region to the extent that there is not a conflict of interest. The Utilization Management Policies and Procedures shall define when such a conflict may exist and shall describe the remedy.

 

4.11.1.4

The Contractor shall have a Utilization Management Committee comprised of network Providers within each Service Region. The Contractor may have one (1) independent Utilization Management Committee for all of the Service Regions in which it is operating, if there is representation from each Service Region on the Committee. The Utilization Management committee is accountable to the Medical Director and governing body of the Contractor. The Utilization Management Committee shall meet on a regular basis and

 

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maintain records of activities, findings, recommendations, and actions. Reports of these activities shall be made available to DCH upon request.

 

4.11.1.5

The Contractor, and any delegated Utilization Review agent, shall not permit or provide compensation or anything of value to its employees, agents, or contractors based on:

 

4.11.1.5.1

Either a percentage of the amount by which a Claim is reduced for payment or the number of Claims or the cost of services for which the person has denied authorization or payment; or

 

4.11.1.5.2

Any other method that encourages the rendering of a Proposed Action.

 

4.11.2

Prior Authorization and Pre-Certification

 

4.11.2.1

The Contractor shall not require Prior Authorization or Pre-Certification for Emergency Services, Post-Stabilization Services, or Urgent Care services, as described in Section 4.6.1, 4.6.2, and 4.6.3.

 

4.11.2.2

The Contractor shall require Prior Authorization and/or Pre-Certification for all non-emergent and non-urgent inpatient admissions except for normal newborn deliveries.

 

4.11.2.3

The Contractor may require Prior Authorization and/or Pre-Certification for all non-emergent, Out-of-Network services.

 

4.11.2.4

Prior Authorization and Pre-Certification shall be conducted by a currently licensed, registered or certified Health Care Professional who is appropriately trained in the principles, procedures and standards of Utilization Review.

 

4.11.2.5

The Contractor shall notify the Provider of Prior Authorization determinations in accordance with the following timeframes:

 

4.11.2.5.1

Standard Service Authorizations. Prior Authorization decisions for non-urgent services shall be made within fourteen (14) Calendar Days of receipt of the request for services. An extension may be granted for an additional fourteen (14) Calendar Days if the Member or the Provider requests an extension, or if the Contractor justifies to DCH a need for additional information and the extension is in the Member’s interest.

 

4.11.2.5.2

Expedited Service Authorizations. In the event a Provider indicates, or the Contractor determines, that following the standard timeframe could seriously jeopardize the Member’s life or health the Contractor shall make an expedited authorization determination and provide notice within twenty-four (24) hours. The Contractor may extend the twenty-

 

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four (24) hour time period for up to five (5) Business Days if the Member or the Provider requests an extension, or if the Contractor justifies to DCH a need for additional information and the extension is in the Member’s interest.

 

4.11.2.5.3

Authorization for services that have been delivered. Determinations for authorization involving health care services that have been delivered shall be made within thirty (30) Calendar Days of receipt of the necessary information.

 

4.11.2.6

The Contractor’s policies and procedures for authorization shall include consulting with the requesting Provider when appropriate.

 

4.11.3

Referral Requirements

 

4.11.3.1

The Contractor may require that Members obtain a Referral from their PCP prior to accessing non-emergency specialized services.

 

4.11.3.2

In the Utilization Management Policies and Procedures discussed in Section 4.11.1.1, the Contractor shall address:

 

4.11.3.2.1

When a Referral from the Member’s PCP is required;

 

4.11.3.2.2

How a Member obtains a Referral to an In-Network Provider or an Out-of-Network Provider when there is no Provider within the Contractor’s network that has the appropriate training or expertise to meet the particular health needs of the Member;

 

4.11.3.2.3

How a Member with a Condition which requires on-going care from a specialist may request a standing Referral; and

 

4.11.3.2.4

How a Member with a life-threatening Condition or disease which requires specialized medical care over a prolonged period of time may request and obtain access to a specialty care center.

 

4.11.3.3

The Contractor shall prohibit Providers from making Referrals for designated health services to Health Care entities with which the Provider or a Member of the Provider’s family has a Financial Relationship.

 

4.11.3.4

DCH strongly encourages the Contractor to develop electronic, web-based Referral processes and systems. In the event a Referral is made via the telephone, the Contractor shall ensure that Referral data, including the final decision, is maintained in a data file that can be accessed electronically by the Contractor, the Provider and DCH.

 

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4.11.3.5

In conjunction with the other Utilization Management policies, the Contractor shall submit the Referral processes to DCH for review and approval.

 

4.11.4

Transition of Members

 

4.11.4.1

Although Referral, Prior Authorization or Pre-certification are not required, the Contractor may require notification from the current Provider in the following circumstances:

 

4.11.4.1.1

The Member has been diagnosed with a significant medical Condition within the last thirty (30) Calendar Days;

 

4.11.4.1.2

The Member needs an organ or tissue replacement;

 

4.11.4.1.3

The Member is receiving ongoing services such as chemotherapy and/or radiation; or

 

4.11.4.1.4

The Member has received Prior Authorization for services (from either another CMO plan or the State or its Agent), such as scheduled surgeries, or out-of-area specialty services.

 

4.11.4.2

When relinquishing Members, the Contractor shall cooperate with the receiving CMO plan regarding the course of on-going care with a specialist or other Provider.

 

4.11.5

Court-Ordered Evaluations and Services

 

4.11.5.1

In the event a Member requires Medicaid-covered services ordered by a State or federal court, the Contractor shall fully comply with all court orders while maintaining appropriate Utilization Management practices.

 

4.11.6

Second Opinions

 

4.11.6.1

The Contractor shall provide for a second opinion in any situation when there is a question concerning a diagnosis or the options for surgery or other treatment of a health Condition when requested by any Member of the Health Care team, a Member, parent(s) and/or guardian (s), or a social worker exercising a custodial responsibility.

 

4.11.6.2

The second opinion must be provided by a qualified Health Care Professional within the network, or the Contractor shall arrange for the Member to obtain one outside the Provider network.

 

4.11.6.3

The second opinion shall be provided at no cost to the Member.

 

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4.11.7

Care Coordination and Case Management

 

4.11.7.1

The Contractor shall be responsible for the Care Coordination/Case Management of all Members and shall make special effort to identify Members who have the greatest need for Care Coordination, including those who have catastrophic, or other high-cost or high-risk Conditions.

 

4.11.7.2

The Contractor’s Care Coordination system shall emphasize prevention, continuity of care, and coordination of care. The system will advocate for, and link Members to, services as necessary across Providers and settings. Care Coordination functions include:

 

4.11.7.2.1

Early identification of Members who have or may have special needs;

 

4.11.7.2.2

Assessment of a Member’s risk factors;

 

4.11.7.2.3

Development of a plan of care;

 

4.11.7.2.4

Referrals and assistance to ensure timely access to Providers;

 

4.11.7.2.5

Coordination of care actively linking the Member to Providers, medical services, residential, social and other support services where needed;

 

4.11.7.2.6

Monitoring;

 

4.11.7.2.7

Continuity of care; and

 

4.11.7.2.8

Follow-up and documentation.

 

4.11.7.3

The Contractor shall develop and implement a Care Coordination and case management system to ensure:

 

4.11.7.3.1

Timely access and delivery of Health Care and services required by Members;

 

4.11.7.3.2

Continuity of Members’ care; and

 

4.11.7.3.3

Coordination and integration of Members’ care.

 

4.11.7.4

These policies shall include, at a minimum, the following elements:

 

4.11.7.4.1

The provision of an individual needs assessment and diagnostic assessment; the development of an individual treatment plan, as necessary, based on the needs assessment; the establishment of treatment objectives; the monitoring of outcomes; and a process to ensure that treatment plans are revised as necessary. These procedures

 

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must be designed to accommodate the specific cultural and linguistic needs of the Contractor’s Members;

 

4.11.7.4.2

A strategy to ensure that all Members and/or authorized family members or guardians are involved in treatment planning;

 

4.11.7.4.3

Procedures and criteria for making Referrals to specialists and subspecialists;

 

4.11.7.4.4

Procedures and criteria for maintaining care plans and Referral Services when the Member changes PCPs; and

 

4.11.7.4.5

Capacity to implement, when indicated, case management functions such as individual needs assessment, including establishing treatment objectives, treatment follow-up, monitoring of outcomes, or revision of treatment plan.

 

4.11.7.5

The Contractor shall submit the Care Coordination and Case Management Policies and Procedures to DCH for review and approval within ninety (90) Calendar Days of Contract Award.

 

4.11.8

Disease Management

 

4.11.8.1

At a time to be determined by DCH, the Contractor shall develop disease management programs for individuals with Chronic Conditions.

 

4.11.8.2

The Contractor shall have disease management programs for Members with diabetes and asthma.

 

4.11.8.3

In addition, the Contractor shall develop programs for at least two (2) additional Conditions to be chosen from the following list:

 

4.11.8.3.1

Perinatal case management;

 

4.11.8.3.2

Obesity;

 

4.11.8.3.3

Hypertension;

 

4.11.8.3.4

Sickle cell disease; or

 

4.11.8.3.5

HIV/AIDS.

 

4.11.9

Discharge Planning

 

4.11.9.1

The Contractor shall maintain and operate a formalized discharge planning program that includes a comprehensive evaluation of the Member’s health

 

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needs and identification of the services and supplies required to facilitate appropriate care following discharge from an institutional clinical setting.

 

4.11.10

Reporting Requirements

 

4.11.10.1

The Contractor shall submit Utilization Management Reports to DCH as described in Section 4.18.4.5.

 

4.11.10.2

The Contractor shall submit monthly Prior Authorization and Pre-Certification Reports to DCH as described in Section 4.18.3.2.

 

4.12	QUALITY IMPROVEMENT

 

4.12.1

General Provisions

 

4.12.1.1

The Contractor shall provide for the delivery of Quality care with the primary goal of improving the health status of Members and, where the Member’s Condition is not amenable to improvement, maintain the Member’s current health status by implementing measures to prevent any further decline in Condition or deterioration of health status. This shall include the identification of Members at risk of developing Conditions, the implementation of appropriate interventions and designation of adequate resources to support the intervention(s).

 

4.12.1.2

The Contractor shall seek input from, and work with, Members, Providers and community resources and agencies to actively improve the Quality of care provided to Members.

 

4.12.1.3

The Contractor shall establish a multi-disciplinary Quality Oversight Committee to oversee all Quality functions and activities, This committee shall meet at least quarterly, but more often if warranted.

 

4.12.2

Quality Assessment Performance Improvement (QAPI) Program

 

4.12.2.1

The Contractor shall have in place an ongoing QAPI program consistent with 42 CFR 438.240.

 

4.12.2.2

The Contractor’s QAPI program shall be based on the latest available research in the area of Quality assurance and at a minimum must include:

 

4.12.2.2.1

A method of monitoring, analysis, evaluation and improvement of the delivery, Quality and appropriateness of Health Care furnished to all Members (including under and over Utilization of services), including those with special Health Care needs;

 

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4.12.2.2.2

Written policies and procedures for Quality assessment, Utilization Management and continuous Quality improvement that are periodically assessed for efficacy;

 

4.12.2.2.3

A health information system sufficient to support the collection, integration, tracking, analysis and reporting of data;

 

4.12.2.2.4

Designated staff with expertise in Quality assessment, Utilization Management and continuous Quality improvement;

 

4.12.2.2.5

Reports that are evaluated, indicated recommendations that are implemented, and feedback provided to Providers and Members;

 

4.12.2.2.6

A methodology and process for conducting and maintaining Provider profiling;

 

4.12.2.2.7

Quarterly Reports to the Contractor’s multi-disciplinary Quality oversight committee and DCH on results, conclusions, recommendations and implemented system changes;

 

4.12.2.2.8

Annual performance improvement projects (PIPs) that focus on clinical and non-clinical areas; and

 

4.12.2.2.9

Annual Reports on performance improvement projects and a process for evaluation of the impact and assessment of the Contractor’s QAPI program.

 

4.12.2.3

The Contractor’s QAPI Program Plan must be submitted to DCH for review and approval within ninety (90) Calendar Days of Contract Award.

 

4.12.2.4

The Contractor shall submit any changes to its QAPI Program Plan to DCH for review and prior approval sixty (60) Calendar Days prior to implementation of the change.

 

4.12.2.5

Upon the request of DCH the Contractor shall provide any information and documents related to the implementation of the QAPI program.

 

4.12.3

Performance Improvement Projects

 

4.12.3.1

As part of its QAPI program the Contractor shall conduct clinical and non-clinical performance improvement projects in accordance with DCH and federal protocols. In designing its performance improvement projects the Contractor shall:

 

4.12.3.1.1

Show that the selected area of study is based on a demonstration of need and is expected to achieve measurable benefit to the Member (rationale);

 

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4.12.3.1.2

Establish clear, defined and measurable goals and objectives that the Contractor shall achieve in each year of the project;

 

4.12.3.1.3

Measure performance using Quality indicators that are objective, measurable, clearly defined and that allow tracking of performance and improvement over time;

 

4.12.3.1.4

Implement interventions designed to achieve Quality improvements;

 

4.12.3.1.5

Evaluate the effectiveness of the interventions;

 

4.12.3.1.6

Establish standardized performance measures (such as HEDIS or another similarly standardized product);

 

4.12.3.1.7

Plan and initiate activities for increasing or sustaining improvement; and

 

4.12.3.1.8

Document the data collection methodology used (including sources) and steps taken to assure data is valid and reliable.

 

4.12.3.2

Each performance improvement project must be completed in a time period determined by DCH, to allow information on the success of the project in the aggregate to produce new information on Quality of care each year.

 

4.12.3.3

The Contractor shall perform the following required clinical performance improvement projects, ongoing for the duration of the GHF Contract period:

 

4.12.3.3.1

One (1) in the area of Health Check screens;

 

4.12.3.3.2

One (1) in the area of immunizations; and

 

4.12.3.3.3

One (1) in the area of blood lead screens.

 

4.12.3.3.4

One (1) in the area of detection of chronic kidney disease.

 

4.12.3.4

The Contractor shall perform one (1) optional clinical performance improvement project from the following areas:

 

4.12.3.4.1

Coordination/continuity of care;

 

4.12.3.4.2

Chronic care management;

 

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4.12.3.4.3

High volume Conditions; or

 

4.12.3.4.4

High risk Conditions.

 

4.12.3.5

The Contractor shall perform the following required non-clinical performance improvement projects:

 

4.12.3.5.1

One (1) in the area of Member satisfaction; and

 

4.12.3.5.2

One (1) in the area of Provider satisfaction.

 

4.12.3.6

The Contractor shall perform one (1) optional non-clinical performance improvement project from the following areas:

 

4.12.3.6.1

Cultural competence;

 

4.12.3.6.2

Appeals/Grievance/Provider Complaints;

 

4.12.3.6.3

Access/service capacity; or

 

4.12.3.6.4

Appointment availability.

 

4.12.3.7

The Contractor shall submit its Proposed Performance Improvement Projects to DCH for review and prior approval within ninety (90) Calendar Days of Contract Award.

 

4.12.3.8

The Contractor shall meet the established goals and objectives, as determined by DCH, for its performance improvement projects. The Contractor shall submit to DCH any and all data necessary to enable DCH to measure the Contractor’s performance under this Section.

 

4.12.4

Practice Guidelines

 

4.12.4.1

The Contractor shall adopt a minimum of three (3) evidence-based clinical practice guidelines, one of which shall be for chronic kidney disease. Such guidelines shall:

 

4.12.4.1.1

Be based on the health needs and opportunities for improvement identified as part of the QAPI program;

 

4.12.4.1.2

Be based on valid and reliable clinical evidence or a consensus of Health Care Professionals in the particular field;

 

4.12.4.1.3

Consider the needs of the Members;

 

4.12.4.1.4

Be adopted in consultation with network Providers; and

 

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4.12.4.1.5

Be reviewed and updated periodically as appropriate.

 

4.12.4.2

The Contractor shall submit the Practice Guidelines, which shall include a methodology for measuring and assessing compliance, to DCH for review and prior approval as part of the QAPI program plan within ninety (90) Calendar Days of Contract Award.

 

4.12.4.3

The Contractor shall disseminate the guidelines to all affected Providers and, upon request, to Members.

 

4.12.4.4

The Contractor shall ensure that decisions for Utilization Management, Member education, coverage of services, and other areas to which the guidelines apply are consistent with the guidelines.

 

4.12.4.5

In order to ensure consistent application of the guidelines the Contractor shall encourage Providers to utilize the guidelines, and shall measure compliance with the guidelines, until ninety percent (90%) or more of the Providers are consistently in compliance. The Contractor may use Provider incentive strategies to improve Provider compliance with guidelines.

 

4.12.5

Focused Studies

 

4.12.5.1

The Contractor shall also perform a minimum of two (2) focused studies each year, commencing with the second (2nd) year of operations. One (1) study shall focus on preventive care services.

 

4.12.5.2

The Contractor shall submit to DCH for approval the areas in which it will conduct focused studies on the first (1st) day of the fourth (4th) quarter of the first (1st) year of operations.

 

4.12.6

Patient Safety Plan

 

4.12.6.1

The Contractor shall have a structured Patient Safety Plan to address concerns or complaints regarding clinical care. This plan must include written policies and procedures for processing of Member complaints regarding the care they received. Such policies and procedures shall include:

 

4.12.6.1.1

A system of classifying complaints according to severity;

 

4.12.6.1.2

A review by the Medical Director and a mechanism for determining which incidents will be forwarded to Peer Review and Credentials Committees; and

 

4.12.6.1.3

A summary of incident(s), including the final disposition, included in the Provider profile.

 

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4.12.6.2

The Contractor shall submit the Patient Safety Plan to DCH for review and approval within ninety (90) Calendar Days of the Contract Award.

 

4.12.7

Performance Incentives

 

4.12.7.1

The Contractor may be eligible for performance Incentives as described in Section 7.0. All Incentives must comply with the federal managed care Incentive Arrangement requirements pursuant to 42 CFR 438.6 and the State Medicaid Manual 2089.3.

 

4.12.8

External Quality Review

 

4.12.8.1

DCH will contract with an External Quality Review Organization (EQRO) to conduct annual, external, independent reviews of the Quality outcomes, timeliness of, and access to, the services covered in this Contract. The Contractor shall collaborate with DCH’s EQRO to develop studies, surveys and other analytic activities to assess the Quality of care and services provided to Members and to identify opportunities for CMO plan improvement. To facilitate this process the Contractor shall supply data, including but not limited to Claims data and Medical Records, to the EQRO.

 

4.12.9

Reporting Requirements

 

4.12.9.1

The Contractor’s Quality Oversight Committee shall submit Quality Oversight Committee Reports to DCH as described in Section 4.18.4.6.

 

4.12.9.2

The Contractor shall submit Performance Improvement Project Reports as described in Section 4.18.5.1.

 

4.12.9.3

The Contractor shall submit annual Focused Studies Reports to DCH as described in Section 4.18.5.2.

 

4.12.9.4

The Contractor shall submit annual Patient Safety Plan Reports to DCH as described in Section 4.18.5.3.

 

4.13	FRAUD AND ABUSE

 

4.13.1

Program Integrity

 

4.13.1.1

The Contractor shall have a written Program Integrity Program, including a mandatory compliance plan, designed to guard against Fraud and Abuse. This Program Integrity Program shall include policies, procedures, and standards of conduct for the prevention, detection, reporting, and corrective action for suspected cases of Fraud and Abuse in the administration and delivery of services under this Contract.

 

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4.13.1.2

The Contractor shall submit its Program Integrity Policies and Procedures, which include the compliance plan and pharmacy lock-in program described below, to DCH for approval within sixty (60) Calendar Days of Contract Award.

 

4.13.2

Compliance Plan

 

4.13.2.1

The Contractor’s compliance plan shall include, at a minimum, the following:

 

4.13.2.1.1

The designation of a Compliance Officer who is accountable to the Contractor’s senior management and is responsible for ensuring that policies to establish effective lines of communication between the Compliance Officer and the Contractor’s staff, and between the Compliance Officer and DCH staff, are followed;

 

4.13.2.1.2

Provision for internal monitoring and auditing of reported Fraud and Abuse violations, including specific methodologies for such monitoring and auditing;

 

4.13.2.1.3

Policies to ensure that all officers, directors, managers and employees know and understand the provisions of the Contractor’s Fraud and Abuse compliance plan;

 

4.13.2.1.4

Policies to establish a compliance committee that periodically meets and reviews Fraud and Abuse compliance issues;

 

4.13.2.1.5

Policies to ensure that any individual who reports CMO plan violations or suspected Fraud and Abuse will not be retaliated against;

 

4.13.2.1.6

Polices of enforcement of standards through well-publicized disciplinary standards;

 

4.13.2.1.7

Provision of a data system, resources and staff to perform the Fraud and Abuse and other compliance responsibilities;

 

4.13.2.1.8

Procedures for the detection of Fraud and Abuse that includes, at a minimum, the following:

 

i.

Claims edits;

 

ii.

Post-processing review of Claims;

 

iii.

Provider profiling and Credentialing;

 

iv.

Quality Control; and

 

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v.

Utilization Management.

 

4.13.2.1.9

Written standards for organizational conduct;

 

4.13.2.1.10

Effective training and education for the Compliance Officer and the organization’s employees, management, board Members, and Subcontractors;

 

4.13.2.1.11

Inclusion of information about Fraud and Abuse identification and reporting in Provider and Member materials;

 

4.13.2.1.12

Provisions for the investigation, corrective action and follow-up of any suspected Fraud and Abuse reports; and

 

4.13.2.1.13

Procedures for reporting suspected Fraud and Abuse cases to the State Program Integrity Unit, including timelines and use of State approved forms.

 

4.13.2.2

As part of the Program Integrity Program the Contractor may implement a pharmacy lock-in program. The policies, procedures and criteria for establishing a lock-in program shall be submitted to DCH for review and approval as part of the Program Integrity Policies and Procedures discussed in Section 4.13.1.2. The pharmacy lock-in program shall:

 

4.13.2.2.1

Allow Members to change pharmacies for good cause, as determined by the Contractor after discussion with the Provider(s) and the pharmacist. Valid reasons for change should include recipient relocation or the pharmacy does not provide the prescribed drug;

 

4.13.2.2.2

Provide Case management and education reinforcement of appropriate medication use;

 

4.13.2.2.3

Annually assess the need for lock-in for each Member; and

 

4.13.2.2.4

Require that the Contractor’s Compliance Officer report on the program on a quarterly basis to DCH.

 

4.13.3

Coordination with DCH and Other Agencies

 

4.13.3.1

The Contractor shall cooperate and assist any State or federal agency charged with the duty of identifying, investigating, or prosecuting suspected Fraud and Abuse cases, including permitting access to the Contractor’s place of business during normal business hours, providing requested information, permitting access to personnel, financial and Medical Records, and providing internal

 

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reports of investigative, corrective and legal actions taken relative to the suspected case of Fraud and Abuse.

 

4.13.3.2

The Contractor’s Compliance Officer shall work closely, including attending quarterly meetings, with DCH’s program integrity staff to ensure that the activities of one entity do not interfere with an ongoing investigation being conducted by the other entity.

 

4.13.3.3

The Contractor shall inform DCH immediately about known or suspected cases and it shall not investigate or resolve the suspicion without making DCH aware of, and if appropriate involved in, the investigation, as determined by DCH.

 

4.13.4

Reporting Requirements

 

4.13.4.1

The Contractor shall submit a Fraud and Abuse Report, as described in Section 4.18.4.7 to DCH on a quarterly basis. This Report shall include information on the pharmacy lock-in program described in Section 4.13.2.2.

 

4.14	INTERNAL GRIEVANCE SYSTEM

 

4.14.1

General Requirements

 

4.14.1.1

The Contractor’s Grievance System shall include a Grievance process, an Appeal process and access to the State’s Administrative Law Hearing (State Fair Hearing) system. The Contractor’s Grievance System is an internal process that shall be exhausted by the Member prior to access to an Administrative Law Hearing.

 

4.14.1.2

The Contractor shall develop written Grievance System Policies and Procedures that detail the operation of the Grievance System. The Contractor’s policies and procedures shall be available in the Member’s primary language. The Grievance System Policies and Procedures shall be submitted to DCH for review and approval within sixty (60) Calendar Days of Contract Award.

 

4.14.1.3

The Contractor shall process each Grievance and Appeal using applicable State and federal statutory, regulatory, and GHF Contractual provisions, and the Contractor’s written policies and procedures. Pertinent facts from all parties must be collected during the investigation.

 

4.14.1.4

The Contractor shall give Members any reasonable assistance in completing forms and taking other procedural steps for both Grievances and Appeals. This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTD and interpreter capability.

 

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4.14.1.5

The Contractor shall acknowledge receipt of each filed Grievance and Appeal in writing within ten (10) Business Days of receipt. The Contractor shall have procedures in place to notify all Members in their primary language of Grievance and Appeal resolutions.

 

4.14.1.6

The Contractor shall ensure that the individuals who make decisions on Grievances and Appeals were not involved in any previous level of review or decision-making; and are Health Care Professionals who have the appropriate clinical expertise, as determined by DCH, in treating the Member’s Condition or disease if deciding any of the following:

 

4.14.1.6.1

An Appeal of a denial that is based on lack of Medical Necessity;

 

4.14.1.6.2

A Grievance regarding denial of expedited resolutions of Appeal; and

 

4.14.1.6.3

Any Grievance or Appeal that involves clinical issues.

 

4.14.1.7

The Contractor shall establish and maintain an expedited review process for Appeals when the Contractor determines (based on a request from the Member) or the Provider indicates (in making the request on the Member’s behalf) that taking the time for a standard resolution could seriously jeopardize the Member’s life or health or ability to attain, maintain, or regain maximum function. The Member, the Member’s Authorized Representative, or the Provider acting on behalf of the Member with the Member’s written consent, may file an expedited Appeal either orally or in writing. The Contractor shall ensure that punitive action is not taken against either a Provider who requests an expedited resolution, or a Provider that supports a Member’s Appeal.

 

4.14.2

Grievance Process

 

4.14.2.1

A Member or Member’s Authorized Representative may file a Grievance to the Contractor either orally or in writing. A Grievance may be filed about any matter other than a Proposed Action. A Provider cannot file a Grievance on behalf of a Member.

 

4.14.2.2

The Contractor shall ensure that the individuals who make decisions on Grievances that involve clinical issues or denial of an expedited review of an Appeal are Health Care Professionals who have the appropriate clinical expertise, as determined by DCH, in treating the Member’s Condition or disease and who were not involved in any previous level of review or decision-making.

 

4.14.2.3

The Contractor shall provide written notice of the disposition of the Grievance as expeditiously as the Member’s health Condition requires but shall not exceed ninety (90) Calendar Days of the filing date.

 

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4.14.2.4

The Contractor may extend the timeframe for disposition of a Grievance for up to fourteen (14) Calendar Days if the Member requests the extension or the Contractor demonstrates (to the satisfaction of DCH, upon its request) that there is a need for additional information and how the delay is in the Member’s interest. If the Contractor extends the timeframe, it must, for any extension not requested by the Member, give the Member written notice of the reason for the delay.

 

4.14.3

Proposed Action

 

4.14.3.1

All Proposed Actions shall be made by a physician, or other peer review consultant, who has appropriate clinical expertise in treating the Member’s Condition or disease.

 

4.14.3.2

In the event of a Proposed Action, the Contractor shall notify the Member in writing. The Contractor shall also provide written notice of a Proposed Action to the Provider. This notice must meet the language and format requirements in accordance with Section 4.3.2 of this Contract and be sent in accordance with the timeframes described in Section 4.14.3.4.

 

4.14.3.3

The notice of Proposed Action must contain the following:

 

4.14.3.3.1

The Action the Contractor has taken or intends to take.

 

4.14.3.3.2

The reasons for the Action.

 

4.14.3.3.3

The Member’s right to file an Appeal through the Contractor’s internal Grievance System as described in Section 4.14.

 

4.14.3.3.4

The Provider’s right to file a Provider Complaint as described in Section 4.9.7;

 

4.14.3.3.5

The requirement that a Member exhaust the Contractor’s internal Grievance System and a Provider exhaust the Provider Complaint process prior to requesting a State Administrative Law Hearing;

 

4.14.3.3.6

The circumstances under which expedited review is available and how to request it; and

 

4.14.3.3.7

The Member’s right to have Benefits continue pending resolution of the Appeal with the Contractor or with the State Administrative Law Hearing, how to request that Benefits be continued, and the circumstances under which the Member may be required to pay the costs of these services.

 

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4.14.3.4

The Contractor shall mail the Notice of Proposed Action within the following timeframes:

 

4.14.3.4.1

For termination, suspension, or reduction of previously authorized Covered Services at least ten (10) Calendar Days before the date of Proposed Action or not later than the date of Proposed Action in the event of one of the following exceptions:

 

i.

The Contractor has factual information confirming the death of a Member.

 

ii.

The Contractor receives a clear written statement signed by the Member that he or she no longer wishes services or gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information.

 

iii.

The Member’s whereabouts are unknown and the post office returns Contractor mail directed to the Member indicating no forwarding address (refer to 42 CFR 431.231(d) for procedures if the Member’s whereabouts become known).

 

iv.

The Member’s Provider prescribes a change in the level of medical care.

 

v.

The date of action will occur in less than ten (10) Calendar Days in accordance with 42 CFR 483.12(a)(5)(ii),

 

vi.

The Contractor may shorten the period of advance notice to five (5) Calendar Days before date of action if the Contractor has facts indicating that action should be taken because of probable Member Fraud and the facts have been verified, if possible, through secondary sources.

 

4.14.3.4.2

For denial of payment, at the time of any Proposed Action affecting the Claim.

 

4.14.3.4.3

For standard Service Authorization decisions that deny or limit services, within the timeframes required in Section 4.11.2.5.

 

4.14.3.4.4

If the Contractor extends the timeframe for the decision and issuance of notice of Proposed Action according to Section 4.11.2.5, the Contractor shall give the Member written notice of the reasons for the decision to extend Grievance if he or she disagrees with that decision. The Contractor shall issue and carry out its determination as

 

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expeditiously as the Member’s health requires and no later than the date the extension expires.

 

4.14.3.4.5

For authorization decisions not reached within the timeframes required in Section 4.11.2.5 for either standard or expedited Service Authorizations, Notice of Proposed Action shall be mailed on the date the timeframe expires, as this constitutes a denial and is thus a Proposed Action.

 

4.14.4

Appeal Process

 

4.14.4.1

An Appeal is the request for review of a “Proposed Action”. The Member, the Member’s Authorized Representative, or the Provider acting on behalf of the Member with the Member’s written consent, may file an Appeal either orally or in writing. Unless the Member or Provider requests expedited review, the Member, the Member’s Authorized Representative, or the Provider acting on behalf of the Member with the Member’s written consent, must follow an oral filing with a written, signed, request for Appeal.

 

4.14.4.2

The Member, the Member’s Authorized Representative, or the Provider acting on behalf of the Member with the Member’s written consent, may file an Appeal to the Contractor within thirty (30) Calendar Days from the date of the notice of Proposed Action.

 

4.14.4.3

Appeals shall be filed directly with the Contractor, or its delegated representatives. The Contractor may delegate this authority to an Appeal committee, but the delegation must be in writing.

 

4.14.4.4

The Contractor shall ensure that the individuals who make decisions on Appeals are individuals who were not involved in any previous level of review or decision-making; and who are Health Care Professionals who have the appropriate clinical expertise in treating the Member’s Condition or disease if deciding any of the following:

 

4.14.4.4.1

An Appeal of a denial that is based on lack of Medical Necessity.

 

4.14.4.4.2

An Appeal that involves clinical issues.

 

4.14.4.5

The Appeals process shall provide the Member, the Member’s Authorized Representative, or the Provider acting on behalf of the Member with the Member’s written consent, a reasonable opportunity to present evidence and allegations of fact or law, in person, as well as in writing. The Contractor shall inform the Member of the limited time available to provide this in case of expedited review.

 

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4.14.4.6

The Appeals process must provide the Member, the Member’s Authorized Representative, or the Provider acting on behalf of the Member with the Member’s written consent, opportunity, before and during the Appeals process, to examine the Member’s case file, including Medical Records, and any other documents and records considered during the Appeals process.

 

4.14.4.7

The Appeals process must include as parties to the Appeal the Member, the Member’s Authorized Representative, the Provider acting on behalf of the Member with the Member’s written consent, or the legal representative of a deceased Member’s estate.

 

4.14.4.8

The Contractor shall resolve each Appeal and provide written notice of the Appeal resolution, as expeditiously as the Member’s health Condition requires but shall not exceed forty-five (45) Calendar Days from the date the Contractor receives the Appeal. For expedited reviews of an Appeal and notice to affected parties, the Contractor has no longer than seventy-two (72) hours or as expeditiously as the Member’s physical or mental health requires. If the Contractor denies a Member’s request for expedited review, it must transfer the Appeal to the timeframe for standard resolution specified herein and must make reasonable efforts to give the Member prompt oral notice of the denial, and follow up within two (2) Calendar Days with a written notice. The Contractor shall also make reasonable efforts to provide oral notice for resolution of an expedited review of an Appeal.

 

4.14.4.9

The Contractor may extend the timeframe for standard or expedited resolution of the Appeal by up to fourteen (14) Calendar Days if the Member, Member’s Authorized Representative, or the Provider acting on behalf of the Member with the Member’s written consent, requests the extension or the Contractor demonstrates (to the satisfaction of DCH, upon its request) that there is need for additional information and how the delay is in the Member’s interest. If the Contractor extends the timeframe, it must, for any extension not requested by the Member, give the Member written notice of the reason for the delay.

 

4.14.5

Notice of Adverse Action

 

4.14.5.1

If the Contractor upholds the Proposed Action in response to a Grievance or Appeal filed by the Member, the Contractor shall issue a Notice of Adverse Action within the timeframes as described in Section 4.14.4.8 and 4.14.4.9.

 

4.14.5.2

The Notice of Adverse Action shall meet the language and format requirements as specified in 4.3 and include the following:

 

4.14.5.2.1

The results and date of the adverse Action;

 

4.14.5.2.2

The right to request a State Administrative Law Hearing within thirty (30) Calendar Days and how to do so;

 

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4.14.5.2.3

The right to continue to receive Benefits pending a State Administrative Law Hearing;

 

4.14.5.2.4

How to request the continuation of Benefits;

 

4.14.5.2.5

Information explaining that the Member may be liable for the cost of any continued Benefits if the Contractor’s action is upheld in a State Administrative Law Hearing.

 

4.14.5.2.6

The action the Contractor has taken on intends to take;

 

4.14.5.2.7

The reasons for the action;

 

4.14.5.2.8

The Member’s or the Provider’s right to file an appeal;

 

4.14.5.2.9

The Member’s right to request a State fair hearing;

 

4.14.5.2.10

Procedures for exercising the Member’s rights to appeal or grieve;

 

4.14.5.2.11

Circumstances under which expedited resolution is available and how to request it; and

 

4.14.5.2.12

The Member’s rights to have benefits continue pending the resolution of the appeal, how to request that benefits be continued, and the circumstances under which the Member may be required to pay the costs of these services.

 

4.14.6

Administrative Law Hearing

 

4.14.6.1

The State will maintain an independent Administrative Law Hearing process as defined in the Georgia Administrative Procedure Act (O.C.G.A Title 50, Chapter 13) and as required by federal law, 42 CFR 431.200. The Administrative Law Hearing process shall provide Members an opportunity for a hearing before an impartial Administrative Law Judge. The Contractor shall comply with decisions reached as a result of the Administrative Law Hearing process.

 

4.14.6.2

A Member or Member’s Authorized Representative may request in writing an Administrative Law Hearing within thirty (30) Calendar Days of the date the Notice of Adverse Action is mailed by the Contractor. The parties to the Administrative Law Hearing shall include the Contractor as well as the Member, Member’s Authorized Representative, or representative of a deceased Member’s estate. A Provider cannot request an Administrative Law Hearing on behalf of a Member.

 

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4.14.6.3

A Member may request a Continuation of Benefits as described in Section 4.14.7 while an Administrative Law Hearing is pending.

 

4.14.6.4

The Contractor shall make available any records and any witnesses at its own expense in conjunction with a request pursuant to an Administrative Law Hearing.

 

4.14.7

Continuation of Benefits while the Contractor Appeal and Administrative Law Hearing are Pending

 

4.14.7.1

As used in this Section, “timely” filing means filing on or before the later of the following:

 

4.14.7.1.1

Within ten (10) Calendar Days of the Contractor mailing the Notice of Adverse Action.

 

4.14.7.1.2

The intended effective date of the Contractor’s Proposed Action.

 

4.14.7.2

The Contractor shall continue the Member’s Benefits if the Member or the Member’s Authorized Representative files the Appeal timely; the Appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; the services were ordered by an authorized Provider; the original period covered by the original authorization has not expired; and the Member requests extension of the Benefits.

 

4.14.7.3

If, at the Member’s request, the Contractor continues or reinstates the Member’s benefit while the Appeal or Administrative Law Hearing is pending, the Benefits must be continued until one of the following occurs:

 

4.14.7.3.1

The Member withdraws the Appeal or request for the Administrative Law Hearing.

 

4.14.7.3.2

Ten (10) Calendar Day pass after the Contractor mails the Notice of Adverse Action, unless the Member, within the ten (10) Calendar Day timeframe, has requested an Administrative Law Hearing with continuation of Benefits until an Administrative Law Hearing decision is reached.

 

4.14.7.3.3

An Administrative Law Judge issues a hearing decision adverse to the Member.

 

4.14.7.3.4

The time period or service limits of a previously authorized service has been met.

 

4.14.7.4

If the final resolution of Appeal is adverse to the Member, that is, upholds the Contractor action, the Contractor may recover from the Member the cost of

 

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the services furnished to the Member while the Appeal is pending, to the extent that they were furnished solely because of the requirements of this Section.

 

4.14.7.5

If the Contractor or the Administrative Law Judge reverses a decision to deny, limit, or delay services that were not furnished while the Appeal was pending, the Contractor shall authorize or provide this disputed services promptly, and as expeditiously as the Member’s health Condition requires.

 

4.14.7.6

If the Contractor or the Administrative Law Judge reverses a decision to deny authorization of services, and the Member received the disputed services while the Appeal was pending, the Contractor shall pay for those services.

 

4.14.8

Reporting Requirements

 

4.14.8.1

The Contractor shall log and track all Grievances, Proposed Actions, Appeals and Administrative Law Hearing requests, as described in Section 4.18.4.8.

 

4.14.8.2

The Contractor shall maintain records of Grievances, whether received verbally or in writing, that include a short, dated summary of the problems, name of the grievant, date of the Grievance, date of the decision, and the disposition.

 

4.14.8.3

The Contractor shall maintain records of Appeals, whether received verbally or in writing, that include a short, date summary of the issues, name of the appellant, date of Appeal, date of decision, and the resolution.

 

4.14.8.4

DCH may publicly disclose summary information regarding the nature of Grievances and Appeals and related dispositions or resolutions in consumer information materials.

 

4.14.8.5

The Contractor shall submit quarterly Grievance System Reports to DCH as described in Section 4.18.4.7.

 

4.15	ADMINISTRATION AND MANAGEMENT

 

4.15.1

General Provisions

 

4.15.1.1

The Contractor shall be responsible for the administration and management of all requirements of this Contract. All costs related to the administration and management of this Contract shall be the responsibility of the Contractor.

 

4.15.2

Place of Business and Hours of Operation

 

4.15.2.1

The Contractor shall maintain a central business office within the Service Region in which it is operating. If the Contractor is operating in more than

 

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one (1) Service Region, there must be one (1) central business office and an additional office in each Service Region. If a Contractor is operating in two (2) or more contiguous Service Regions, the Contractor may establish one (1) central business office for all Service Regions. This business office must be centrally located within the contiguous Service Regions and in a location accessible for foot and vehicle traffic. The Contractor may establish more than one (1) business office within a Service Region, but must designate one (1) of the offices as the central business office.

 

4.15.2.2

All documentation must reflect the address of the location identified as the legal, duly licensed, central business office. This business office must be open at least between the hours of 8:30 a.m. and 5:30 p.m. EST, Monday through Friday. The Contractor shall ensure that the office(s) are adequately staffed to ensure that Members and Providers receive prompt and accurate responses to inquiries.

 

4.15.2.3

The Contractor shall ensure that all business offices, and all staff that perform functions and duties, related to this Contract are located within the United States.

 

4.15.2.4

The Contractor shall provide live access, through its telephone hot-line as described in Section 4.3.7 and Section 4.9.5. The Contractor shall provide access twenty-four (24) hours a day, seven (7) days per week to its Web site.

 

4.15.3

Training

 

4.15.3.1

The Contractor shall conduct on-going training for all of its staff, in all departments, to ensure appropriate functioning in all areas and to ensure that staff is aware of all programmatic changes.

 

4.15.3.2

The Contractor shall submit a staff training plan to DCH for review and approval within ninety (90) days of Contract Award.

 

4.15.4

Data Certification

 

4.15.4.1

The Contractor shall certify all data pursuant to 42 CFR 438.606. The data that must be certified include, but are not limited to, Enrollment information, Encounter Data, and other information required by the State and contained in Contracts, proposals and related documents. The data must be certified by one of the following: the Contractor’s Chief Executive Officer, the Contractor’s Chief Financial Officer, or an individual who has delegated authority to sign for, and who Reports directly to the Contractor’s Chief Executive Officer or Chief Financial Officer. The certification must attest, based on best knowledge, information, and belief, as follows:

 

4.15.4.1.1

To the accuracy, completeness and truthfulness of the data.

 

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4.15.4.1.2

To the accuracy, completeness and truthfulness of the documents specified by the State.

 

4.15.4.2

The Contractor shall submit the certification concurrently with the certified data.

 

4.15.5

Implementation Plan

 

4.15.5.1

The Contractor shall develop an Implementation Plan that details the procedures and activities that will be accomplished during the period between the awarding of this Contract and the start date of GHF. This Implementation Plan shall have established deadlines and timeframes for the implementation activities and shall include coordination and cooperation with DCH and its representatives during all phases.

 

4.15.5.2

The Contractor shall submit its Implementation Plan to DCH for DCH’s review and approval within thirty (30) Calendar Days of Contract Award. Implementation of the Contract shall not commence prior to DCH approval.

 

4.15.5.3

The Contractor will not receive any additional payment to cover start up or implementation costs.

 

4.16	CLAIMS MANAGEMENT

 

4.16.1

General Provisions

 

4.16.1.1

The Contractor shall administer an effective, accurate and efficient Claims processing function that adjudicates and settles Provider Claims for Covered Services that are filed within the time frames specified by this Section and in compliance with all applicable State and federal laws, rules and regulations.

 

4.16.1.2

The Contractor shall maintain a Claims management system that can identify date of receipt (the date the Contractor receives the Claim as indicated by the date-stamp), real-time-accurate history of actions taken on each Provider Claim (i.e. paid, denied, suspended, Appealed, etc.), and date of payment (the date of the check or other form of payment).

 

4.16.1.3

At a minimum, the Contractor shall run one (1) Provider payment cycle per week, on the same day each week, as determined by the Contractor. The Contractor shall develop a payment schedule to be submitted to DCH for review and upon approval within sixty (60) days of Contract Award.

 

4.16.1.4

The Contractor shall support an Automated Clearinghouse (ACH) mechanism that allows Providers to request and receive electronic funds transfer (EFT) of Claims payments.

 

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4.16.1.5

The Contractor shall encourage that its Providers, as an alternative to the filing of paper-based Claims, submit and receive Claims information through electronic data interchange (EDI), i.e. electronic Claims. Electronic Claims must be processed in adherence to information exchange and data management requirements specified in Section 4.17. As part of this Electronic Claims Management (ECM) function, the Contractor shall also provide on-line and phone-based capabilities to obtain Claims processing status information.

 

4.16.1.6

The Contractor shall generate Explanation of Benefits and Remittance Advices in accordance with State standards for formatting, content and timeliness.

 

4.16.1.7

The Contractor shall not pay any Claim submitted by a Provider who is excluded or suspended from the Medicare, Medicaid or SCHIP programs for Fraud, abuse or waste or otherwise included on the Department of Health and Human Services Office of Inspector General exclusions list, or employs someone on this list. The Contractor shall not pay any Claim submitted by a Provider that is on payment hold under the authority of DCH or its Agent(s).

 

4.16.1.8

Not later than the fifteenth (15th) business day after the receipt of a Provider Claim that does not meet Clean Claim requirements, the Contractor shall suspend the Claim and request in writing (notification via e-mail, the CMO plan Web Site/Provider Portal or an interim Explanation of Benefits satisfies this requirement) all outstanding information such that the Claim can be deemed clean. Upon receipt of all the requested information from the Provider, the CMO plan shall complete processing of the Claim within fifteen (15) Business Days.

 

4.16.1.9

Claims suspended for additional information must be closed (paid or denied) by the thirtieth (30th) Calendar Day following the date the Claim is suspended if all requested information is not received prior to the expiration of the 30-day period. The Contractor shall send Providers written notice (notification via e-mail, the CMO plan Web site/Provider Portal or an Explanation of Benefits satisfies this requirement) for each Claim that is denied, including the reason(s) for the denial, the date Contractor received the Claim, and a reiteration of the outstanding information required from the Provider to adjudicate the Claim.

 

4.16.1.10

The Contractor plan must process, and finalize, all appealed Claims to a paid or denied status within (30) Business Days of receipt of the Appealed Claim.

 

4.16.1.11

The Contractor shall finalize all Claims, including appealed Claims, within twenty-four (24) months of the date of service.

 

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4.16.1.12

The Contractor may deny a Claim for failure to file timely if a Provider does not submit Claims to them within one hundred and twenty (120) Calendar Days of the date of service but must deny any Claim not initially submitted to the Contractor by the one hundred and eighty-first (181st) Calendar Day from the date of service, unless the Contractor or its vendors created the error. If a Provider files erroneously with another CMO plan or with the State, but produces documentation verifying that the initial filing of the Claim occurred within the one hundred and twenty (120) Calendar Day period, the Contractor shall process the Provider’s Claim without denying for failure to timely file.

 

4.16.1.13

The Contractor shall inform all network Providers about the information required to submit a Clean Claim at least forty-five (45) Calendar Days prior to the Operational Start Date and as a provision within the Contractor/Provider Contract. The Contractor shall make available to network Providers Claims coding and processing guidelines for the applicable Provider type. The Contractor shall notify Providers ninety (90) Calendar Days before implementing changes to Claims coding and processing guidelines.

 

4.16.1.14

The Contractor shall assume all costs associated with Claim processing, including the cost of reprocessing/resubmission, due to processing errors caused by the Contractor or to the design of systems within the Contractor’s span of control.

 

4.16.1.15

In addition to the specific Web site requirements outlined above, the Contractor’s Web site shall be functionally equivalent to the Web site maintained by the State’s Medicaid fiscal agent.

 

4.16.2

Other Considerations

 

4.16.2.1

An adjustment to a paid Claim shall not be counted as a Claim for the purposes of reporting.

 

4.16.2.2

Electronic Claims shall be treated as identical to paper-based Claims for the purposes of reporting.

 

4.16.3

Reporting Requirements

 

4.16.3.1

The Contractor shall submit Claims Processing Reports to DCH as described in section 4.18.3.3.

 

4.17	INFORMATION MANAGEMENT AND SYSTEMS

 

4.17.1

General Provisions

 

4.17.1.1

The Contractor shall have Information management processes and Information Systems (hereafter referred to as Systems) that enable it to meet

 

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GHF requirements, State and federal reporting requirements, all other Contract requirements and any other applicable State and federal laws, rules and regulations including HIPAA.

 

4.17.1.2

The Contractor’s Systems shall possess capacity sufficient to handle the workload projected for the start of the program and will be scaleable and flexible so they can be adapted as needed, within negotiated timeframes, in response to program or Enrollment changes.

 

4.17.1.3

The Contractor shall provide a Web-accessible system hereafter referred to as the DCH Portal that designated DCH and other state agency resources can use to access Quality and performance management information as well as other system functions and information as described throughout this Contract. Access to the DCH Portal shall be managed as described in section 4.17.5.

 

4.17.1.4

The Contractor shall participate in DCH’s Systems Work Group. The Systems Work Group will meet on a designated schedule as agreed to by DCH, its agents and every Contractor.

 

4.17.1.5

The Contractor shall provide a continuously available electronic mail communication link (E-mail system) with the State. This system shall be:

 

4.17.1.5.1

Available from the workstations of the designated Contractor contacts; and

 

4.17.1.5.2

Capable of attaching and sending documents created using software products other than Contractor systems, including the State’s currently installed version of Microsoft Office and any subsequent upgrades as adopted.

 

4.17.1.6

By no later than the 30th of April of each year, the Contractor will provide DCH with a systems refresh plan for the upcoming State fiscal year. The plan will outline how Systems within the Contractor’s Span of Control will be systematically assessed to determine the need to modify, upgrade and/or replace application software, operating hardware and software, telecommunications capabilities, information management policies and procedures, and/or systems management policies and procedures in response to changes in business requirements, technology obsolescence, staff turnover and other relevant factors. The systems refresh plan will also indicate how the Contractor will insure that the version and/or release level of all of its System components (application software, operating hardware, operating software) are always formally supported by the original equipment manufacturer (OEM), software development firm (SDF) or a third party authorized by the OEM and/or SDF to support the System component.

 

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4.17.2

Global System Architecture and Design Requirements

 

4.17.2.1

The Contractor shall comply with federal and State policies, standards and regulations in the design, development and/or modification of the Systems it will employ to meet the aforementioned requirements and in the management of Information contained in those Systems. Additionally, the Contractor shall adhere to DCH and State-specific system and data architecture preferences as indicated in this Contract.

 

4.17.2.2

The Contractor’s Systems shall:

 

4.17.2.2.1

Employ a relational data model in the architecture of its databases and relational database management system (RDBMS) to operate and maintain them;

 

4.17.2.2.2

Be SQL and ODBC compliant;

 

4.17.2.2.3

Adhere to Internet Engineering Task Force/Internet Engineering Standards Group standards for data communications, including TCP and IP for data transport;

 

4.17.2.2.4

Conform to standard code sets detailed in Attachment L;

 

4.17.2.2.5

Conform to HIPAA standards for data and document management that are currently under development within one hundred twenty (120) Calendar Days of the standard’s effective date or, if earlier, the date stipulated by CMS;

 

4.17.2.2.6

Contain controls to maintain information integrity. These controls shall be in place at all appropriate points of processing. The controls shall be tested in periodic and spot audits following a methodology to be developed jointly by and mutually agreed upon by the Contractor and DCH; and

 

4.17.2.2.7

Partner with the State in the development of future standard code sets not specific to HIPAA or other federal effort and will conform to such standards as stipulated in the plan to implement the standards.

 

4.17.2.3

Where Web services are used in the engineering of applications, the Contractor’s Systems shall conform to World Wide Web Consortium (W3C) standards such as XML, UDDI, WSDL and SOAP so as to facilitate integration of these Systems with DCH and other State systems that adhere to a service-oriented architecture.

 

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4.17.2.4

Audit trails shall be incorporated into all Systems to allow information on source data files and documents to be traced through the processing stages to the point where the Information is finally recorded. The audit trails shall:

 

4.17.2.4.1

Contain a unique log-on or terminal ID, the date, and time of any create/modify/delete action and, if applicable, the ID of the system job that effected the action;

 

4.17.2.4.2

Have the date and identification “stamp” displayed on any on-line inquiry;

 

4.17.2.4.3

Have the ability to trace data from the final place of recording back to its source data file and/or document shall also exist;

 

4.17.2.4.4

Be supported by listings, transaction Reports, update Reports, transaction logs, or error logs;

 

4.17.2.4.5

Facilitate auditing of individual Claim records as well as batch audits; and

 

4.17.2.4.6

Be maintained for seven (7) years in either live and/or archival systems. The duration of the retention period may be extended at the discretion of and as indicated to the Contractor by the State as needed for ongoing audits or other purposes.

 

4.17.2.5

The Contractor shall house indexed images of documents used by Members and Providers to transact with the Contractor in the appropriate database(s) and document management systems so as to maintain the logical relationships between certain documents and certain data. The Contractor shall follow all applicable requirements for the management of data in the management of documents.

 

4.17.2.6

The Contractor shall institute processes to insure the validity and completeness of the data it submits to DCH. At its discretion, DCH will conduct general data validity and completeness audits using industry-accepted statistical sampling methods. Data elements that will be audited include but are not limited to: Member ID, date of service, Provider ID, category and sub category (if applicable) of service, diagnosis codes, procedure codes, revenue codes, date of Claim processing, and date of Claim payment.

 

4.17.2.7

Where a System is herein required to, or otherwise supports, the applicable batch or on-line transaction type, the system shall comply with HIPAA-standard transaction code sets as specified in Attachment L.

 

4.17.2.8

The Contractor System(s) shall conform to HIPAA standards for information exchange that are currently under development within one hundred twenty (120) Calendar Days of the standard’s effective date or, if earlier, the date stipulated by CMS.

 

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4.17.2.9

The layout and other applicable characteristics of the pages of Contractor Web sites shall be compliant with Federal “section 508 standards” and Web Content Accessibility Guidelines developed and published by the Web Accessibility Initiative.

 

4.17.2.10

Contractor Systems shall conform to any applicable Application, Information and Data, Middleware and Integration, Computing Environment and Platform, Network and Transport, and Security and Privacy policy and standard issued by GTA as stipulated in the appropriate policy/standard. These policies and standards can be accessed at:

 

▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇.▇▇▇/▇▇/▇▇▇▇▇▇▇_▇▇▇▇▇▇▇▇▇▇▇▇/▇,▇▇▇▇,▇▇▇▇▇▇▇_▇▇▇▇▇▇▇,▇▇. html

 

4.17.3

Data and Document Management Requirements by Major Information Type

 

4.17.3.1

In order to meet programmatic, reporting and management requirements, the Contractor’s systems shall serve as either the Authoritative Host of key data and documents or the host of valid, replicated data and documents from other systems. Attachment L lays out the requirements for managing (capturing, storing and maintaining) data and documents for the major information types and subtypes associated with the aforementioned programmatic, reporting and management requirements.

 

4.17.4

System and Data Integration Requirements

 

4.17.4.1

All of the Contractor’s applications, operating software, middleware, and networking hardware and software shall be able to interface with the State’s systems and will conform to standards and specifications set by the Georgia Technology Authority and the agency that owns the system. These standards and specifications are detailed in Attachment L.

 

4.17.4.2

The Contractor’s System(s) shall be able to transmit and receive transaction data to and from the MMIS as required for the appropriate processing of Claims and any other transaction that may be performed by either System.

 

4.17.4.3

Each month the Contractor shall generate encounter data files from its claims management system(s) and/or other sources. The files will contain settled Claims and Claim adjustments and encounters from Providers with whom the Contractor has a capitation arrangement for the most recent month for which all such transactions were completed. The Contractor will provide these files electronically to DCH and/or its designated agent in adherence to the procedure and format indicated in Attachment L.

 

4.17.4.4

The Contractor’s System(s) shall be capable of generating files in the prescribed formats for upload into state Systems used specifically for program integrity and compliance purposes.

 

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4.17.4.5

The Contractor’s System(s) shall possess mailing address standardization functionality in accordance with US Postal Service conventions.

 

4.17.5

System Access Management and Information Accessibility Requirements

 

4.17.5.1

The Contractor’s System shall employ an access management function that restricts access to varying hierarchical levels of system functionality and Information. The access management function shall:

 

4.17.5.1.1

Restrict access to Information on a “need to know” basis, e.g. users permitted inquiry privileges only will not be permitted to modify information;

 

4.17.5.1.2

Restrict access to specific system functions and information based on an individual user profile, including inquiry only capabilities; global access to all functions will be restricted to specified staff jointly agreed to by DCH and the Contractor; and

 

4.17.5.1.3

Restrict attempts to access system functions to three (3), with a system function that automatically prevents further access attempts and records these occurrences,

 

4.17.5.2

The Contractor shall make System Information available to duly Authorized Representatives of DCH and other State and federal agencies to evaluate, through inspections or other means, the Quality, appropriateness and timeliness of services performed.

 

4.17.5.3

The Contractor shall have procedures to provide for prompt transfer of System Information upon request to other In-Network or Out-of-Network Providers for the medical management of the Member in adherence to HIPAA and other applicable requirements.

 

4.17.5.4

All Information, whether data or documents, and reports that contain or make references to said Information, involving or arising out of this Contract are owned by DCH. The Contractor is expressly prohibited from sharing or publishing DCH information and reports without the prior written consent of DCH. In the event of a dispute regarding the sharing or publishing of information and reports, DCH’s decision on this matter shall be final and not subject to change.

 

4.17.6

Systems Availability and Performance Requirements

 

4.17.6.1

The Contractor will ensure that Member and Provider portal and/or phone-based functions and information, such as confirmation of CMO Enrollment (CCE) and electronic claims management (ECM), Member services and

 

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Provider services, are available to the applicable System users twenty-four (24) hours a day, seven (7) Days a week, except during periods of scheduled System Unavailability agreed upon by DCH and the Contractor. Unavailability caused by events outside of a Contractor’s span of control is outside of the scope of this requirement.

 

4.17.6.2

The Contractor shall ensure that at a minimum all other System functions and Information are available to the applicable system users between the hours of 7:00 a.m. and 7:00 p.m. Monday through Friday.

 

4.17.6.3

The Contractor shall ensure that the average response time that is controllable by the Contractor is no greater than the requirements set forth below, at least ninety percent (90%) of the available production time between 7:00 a.m. and 7:00 p.m. Monday through Friday for all applicable system functions except a) during periods of scheduled downtime, as scheduled, b) during periods of unscheduled unavailability caused by systems and telecommunications technology outside of the Contractor’s span of control or c) for Member and Provider portal and phone-based functions such as CCE and ECM that are expected to be available twenty-four (24) hours a day, seven (7) days a week:

 

4.17.6.3.1

Record Search Time – The response time shall be within five (5) seconds for ninety-five percent (95%) of the record searches as measured from a representative sample of DCH System Access Devices;

 

4.17.6.3.2

Record Retrieval Time – The response time will be within five (5) seconds for ninety-five percent (95%) of the records retrieved as measured from a representative sample of DCH System Access Devices;

 

4.17.6.3.3

Screen Edit Time – The response time will be within three (3) seconds for ninety-five percent (95%) of the time as measured from a representative sample of DCH System Access Devices.

 

4.17.6.3.4

New Screen/Page Time – The response time will be within three (3) seconds for ninety-five percent (95%) of the time as measured from a representative sample of DCH System Access Devices;

 

4.17.6.3.5

Confirmation of CMO Enrollment Response Time – The response time will be within five (5) seconds for ninety-five percent (95%) of the time as measured from a representative sample of user System Access Devices; and

 

4.17.6.3.6

On-line Adjudication Response Time – The response time will be within five (5) seconds ninety-nine percent (99%) of the time as

 

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measured from a representative sample of user System Access Devices.

 

4.17.6.4

The Contractor shall develop an automated method of monitoring the CCE and ECM functions on at least a thirty (30) minute basis twenty-four (24) hours a day, seven (7) Days per week. The monitoring method shall separately monitor for availability and performance/response time each component of the CCE and ECM systems, such as the voice response system, the PC software response, direct line use, the swipe box method and ECM on-line pharmacy system.

 

4.17.6.5

Upon discovery of any problem within its Span of Control that may jeopardize System availability and performance as defined in this Section of the Contract, the Contractor shall notify the applicable DCH staff in person, via phone, electronic mail and/or surface mail.

 

4.17.6.6

The Contractor shall deliver notification as soon as possible but no later than 7:00 p.m. if the problem occurs during the business day and no later than 9:00 a.m. the following business day if the problem occurs after 7:00 p.m.

 

4.17.6.7

Where the operational problem results in delays in report distribution or problems in on-line access during the business day, the Contractor shall notify the applicable DCH staff within fifteen (15) minutes of discovery of the problem, in order for the applicable work activities to be rescheduled or be handled based on System Unavailability protocols.

 

4.17.6.8

The Contractor shall provide to appropriate DCH staff information on System Unavailability events, as well as status updates on problem resolution. These up-dates shall be provided on an hourly basis and made available via electronic mail, telephone and the Contractor’s Web Site/DCH Portal.

 

4.17.6.9

Unscheduled System Unavailability of CCE and ECM functions, caused by the failure of systems and telecommunications technologies within the Contractor’s Span of Control will be resolved, and the restoration of services implemented, within thirty (30) minutes of the official declaration of System Unavailability. Unscheduled System Unavailability to all other Contractor System functions caused by systems and telecommunications technologies within the Contractor’s Span of Control shall be resolved, and the restoration of services implemented, within four (4) hours of the official declaration of System Unavailability.

 

4.17.6.10

Cumulative System Unavailability caused by systems and telecommunications technologies within the Contractor’s span of control shall not exceed one (1) hour during any continuous five (5) Day period.

 

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4.17.6.11

The Contractor shall not be responsible for the availability and performance of systems and telecommunications technologies outside of the Contractor’s Span Of Control.

 

4.17.6.12

Full written documentation that includes a Corrective Action Plan, that describes how the problem will be prevented from occurring again, shall be delivered within five (5) Business Days of the problem’s occurrence.

 

4.17.6.13

Regardless of the architecture of its Systems, the Contractor shall develop and be continually ready to invoke a business continuity and disaster recovery (BC-DR) plan that at a minimum addresses the following scenarios: (a) the central computer installation and resident software are destroyed or damaged, (b) System interruption or failure resulting from network, operating hardware, software, or operational errors that compromises the integrity of transactions that are active in a live system at the time of the outage, (c) System interruption or failure resulting from network, operating hardware, software or operational errors that compromises the integrity of data maintained in a live or archival system, (d) System interruption or failure resulting from network, operating hardware, software or operational errors that does not compromise the integrity of transactions or data maintained in a live or archival system but does prevent access to the System, i.e. causes unscheduled System Unavailability.

 

4.17.6.14

The Contractor shall periodically, but no less than annually, test its BC-DR plan through simulated disasters and lower level failures in order to demonstrate to the State that it can restore System functions per the standards outlined elsewhere in this Section of the Contract.

 

4.17.6.15

In the event that the Contractor fails to demonstrate in the tests of its BC-DR plan that it can restore system functions per the standards outlined in this Contract, the Contractor shall be required to submit to the State a Corrective Action Plan that describes how the failure will be resolved. The Corrective Action Plan will be delivered within five (5) Business Days of the conclusion of the test.

 

4.17.7

System User and Technical Support Requirements

 

4.17.7.1

Beginning sixty (60) Calendar Days prior to the scheduled start of operations, the Contractor shall provide Systems Help Desk (SHD) services to all DCH staff and the other agencies that may have direct access to Contractor systems.

 

4.17.7.2

The SHD shall be available via local and toll free telephone service and via e-mail from 7 a.m. to 7 p.m. EST Monday through Friday, with the exception of State holidays. Upon State request, the Contractor shall staff the SHD on a State holiday, Saturday, or Sunday.

 

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4.17.7.3

SHD staff shall answer user questions regarding Contractor System functions and capabilities; report recurring programmatic and operational problems to appropriate Contractor or DCH staff for follow-up; redirect problems or queries that are not supported by the SHD, as appropriate, via a telephone transfer or other agreed upon methodology; and redirect problems or queries specific to data access authorization to the appropriate State login account administrator.

 

4.17.7.4

The Contractor shall submit to DCH for review and approval its SHD Standards. At a minimum, these standards shall require that between the hours of 7 a.m. and 7 p.m. EST ninety percent (90%) of calls are answered by the fourth (4th) ring, the call abandonment rate is five percent (5%) or less, the average hold time is two (2) minutes or less, and the blocked call rate does not exceed one percent (1%).

 

4.17.7.5

Individuals who place calls to the SHD between the hours of 7 p.m. and 7 a.m. EST shall be able to leave a message. The Contractor’s SHD shall respond to messages by noon the following Business Day.

 

4.17.7.6

Recurring problems not specific to System Unavailability identified by the SHD shall be documented and reported to Contractor management within one (1) Business Day of recognition so that deficiencies are promptly corrected.

 

4.17.7.7

Additionally, the Contractor shall have an IT service management system that provides an automated method to record, track, and report on all questions and/or problems reported to the SHD. The service management system shall:

 

4.17.7.7.1

Assign a unique number to each recorded incident;

 

4.17.7.7.2

Create State defined extract files that contain summary information on all problems/issues received during a specified time frame;

 

4.17.7.7.3

Escalate problems based on their priority and the length of time they have been outstanding;

 

4.17.7.7.4

Perform key word searches that are not limited to certain fields and allow for searches on all fields in the database;

 

4.17.7.7.5

Notify support personnel when a problem is assigned to them and re-notify support personnel when an assigned problem has escalated to a higher priority;

 

4.17.7.7.6

List all problems assigned to a support person or group;

 

4.17.7.7.7

Perform searches for duplicate problems when a new problem is entered;

 

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4.17.7.7.8

Allow for entry of at least five hundred (500) characters of free form text to describe problems and resolutions; and

 

4.17.7.7.9

Generate Reports that identify categories of problems encountered, length of time for resolution, and any other State-defined criteria.

 

4.17.7.8

The Contractor’s call center systems shall have the capability to track call management metrics identified in Attachment L.

 

4.17.8

System Change Management Requirements

 

4.17.8.1

The Contractor shall absorb the cost of routine maintenance, inclusive of defect correction, System changes required to effect changes in State and federal statute and regulations, and production control activities, of all Systems within its Span of control.

 

4.17.8.2

The Contractor shall provide to DCH prior written notice of non-routine System changes excluding changes prompted by events described in Section 4.17.6 and including proposed corrections to known system defects, within ten (10) Calendar Days of the projected date of the change. As directed by the state, the Contractor shall discuss the proposed change in the Systems Work Group.

 

4.17.8.3

The Contractor shall respond to State reports of System problems not resulting in System Unavailability according to the following timeframes:

 

4.17.8.3.1

Within five (5) Calendar Days of receipt the Contractor shall respond in writing to notices of system problems.

 

4.17.8.3.2

Within fifteen (15) Calendar Days, the correction will be made or a Requirements Analysis and Specifications document will be due.

 

4.17.8.3.3

The Contractor will correct the deficiency by an effective date to be determined by DCH.

 

4.17.8.3.4

Contractor systems will have a system-inherent mechanism for recording any change to a software module or subsystem.

 

4.17.8.4

The Contractor shall put in place procedures and measures for safeguarding the State from unauthorized modifications to Contractor Systems.

 

4.17.8.5

Unless otherwise agreed to in advance by DCH as part of the activities described in Section 4.17.8.3, scheduled System Unavailability to perform System maintenance, repair and/or upgrade activities shall take place between 11 p.m. on a Saturday and 6 a.m on the following Sunday.

 

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4.17.9

System Security and Information Confidentiality and Privacy Requirements

 

4.17.9.1

The Contractor shall provide for the physical safeguarding of its data processing facilities and the systems and information housed therein. The Contractor shall provide DCH with access to data facilities upon DCH request. The physical security provisions shall be in effect for the life of this Contract.

 

4.17.9.2

The Contractor shall restrict perimeter access to equipment sites, processing areas, and storage areas through a card key or other comparable system, as well as provide accountability control to record access attempts, including attempts of unauthorized access.

 

4.17.9.3

The Contractor shall include physical security features designed to safeguard processor site(s) through required provision of fire retardant capabilities, as well as smoke and electrical alarms, monitored by security personnel.

 

4.17.9.4

The Contractor shall ensure that the operation of all of its systems is performed in accordance with State and federal regulations and guidelines related to security and confidentiality and meet all privacy and security requirements of HIPAA regulations. Relevant publications are included in Attachment L.

 

4.17.9.5

The Contractor will put in place procedures, measures and technical security to prohibit unauthorized access to the regions of the data communications network inside of a Contractor’s Span of Control.

 

4.17.9.6

The Contractor shall ensure compliance with:

 

4.17.9.6.1

42 CFR Part 431 Subpart F (confidentiality of information concerning applicants and Members of public medical assistance programs);

 

4.17.9.6.2

42 CFR Part 2 (confidentiality of alcohol and drug abuse records); and

 

4.17.9.6.3

Special confidentiality provisions related to people with HIV/AIDS and mental illness.

 

4.17.9.7

The Contractor shall provide its Members with a privacy notice as required by HIPAA. The Contractor shall provide the State with a copy of its Privacy Notice for its filing.

 

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4.17.10

Information Management Process and Information Systems Documentation Requirements

 

4.17.10.1

The Contractor shall ensure that written System Process and Procedure Manuals document and describe all manual and automated system procedures for its information management processes and information systems.

 

4.17.10.2

The Contractor shall develop, prepare, print, maintain, produce, and distribute distinct System Design and Management Manuals, User Manuals and Quick/Reference Guides, and any updates thereafter, for DCH and other agency staff that use the DCH Portal. :

 

4.17.10.3

The System User Manuals shall contain information about, and instructions for, using applicable System functions and accessing applicable system data.

 

4.17.10.4

When a System change is subject to State sign off, the Contractor shall draft revisions to the appropriate manuals prior to State sign off of the change.

 

4.17.10.5

All of the aforementioned manuals and reference guides shall be available in printed form and on-line via the DCH Portal. The manuals will be published in accordance to the applicable DCH and/or GTA standard.

 

4.17.10.6

Updates to the electronic version of these manuals shall occur in real time; updates to the printed version of these manuals shall occur within ten (10) Business Days of the update taking effect.

 

4.17.11

Reporting Requirements

 

4.17.11.1

The Contractor shall submit a monthly Systems Availability and Performance Report to DCH as described in Section 4.18.3.4.

 

4.18	REPORTING REQUIREMENTS

 

4.18.1

General Procedures

 

4.18.1.1

The Contractor shall comply with all the reporting requirements established by this Contract. The Contractor shall create Reports using the formats, including electronic formats, instructions, and timetables as specified by DCH, at no cost to DCH. Changes to the format must be approved by DCH prior to implementation. The Contractor shall transmit and receive all transactions and code sets required by the HIPAA regulations in accordance with Section 21.2. The Contractor’s failure to submit the Reports as specified may result in the assessment of liquidated damages as described in Section 23.0.

 

4.18.1.1.1

The Contractor shall submit the Deliverables and Reports for DCH review and approval according to the following timelines, unless otherwise indicated.

 

i.

Annual Reports shall be submitted within thirty (30) Calendar Days following the twelfth (12th) month Members are enrolled in the CMO plan;

 

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ii.

Quarterly Reports shall be submitted by April 30, July 30, October 30, and January 30, for the quarter immediately preceeding the due date;

 

iii.

Monthly Reports shall be submitted within fifteen (15) Calendar Days of the end of each month; and

 

iv.

Weekly Reports shall be submitted on the same day of each week, as determined by DCH.

 

4.18.1.2

These reports shall be submitted to DOI according to their requirements, including required timeframes. The Contractor shall submit to DOI any and all reports required by DOI. While some of these reports have been specified in this Contract, this is not intended to be an exhaustive list of reports due to DOI; rather certain financial reports have been highlighted in this Contract. For reports required by DOI and DCH, the Contractor shall submit such reports according to the DOI schedule of due dates. While such schedule may be duplicated in this Contract, should the DOI schedule of due dates be amended at a future date, the due dates in this Contract shall automatically change to the new DOI due dates.

 

4.18.1.3

The Contractor shall, upon request of DCH, generate any additional data or reports at no additional cost to DCH within a time period prescribed by DCH. The Contractor’s responsibility shall be limited to data in its possession,

 

4.18.2

Weekly Reporting

 

4.18.2.1

Member Information Report

 

4.18.2.1.1

Pursuant to Section 4.1.4.1 the Contractor shall submit a Member Information Report. The report shall include information on the Members that change addresses or move outside the Service Region. The Contractor shall also report any information that may affect the Member’s eligibility for GHF including, but not limited to, changes in income or employment, family size, or incarceration. The minimum data elements that will be required for this report are described in Attachment L.

 

4.18.2.2

Telephone and Internet Activity Report

 

4.18.2.2.1

Pursuant to Sections 4.3.11.1 and 4.9.8.1 the Contractor shall submit a Member Telephone and Internet Activity Report and a Provider

 

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Telephone and Internet Activity Report. Each Telephone and Internet Activity Report shall include the following information:

 

i.

Call volume;

 

ii.

E-mail volume;

 

iii.

Average call length;

 

iv.

Average hold time;

 

v.

Abandoned Call rate;

 

vi.

Accuracy rate based on CMO’s Call Center Quality Criteria and Protocols;

 

vii.

Content of call or e-mail and resolution; and

 

viii.

Blocked Call rate.

 

4.18.2.2.2

The above information may be submitted as a summary report, in a format to be determined by DCH. The Contractor shall maintain, and make available at the request of DCH, any and all supporting documentation.

 

4.18.3

Monthly Reporting

 

4.18.3.1

Eligibility and Enrollment Reconciliation Report

 

4.18.3.1.1

Pursuant to Section 4.1.4.2 the Contractor shall submit an Eligibility and Enrollment Reconciliation Report that reconciles eligibility data to the Contractor’s Enrollment records. The written report shall verify that the Contractor has an Enrollment record for all Members that are eligible for Enrollment in the CMO plan.

 

4.18.3.2

Prior Authorization and Pre-Certification Report

 

4.18.3.2.1

Pursuant to Section 4.11.10.2 the Contractor shall submit Prior Authorization and Pre-Certification Reports that summarize all requests in the preceding month for Prior Authorization and Pre-Certification. The Report shall include, at a minimum, the following information:

 

i.

Total number of requests for Prior Authorization and Pre-Certification requested by type of service;

 

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ii.

Total number of requests for Prior Authorization and Pre-Certification processed within fourteen (14) Calendar Days for standard Service Authorizations;

 

iii.

Total number of requests for extension of the fourteen (14) Calendar Days for standard Service Authorizations;

 

iv.

Total number of requests for Prior Authorization and Pre-Certification processed within twenty-four (24) hours for expedited Service Authorizations;

 

v.

Total number of requests for the extension of the twenty-four (24) hours for expedited Service Authorizations;

 

vi.

Total number of requests for authorization processed within thirty (30) Calendar Days for determination for services that have been delivered;

 

vii.

Total number of requests approved by type of service; and

 

viii.

Total number of requests denied by type of service.

 

4.18.3.3

Claims Processing Report

 

4.18.3.3.1

Pursuant to Section 4.16.3.1 the Contractor shall submit a Claims Processing Report that at a minimum contains the following:

 

i.

Number and dollar value of Claims processed by Provider type and processing status (adjudicated and paid, adjudicated and not paid, suspended, appealed, denied);

 

ii.

Aging of Claims: number, dollar value and status of Claims filed in most recent and prior months (defined as six (6) months previous) by Provider type and processing status; and

 

iii.

Cumulative percentage for the current fiscal year of Clean Claim s processed and paid within thirty (30) calendar and ninety (90) Calendar Days of receipt.

 

4.18.3.4

System Availability and Performance Report

 

4.18.3.4.1

Pursuant to Section 4.16.3.1 the Contractor shall submit a System Availability and Performance Report that shall report the following information:

 

i.

Record Search Time

 

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ii.

Record Retrieval Time

 

iii.

Screen Edit Time

 

iv.

New Screen/Page Time

 

v.

Print Initiation Time

 

vi.

Confirmation of CMO Enrollment Response Time

 

vii.

Online Claims Adjudication Response Time

 

4.18.4

Quarterly Reporting

 

4.18.4.1

EPSDT Report

 

4.18.4.1.1

Pursuant to Section 4.7.6.1 the Contractor shall submit an EPSDT Report for Medicaid Members and PeachCare for Kids Members that identifies at a minimum the following:

 

i.

Number of Health Check eligible Members;

 

ii.

Number of live births;

 

iii.

Number of initial newborn visits within twenty-four (24) hours of birth;

 

iv.

Number of Members who received all scheduled EPSDT screenings in accordance with the periodicity schedule;

 

v.

Number of Members who received dental examinations services by an oral health professional;

 

vi.

Number of Members that received an initial health visit and screening within ninety (90) Calendar Days of Enrollment;

 

vii.

Number of diagnostic and treatment services, including Referrals; and

 

viii.

Number and rate of blood lead screening.

 

4.18.4.1.2

Reports shall capture Medicaid Members and PeachCare for Kids Members separately.

 

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4.18.4.1.3

DCH, at its sole discretion, may add additional data to the EPSDT Report if DCH determines that it is necessary for monitoring purposes.

 

4.18.4.2

Timely Access Report

 

4.18.4.2.1

Pursuant to Section 4.8.19.2 the Contractor shall submit Timely Access Reports that monitor the time lapsed between a Member’s initial request for an office appointment and the date of the appointment. These data for the Timely Access Reports may be collected using statistical sampling methods (including periodic Member and/or Provider surveys). The report shall include:

 

i.

Total number of appointment requests;

 

ii.

Total number of requests that meet the waiting time standards;

 

iii.

Total number of requests that exceed the waiting time standards; and

 

iv.

Average waiting time for those requests that exceed the waiting time standards. Information for items iii and iv shall be provided for each provider type/class.

 

4.18.4.3

Provider Complaints Report

 

4.18.4.3.1

Pursuant to Section 4.9.8.2 the Contractor shall submit a Provider Complaints Report that includes, at a minimum, the following:

 

i.

Number of complaints by type;

 

ii.

Type of assistance provided; and

 

iii.

Administrative disposition of the case.

 

4.18.4.4

FQHC Report

 

4.18.4.4.1

Pursuant to 4.10.5.1 the Contractor shall submit FQHC Payment Reports that that identify Contractor payments made to each FQHC and RHC for each Covered Services provided to Members.

 

4.18.4.5

Utilization Management Report

 

4.18.4.5.1

Pursuant to Section 4.11.10.1 the Contractor shall submit a Utilization Management Report on Utilization patterns and aggregate trend analysis. The Contractor shall also submit individual physician profiles to DCH. These Reports should provide to DCH analysis and

 

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interpretation of Utilization patterns, including but not limited to, high volume services, high risk services, services driving cost increases, including prescription drug utilization; Fraud and Abuse trends; and Quality and disease management. The Contractor shall provide ad hoc Reports pursuant to the requests of DCH. The Contractor shall submit its proposed reporting mechanism, including focus of study, data sources, etc. to DCH for approval.

 

4.18.4.5.2

Utilization Management Reports shall include an analysis of data and identification of opportunities for improvement and follow up of the effectiveness of the intervention. The reports shall include, at a minimum, the following data:

 

i.

Number of UM cases handled, by type;

 

ii.

Number of denials (medical/dental/behavioral health/pharmaceutical);

 

iii.

Number of appeals;

 

iv.

Monitoring of at least four (4) types of utilization data for over-utilization and under-utilization. This should be measured against an established threshold (length of stay, unplanned readmissions, procedure rates, member complaints, etc.)

 

4.18.4.5.3

The Contractor shall select three (3) of the following elements to monitor in its physician profiles. Each element should be measured against an established threshold.

 

i.

Member access (encounters per member per year, new patient visit within 6 months, ER use per member per year, etc.)

 

ii.

Preventive care (EPSDT rates, breast cancer screening rates, immunizations, etc.)

 

iii.

Disease management (asthma ER/IP encounters, HBA1C rates, etc.)

 

iv.

Pharmacy utilization (generics, asthma medications, etc.)

 

4.18.4.6

Quality Oversight Committee Report

 

4.18.4.6.1

Pursuant to Section 4.12.9.1 the Contractor shall submit a Quality Oversight Committee Report that shall include a summary of results, conclusions, recommendations and implemented system changes for the QAPI program.

 

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4.18.4.7

Fraud and Abuse Report

 

4.18.4.7.1

Pursuant to Section 4.13.4.1 the Contractor shall submit a Fraud and Abuse Report which shall include, at a minimum, the following:

 

i.

Source of complaint;

 

ii.

Alleged persons or entities involved;

 

iii.

Nature of complaint;

 

iv.

Approximate dollars involved;

 

v.

Date of the complaint;

 

vi.

Disciplinary action imposed;

 

vii.

Administrative disposition of the case;

 

viii.

Investigative activities, corrective actions, prevention efforts, and results; and

 

ix.

Trending and analysis as it applies to: Utilization Management; Claims management; post-processing review of Claims; and Provider profiling.

 

4.18.4.8

Grievance System Report

 

4.18.4.8.1

Pursuant to Section 4.14.8.1 the Contractor shall submit a summary of Grievance, Appeals and Administrative Law Hearing requests. The report shall, at a minimum, include the following:

 

i.

Number of complaints by type;

 

ii.

Type of assistance provided; and

 

iii.

Administrative disposition of the case.

 

4.18.4.9

Cost Avoidance Report

 

4.18.4.9.1

Pursuant to Section 8.6.1 the Contractor shall submit a Cost Avoidance Report that identifies all cost avoided claims for Members with third party coverage from private insurance carriers and other responsible third parties.

 

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4.18.4.10

Medical Loss Ratio Report

 

4.18.4.10.1

Pursuant to Section 8.6.2, the Contractor shall submit monthly, a Medical Loss Ratio report that captures medical expenses relative to capitation payments received on a cumulative year to date basis. The Medical Loss Ratio report shall include:

 

i.

Capitation payments received;

 

ii.

Medical expenses by provider grouping including, but not limited to:

 

a)

Direct payments to Providers for covered medical services;

 

b)

Capitated payments to providers; and

 

c)

Payments to subcontractors for covered benefits and services.

 

iii.

An Estimate of incurred but not reported IBNR expenses;

 

iv.

Actuarial certification that the report, including the estimate of IBNR, has been reviewed for accuracy; and

 

v.

Supporting claims lag tables by claim type.

 

4.18.4.11

Independent Audit and Income Statement

 

4.18.4.11.1

The Contractor shall submit to DOI:

 

i.

A quarterly report on the form prescribed by the National Association of Insurance Commissioners for Health Maintenance Organizations pursuant to Section 8.6.6; and

 

ii.

A quarterly income statement on the form prescribed by the NAIC for HMOs pursuant to Section 8.6.6.

 

4.18.5

Annual Reports

 

4.18.5.1

Performance Improvement Projects Reports

 

4.18.5.1.1

Pursuant to Section 4.12.9.2 the Contractor shall submit a Performance Improvement Projects Report that includes the study design, analysis, status and results on performance improvement projects. Status Reports on Performance Improvement Projects may be requested more frequently by DCH.

 

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4.18.5.2

Focused Studies Report

 

4.18.5.2.1

Pursuant to Section 4.12.9.3 the Contractor shall, on the first (1st) day of the fourth (4th) quarter of the first (1st) year of operations submit a Focus Studies Report that includes the study design, analysis and results for each of the two required focused studies. The Contractor shall submit annual Reports on the focused studies thereafter.

 

4.18.5.3

Patient Safety Reports

 

4.18.5.3.1

Pursuant to Section 4.12.9.4 the Contractor shall submit a Patient Safety Report that includes, at a minimum, the following:

 

i.

A system of classifying complaints according to severity;

 

ii.

Review by Medical Director and mechanism for determining which incidents will be forwarded to Peer Review and Credentials Committees; and

 

iii.

Summary of incident(s) included in Provider Profile.

 

4.18.5.4

Systems Refresh Plan

 

4.18.5.4.1

Pursuant to Section 4.17.1.6 the Contractor shall submit to DCH a Systems Refresh Plan no later than the 30th of April each year.

 

4.18.5.5

Independent Audit and Income Statement

 

4.18.5.5.1

The Contractor shall submit to DOI:

 

i.

An annual report on the form prescribed by the National Association of Insurance Commissioners (NAIC) for Health Maintenance Organizations pursuant to Section 8.6.6;

 

ii.

An annual income statement pursuant to Section 8.6.6; and

 

iii.

An annual audit of its business transactions pursuant to Section 8.6.6.

 

4.18.5.6

“SAS 70” Report

 

4.18.5.6.1

Pursuant to Section 8.6.4, the Contractor shall submit to DCH an annual SAS 70 Report conducted by an independent auditing firm. The first SAS 70 Report will be due in 2006 from Contractors

 

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operating in the Atlanta and Central Service Regions and in 2007 from Contractors operating in East, North, Southeast, and Southwest Service Regions.

 

4.18.5.7

Disclosure of Information on Annual Business Transactions

 

4.18.5.7.1

Pursuant to Section 8.6.5, the Contractor shall submit to DCH, in a format specified by DCH, an annual Disclosure of Information on Annual Business Transactions.

 

4.18.6

Ad Hoc Reports

 

4.18.6.1

State Quality Monitoring Reports

 

4.18.6.1.1

Pursuant to section 2.8.1 the Contractor shall report, upon request by DCH, information to support the State’s Quality Monitoring Functions in accordance with 42 CFR 438.204. These Reports shall include information on:

 

i.

The availability of services;

 

ii.

The adequacy of the Contractor’s capacity and services;

 

iii.

The Contractor’s coordination and continuity of care for Members;

 

iv.

The coverage and authorization of services;

 

v.

The Contractor’s policies and procedures for selection and retention of Providers;

 

vi.

The Contractor’s compliance with Member information requirements in accordance with 42CFR 438.10;

 

vii.

The Contractor’s compliance with 45 CFR relative to Member’s confidentiality;

 

viii.

The Contractor’s compliance with Member Enrollment and Disenrollment requirements and limitations;

 

ix.

The Contractor’s Grievance System;

 

x.

The Contractor’s oversight of all subcontractual relationships and delegations therein;

 

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xi.

The Contractor’s adoption of practice guidelines, including the dissemination of the guidelines to Providers and Provider’s application of them;

 

xii.

The Contractor’s quality assessment and performance improvement program; and

 

xiii.

The Contractor’s health information systems.

 

4.18.6.2

Provider Network Adequacy and Capacity Report

 

4.18.6.2.1

Pursuant to Section 4.8.19.1 the Contractor shall submit a Provider Network Adequacy and Capacity Report that demonstrates that the Contractor offers an appropriate range of preventive, Primary Care and specialty services that is adequate for the anticipated number of Members for the service area and that its network of Providers is sufficient in number, mix and geographic distribution to meet the needs of the anticipated number of Members in the service area.

 

4.18.6.2.2

This Provider Network Adequacy and Capacity Report shall list all Providers enrolled in the Contractor’s Provider network, including but not limited to, physicians, hospitals, FQHC/RHCs, home health agencies, pharmacies, Durable Medical Equipment vendors, behavioral health specialists, ambulance vendors, and dentists. Each Provider shall be identified by a unique identifying Provider number as specified in Section 4.8.1.4. This unique identifier shall appear on all Encounter Data transmittals. In addition to the listing, the Provider Network Adequacy and Capacity Report shall identify:

 

i.

Provider additions and deletions from the preceding month;

 

ii.

All OB/GYN Providers participating in the Contractor’s network, and those with open panels; and

 

iii.

List of Primary Care Providers with open panels.

 

4.18.6.2.3

The Reports shall be submitted to DCH at the following times:

 

i.

Sixty (60) Calendar Days after Contract Award and quarterly thereafter;

 

ii.

Upon DCH request;

 

iii.

Upon Enrollment of a new population in the Contractor’s plan; and

 

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iv.

Any time there has been a significant change in the Contractor’s operations that would affect adequate capacity and services. A significant change is defined as any of the following:

 

•

A decrease in the total number of PCPs by more than five percent (5%);

 

•

A loss of Providers in a specific specialty where another Provider in that specialty is not available within sixty (60) miles; or

 

•

A loss of a hospital in an area where another CMO plan hospital of equal service ability is not available within thirty (30) miles; or

 

•

Other adverse changes to the composition of the network which impair or deny the Members’ adequate access to CMO plan Providers.

 

4.18.6.3

Third Party Liability and Coordination of Benefits Report

 

4.18.6.3.1

Pursuant to Section 8.6.3 the Contractor shall submit a Third Party Liability and Coordination of Benefits Report that includes any Third Party Resources available to a Member discovered by the Contractor, in addition to those provided to the Contractor by DCH pursuant to Section 2.11.1, within ten (10) Business Days of verification of such information. The Contractor shall report any known changes to such resources in the same manner.

 

5.0	DELIVERABLES

 

5.1	CONFIDENTIALITY

 

5.1.1

The Contractor shall ensure that any Deliverables that contain information about individuals that is protected by confidentiality and privacy laws shall be prominently marked as “CONFIDENTIAL” and submitted to DCH in a manner that ensures that unauthorized individuals do not have access to the information. The Contractor shall not make public such reports. Failure to ensure confidentiality may result in sanctions and liquidated damages as described in Section 23.

 

5.2	NOTICE OF DISAPPROVAL

 

5.2.1

DCH will provide written notice of disapproval of a Deliverable to the Contractor within fourteen (14) Calendar Days of submission if it is disapproved.

 

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5.2.2

The notice of disapproval shall state the reasons for disapproval as specifically as is reasonably necessary and the nature and extent of the corrections required for meeting the Contract requirements.

 

5.3	RESUBMISSION WITH CORRECTIONS

 

5.3.1

Within fourteen (14) Calendar Days of receipt of a notice of disapproval, the Contractor shall make the corrections and resubmit the Deliverable.

 

5.4	NOTICE OF APPROVAL/DISAPPROVAL OF RESUBMISSION

 

5.4.1

Within thirty (30) Calendar Days following resubmission of any disapproved Deliverable, DCH will give written notice to the Contractor of approval, Conditional approval or disapproval.

 

5.5	DCH FAILS TO RESPOND

 

5.5.1

In the event that DCH fails to respond to a Contractor’s resubmission within the applicable time period, the Contractor may either:

 

5.5.1.1

Notify DCH in writing that it intends to proceed with subsequent work unless DCH provides written notice of disapproval within fourteen (14) Calendar Days from the date DCH receives the Contractor’s notice.

 

5.5.1.2

Notify DCH that it intends to delay subsequent work until DCH responds in writing to the resubmission.

 

5.6	REPRESENTATIONS

 

5.6.1

By submitting a Deliverable or report, the Contractor represents that to the best of its knowledge, it has performed the associated tasks in a manner that will, in concert with other tasks, meet the objectives stated or referred to in the Contract.

 

5.6.2

By approving a Deliverable or report, DCH represents only that it has reviewed the Deliverable or report and detected no errors or omissions of sufficient gravity to defeat or substantially threaten the attainment of those objectives and to warrant the Withholding or denial of payment for the work completed. DCH’S acceptance of a Deliverable or report does not discharge any of the Contractor’s Contractual obligations with respect to that Deliverable or report.

 

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5.7	CONTRACT DELIVERABLES

 

Deliverable		Contract Section		Due Date
PCP Auto-assignment Policies		4.1.2.3		Within 60 Calendar Days of Contract Award
Member Handbook		4.3.3.5		Within 60 Calendar Days of Contract Award
Provider Directory		4.3.5.3		Within 60 Calendar Days of Contract Award
Sample Member ID card		4.3.6.4		Within 60 Calendar Days of Contract Award
Telephone Hotline Policies and Procedures (Member and Provider)		4.3.7.3 4.9.6		Within 60 Calendar Days of Contract Award
Call Center Quality Criteria and Protocols		4.3.7.9 4.9.5.8		Within 60 Calendar Days of Contract Award
Web site Screenshots		4.3.8.5 4.9.6		60 Calendar Days prior to implementation of GHF
Cultural Competency Plan		4.3.9.3		Within 60 Calendar Days of Contract Award
Marketing Plan and Materials		4.4.3.1		Within 60 Calendar Days of Contract Award
Provider Marketing Materials		4.4.4.1		Within 60 Calendar Days of Contract Award
MH/SA Policies and Procedures		4.6.10		Within 60 Calendar Days of Contract Award
EPSDT policies and procedures		4.7.1.3		Within 60 Calendar Days of Contract Award
Provider Selection and Retention Policies and Procedures		4.8.1.5		Within 60 Calendar Days of Contract Award
Provider Network Listing spreadsheet for all requested Provider types and Provider Letters of Intent or executed Signature Pages of Provider Contracts not previously submitted as part of the RFP response		4.8.1.7		Within 60 Calendar Days of Contract Award

 

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Deliverable		Contract Section		Due Date
Final Provider Network Listing spreadsheet for all requested Provider types, Signature Pages for all Providers, and written acknowledgements from all Providers part of a PPO, IPO, or other network stating they know they are in the Contractor’s network, know they are accepting Medicaid patients, and are accepting the terms and conditions of the Provider Contract.		4.8.1.8		90 Calendar Days prior to implementation of GHF
PCP Selection Policies and Procedures		4.8.2.2		Within 60 Calendar Days of Contract Award
Credentialing and Re-Credentialing Policies and Procedures		4.8.13.4		Within 60 Calendar Days of Contract Award
Provider Handbook		4.9.2.4		Within 60 Calendar Days of Contract Award
Provider Training Manuals		4.9.3.2		Within 60 Calendar Days of Contract Award
Provider Complaint System Policies and Procedures		4.9.7.2		Within 60 Calendar Days of Contract Award
Utilization Management Policies and Procedures		4.11.1.2		Within 60 Calendar Days of Contract Award
Care Coordination and Case Management Policies and Procedures		4.11.8.3		Within 60 Calendar Days of Contract Award
Quality Assessment and Performance Improvement Plan		4.12.2.3		Within 90 Calendar Days of Contract Award
Proposed Performance Improvement Projects		4.12.3.7		Within 90 Calendar Days of Contract Award
Practice Guidelines		4.12.4.2		Within 90 Calendar Days of Contract Award
Focused Studies		4.12.5.2		1st day of the 4th Quarter of the 1st year
Patient Safety Plan		4.12.6.2		Within 90 Calendar Days of Contract Award
Program Integrity Policies and Procedures		4.13.1.2		Within 60 Calendar Days of Contract Award
Grievance System Policies and Procedures		4.14.1.2		Within 60 Calendar Days of Contract Award
Staff Training Plan		4.15.3.2		Within 90 Calendar Days of Contract Award

 

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Deliverable		Contract Section		Due Date
Implementation Plan		4.15.5.2		Within 60 Calendar Days of Contract Award
Payment Schedule		4.16.1.4		Within 60 Calendar Days of Contract Award
Business Continuity Plan		4.17		Within 60 Calendar Days of Contract Award
System Users Manuals and Guides		4.17		Within 60 Calendar Days of Contract Award
Information Management Policies and Procedures		4.17		Within 60 Calendar Days of Contract Award

 

5.8	CONTRACT REPORTS

 

Report		Contract Section		Due Date
Member Information Report		4.18.2.1		Weekly
Telephone and Internet Activity Report		4.18.2.2		Weekly
Eligibility and Enrollment Reconciliation Report		4.18.3.1		Monthly
Prior Authorization and Pre-Certification Report		4.18.3.2		Monthly
Claims Processing Report		4.18.3.4		Monthly
System Availability and Performance Report		4.18.3.4		Monthly
EPSDT Report		4.18.4.1		Quarterly
Timely Access Report		4.18.4.2		Quarterly
Provider Complaints Report		4.18.4.3		Quarterly
FQHC Report		4.18.4.4		Quarterly
Utilization Management Report		4.18.4.5		Quarterly
Quality Oversight Committee Report		4.18.4.6		Quarterly
Fraud and Abuse Report		4.18.4.7		Quarterly
Grievance System Report		4.18.4.8		Quarterly
Cost Avoidance and Post Payment Recovery Report		4.18.4.9		Quarterly
Medical Loss Ratio Report		4.18.4.10		Quarterly
Independent Audit and Income Statement		4.18.4.10		Quarterly
Performance Improvement Projects Report		4.18.5.1		Annually
Focused Studies Report		4.18.5.2		Annually
Patient Safety Report		4.18.5.3		Annually

 

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Independent Audit and Income Statement		4.18.5.4		Annually
“SAS 70” Report		4.18.5.5		Annually
Disclosure of Information on Annual Business Transactions		4.18.5.6		Annually
State Quality Monitoring Report		4.18.6.1		Upon request by DCH
Provider Network Adequacy and Capacity Report		4.18.6.2		Sixty Days after Contract Award; Quarterly; and Any time there is a significant change.
Third Party Liability and Coordination of Benefits Report		4.18.6.1.3		Within 10 Days of verification

 

6.0	TERM OF CONTRACT

 

6.1

This Contract shall begin on July 1, 2005 and shall continue until the close of the then current State fiscal year unless renewed as hereinafter provided. DCH is hereby granted six (6) options to renew this Contract for an additional term of up to one (1) State fiscal year, which shall begin on July 1, and end at midnight on June 30, of the following year, each upon the same terms, Conditions and Contractor’s price in effect at the time of the renewal. The option shall be exercisable solely and exclusively by DCH. As to each term, the Contract shall be terminated absolutely at the close of the then current State fiscal year without further obligation by DCH.

 

7.0	PAYMENT FOR SERVICES

 

7.1

DCH will compensate the Contractor a prepaid, per member per month capitation rate for each GCS Member enrolled in the Contractor’s plan. The number of enrolled Members in each rate cell category will be determined by the records maintained in the Medicaid Member Information System (MMIS) maintained by DCH's fiscal agent. The monthly compensation will be the final negotiated rate for each rate cell multiplied by the number of enrolled Members in each rate cell category. The Contractor must provide to DCH, and keep current, its tax identification number, billing address, and other contact information. Pursuant to the terms of this Contract, should DCH assess liquidated damages or other remedies or actions for noncompliance or deficiency with the terms of this Contract, such amount shall be withheld from the prepaid, monthly compensation for the following month, and for continuous consecutive months thereafter until such noncompliance or deficiency is corrected.

 

7.2	The relevant Deliverables shall be mailed to the Project Leader named in the Notice provision of this Contract.

 

7.3	The total of all payments made by DCH to Contractor under this Contract shall not exceed the per Member per month Capitation payments agreed to under Attachment

 

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H, which has been provided for through the use of State or federal grants or other funds. With the exception of payments provided to the Contractor in accordance with Section 7.4 on Performance Incentives, DCH will have no responsibility for payment beyond that amount. Also as specified in Section 7.4.2 the total of all payments to the Contract will not exceed one hundred and five percent (105%) of the Capitation payment pursuant to 42 CFR 438.6 (hereinafter the “maximum funds”). It is expressly understood that the total amount of payment to the Contractor will not exceed the maximum funds provided above, unless Contractor has obtained prior written approval, in the form of a Contract amendment, authorizing an increase in the total payment. Additionally, the Contractor agrees that DCH will not pay or otherwise compensate the Contractor for any work that it performs in excess of the Maximum Funds.

 

7.4	Performance Incentives

 

7.4.1

The Contractor may be eligible for financial performance incentives. In order to be eligible for the financial performance incentives described below the Contractor must be fully compliant in all areas of the Contract. All incentives must comply with the federal managed care Incentive Arrangement requirements pursuant to 42 CFR 438.6 and the State Medlcaid Manual 2089.3.

 

7.4.2

The total of all payments paid to the Contractor under this Contract shall not exceed one hundred and five percent (105%) of the Capitation payment pursuant to 42 CFR 438.6.

 

7.4.3

The amount of financial performance incentive and allocation methodology will be developed solely by DCH.

 

7.4.3.1

Health Check Screening Initiative

 

7.4.3.1.1

The Contractor may be eligible for a performance incentive payment if the Contractor’s performance exceeds the minimum compliance standard for Health Check visits.

 

7.4.3.1.2

The payment to the Contractor, if any, shall depend upon the percentage of Health Check well-child visits and screens achieved by the Contractor in excess of the minimum required compliance standard of eighty percent (80%). Payment shall be based on information obtained from Encounter Data.

 

7.4.3.2

Blood Lead Screening Test Incentive

 

7.4.3.2.1

Pursuant to the requirements outlined in Section 4.7.3.2, the Contractor may be eligible for a performance incentive payment if the Contractor’s performance exceeds the minimum compliance standard

 

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for blood lead screening tests provided to children age nine (9) months to thirty (30) months of age.

 

7.4.3.2.2

The payment to the Contractor, if any, shall depend upon the percentage of lead screening blood tests performed per unduplicated child during the Contract period, in excess of the minimum required compliance standard of eighty percent (80%) blood lead screening for children age nine (9) months to thirty (30) months of age. Payment shall be based on information obtained from Encounter Data.

 

7.4.3.3

Dental Visits Incentive

 

7.4.3.3.1

The Contractor may be eligible for financial performance incentives if the Contractor’s performance exceeds the minimum compliance standard for the provision of children’s dental services, as specified in Section 4.7.3.7, and as reported in Encounter Data. Dental services mean any dental service that is reported using a dental HCPC code or an ADA dental Claim form.

 

7.4.3.3.2

The payment to the Contractor, if any, shall be based on the percentage or number of visits achieved by the Contractor in excess of the minimum compliance standard of an eighty percent (80%) rate of Health Check eligible children receiving visits.

 

7.4.3.4

Newborn Enrollment Notification Incentive

 

7.4.3.4.1

Pursuant to the requirements outlined in Section 4.1.3 the Contractor may be eligible for financial incentive payments based on the Contractor’s compliance with newborn Enrollment notification to DCH. Minimum Contractor compliance with newborn Enrollment notification is notification to DCH within twenty-four (24) hours of the birth of each newborn.

 

7.4.3.4.2

The payment to the Contractor, if any, shall depend upon the number of newborn Enrollment notifications received by DCH within the first twelve (12) hours of the birth of the newborn.

 

7.4.3.5

EPSDT Tracking and Notices for Missed Appointments and Referrals

 

7.4.3.5.1

Pursuant to the requirements outlined in Section 4.7 the Contractor may be eligible for incentive payments based on the Contractor’s follow-up, in the form of a telephone call or second (2nd) notice, to Health Check eligible Members who have received an initial notice of missed screens.

 

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8.0	FINANCIAL MANAGEMENT

 

8.1	GENERAL PROVISIONS

 

8.1.1

The Contractor shall be responsible for the sound financial management of the CMO plan.

 

8.2	SOLVENCY AND RESERVES STANDARDS

 

8.2.1

The Contractor shall establish and maintain such net worth, working capital and financial reserves as required pursuant to O.C.G.A. § 33-21.

 

8.2.2

The Contractor shall provide assurances to the State that its provision against the risk of insolvency is adequate such that its Members shall not be liable for its debts in the event of insolvency.

 

8.2.3

As part of its accounting and budgeting function, the Contractor shall establish an actuarially sound process for estimating and tracking incurred but not reported costs. As part of its reserving process the Contractor shall conduct annual reviews to assess its reserving methodology and make adjustments as necessary.

 

8.3	REINSURANCE

 

8.3.1

DCH will not administer a Reinsurance program funded from capitation payment Withholding.

 

8.3.2

In addition to basic financial measures required by State law and discussed in section 8.2.1 and section 26, the Contractor shall meet financial viability standards. The Contractor shall maintain net equity (assets minus liability) equal to at least one (1) month’s capitation payments under this Contract. In addition, the Contractor shall maintain a current ratio (current assets/current liabilities) of greater than or equal to 1.0.

 

8.3.3

In the event the Contractor does not meet the minimum financial viability standards outlined in 8.3.2, the Contractor shall obtain Reinsurance that meets all DOI requirements. While commercial Reinsurance is not required, DCH recommends that Contractors obtain commercial Reinsurance rather than self-insuring.

 

8.4	THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS

 

8.4.1

Third party liability refers to any other health insurance plan or carrier (e.g., individual, group, employer-related, self-insured or self-funded, or commercial carrier, automobile insurance and worker’s compensation) or program, that is, or may be, liable to pay all or part of the Health Care expenses of the Member.

 

8.4.1.1

Pursuant to Section 1902(a)(25) of the Social Security Act and 42 CFR 433 Subpart D, DCH hereby authorizes the Contractor as its agent to identify and cost avoid Claims for all CMO plan Members, including PeachCare for Kids Members.

 

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8.4.1.2

The Contractor shall make reasonable efforts to determine the legal liability of third parties to pay for services furnished to CMO plan Members. To the extent permitted by State and federal law, the Contractor shall use Cost Avoidance processes to ensure that primary payments from the liable third party are identified, as specified below.

 

8.4.1.3

If the Contractor is unsuccessful in obtaining necessary cooperation from a Member to identify potential Third Party Resources after sixty (60) Calendar Days of such efforts, the Contractor may inform DCH, in a format to be determined by DCH, that efforts have been unsuccessful.

 

8.4.2

Cost Avoidance

 

8.4.2.1

The Contractor shall cost avoid all Claims or services that are subject to payment from a third party health insurance carrier, and may deny a service to a Member if the Contractor is assured that the third party health insurance carrier will provide the service, with the exception of those situations described below. However, if a third party health insurance carrier requires the Member to pay any cost-sharing amounts (e.g., copayment, coinsurance, deductible), the Contractor shall pay the cost sharing amounts. The Contractor’s liability for such cost sharing amounts shall not exceed the amount the Contractor would have paid under the Contractor’s payment schedule for the service.

 

8.4.2.2

Further, the Contractor shall not withhold payment for services provided to a Member if third party liability, or the amount of third party liability, cannot be determined, or if payment will not be available within sixty (60) Calendar Days.

 

8.4.2.3

The requirement of Cost Avoidance applies to all Covered Services except Claims for labor and delivery, including inpatient hospital care and postpartum care, prenatal services, preventive pediatric services, and services provided to a dependent covered by health insurance pursuant to a court order. For these services the Contractor shall ensure that services are provided without regard to insurance payment issues and must provide the service first. The Contractor shall then coordinate with DCH or it agent to enable DCH to recover payment from the potentially liable third party.

 

8.4.2.4

If the Contractor determines that third party liability exists for part or all of the services rendered, the Contractor shall:

 

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8.4.2.4.1

Notify Providers and supply third party liability data to a Provider whose Claim is denied for payment due to third party liability; and

 

8.4.2.4.2

Pay the Provider only the amount, if any, by which the Provider’s allowable Claim exceeds the amount of third party liability.

 

8.4.3

Compliance

 

8.4.3.1

DCH may determine whether the Contractor is in compliance with this Section by inspecting source documents for timeliness of billing and accounting for third party payments.

 

8.5	PHYSICIAN INCENTIVE PLAN

 

8.5.1

The Contractor may establish physician incentive plans pursuant to federal and State regulations, including 42 CFR 422.208 and 422.210, and 42 CFR 438.6.

 

8.5.2

The Contractor shall disclose any and all such arrangements to DCH, and upon request, to Members. Such disclosure shall include:

 

8.5.2.1

Whether services not furnished by the physician or group are covered by the incentive plan;

 

8.5.2.2

The type of Incentive Arrangement;

 

8.5.2.3

The percent of Withhold or bonus; and,

 

8.5.2.4

The panel size and if patients are pooled, the method used.

 

8.5.3

Upon request, the Contractor shall report adequate information specified by the regulations to DCH in order that DCH will adequately monitor the CMO plan.

 

8.5.4

If the Contractor’s physician incentive plan includes services not furnished by the physician/group, the Contractor shall: (1) ensure adequate stop loss protection to individual physicians, and must provide to DCH proof of such stop loss coverage, including the amount and type of stop loss; and (2) conduct annual Member surveys, with results disclosed to DCH, and to Members, upon request.

 

8.5.5

Such physician incentive plans may not provide for payment, either directly or indirectly, to a physician or physician group as an inducement to reduce or limit medically necessary services furnished to an individual.

 

8.6	REPORTING REQUIREMENTS

 

8.6.1

The Contractor shall submit to DCH quarterly Cost Avoidance Reports as described in Section 4.18.4.9.

 

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8.6.2

The Contractor shall submit to DCH quarterly Medical Loss Ratio Reports that detail direct medical expenditures for Members and premiums paid by the Contractor, as described in Section 4.18.4.10.

 

8.6.3

The Contractor shall submit to DCH Third Party Liability and Coordination of Benefits Reports within ten (10) Business Days of verification of available Third Party Resources to a Member, as described in Section 4.18.6.3. The Contractor shall report any known changes to such resources in the same manner.

 

8.6.4

The Contractor, at its sole expense, shall submit by May 15 (or a later date if approved by DCH) of each year a “Report on Controls Placed in Operation and Tests of Operating Effectiveness”, meeting all standards and requirements of the AICPA’s SAS 70, for the Contractor’s operations performed for DCH under the GHF Contract.

 

8.6.4.1

The audit shall be conducted by an independent auditing firm, which has prior SAS 70 audit experience. The auditor must meet all AICPA standards for independence. The selection of, and contract with the independent auditor shall be subject to the approval of DCH and the State Auditor. Since such audits are not intended to fully satisfy all auditing requirements of DCH, the State Auditor reserves the right to fully and completely audit at their discretion the Contractor’s operation, including all aspects which will have effect upon the DCH account, either on an interim audit basis or at the end of the State’s fiscal year. DCH also reserves the right to designate other auditors or reviewers to examine the Contractor’s operations and records for monitoring and/or stewardship purposes.

 

8.6.4.2

For a vendor with an operations start date of January 1, 2006, the 1st SAS 70 report is due for the period October 1, 2005, through March 31, 2006. This report will be due May 15, 2006. For a vendor with an operations start date of July 1, 2006, the first SAS 70 is due for the period April 1, 2006, through March 31, 2007. This report will be due May 15, 2007. For a vendor with an operations start date of December 1, 2006, the 1st SAS 70 report is due for the period September 1, 2006, through March 31, 2007. This report will be due May 15, 2007. It should be noted that some of the time periods for the SAS 70 report might apply prior to GHF activation. Subsequent years reports shall be due May 15 of each year and apply to the preceding twelve (12) month period April through March.

 

8.6.4.3

The independent auditing firm shall simultaneously deliver identical reports of its findings and recommendations to the Contractor and DCH within forty-five (45) Calendar Days after the close of each review period. The audit shall be conducted and the report shall be prepared in accordance with generally accepted auditing standards for such audits as defined in the publications of the AICPA, entitled “Statements on Auditing Standards” (SAS). In particular, both the “Statements on Auditing Standards Number 70-Reports on the

 

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Processing of Transactions by Service Organizations” and the AICPA Audit Guide, “Audit Guide of Service-Center-Produced Records” are to be used.

 

8.6.4.4

The Contractor shall respond to the audit findings and recommendations within thirty (30) Calendar Days of receipt of the audit and shall submit an acceptable proposed corrective action to DCH. The Contractor shall implement the corrective action plan within forty (40) Calendar Days of its approval by DCH.

 

8.6.5

The Contractor shall submit to DCH a “Disclosure of Information on Annual Business Transactions”. This report must include:

 

8.6.5.1

Definition of A Party in Interest – As defined in section 1318(b) of the Public Health Service Act, a party in interest is:

 

8.6.5.1.1

Any director, officer, partner, or employee responsible for management or administration of an HMO; any person who is directly or indirectly the beneficial owner of more than five percent (5%) of the equity of the HMO; any person who is the beneficial owner of a mortgage, deed of trust, note, or other interest secured by, and valuing more than five percent (5%) of the HMO; or, in the case of an HMO organized as a nonprofit corporation, an incorporator or Member of such corporation under applicable State corporation law;

 

8.6.5.1.2

Any organization in which a person described in section 8.6.5.1.1 is director, officer or partner; has directly or indirectly a beneficial interest of more than five percent (5%) of the equity of the HMO; or has a mortgage, deed of trust, note, or other interest valuing more than five percent (5%) of the assets of the HMO;

 

8.6.5.1.3

Any person directly or indirectly controlling, controlled by, or under common control with a HMO; or

 

8.6.5.1.4

Any spouse, child, or parent of an individual described in sections 8.6.5.1.1, Section 8.6.5.1.2, or Section 8.6.5.1.3.

 

8.6.5.2

Types of Transactions Which Must Be Disclosed – Business transactions which must be disclosed include:

 

8.6.5.2.1

Any sale, exchange or lease of any property between the HMO and a party in interest;

 

8.6.5.2.2

Any lending of money or other extension of credit between the HMO and a party in interest; and

 

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8.6.5.2.3

Any furnishing for consideration of goods, services (including management services) or facilities between the HMO and the party in interest. This does not include salaries paid to employees for services provided in the normal course of their employment;

 

8.6.5.3

The information which must be disclosed in the transactions listed in Section 8.6.5.2 between an HMO and a party of interest includes:

 

8.6.5.3.1

The name of the party in interest for each transaction;

 

8.6.5.3.2

A description of each transaction and the quantity or units involved;

 

8.6.5.3.3

The accrued dollar value of each transaction during the fiscal year; and

 

8.6.5.3.4

Justification of the reasonableness of each transaction.

 

8.6.6

The Contractor shall submit all necessary reports, documentation, to DOI as required by State law, which may include, but is not limited to the following:

 

8.6.6.1

Pursuant to State law and regulations, an annual report on the form prescribed by the National Association of Insurance Commissioners (NAIC) for HMOs, on or before March 1 of each calendar year.

 

8.6.6.2

An annual income statement detailing the Contractor’s fourth quarter and year to date earned revenue and incurred expenses as a result of this Contract on or before March 1 of each year. This annual income statement shall be accompanied by a Medical Loss Ratio report for the corresponding period and a reconciliation of the Medical Loss Ratio report to the annual NAIC filing on an accrual basis.

 

8.6.6.3

Pursuant to state law and regulations, a quarterly report on the form prescribed by the NAIC for HMOs filed on or before: May 15th for the first quarter of the year, August 15th for the second quarter of the year, and November 15th, for the third quarter of the year.

 

8.6.6.4

A quarterly income statement detailing the Contractor’s quarterly and year to date earned revenue and incurred expenses as a result of this contract filed on or before: May 15th, for the first quarter of the year, August 15th, for the second quarter of the year, and November 15th, for the third quarter of the year. Each quarterly income statement shall be accompanied by a Medical Loss Ratio report for the corresponding period and reconciliation of the Medical Loss Ratio report to the quarterly NAIC filing on an accrual basis.

 

8.6.6.5

An annual independent audit of its business transactions to be performed by a licensed and certified public accountant, in accordance with National Association of Insurance Commissioners Annual Statement Instructions

 

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regarding the Annual Audited Financial Report, including but not limited to the financial transactions made under this contract.

 

9.0	PAYMENT OF TAXES

 

9.1	Contractor will forthwith pay all taxes lawfully imposed upon it with respect to this Contract or any product delivered in accordance herewith. DCH makes no representation whatsoever as to the liability or exemption from liability of Contractor to any tax imposed by any governmental entity.

 

9.2	The Contractor shall remit the Quality Assessment fee, as provided for in O.C.G.A §31-8-170 et seq., in the manner prescribed by DCH.

 

10.0	RELATIONSHIP OF PARTIES

 

10.1

Neither Party is an agent, employee, or servant of the other. It is expressly agreed that the Contractor and any Subcontractors and agent, officers, and employees of the Contractor or any Subcontractor in the performance of this Contract shall act as independent contractors and not as officers or employees of DCH. The parties acknowledge, and agree, that the Contractor, its agent, employees, and servants shall in no way hold themselves out as agent, employees, or servants of DCH. It is further expressly agreed that this Contract shall not be construed as a partnership or joint venture between the Contractor or any Subcontractor and DCH.

 

11.0	INSPECTION OF WORK

 

11.1

DCH, the State Contractor, the Department of Health and Human Services, the General Accounting Office, the Comptroller General of the United States, if applicable, or their Authorized Representatives, shall have the right to enter into the premises of the Contractor and/or all Subcontractors, or such other places where duties under this Contract are being performed for DCH, to inspect, monitor or otherwise evaluate the services or any work performed pursuant to this Contract. All inspections and evaluations of work being performed shall be conducted with prior notice and during normal business hours. All inspections and evaluations shall be performed in such a manner as will not unduly delay work.

 

12.0	STATE PROPERTY

 

12.1

The Contractor agrees that any papers, materials and other documents that are produced or that result, directly or indirectly, from or in connection with the Contractor’s provision of the services under this Contract shall be the property of DCH upon creation of such documents, for whatever use that DCH deems

 

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appropriate, and the Contractor further agrees to execute any and all documents, or to take any additional actions that may be necessary in the future to effectuate this provision fully. In particular, if the work product or services include the taking of photographs or videotapes of individuals, the Contractor shall obtain the consent from such individuals authorizing the use by DCH of such photographs, videotapes, and names in conjunction with such use. Contractor shall also obtain necessary releases from such individuals, releasing DCH from any and all Claims or demands arising from such use.

 

12.2

The Contractor shall be responsible for the proper custody and care of any State-owned property furnished for the Contractor’s use in connection with the performance of this Contract. The Contractor will also reimburse DCH for its loss or damage, normal wear and tear excepted, while such property is in the Contractor’s custody or use.

 

13.0	OWNERSHIP AND USE OF DATA/ UPGRADES

 

13.1	OWNERSHIP AND USE OF DATA

 

13.1.1

All data created from information, documents, messages (verbal or electronic), Reports, or meetings involving or arising out of this Contract is owned by DCH, hereafter referred to as DCH Data. The Contractor shall make all data available to DCH, who will also provide it to CMS upon request. The Contractor is expressly prohibited from sharing or publishing DCH Data or any information relating to Medicaid data without the prior written consent of DCH. In the event of a dispute regarding what is or is not DCH Data, DCH’s decision on this matter shall be final and not subject to Appeal.

 

13.2	SOFTWARE AND OTHER UPGRADES

 

13.2.1

The Parties also understand and agree that any upgrades or enhancements to software programs, hardware, or other equipment, whether electronic or physical, shall be made at the Contractor’s expense only, unless the upgrade or enhancement is made at DCH’s request and solely for DCH’s use. Any upgrades or enhancements requested by and made for DCH’s sole use shall become DCH’s property without exception or limitation. The Contractor agrees that it will facilitate DCH’s use of such upgrade or enhancement and cooperate in the transfer of ownership, installation, and operation by DCH.

 

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14.0	CONTRACTOR STAFFING

 

14.1	STAFFING ASSIGNMENTS AND CREDENTIALS

 

14.1.1

The Contractor warrants and represents that all persons, including independent Contractors and consultants assigned by it to perform this Contract, shall be employees or formal agents of the Contractor and shall have the credentials necessary (i.e., licensed, and bonded, as required) to perform the work required herein. The Contractor shall include a similar provision in any contract with any Subcontractor selected to perform work hereunder. The Contractor also agrees that DCH may approve or disapprove the Contractor’s Subcontractors or its staff assigned to this Contract prior to the proposed staff assignment. DCH’s decision on this matter shall not be subject to Appeal.

 

14.1.2

In addition, the Contractor warrants that all persons assigned by it to perform work under this Contract shall be employees or authorized Subcontractors of the Contractor and shall be fully qualified, as required in the RFP and specified in the Contractor’s proposal and in this Contract, to perform the services required herein. Personnel commitments made in the Contractor’s proposal shall not be changed unless approved by DCH in writing. Staffing will include the named individuals at the levels of effort proposed.

 

14.1.3

The Contractor shall provide and maintain sufficient qualified personnel and staffing to enable the Deliverables to be provided in accordance with the RFP, the Contractor’s proposal and this Contract. The Contractor shall submit to DCH, within ninety (90) days of Contract award, a detailed staffing plan, including the employees and management for all CMO functions.

 

14.1.4

At a minimum, the Contractor shall provide the following staff:

 

14.1.4.1

An Executive Administrator who is a full-time administrator with clear authority over the general administration and implementation of the requirements detailed in this Contract.

 

14.1.4.2

A Medical Director who is a licensed physician in the State of Georgia. The Medical Director shall be actively involved in all major clinical program components of the CMO plan, shall be responsible for the sufficiency and supervision of the Provider network, and shall ensure compliance with federal, State and local reporting laws on communicable diseases, child abuse, neglect, etc.

 

14.1.4.3

A Quality Improvement/Utilization Director.

 

14.1.4.4

A Chief Financial Officer who oversees all budget and accounting systems.

 

14.1.4.5

An Information Management and Systems Director and a complement of technical analysts and business analysts as needed to maintain the operations of Contractor Systems and to address System issues in accordance with the terms of this contract.

 

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14.1.4.6

A Pharmacist who is licensed in the State of Georgia;

 

14.1.4.7

A Dental Consultant who is a licensed dentist in the State of Georgia.

 

14.1.4.8

A Mental Health Coordinator who is a licensed mental health professional in the State of Georgia.

 

14.1.4.9

A Member Services Director.

 

14.1.4.10

A Provider Services Director.

 

14.1.4.11

A Provider Relations Liaison.

 

14.1.4.12

A Grievance/Complaint Coordinator.

 

14.1.4.13

Compliance Officer.

 

14.1.4.14

A Prior Authorization/Pre-Certification Coordinator who is a physician, registered nurse, or physician’s assistant licensed in the State of Georgia.

 

14.1.4.15

Sufficient staff in all departments, including but not limited to, Member services, Provider services, and prior authorization and concurrent review services to ensure appropriate functioning in all areas.

 

14.1.5

The Contractor shall conduct on-going training of staff in all departments to ensure appropriate functioning in all areas.

 

14.1.6

The Contractor shall comply with all staffing/personnel obligations set out in the RFP and this Contract, including but not limited to those pertaining to security, health, and safety issues.

 

14.2	STAFFING CHANGES

 

14.2.1

The Contractor shall notify DCH in the event of any changes to key staff, including the Executive Administrator, Medical Director, Quality Improvement/Utilization Director, Management Information Systems Director, and Chief Financial Officer. The Contractor shall replace any of the key staff with a person of equivalent experience, knowledge and talent.

 

14.2.2

DCH also may require the removal or reassignment of any Contractor employee or Subcontractor employee that DCH deems to be unacceptable. DCH’s decision on this matter shall not be subject to Appeal. Notwithstanding the above provisions, the Parties acknowledge and agree that the Contractor may terminate any of its employees designated to perform work or services under this Contract, as permitted by applicable law. In the event of Contractor termination of any key staff identified in 14.1.4, the Contractor shall provide DCH with immediate notice of the termination,

 

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the reason(s) for the termination, and an action plan for replacing the discharged employee.

 

14.3	CONTRACTOR’S FAILURE TO COMPLY

 

14.3.1

Should the Contractor at any time: 1) refuse or neglect to supply adequate and competent supervision; 2) refuse or fail to provide sufficient and properly skilled personnel, equipment, or materials of the proper quality or quantity; 3) fail to provide the services in accordance with the timeframes, schedule or dates set forth in this Contract; or 4) fail in the performance of any term or condition contained in this Contract, DCH may (in addition to any other contractual, legal or equitable remedies) proceed to take any one or more of the following actions after five (5) Calendar Days written notice to the Contractor:

 

14.3.1.1

Withhold any monies then or next due to the Contractor;

 

14.3.1.2

Obtain the services or their equivalent from a third party, pay the third party for same, and Withhold the amount so paid to third party from any money then or thereafter due to the Contractor; or

 

14.3.1.3

Withhold monies in the amount of any damage caused by any deficiency or delay in the services.

 

15.0	CRIMINAL BACKGROUND CHECKS

 

15.1	The Contractor shall, upon request, provide DCH with a resume or satisfactory criminal background check or both of any Members of its staff or a Subcontractor’s staff assigned to or proposed to be assigned to any aspect of the performance of this Contract.

 

16.0	SUBCONTRACTS

 

16.1	USE OF SUBCONTRACTORS

 

16.1.1

The Contractor will not subcontract or permit anyone other than Contractor personnel to perform any of the work, services, or other performances required of the Contractor under this Contract, or assign any of its rights or obligations hereunder, without the prior written consent of DCH. Prior to hiring or entering into an agreement with any Subcontractor, any and all Subcontractors shall be approved by DCH. DCH reserves the right to inspect all subcontract agreements at any time during the Contract period. Upon request from DCH the Contractor shall provide in writing the names of all proposed or actual Subcontractors. The Contractor is solely accountable for all functions and responsibilities contemplated and required by this

 

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Contract, whether the Contractor performs the work directly or through a Subcontractor.

 

16.1.2

All contracts between the Contractor and Subcontractors must be in writing and must specify the activities and responsibilities delegated to the Subcontractor. The contracts must also include provisions for revoking delegation or imposing other sanctions if the Subcontractor’s performance is inadequate.

 

16.1.3

All contracts must ensure that the Contractor evaluates the prospective Subcontractor’s ability to perform the activities to be delegated; monitors the Subcontractor’s performance on an ongoing basis and subjects it to formal review according to a periodic schedule established by DCH and consistent with industry standards or State laws and regulations; and identifies deficiencies or areas for improvement and that corrective action is taken.

 

16.1.4

The Contractor shall give DCH immediate notice in writing by registered mail or certified mail of any action or suit filed by any Subcontractor and prompt notice of any Claim made against the Contractor by any Subcontractor or vendor that, in the opinion of Contractor, may result in litigation related in any way to this Contract.

 

16.1.5

All Subcontractors must fulfill the requirements of 42 CFR 438.6 as appropriate.

 

16.1.6

All Provider contracts shall be in compliance with the requirements and provisions as set forth in Section 4.10 of this Contract.

 

16.2	COST OR PRICING BY SUBCONTRACTORS

 

16.2.1

The Contractor shall submit, or shall require any Subcontractors hereunder to submit, cost or pricing data for any subcontract to this Contract prior to award. The Contractor shall also certify that the information submitted by the Subcontractor is, to the best of their knowledge and belief, accurate, complete and current as of the date of agreement, or the date of the negotiated price of the subcontract to the Contract or amendment to the Contract. The Contractor shall insert the substance of this Section in each subcontract hereunder.

 

16.2.2

If DCH determines that any price, including profit or fee negotiated in connection with this Contract, or any cost reimbursable under this Contract was increased by any significant sum because of the inaccurate cost or pricing data, then such price and cost shall be reduced accordingly and this Contract and the subcontract shall be modified in writing to reflect such reduction.

 

17.0	LICENSE, CERTIFICATE, PERMIT REQUIREMENT

 

17.1	The Contractor warrants that it is qualified to do business in the State and is not prohibited by its articles of incorporation, bylaws or the law of the State under which

 

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it is incorporated from performing the services under this Contract. The Contractor shall have and maintain a Certificate of Authority pursuant to O.C.G.A. §33-21, and shall obtain and maintain in good standing any Georgia-licenses, certificates and permits, whether State or federal, that are required prior to and during the performance of work under this Contract. Loss of the licenses certificates and permits, and Certificate of Authority for health maintenance organizations shall be cause for termination of the Contract pursuant to Section 22 of this Contract. In the event the Certificate of Authority, or any other license or permit is canceled, revoked, suspended or expires during the term of this Contract, the Contractor shall inform the State immediately and cease all activities under this Contract, until further instruction from DCH. The Contractor agrees to provide DCH with certified copies of all licenses, certificates and permits necessary upon request.

 

17.2

The Contractor shall be accredited by the National Committee for Quality Assurance (NCQA) for MCO, URAC (Health Plan accreditation), Accreditation Association for Ambulatory Health Care (AAAHC) for MCO, or Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for MCO, or shall be actively seeking and working towards such accreditation. The Contractor shall provide to DCH upon request any and all documents related to achieving such accreditation and DCH shall monitor the Contractor’s progress towards accreditation. DCH may require that the Contractor achieve such accreditation by year three of this Contract.

 

18.0	RISK OR LOSS AND REPRESENTATIONS

 

18.1	DCH takes no title to any of the Contractor’s goods used in providing the services and/or Deliverables hereunder and the Contractor shall bear all risk of loss for any goods used in performing work pursuant to this Contract.

 

18.2	The Parties agree that DCH may reasonably rely upon the representations and certifications made by the Contractor, including those made by the Contractor in the Contractor’s response to the RFP and this Contract, without first making an independent investigation or verification.

 

18.3	The Parties also agree that DCH may reasonably rely upon any audit report, summary, analysis, certification, review, or work product that the Contractor produces in accordance with its duties under this Contract, without first making an independent investigation or verification.

 

19.0	PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES

 

19.1	The Contractor, in the performance of this Contract, shall not offer or give, directly or indirectly, to any employee or agent of the State, any gift, money or anything of value, or any promise, obligation, or contract for future reward or compensation at

 

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any time during the term of this Contract, and shall comply with the disclosure requirements set forth in O.C.G.A. § 45-1-6.

 

19.2

The Contractor also states and warrants that it has complied with all disclosure and registration requirements for vendor lobbyists as set forth in O.C.G.A. § 21-5-1, et. seq. and all other applicable law, including but not limited to registering with the State Ethics Commission. In addition, the Contractor states and warrants that no federal money has been used for any lobbying of State officials, as required under applicable federal law. For the purposes of this Contract, vendor lobbyists are those who lobby State officials on behalf of businesses that seek a contract to sell goods or services to the State or oppose such contract.

 

20.0	RECORDS REQUIREMENTS

 

20.1	GENERAL PROVISIONS

 

20.1.1

The Contractor agrees to maintain books, records, documents, and other evidence pertaining to the costs and expenses of this Contract to the extent and in such detail as will properly reflect all costs for which payment is made under the provisions of this Contract and/or any document that is a part of this Contract by reference or inclusion. The Contractor’s accounting procedures and practices shall conform to generally accepted accounting principles, and the costs properly applicable to the Contract shall be readily ascertainable.

 

20.2	RECORDS RETENTION REQUIREMENTS

 

20.2.1

The Contractor shall preserve and make available all of its records pertaining to the performance under this Contract for a period of seven (7) years from the date of final payment under this Contract, and for such period, if any, as is required by applicable statute or by any other section of this Contract. If the Contract is completely or partially terminated, the records relating to the work terminated shall be preserved and made available for period of seven (7) years from the date of termination or of any resulting final settlement. Records that relate to Appeals, litigation, or the settlements of Claims arising out of the performance of this Contract, or costs and expenses of any such agreements as to which exception has been taken by the State Contractor or any of his duly Authorized Representatives, shall be retained by Contractor until such Appeals, litigation, Claims or exceptions have been disposed of.

 

20.3	ACCESS TO RECORDS

 

20.3.1

The State and federal standards for audits of DCH agents, contractors, and programs are applicable to this section and are incorporated by reference into this Contract as though fully set out herein.

 

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20.3.2

Pursuant to the requirements of 42 CFR 434.6(a)(5) and 42 CFR 434.38, the Contractor shall make all of its books, documents, papers, Provider records, Medical Records, financial records, data, surveys and computer databases available for examination and audit by DCH, the State Attorney General, the State Health Care Fraud Control Unit, the State Department of Audits, or authorized State or federal personnel. Any records requested hereunder shall be produced immediately for on-site review or sent to the requesting authority by mail within fourteen (14) Calendar Days following a request. All records shall be provided at the sole cost and expense of the Contractor. DCH shall have unlimited rights to use, disclose, and duplicate all information and data in any way relating to this Contract in accordance with applicable State and federal laws and regulations.

 

20.4	MEDICAL RECORD REQUESTS

 

20.4.1

The Contractor shall ensure a copy of the Member’s Medical Record is made available, without charge, upon the written request of the Member or Authorized Representative within fourteen (14) Calendar Days of the receipt of the written request.

 

20.4.2

The Contractor shall ensure that Medical Records are furnished at no cost to a new PCP, Out-of-Network Provider or other specialist, upon Member’s request, no later than fourteen (14) Calendar Days following the written request.

 

21.0	CONFIDENTIALITY REQUIREMENTS

 

21.1	GENERAL CONFIDENTIALITY REQUIREMENTS

 

21.1.1

The Contractor shall treat all information, including Medical Records and any other health and Enrollment information that identifies a particular Member or that is obtained or viewed by it or through its staff and Subcontractors performance under this Contract as confidential information, consistent with the confidentiality requirements of 45 CFR parts 160 and 164. The Contractor shall not use any information so obtained in any manner, except as may be necessary for the proper discharge of its obligations. Employees or authorized Subcontractors of the Contractor who have a reasonable need to know such information for purposes of performing their duties under this Contract shall use personal or patient information, provided such employees and/or Subcontractors have first signed an appropriate non-disclosure agreement that has been approved and maintained by DCH. The Contractor shall remove any person from performance of services hereunder upon notice that DCH reasonably believes that such person has failed to comply with the confidentiality obligations of this Contract. The Contractor shall replace such removed personnel in accordance with the staffing requirements of this Contract. DCH, the Georgia Attorney General, federal officials as authorized by federal law or regulations, or the Authorized Representatives of these parties shall have access to all

 

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confidential information in accordance with the requirements of State and federal laws and regulations.

 

21.2	HIPAA COMPLIANCE

 

21.2.1

The Contractor shall assist DCH in its efforts to comply with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and its amendments, rules, procedures, and regulations. To that end, the Contractor shall cooperate and abide by any requirements mandated by HIPAA or any other applicable laws. The Contractor acknowledges that HIPAA may require the Contractor and DCH to sign a business associate agreement or other documents for compliance purposes, including but not limited to a business associate agreement. The Contractor shall cooperate with DCH on these matters and sign whatever documents may be required for HIPAA compliance and bide by their terms and conditions.

 

22.0	TERMINATION OF CONTRACT

 

22.1	GENERAL PROCEDURES

 

22.1.1

This Contract may terminate, or may be terminated, by DCH for any or all of the following reasons:

 

22.1.1.1

Default by the Contractor, upon thirty (30) Calendar Days notice;

 

22.1.1.2

Convenience of DCH, upon thirty (30) Calendar Days notice;

 

22.1.1.3

Immediately, in the event of insolvency, Contract breach, or declaration of bankruptcy by the Contractor; or

 

22.1.1.4

Immediately, when sufficient appropriated funds no longer exist for the payment of DCH’s obligation under this Contract.

 

22.2	TERMINATION BY DEFAULT

 

22.2.1

In the event DCH determines that the Contractor has defaulted by failing to carry out the substantive terms of this Contract or failing to meet the applicable requirements in 1932 and 1903(m) of the Social Security Act, DCH may terminate the Contract in addition to or in lieu of any other remedies set out in this Contract or available by law.

 

22.2.2

Prior to the termination of this Contract, DCH will:

 

22.2.2.1

Provide written notice of the intent to terminate at least thirty (30) Calendar Days prior to the termination date, the reason for the termination, and the time

 

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and place of a hearing to give the Contractor an opportunity to Appeal the determination and/or cure the default;

 

22.2.2.2

Provide written notice of the decision affirming or reversing the proposed termination of the Contract, and for an affirming decision, the effective date of the termination; and

 

22.2.2.3

For an affirming decision, give Members or the Contractor notice of the termination and information consistent with 42 CFR 438.10 on their options for receiving Medicaid services following the effective date of termination.

 

22.3	TERMINATION FOR CONVENIENCE

 

22.3.1

DCH may terminate this Contract for convenience and without cause upon thirty (30) Calendar Days written notice. Termination for convenience shall not be a breach of the Contract by DCH. The Contractor shall be entitled to receive, and shall be limited to, just and equitable compensation for any satisfactory authorized work performed as of the termination date. Availability of funds shall be determined solely by DCH.

 

22.4	TERMINATION FOR INSOLVENCY OR BANKRUPTCY

 

22.4.1

The Contractor’s insolvency, or the Contractor’s filing of a petition in bankruptcy, shall constitute grounds for termination for cause. In the event of the filing of a petition in bankruptcy the Contractor shall immediately advise DCH. If DCH reasonably determines that the Contractor’s financial condition is not sufficient to allow the Contractor to provide the services as described herein in the manner required by DCH, DCH may terminate this Contract in whole or in part, immediately or in stages. The Contractor’s financial condition shall be presumed not sufficient to allow the Contractor to provide the services described herein, in the manner required by DCH if the Contractor can not demonstrate to DCH’s satisfaction that the Contractor has risk reserves and a minimum net worth sufficient to meet the statutory standards for licensed health care plans. The Contractor shall cover continuation of services to Members for the duration of period for which payment has been made, as well as for inpatient admissions up to discharge.

 

22.5	TERMINATION FOR INSUFFICIENT FUNDING

 

22.5.1

In the event that federal and/or State funds to finance this Contract become unavailable, DCH may terminate the Contract in writing with thirty (30) Calendar Days notice to the Contractor. The Contractor shall be entitled to receive, and shall be limited to, just and equitable compensation for any satisfactory authorized work performed as of the termination date. Availability of funds shall be determined solely by DCH.

 

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22.6	TERMINATION PROCEDURES

 

22.6.1

DCH will issue a written notice of termination to the Contractor by certified mail, return receipt requested, or in person with proof of delivery. The notice of termination shall cite the provision of this Contract giving the right to terminate, the circumstances giving rise to termination, and the date on which such termination shall become effective. Termination shall be effective at 11:59 p.m. EST on the termination date.

 

22.6.2

Upon receipt of notice of termination or on the date specified in the notice of termination and as directed by DCH, the Contractor shall:

 

22.6.2.1

Stop work under the Contract on the date and to the extent specified in the notice of termination;

 

22.6.2.2

Place no further orders or Subcontract for materials, services, or facilities, except as may be necessary for completion of such portion of the work under the Contract as is not terminated

 

22.6.2.3

Terminate all orders and Subcontracts to the extent that they relate to the performance of work terminated by the notice of termination;

 

22.6.2.4

Assign to DCH, in the manner and to the extent directed by the Contract Administrator, all of the right, title, and interest of Contractor under the orders or subcontracts so terminated, in which case DCH will have the right, at its discretion, to settle or pay any or all Claims arising out of the termination of such orders and Subcontracts;

 

22.6.2.5

With the approval of the Contract Administrator, settle all outstanding liabilities and all Claims arising out of such termination or orders and subcontracts, the cost of which would be reimbursable in whole or in part, in accordance with the provisions of the Contract;

 

22.6.2.6

Complete the performance of such part of the work as shall not have been terminated by the notice of termination;

 

22.6.2.7

Take such action as may be necessary, or as the Contract Administrator may direct, for the protection and preservation of any and all property or information related to the Contract that is in the possession of Contractor and in which DCH has or may acquire an interest;

 

22.6.2.8

Promptly make available to DCH, or another CMO plan acting on behalf of DCH, any and all records, whether medical or financial, related to the Contractor’s activities undertaken pursuant to this Contractor. Such records shall be provided at no expense to DCH;

 

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22.6.2.9

Promptly supply all information necessary to DCH, or another CMO plan acting on behalf of DCH, for reimbursement of any outstanding Claims at the time of termination; and

 

22.6.2.10

Submit a termination plan to DCH for review and approval that includes the following terms:

 

22.6.2.10.1

Maintain Claims processing functions as necessary for ten (10) consecutive months in order to complete adjudication of all Claims;

 

22.6.2.10.2

Comply with all duties and/or obligations incurred prior to the actual termination date of the Contract, including but not limited to, the Appeal process as described in Section 4.14;

 

22.6.2.10.3

File all Reports concerning the Contractor’s operations during the term of the Contract in the manner described in this Contract;

 

22.6.2.10.4

Ensure the efficient and orderly transition of Members from coverage under this Contract to coverage under any new arrangement developed by DCH in accordance with procedures set forth in Section 4:11.4;

 

22.6.2.10.5

Maintain the financial requirements, and insurance set forth in this Contract until DCH provides the Contractor written notice that all continuing obligations of this Contract have been fulfilled; and

 

22.6.2.10.6

Submit Reports to DCH every thirty (30) Calendar Days detailing the Contractor’s progress in completing its continuing obligations under this Contract until completion.

 

22.6.3

Upon completion of these continuing obligations, the Contractor shall submit a final report to DCH describing how the Contractor has completed its continuing obligations. DCH will advise, within twenty (20) Calendar Days of receipt of this report, if all of the Contractor’s obligations are discharged. If DCH finds that the final report does not evidence that the Contractor has fulfilled its continuing obligations, then DCH will require the Contractor to submit a revised final report to DCH for approval.

 

22.7	TERMINATION CLAIMS

 

22.7.1

After receipt of a notice of termination, the Contractor shall submit to the Contract Administrator any termination claim in the form, and with the certification prescribed by, the Contract Administrator. Such claim shall be submitted promptly but in no event later than ten (10) months from the effective date of termination. Upon failure of the Contractor to submit its termination claim within the time allowed, the Contract Administrator may, subject to any review required by the State procedures in effect as of the date of execution of the Contract, determine, on the basis of information

 

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available, the amount, if any, due to the Contractor by reason of the termination and shall thereupon cause to be paid to the Contractor the amount so determined.

 

22.7.2

Upon receipt of notice of termination, the Contractor shall have no entitlement to receive any amount for lost revenues or anticipated profits or for expenditures associated with this Contract or any other contract. Upon termination the Contractor shall be paid in accordance with the following:

 

22.7.2.1

At the Contract price(s) for completed Deliverables and/or services delivered to and accepted by DCH; and/or

 

22.7.2.2

At a price mutually agreed upon by the Contractor and DCH for partially completed Deliverables and/or services.

 

22.7.3

In the event the Contractor and DCH fail to agree in whole or in part as to the amounts with respect to costs to be paid to the Contractor in connection with the total or partial termination of work pursuant to this article, DCH will determine, on the basis of information available, the amount, if any, due to the Contractor by reason of termination and shall pay to the Contractor the amount so determined.

 

23.0	LIQUIDATED DAMAGES

 

23.1	GENERAL PROVISIONS

 

23.1.1

In the event the Contractor fails to meet the terms, conditions, or requirements of this Contract and financial damages are difficult or impossible to ascertain exactly, the Contractor agrees that DCH may assess liquidated damages, not penalties, against the Contractor for the deficiencies. The Parties further acknowledge and agree that the specified liquidated damages are reasonable and the result of a good faith effort by the Parties to estimate the actual harm caused by the Contractor’s breach. The Contractor’s failure to meet the requirements in this Contract will be divided into four (4) categories of events.

 

23.1.2

Notwithstanding any sanction or liquidated damages imposed upon the Contractor other than Contract termination, the Contractor shall continue to provide all Covered Services and care management.

 

23.2	CATEGORY 1

 

23.2.1

Liquidated damages up to $100,000 per violation may be imposed for Category 1 events. For Category 1 events, the Contractor shall submit a written corrective action plan to DCH for review and approval prior to implementing the corrective action. Category 1 events will be monitored by DCH to determine compliance and shall include and constitute the following:

 

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23.2.1.1

Acts that discriminate among Members on the basis of their health status or need for health care services; and

 

23.2.1.2

Misrepresentation of actions or falsification of information furnished to CMS or the State.

 

23.2.1.3

Failure to implement requirements stated in the Contractor’s proposal, the RFP, this Contract, or other material failures in the Contractor’s duties.

 

23.3	CATEGORY 2

 

23.3.1

Liquidated damages up to $25,000 per violation may be imposed for the Category 2 events. For Category 2 events, the Contractor shall submit a written corrective action plan to DCH for review and approval prior to implementing the corrective action. Category 2 events will be monitored by DCH to determine compliance and include the following:

 

23.3.1.1

Substantial failure to provide medically necessary services that the Contractor is required to provide under law, or under this Contract, to a Member covered under this Contract;

 

23.3.1.2

Misrepresentation or falsification of information furnished to a Member, Potential Member, or health care Provider;

 

23.3.1.3

Failure to comply with the requirements for physician incentive plans, as set forth in 42 CFR 422.208 and 422.210;

 

23.3.1.4

Distribution directly, or indirectly, through any Agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information;

 

23.3.1.5

Violation of any other applicable requirements of section 1903(m) or 1932 of the Social Security Act and any implementing regulations;

 

23.3.1.6

Failure of the Contractor to assume full operation of its duties under this Contract in accordance with the transition timeframes specified herein;

 

23.3.1.7

Imposition of premiums or charges on Members that are in excess of the premiums or charges permitted under the Medicaid program (the State will deduct the amount of the overcharge and return it to the affected Member).

 

23.3.1.8

Failure to resolve Member Appeals and Grievances within the timeframes specified in this Contract;

 

23.3.1.9

Failure to ensure client confidentiality in accordance with 45 CFR 160 and 164; and

 

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23.3.1.10

Violation of a subcontracting requirement in the Contract.

 

23.4	CATEGORY 3

 

23.4.1

Liquidated damages up to $5,000.00 per day may be imposed for Category 3 events. For Category 3 events, a written corrective action plan may be required and corrective action must be taken. In the case of Category 3 events, if corrective action is taken within four (4) Business Days, then liquidated damages may be waived at the discretion of DCH. Category 3 events will be monitored by DCH to determine compliance and shall include the following:

 

23.4.1.1

Failure to submit required Reports and Deliverables in the timeframes prescribed in Section 4.18 and Section 5.7;

 

23.4.1.2

Submission of incorrect or deficient Deliverables or Reports as determined by DCH;

 

23.4.1.3

Failure to comply with the Claims processing standards as follows:

 

23.4.1.3.1

Failure to process and finalize to a paid or denied status ninety-seven percent (97%) of all Clean Claims within fifteen (15) Business Days during a fiscal year;

 

23.4.1.3.2

Failure to process and finalize to a paid or denied status ninety-nine percent (99%) of all Clean Claims within thirty (30) Business Days of receipt during a fiscal year; and

 

23.4.1.3.3

Failure to pay Providers interest at an eighteen percent (18%) annual rate, calculated daily for the full period during which a clean, unduplicated Claim is not adjudicated within the claims processing deadlines.

 

23.4.1.4

Failure to comply with the EPSDT initial health visit and screening requirements for Health Check eligibles within sixty (60) Calendar Days as described in Section 4.7.

 

23.4.1.5

Failure to comply with the EPSDT periodicity schedule for eighty percent (80%) of Health Check eligibles as described Section 4.7.

 

23.4.1.6

Failure to provide an initial visit within fourteen (14) Calendar Days for all newly enrolled women who are pregnant in accordance with Sections 4.6.9.1 and 4.8.13.4.

 

23.4.1.7

Failure to comply with the Notice of Proposed Action and Notice of Adverse Action requirements as described in Sections 4.14.3 and 4.14.5.

 

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23.4.1.8

Failure to comply with any corrective action plans as required by DCH.

 

23.4.1.9

Failure to seek, collect and/or report third party information as described in Section 8.4.

 

23.4.1.10

Failure to comply with the Contractor staffing requirements as described in Section 14.3.

 

23.4.1.11

Failure of Contractor to issue written notice to Members upon Provider’s notice of termination in the Contractor’s plan as described in Sections 4.8.17.3 and 4.8.17.4.

 

23.4.1.12

Failure to comply with federal law regarding sterilizations, hysterectomies, and abortions and as described in Section 4.6.5.

 

23.5	CATEGORY 4

 

23.5.1

Liquidated damages as specified below may be imposed for Category 4 events. Imposition of liquidated damages will not relieve the Contractor from submitting and implementing corrective action plans or corrective action as determined by DCH. Category 4 events will be monitored by DCH to determine compliance and include the following:

 

23.5.1.1

Failure to implement the business continuity-disaster recovery (BC-DR) plan as follows:

 

23.5.1.1.1

Implementation of the (BC-DR) plan exceeds the proposed time by two (2) or less Calendar Days: five thousand dollars ($5,000) per day up to day 2;

 

23.5.1.1.2

Implementation of the (BC-DR) plan exceeds the proposed time by more than (2) and up to five (5) Calendar Days: ten thousand dollars ($10,000) per each day beginning with Day 3 and up to Day 5;

 

23.5.1.1.3

Implementation of the (BC-DR) plan exceeds the proposed time by more than five (5) and up to ten (10) Calendar Days, twenty-five thousand dollars ($25,000) per day beginning with Day 6 and up to Day 10; and

 

23.5.1.1.4

Implementation of the (BC-DR) plan exceeds the proposed time by more than ten (10) Calendar Days: fifty thousand dollars ($50,000) per each day beginning with Day 11.

 

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23.5.1.2

Unscheduled System Unavailability (other than CCE and ECM functions described below) occurring during a continuous five (5) Business Day period, may be assessed as follows:

 

23.5.1.2.1

Greater than or equal to two (2) and less than twelve (12) hours cumulative: up to one hundred twenty-five dollars ($125) for each thirty (30) minutes or portions thereof;

 

23.5.1.2.2

Greater than or equal to twelve (12) and less than twenty-four (24) hours cumulative: up to two hundred fifty dollars ($250) for each thirty (30) minutes or portions thereof; and

 

23.5.1.2.3

Greater than or equal to twenty-four (24) hours cumulative: up to five hundred dollars ($500) for each thirty (30) minutes or portions thereof up to a maximum of twenty-five thousand dollars ($25,000) per occurrence.

 

23.5.1.3

Confirmation of CMO Enrollment (CCE) or Electronic Claims Management (ECM) system downtime. In any calendar week, penalties may be assessed as follows for downtime outside the State’s control of any component of the CCE and ECM systems, such as the voice response system and PC software response system:

 

23.5.1.3.1

Less than twelve (12) hours cumulative: up to two hundred fifty dollars ($250) for each thirty (30) minutes or portions thereof;

 

23.5.1.3.2

Greater than or equal to twelve (12) and less than twenty-four (24) hours cumulative: up to five hundred ($500) for each thirty (30) minutes or portions thereof; and

 

23.5.1.3.3

Greater than or equal to twenty-four (24) hours cumulative: up to one thousand dollars ($1,000) for each thirty (30) minutes or portions thereof up to a maximum of fifty thousand dollars ($50,000) per occurrence.

 

23.5.1.4

Failure to make available to the state and/or its agent readable, valid extracts of Encounter Information for a specific month within fifteen (15) Calendar Days of the close of the month: five hundred dollars ($500) per day. After fifteen (15) Calendar Days of the close of the month: two thousand dollars ($2000) per day.

 

23.5.1.5

Failure to correct a system problem not resulting in System Unavailability within the allowed timeframe, where failure to complete was not due to the action or inaction on the part of DCH as documented in writing by the Contractor:

 

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23.5.1.5.1

One (1) to fifteen (15) Calendar Days late: two hundred and fifty dollars ($250) per Calendar Day for Days 1 through 15;

 

23.5.1.5.2

Sixteen (16) to thirty (30) Calendar Days late: five hundred dollars ($500) per Calendar Day for Days 16 through 30; and

 

23.5.1.5.3

More than thirty (30) Calendar Days late: one thousand dollars ($1,000) per Calendar Day for Days 31 and beyond.

 

23.5.1.6

Failure to meet the Telephone Hotline performance standards:

 

23.5.1.6.1

$1,000.00 for each percentage point that is below the target answer rate of eighty percent (80%) in thirty (30) seconds;

 

23.5.1.6.2

$1,000.00 for each percentage point that is above the target of a one percent (1%) Blocked Call rate; and

 

23.5.1.6.3

$1,000.00 for each percentage point that is above the target of a five percent (5%) Abandoned Call rate.

 

23.6	OTHER REMEDIES

 

23.6.1

In addition other liquidated damages described above for Category 1-4 events, DCH may impose the following other remedies:

 

23.6.1.1

Appointment of temporary management of the Contractor as provided in 42 CFR 438.706, if DCH finds that the Contractor has repeatedly failed to meet substantive requirements in section 1903 (m) or section 1932 of the Social Security Act;

 

23.6.1.2

Granting Members the right to terminate Enrollment without cause and notifying the affected Members of their right to disenroll;

 

23.6.1.3

Suspension of all new Enrollment, including default Enrollment, after the effective date of remedies;

 

23.6.1.4

Suspension of payment to the Contractor for Members enrolled after the effective date of the remedies and until CMS or DCH is satisfied that the reason for imposition of the remedies no longer exists and is not likely to occur;

 

23.6.1.5

Termination of the Contract if the Contractor fails to carry out the substantive terms of the Contract or fails to meet the applicable requirements in 1932 and 1903(m) of the Social Security Act;

 

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23.6.1.6

Civil Monetary Fines in accordance with 42 CFR 438.704; and

 

23.6.1.7

Additional remedies allowed under State statute or State regulation that address areas of non-compliance specified in 42 CFR 438.700.

 

23.7	NOTICE OF REMEDIES

 

23.7.1

Prior to the imposition of either liquidated damages or other remedies, DCH will issue a written notice of remedies that will include the following:

 

23.7.1.1

A citation to the law, regulation or Contract provision that has been violated;

 

23.7.1.2

The remedies to be applied and the date the remedies will be imposed;

 

23.7.1.3

The basis for DCH’s determination that the remedies should be imposed;

 

23.7.1.4

Request for a corrective action plan, if applicable; and

 

23.7.1.5

The time frame and procedure for the Contractor to dispute DCH’s determination. A Contractor’s dispute of a liquidated damage or remedies shall not stay the effective date of the proposed liquidated damage or remedies.

 

24.0	INDEMNIFICATION

 

24.1

The Contractor hereby releases and agrees to indemnify and hold harmless DCH, the State of Georgia and its departments, agencies and instrumentalities (including the State Tort Claims Trust Fund, the State Authority Liability Trust Fund, The State Employee Broad Form Liability Funds, the State Insurance and Hazard Reserve Fund, and other self-insured funds, all such funds hereinafter collectively referred to as the “Funds”) from and against any and all claims, demands, liabilities, losses, costs or expenses, and attorneys’ fees, caused by, growing out of, or arising from this Contract, due to any act or omission on the part of the Contractor, its agents, employees, customers, invitees, licensees or others working at the direction of the Contractor or on its behalf, or due to any breach of this Contract by the Contractor, or due to the application or violation of any pertinent federal, State or local law, rule or regulation. This indemnification extends to the successors and assigns of the Contractor, and this indemnification survives the termination of the Contract and the dissolution or, to the extent allowed by the law, the bankruptcy of the Contractor.

 

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25.0

INSURANCE

 

25.1	INSURANCE OF CONTRACTOR

 

25.1.1

The Contractor shall, at a minimum, prior to the commencement of work, procure the insurance policies identified below at the Contractor’s own cost and expense and shall furnish DCH with proof of coverage at least in the amounts indicated. It shall be the responsibility of the Contractor to require any Subcontractor to secure the same insurance coverage as prescribed herein for the Contractor, and to obtain a certificate evidencing that such insurance is in effect. In the event that any such insurance is proposed to be reduced, terminated or cancelled for any reason, the Contractor shall Provider to DCH at least thirty (30) Calendar Days written notice. Prior to the reduction, expiration and/or cancellation of any insurance policy required hereunder, the Contractor shall secure replacement coverage upon the same terms and provisions to ensure no lapse in coverage, and shall furnish, at the request of DCH, a certificate of insurance indicating the required coverages. The Contractor shall maintain insurance coverage sufficient to insure against claims arising at any time during the term of the Contract. The provisions of this Section shall survive the expiration or termination of this Contract for any reason. In addition, the Contractor shall indemnify and hold harmless DCH and the State from any liability arising out of the Contractor’s or its Subcontractor’s untimely failure in securing adequate insurance coverage as prescribed herein:

 

25.1.1.1

Workers’ Compensation Insurance, the policy (ies) to insure the statutory limits established by the General Assembly of the State of Georgia. The Workers’ Compensation Policy must include Coverage B – Employer’s Liability Limits of:

 

25.1.1.1.1

Bodily injury by accident: five hundred thousand dollars ($500,000) each accident;

 

25.1.1.1.2

Bodily Injury by Disease: five hundred thousand dollars ($ 500,000) each employee; and

 

25.1.1.1.3

One million dollars ($ 1,000,000) policy limits.

 

25.1.1.2

The Contractor shall require all Subcontractors performing work under this Contract to obtain an insurance certificate showing proof of Worker’s Compensation Coverage.

 

25.1.1.3

The Contractor shall have commercial general liability policy (ies) as follows:

 

25.1.1.3.1

Combined single limits of one million dollars ($1,000,000) per person and three million dollars ($3,000,000) per occurrence;

 

25.1.1.3.2

On an “occurrence” basis; and

 

25.1.1.3.3

Liability for property damage in the amount of three million dollars ($3,000,000) including contents coverage for all records maintained pursuant to this Contract.

 

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26.0	PAYMENT BOND & IRREVOCABLE LETTER OF CREDIT

 

26.1

Within five (5) Business Days of Contract Execution, Contractor shall obtain and maintain in force and effect an irrevocable letter of credit in the amount of $15,000,000.00. On or before January 2, 2006, Contractor shall obtain and maintain in force and effect an irrevocable letter of credit in the amount representing one half of one month’s total Capitation Payment associated with the actual GCS lives in the Atlanta and Central Service Regions enrolled in Contractor’s plan. On or before July 1, 2006, Contractor shall obtain and maintain in force and effect an irrevocable letter of credit in the amount representing one half of one month’s total Capitation Payment associated with the actual GCS lives in the Atlanta, Central, East, and North Service Regions enrolled in Contractor’s plan. On or before January 2, 2007, Contractor shall obtain and maintain in force and effect an irrevocable letter of credit in the amount representing one half of one month’s total Capitation Payment associated with the actual GCS lives in all Service Regions enrolled in Contractor’s plan. Thereafter, on or before January 2 of each succeeding year, Contractor shall obtain and maintain in force and effect an irrevocable letter of credit in an amount prescribed by DCH in its sole discretion, based upon the actual GCS lives in all Service Regions enrolled in Contractor’s plan. In lieu of the irrevocable letter of credit, Contractor may furnish a guarantee, in a form and amount which is acceptable to DCH in its sole discretion.

 

26.2	The irrevocable letter of credit shall be redeemed by DCH if the Contractor is (1) unable to perform the terms and conditions of the Contract, or if (2) the Contractor is terminated by default or bankruptcy, or under both conditions described at one (1) and two (2).

 

26.3

During the Contract period, Contractor shall obtain and maintain a payment bond or guarantee from an entity licensed to do business in the State of Georgia and acceptable to DCH with sufficient financial strength and creditworthiness to assume the payment obligations of Contractor in the event of a default in payment arising from bankruptcy, insolvency, or other cause. Said bond or guarantee shall be delivered to DCH within five (5) Business Days of Contract Execution and shall be in the amount of $5,000,000.00. On or before January 2, 2006, Contractor shall deliver to DCH a bond or guarantee in the amount of one month’s total Capitation Payment, based upon the actual GCS lives enrolled in Contractor’s plan. Said bond or guarantee shall be adjusted annually to reflect the actual GCS lives enrolled in Contractor’s plan as of January 1 of each year.

 

27.0	COMPLIANCE WITH ALL LAWS

 

27.1	NON-DISCRIMINATION

 

27.1.1

The Contractor agrees to comply with applicable federal and State laws, rules and regulations, and the State’s policy relative to nondiscrimination in employment

 

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practices because of political affiliation, religion, race, color, sex, physical handicap, age, or national origin including, but not limited to, Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972 as amended; the Age Discrimination Act of 1975, as amended; Equal Employment Opportunity (45 CFR 74 Appendix A (1), Executive Order 11246 and 11375) and the Americans with Disability Act of 1993 (including but not limited to 28 C.F.R. § 35.100 et seq.). Nondiscrimination in employment practices is applicable to employees for employment, promotions, dismissal and other elements affecting employment.

 

27.2	DELIVERY OF SERVICE AND OTHER FEDERAL LAWS

 

27.2.1

The Contractor agrees that all work done as part of this Contract will comply fully with applicable administrative and other requirements established by applicable federal and State laws and regulations and guidelines, including but not limited to section 1902(a)(7) of the Social Security Act and DCH Medicaid and PeachCare for Kids Policies and Procedures manuals, and assumes responsibility for full compliance with all such applicable laws, regulations, and guidelines, and agrees to fully reimburse DCH for any loss of funds or resources or overpayment resulting from non-compliance by Contractor, its staff, agents or Subcontractors, as revealed in subsequent audits. The provisions of the Fair Labor Standards Act of 1938 (29 U.S.C. § 201 et seq.) and the rules and regulations as promulgated by the United States Department of Labor in Title XXIX of the Code of Federal Regulations are applicable to this Contract. Contractor shall agree to conform with such federal laws as affect the delivery of services under this Contract including but not limited to the Titles VI, VII, XIX, XXI of the Social Security Act, the Federal Rehabilitation Act of 1973, the ▇▇▇▇▇ ▇▇▇▇▇ Act (40 U.S.C. § 276a et seq.), the ▇▇▇▇▇▇▇▇ Anti-Kickback Act (40 U.S.C. § 276c), the Clean Air Act (42 U.S.C. 7401 et seq.) and the Federal Water Pollution Control Act as Amended (33 U.S.C. 1251 et seq.); the ▇▇▇▇ Anti-Lobbying Amendment (31 U.S.C. 1352); and Debarment and Suspension (45 CFR 74 Appendix A (8) and Executive Order 12549 and 12689); the Contractor shall agree to conform to such requirements or regulations as the United States Department of Health and Human Services may issue from time to time. Authority to implement federal requirements or regulations will be given to the Contractor by DCH in the form of a Contract amendment.

 

27.2.2

The Contractor shall include notice of grantor agency requirements and regulations pertaining to reporting and patient rights under any contracts involving research, developmental, experimental or demonstration work with respect to any discovery or invention which arises or is developed in the course of or under such contract, and of grantor agency requirements and regulations pertaining to copyrights and rights in data.

 

27.2.3

The Contractor shall recognize mandatory standards and policies relating to energy efficiency which are contained in the State energy conservation plan issues in compliance with the Energy Policy and Conservation Act (Pub. L. 94-165).

 

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27.3	COST OF COMPLIANCE WITH APPLICABLE LAWS

 

27.3.1

The Contractor agrees that it will bear any and all costs (including but not limited to attorneys’ fees, accounting fees, research costs, or consultant costs) related to, arising from, or caused by compliance with any and all laws, such as but not limited to federal and State statutes, case law, precedent, regulations, policies, and procedures. In the event of a disagreement on this matter, DCH’s determination on this matter shall be conclusive and not subject to Appeal.

 

27.4	GENERAL COMPLIANCE

 

27.4.1

Additionally, the Contractor agrees to comply and abide by all laws, rules, regulations, statutes, policies, or procedures that may govern the Contract, the Deliverables in the Contract, or either party’s responsibilities. To the extent that applicable laws, rules, regulations, statutes, policies, or procedures require the Contractor to take action or inaction, any costs, expenses, or fees associated with that action or inaction shall be borne and paid by the Contractor solely.

 

28.0	CONFLICT RESOLUTION

 

28.1

Any dispute concerning a question of fact or obligation related to or arising from this Contract that is not disposed of by mutual agreement shall be decided by the Contract Administrator who shall reduce his or her decision to writing and mail or otherwise furnish a copy to the Contractor. The written decision of the Contract Administrator shall be final and conclusive, unless the Contractor mails or otherwise furnishes a written Appeal to the Commissioner of DCH within ten (10) Calendar Days from the date of receipt of such decision. The decision of the Commissioner or his duly Authorized Representative for the determination of such Appeal shall be final and conclusive. In connection with any Appeal proceeding under this provision, the Contractor shall be afforded an opportunity to be heard and to offer evidence in support of its Appeal. Pending a final decision of a dispute hereunder, the Contractor shall proceed diligently with the performance of the Contract.

 

29.0	CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE

 

29.1

No official or employee of the State of Georgia or the federal government who exercises any functions or responsibilities in the review or approval of the undertaking or carrying out of the GHF program shall, prior to the completion of the project, voluntarily acquire any personal interest, direct or indirect, in this Contract or the proposed Contract.

 

29.2	The Contractor covenants that it presently has no interest and shall not acquire any interest, direct or indirect, that would conflict in any material manner or degree with, or have a material adverse effect on the performance of its services hereunder. The

 

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Contractor further covenants that in the performance of the Contract no person having any such interest shall be employed.

 

29.3	All of the parties hereby certify that the provisions of O.C.G.A. §45-10-20 through §45-10-28, which prohibit and regulate certain transactions between State officials and employees and the State of Georgia, have not been violated and will not be violated in any respect throughout the term.

 

29.4

In addition, it shall be the responsibility of the Contractor to maintain independence and to establish necessary policies and procedures to assist the Contractor in determining if the actual Contractors performing work under this Contract have any impairments to their independence. To that end, the Contractor shall submit a written plan to DCH within five (5) Business Days of Contract Award in which it outlines its Impartiality and Independence Policies and Procedures relating to how it monitors and enforces Contractor and Subcontractor impartiality and independence. The Contractor further agrees to take all necessary actions to eliminate threats to impartiality and independence, including but not limited to reassigning, removing, or terminating Contractors or Subcontractors.

 

30.0

NOTICE

 

30.1

All notices under this Contract shall be deemed duly given upon delivery, if delivered by hand, or three (3) Calendar Days after posting, if sent by registered or certified mail, return receipt requested, to a party hereto at the addresses set forth below or to such other address as a party may designate by notice pursuant hereto.

 

For DCH:

 

Contract Administration:

 

▇▇▇▇▇ ▇▇▇▇▇▇▇▇

Georgia Department of Community Health

▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ - ▇▇^▇▇ ▇▇▇▇▇

▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇

(▇▇▇) ▇▇▇-▇▇▇▇ – Phone

(▇▇▇) ▇▇▇-▇▇▇▇ – Fax

e-mail address: ▇▇▇▇▇▇▇▇▇@▇▇▇.▇▇▇▇▇.▇▇.▇▇

 

Project Leader:

 

▇▇▇▇▇ ▇▇▇▇▇▇▇▇

Georgia Department of Community Health

▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇ - ▇▇^▇▇ ▇▇▇▇▇

▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇

(▇▇▇) ▇▇▇-▇▇▇▇ – Phone

 

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(▇▇▇) ▇▇▇-▇▇▇▇ – Fax

e-mail address: ▇▇▇▇▇▇▇▇▇@▇▇▇.▇▇▇▇▇.▇▇.▇▇

 

For Contractor:

Peach State Health Plan, Inc.

▇▇▇▇▇▇ ▇ ▇▇▇▇▇▇

▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇

▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇

(▇▇▇) ▇▇▇-▇▇▇▇

(404) - Fax ▇▇▇-▇▇▇▇

e-mail address ▇▇▇▇▇▇▇@▇▇▇▇▇▇▇.▇▇▇

 

30.2	It shall be the responsibility of the Contractor to inform the Contract Administrator of any change in address in writing no later than five (5) Business Days after the change.

 

31.0	MISCELLANEOUS

 

31.1	CHOICE OF LAW OR VENUE

 

31.1.1

This Contract shall be governed in all respects by the laws of the State of Georgia. Any lawsuit or other action brought against DCH or the State based upon or arising from this Contract shall be brought in a court or other forum of competent jurisdiction in ▇▇▇▇▇▇ County in the State of Georgia.

 

31.2	ATTORNEY’S FEES

 

31.2.1

In the event that either party deems it necessary to take legal action to enforce any provision of this Contract, and in the event DCH prevails, the Contractor agrees to pay all expenses of such action including reasonable attorney’s fees and costs at all stages of litigation as awarded by the court, a lawful tribunal, hearing officer or administrative law judge. If the Contractor prevails in any such action, the court or hearing officer, at its discretion, may award costs and reasonable attorney’s fees to the Contractor. The term legal action shall be deemed to include administrative proceedings of all kinds, as well as all actions at law or equity.

 

31.3	SURVIVABILITY

 

31.3.1

The terms, provisions, representations and warranties contained in this Contract shall survive the delivery or provision of all services or Deliverables hereunder.

 

31.4	DRUG-FREE WORKPLACE

 

31.4.1

The Contractor shall certify to DCH that a drug-free workplace shall be provided for the Contractor’s employees during the performance of this Contract as required by the “Drug-Free Workplace Act”, O.C.G.A. § 50-24-1, et seq. and applicable federal law.

 

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The Contractor will secure from any Subcontractor hired to work in a drug-free workplace such similar certification. Any false certification by the Contractor or violation of such certification, or failure to carry out the requirements set forth in the code, may result in the Contractor being suspended, terminated or debarred from the performance of this Contract.

 

31.5	CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER MATTERS

 

31.5.1

The Contractor certifies that it is not presently debarred, suspended, proposed for debarment or declared ineligible for award of contracts by any federal or State agency.

 

31.6

WAIVER

 

31.6.1

The waiver by DCH of any breach of any provision contained in this Contract shall not be deemed to be a waiver of such provision on any subsequent breach of the same or any other provision contained in this Contract and shall not establish a course of performance between the parties contradictory to the terms hereof.

 

31.7	FORCE MAJEURE

 

31.7.1

Neither party to this Contract shall be responsible for delays or failures in performance resulting from acts beyond the control of such party. Such acts shall include, but not be limited to, acts of God, strikes, riots, lockouts, acts of war, epidemics, fire, earthquakes, or other disasters.

 

31.8

BINDING

 

31.8.1

This Contract and all of its terms, conditions, requirements, and amendments shall be binding on DCH and the Contractor and their respective successors and permitted assigns.

 

31.9	TIME IS OF THE ESSENCE

 

31.9.1

Time is of the essence in this Contract. Any reference to “Days” shall be deemed Calendar Days unless otherwise specifically stated.

 

31.10

AUTHORITY

 

31.10.1

DCH has full power and authority to enter into this Contract, and the person acting on behalf of and signing for the Contractor has full authority to enter into this Contract, and the person signing on behalf of the Contractor has been properly authorized and empowered to enter into this Contract on behalf of the Contractor and to bind the Contractor to the terms of this Contract. Each party further acknowledges that it has

 

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had the opportunity to consult with and/or retain legal counsel of its choice, read this Contract, understands this Contract, and agrees to be bound by it.

 

31.11

ETHICS IN PUBLIC CONTRACTING

 

31.11.1

The Contractor understands, states, and certifies that it made its proposal to the RFP without collusion or fraud and that it did not offer or receive any kickbacks or other inducements from any other Contractor, supplier, manufacturer, or Subcontractor in connection with its proposal to the RFP.

 

31.12

CONTRACT LANGUAGE INTERPRETATION

 

31.12.1

The Contractor and DCH agree that in the event of a disagreement regarding, arising out of, or related to, Contract language interpretation, DCH’s interpretation of the Contract language in dispute shall control and govern. DCH’s interpretation of the Contract language in dispute shall not be subject to Appeal under any circumstance.

 

31.13

ASSESSMENT OF FEES

 

31.13.1

The Contractor and DCH agree that DCH may elect to deduct any assessed fees from payments due or owing to the Contractor or direct the Contractor to make payment directly to DCH for any and all assessed fees. The choice is solely and strictly DCH’s choice.

 

31.14

COOPERATION WITH OTHER CONTRACTORS

 

31.14.1

In the event that DCH has entered into, or enters into, agreements with other contractors for additional work related to the services rendered hereunder, the Contractor agrees to cooperate fully with such other contractors. The Contractor shall not commit any act that will interfere with the performance of work by any other contractor.

 

31.14.2

Additionally, if DCH eventually awards this Contract to another contractor, the Contractor agrees that it will not engage in any behavior or inaction that prevents or hinders the work related to the services contracted for in this Contract. In fact, the Contractor agrees to submit a written turn-over plan and/or transition plan to DCH within thirty (30) Days of receiving the Department’s intent to terminate letter. The Parties agree that the Contractor has not successfully met this obligation until the Department accepts its turn-over plan and/or transition plan.

 

31.14.3

The Contractor’s failure to cooperate and comply with this provision, shall be sufficient grounds for DCH to halt all payments due or owing to the Contractor until it becomes compliant with this or any other contract provision. DCH’s determination on the matter shall be conclusive and not subject to Appeal.

 

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31.15

SECTION TITLES NOT CONTROLLING

 

31.15.1

The Section titles used in this Contract are for reference purposes only and shall not be deemed a part of this Contract.

 

31.16

LIMITATION OF LIABILITY/EXCEPTIONS

 

31.16.1

Nothing in this Contract shall limit the Contractor’s indemnification liability or civil liability arising from, based on, or related to claims brought by DCH or any third party or any claims brought against DCH or the State by a third party or the Contractor.

 

31.17

COOPERATION WITH AUDITS

 

31.17.1

The Contractor agrees to assist and cooperate with the Department in any and all matters and activities related to or arising out of any audit or review, whether federal, private, or internal in nature, at no cost to the Department.

 

31.17.2

The parties also agree that the Contractor shall be solely responsible for any costs it incurs for any audit related inquiries or matters. Moreover, the Contractor may not charge or collect any fees or compensation from DCH for any matter, activity, or inquiry related to, arising out of, or based on an audit or review.

 

31.18

HOMELAND SECURITY CONSIDERATIONS

 

31.18.1

The Contractor shall perform the services to be provided under this Contract entirely within the boundaries of the United States. Also, the Contractor will not hire any individual to perform any services under this Contract if that individual is required to have a work visa approved by the U.S. Department of Homeland Security and such individual has not met this requirement.

 

31.18.2

If the Contractor performs services, or uses services, in violation of the foregoing paragraph, the Contractor shall be in material breach of this Contract and shall be liable to the Department for any costs, fees, damages, claims, or expenses it may incur. Additionally, the Contractor shall be required to hold harmless and indemnify DCH pursuant to the indemnification provisions of this Contract.

 

31.18.3

The prohibitions in this Section shall also apply to any and all agents and Subcontractors used by the Contractor to perform any services under this Contract.

 

31.19

PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED

 

31.19.1

The Contractor shall not knowingly have a relationship with an individual, or an affiliate of an individual, who is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or

 

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from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order No. 12549. For the purposes of this Section, a “relationship” is described as follows:

 

31.19.1.1

A director, officer or partner of the Contractor;

 

31.19.1.2

A person with beneficial ownership of five percent (5%) or more of the Contractor entity; and

 

31.19.1.3

A person with an employment, consulting or other arrangement with the Contractor’s obligations under its Contract with the State.

 

31.20

OWNERSHIP AND FINANCIAL DISCLOSURE

 

31.20.1

The Contractor shall disclose financial statements for each person or corporation with an ownership or control interest of five percent (5%) or more in the Contractor’s entity for the prior twelve (12) month period. For the purposes of this Section, a person or corporation with an ownership or control interest shall mean a person or corporation:

 

31.20.1.1

That owns directly or indirectly five percent (5%) or more of the Contractor’s capital or stock or received five percent (5%) or more of its profits;

 

31.20.1.2

That has an interest in any mortgage, deed of trust, note, or other obligation secured in whole or in part by the Contractor or by its property or assets, and that interest is equal to or exceeds five percent (5%) of the total property and assets of the Contractor; and

 

31.20.1.3

That is an officer or director of the Contractor (if it is organized as a corporation) or is a partner in the Contractor’s organization (if it is organized as a partnership).

 

32.0	AMENDMENT IN WRITING

 

32.1

No amendment, waiver, termination or discharge of this Contract, or any of the terms or provisions hereof, shall be binding upon either party unless confirmed in writing. None of the Solicitation Documents may be modified or amended, except by writing executed by both parties. Additionally, CMS approval may be required before any such amendment is effective. DCH will determine, in its sole discretion, when such CMS approval is required. Any agreement of the parties to amend, modify, eliminate or otherwise change any part of this Contract shall not affect any other part of this Contract, and the remainder of this Contract shall continue to be of full force and effect as set out herein.

 

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33.0	CONTRACT ASSIGNMENT

 

33.1	Contractor shall not assign this Contract, in whole or in part, without the prior written consent of DCH, and any attempted assignment not in accordance herewith shall be null and void and of no force or effect.

 

34.0	SEVERABILITY

 

34.1

Any section, subsection, paragraph, term, condition, provision, or other part of this Contract that is judged, held, found or declared to be voidable, void, invalid, illegal or otherwise not fully enforceable shall not affect any other part of this Contract, and the remainder of this Contract shall continue to be of full force and effect as set out herein.

 

35.0	COMPLIANCE WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS (O.C.G.A. § 50-20-1 ET SEQ.)

 

35.1

The Contractor agrees to comply at all times with the provisions of the Federal Single Audit Act (hereinafter called the Act) as amended from time to time, all applicable implementing regulations, including but not limited to any disclosure requirements imposed upon non-profit organizations by the Georgia Department of Audits as a result of the Act, and to make complete restitution to DCH of any payments found to be improper under the provisions of the Act by the Georgia Department of Audits, the Georgia Attorney General’s Office or any of their respective employees, agents, or assigns.

 

36.0	ENTIRE AGREEMENT

 

36.1

This Contract constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, representations or contracts. No written or oral agreements, representatives, statements, negotiations, understandings, or discussions that are not set out, referenced, or specifically incorporated in this Contract shall in any way be binding or of effect between the parties.

 

(Signatures on following page)

 

Page 178 of 214

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WRITTEN CONSENT OF THE BOARD OF DIRECTORS OF PEACH STATE

HEALTH PLAN, INC. TO THE ADOPTION OF CERTAIN ACTIONS AND

RESOLUTIONS IN LIEU OF MEETING

 

The undersigned, being all the members of the Board of Directors of Peach State Health Plan, Inc., a Georgia for-profit health maintenance organization wherein the “CORPORATION”, by written consent pursuant to the Georgia Business Cap Code Section 14-2-821, due hereby adopt as of this 13th day of July, 2005. the following actions and resolutions:

 

ACCEPTANCE OF DCH CONTRACT

 

RESOLVED, that the “CONTRACT” entitled “Georgia Department of Community Health and Peach State for Provision of Services to Georgia Healthy Families, Contract Number 0653” by and between the Department of Community Health of the State of Georgia and the CORPORATION is hereby accepted;

 

FURTHER RESOLVED, that the Vice-President of the CORPORATION, ▇▇▇▇▇▇ ▇ ▇▇▇▇▇▇, is authorized to execute the CONTRACT on behalf of the CORPORATION.

 

In Witness whereof, the undersigned Directors have executed this written consent of directors in lieu of meeting on this 13^th day of July, 2005.

 

 

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SIGNATURE PAGE

 

IN WITNESS WHEREOF, the parties state and affirm that they are duly authorized to bind the respected entities designated below as of the day and year indicated.

 

GEORGIA DEPARTMENT OF COMMUNITY HEALTH
/S/    ▇▇▇ ▇▇▇▇▇▇▇				7/18/05
▇▇▇ ▇▇▇▇▇▇▇, Commissioner				Date
DOAS STATE PURCHASING REPRESENTATIVE
/S/    ▇▇▇▇ ▇▇▇▇▇				7/18/05
▇▇▇▇ ▇▇▇▇▇				Date
CONTRACTOR NAME

By:		/S/    ▇▇▇▇▇▇ ▇ ▇▇▇▇▇▇				7/15/2005
		Signature				Date

▇▇▇▇▇▇ ▇ ▇▇▇▇▇▇
Print/Type Name
Executive Administrator
Title				AFFIX CORPORATE SEAL HERE
				(Corporations without a seal, attach a Certificate of Corporate Resolution)

 

ATTEST:		/s/    Illegible
		** SIGNATURE
		TITLE

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*	Must be President, Vice President, CEO or other authorized officer

 

**	Must be Corporate Secretary

 

Page 179 of ▇▇▇

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▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇ Corporations Division 315 West Tower #2 ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇, ▇▇. Dr. ▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇		CONTROL NUMBER EFFECTIVE DATE JURISDICTION REFERENCE PRINT DATE FORM NUMBER		:   0547424 :   06/15/2005 :   ▇▇▇▇▇▇ :   0077 :   07/13/2005 :   ▇▇▇
▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇, 600 PEACHTREE ST., NE ATLANTA, GA 303082216

 

CERTIFICATE OF INCORPORATION

 

I, ▇▇▇▇▇ ▇▇▇, the Secretary of State and Corporations Commissioner of the State of Georgia, do hereby certify under the seal of my office that

 

PEACH STATE HEALTH PLAN, INC.

ATLANTA, GA

 

has been duly incorporated under the laws of the State of Georgia on the effective date stated above by the filing of articles of incorporation in the Office of the Secretary of State and by obtaining the approval of the Office of the Commissioner of Insurance pursuant to Title 33 of the Official Code of Georgia Annotated.

 

WITNESS my hand and official seal in the City of Atlanta and the State of Georgia on the date set forth above.

 

 

 

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APPLICATION FOR CHARTER FOR

PEACH STATE HEALTH PLAN, INC.

 

The undersigned applicants respectfully submit this Application for Charter for Peach State Health Plan, Inc. pursuant to O.C.G.A. §§ 33-14-4, 33-21-2, and other applicable laws of the State of Georgia and show the following:

 

1.

 

The name of the Corporation is PEACH STATE HEALTH PLAN, INC.

(the “Corporation”).

 

2.

 

The Corporation shall have perpetual duration.

 

3.

 

The incorporators, whose names and addresses are listed below, are as follows:

 

1.

▇▇▇ ▇▇▇▇▇▇

▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇

▇▇. ▇▇▇▇▇, ▇▇ ▇▇▇▇▇

 

2.

▇▇▇▇▇ ▇▇▇▇▇▇

▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇

▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇

 

3.

▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇

▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇

▇▇▇▇▇ ▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇

 

4.

▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇

▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇

▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇

 

5.

▇▇▇▇▇ ▇▇▇▇▇▇▇

▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇

▇▇▇▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇

 

4.

 

All of the incorporators are over twenty-one (21) years of age and are of good moral character. No incorporator has been convicted of a crime involving moral turpitude.

 

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5.

 

Four of the incorporators are citizens of this State and all are citizens of the United States.

 

6.

 

The Corporation is formed to transact the following kinds of insurance: health maintenance organization, accident and sickness, and such additional kinds of insurance as the Corporation may be authorized to transact in accordance with the requirements of O.C.G.A. Title 33.

 

7.

 

The purpose of the Corporation is pecuniary gain and profit, and the general nature of the business to be transacted shall be insurance. The Corporation shall be empowered to engage in any form or any type of business for any lawful purpose or purposes not specifically prohibited to corporations for profit under the laws of the State of Georgia and not otherwise prohibited by O.C.G.A. Title 33; and to have all the rights, powers, privileges and immunities which are now or hereafter may be allowed to like corporations under the laws of the State of Georgia.

 

8.

 

The total number of shares of stock which the Corporation shall be authorized to issue is 5,000,000 shares of $1.00 (one dollar) par value capital stock, all of which shall be designated “Common Stock.” The minimum capitalization of the Corporation shall be $3,000,000, with at least $1,500,000 of paid in capital and $1,500,000 of unrestricted surplus. The shares of Common Stock of the Corporation shall not be subject to assessment.

 

9.

 

The initial Board of Directors, which shall serve for a term not longer than one year, shall consist of three (3) directors, one (1) of whom is a resident of this State and all of whom are citizens of the United States. Such directors shall serve until the next annual meeting of shareholders and until their successors are elected and qualified, or until their resignation or removal, whichever is earlier. The names and addresses of the initial directors are as follows:

 

▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇ ▇▇. ▇▇▇▇▇, ▇▇ ▇▇▇▇▇		▇▇▇▇▇ ▇. ▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇ ▇▇. ▇▇▇▇▇, ▇▇ ▇▇▇▇▇

 

▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇

▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇

▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇

 

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10.

 

After the expiration of the initial term of the directors, the Board shall consist of not less than three (3) nor more than twelve (12) directors, as fixed by resolution of the Board of Directors or shareholders in accordance with applicable law and the Bylaws of the Corporation.

 

11.

 

The incorporators have not subscribed for the purchase of shares of Common Stock of the Corporation.

 

12.

 

The Corporation may incur indebtedness without limitation, other than those limitations provided for by O.C.G.A. Title 33 or applicable provisions of law.

 

13.

 

The officers of the Corporation shall be a President, a Vice President, a Secretary, a Treasurer, and such numbers of other officers as may be fixed by the by-laws of the Corporation. The initial term of officers shall be not longer than one year. Such officers shall be elected by the Board and shall serve until the next annual meeting of the Board of Directors and until their successors are duly elected and qualified or until their resignation or removal from office, whichever is earlier. The initial officers of the Corporation are as follows:

 

1.		▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇ ▇▇. ▇▇▇▇▇, ▇▇ ▇▇▇▇▇		President
2.		▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇ ▇▇. ▇▇▇▇▇, ▇▇ ▇▇▇▇▇		Vice President
3.		▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇		Secretary
4.		▇▇▇▇▇ ▇. ▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇ ▇▇. ▇▇▇▇▇, ▇▇ ▇▇▇▇▇		Treasurer

 

-3-

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14.

 

The initial home office and principal place of business of the Corporation shall be located at ▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇ ▇ ▇▇▇, ▇▇▇▇▇▇▇, ▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇,

 

The initial registered office of the Corporation shall be: ▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇., ▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇, ▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇. The initial registered agent of the Corporation at such address is ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇.

 

15.

 

No director of the Corporation shall be liable to the Corporation or its shareholders for monetary damages for any action taken, or any failure to take any action as a director; provided, however, that to the extent required by applicable law, this paragraph shall not eliminate or limit the liability of a director (i) for any appropriation, in violation of his duties, of any business opportunity of the Corporation, (ii) for acts or omissions which involve intentional misconduct or a knowing violation of law, (iii) for the types of liability set forth in O.C.G.A. Section 14-2-832, or (iv) for any transaction from which the director derived an improper personal benefit. If applicable law is amended to authorize corporate action further eliminating or limiting the liability of directors, then the liability of each director of the Corporation shall be eliminated or limited to the fullest extent permitted by applicable law, as amended. Neither the amendment or repeal of this paragraph, nor the adoption of any provision of this charter inconsistent with this paragraph, shall eliminate or reduce the effect of this paragraph in respect of any acts or omissions occurring prior to such amendment, repeal or adoption of an inconsistent provision.

 

16.

 

In accordance with the provisions of O.C.G.A. § 33-14-16 and other applicable provisions of law, the Corporation is authorized to issue any or all of its policies with or without participation in profits, savings, or unabsorbed portions of premiums, to classify policies issued on a participating or non-participating basis, and to determine the right to participate and the extent of participation of any class or classes of policies.

 

IN WITNESS WHEREOF, the undersigned incorporators have executed this Application for Charter for Peach State Health Plan, Inc. on the 27^th day of February 2004.

 

[SIGNATURES ON NEXT PAGE]

 

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IN THE PROBATE COURT FOR ▇▇▇▇▇▇ COUNTY

STATE OF GEORGIA

 

In Re: Certification of Publication		)
of Charter for Peach State Health		)
Plan, Inc.		)

 

CERTIFICATE OF PUBLICATION

 

I, ▇▇▇▇▇▇ ▇▇▇▇▇▇, Probate Judge of ▇▇▇▇▇▇ County, Georgia, do hereby certify that the Application for Charter for Peach State Health Plan, Inc., a copy of which is attached hereto marked as Exhibit “A” and by reference made a part hereof, has been published once a week for four weeks in the official organ of ▇▇▇▇▇▇ County, Georgia wherein are published the legal advertisements of said County, to wit: the ▇▇▇▇▇▇ County Daily Report, publication dates being October 8, 15, 22, and 29, 2004.

 

IN WITNESS WHEREOF, I have hereby set my hand and seal this 5^th day of November, 2004.

 

 

Prepared by:

▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇

Georgia Bar No. 768862

▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ LLP

▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇.▇., ▇▇▇▇▇ ▇▇▇▇

▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇

▇▇▇-▇▇▇-▇▇▇▇

 

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OFFICE OF

INSURANCE AND SAFETY FIRE COMMISSIONER

 

▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ COMMISSIONER OF INSURANCE SAFETY FIRE COMMISSIONER INDUSTRIAL LOAN COMMISSIONER COMPTROLLER GENERAL		SEVENTH FLOOR, WEST TO ▇▇▇▇▇ BUILDING ▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇, ▇▇., ▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇ (404) 656-2056 TDD# (404) 65 ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇.▇▇▇

 

June 15, 2005

 

▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇

Secretary of State

▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇

▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇

 

Re:	Peach State Health Plan, Inc.

▇▇▇▇▇▇ County, Georgia

Application for Charter

 

Dear Secretary Cox:

 

I am enclosing a Certificate approving the proposed application for charter for Peach State Health Plan, Inc. This application will allow for the company (1) to be formed as a stock insurer under Georgia law and (2) accident and sickness insurance as a Health Maintenance Organization in the State of Georgia.

 

With warmest personal regards, I remain

 

 

THE OFFICE OF INSURANCE AND SAFETY FIRE COMMISSIONER DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN SEX, RELIGION, AGE OR DISIBILITY IN EMPLOYMENT OR THE PROVISION OF PROGRAMS OR SERVICES

 

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OFFICE OF

INSURANCE AND SAFETY FIRE COMMISSIONER

 

▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇ COMMISSIONER OF INSURANCE SAFETY FIRE COMMISSIONER INDUSTRIAL LOAN COMMISSIONER COMPTROLLER GENERAL		CERTIFICATE APPROVING   APPLICATION FOR CHARTER   PEACH STATE HEALTH PLAN, INC.		SEVENTH FLOOR, WEST TO ▇▇▇▇▇ BUILDING ▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇, ▇▇., ▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇ (404) 656-2056 TDD# (404) 65 ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇.▇▇▇

 

I, ▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇, Commissioner of Insurance of the State of Georgia, certify that I have examined the Application for Charter of PEACH STATE HEALTH PLAN, INC. This filing is made pursuant to O.C.G.A. § 33-14-5. This Application was filed in this Office and the publication certified by ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇ of the Probate Court of ▇▇▇▇▇▇, Georgia, on November 5, 2004.

 

Based upon my examination of the Application, I conclude that this proposed Application, if granted, will enable PEACH STATE HEALTH PLAN, INC., to comply with the applicable laws of the State of Georgia. Said Application is, therefore, hereby approved.

 

Given under my Hand and Seal of Office this 15^th day of June, 2005.

 

 

THE OFFICE OF INSURANCE AND SAFETY FIRE COMMISSIONER DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN SEX, RELIGION, AGE OR DISIBILITY IN EMPLOYMENT OR THE PROVISION OF PROGRAMS OR SERVICES

 

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Publication Date: 10/29/04 Invoice # : 900 Account #: 070195-00035

 

PUBLISHER’S AFFIDAVIT

 

STATE OF GEORGIA

COUNTY OF ▇▇▇▇▇▇

Re: Peach State Health Plan

 

Before me, the undersigned, a Notary Public, this day personally came ▇▇▇▇▇ ▇▇▇▇▇▇▇ who, being duly sworn, according to law, says she is an agent of the American Lawyer Media, L.P. publishers of the Daily Report, the official newspaper published in Atlanta, Ga, in said county and state, and that the publication, of which the annexed is a true copy, was published in said newspaper as provided by law on the following dates:

 

10/08/04, 10/15/04, 10/22/04, 10/29/04

 

/S/    ▇▇▇▇▇ ▇▇▇▇▇▇▇

▇▇▇▇▇ ▇▇▇▇▇▇▇

 

Subscribed and sworn to before me this 10/29/04.

 

/S/    ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇

Notary Public

 

 

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ADDENDUM TO CONTRACT No. 0653

 

Notwithstanding any provision of the Contractor’s proposal to the contrary, the Contractor shall use distance/mileage criteria for Auto-Assignment of Members to a PCP.

 

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ATTACHMENT A

 

DRUG FREE WORKPLACE CERTIFICATE

 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)

CERTIFICATION REGARDING DRUG-FREE WORKPLACE

REQUIREMENTS

GRANTEES OTHER THAN INDIVIDUALS

 

By signing and/or submitting this application or grant agreement, the grantee is providing the certification set out below.

 

This certification is required by regulations implementing the Drug-Free Workplace Act of 1988, 45 CFR Part 76, Subpart F. The regulations, published in the January 31,1989 Federal Register, require certification by grantees that they will maintain a drug-free workplace. The certification set out below is a material representation of fact upon which reliance will be placed when HHS makes a determination regarding the award of the grant. False certification or violation of the certification shall be grounds for suspension of payments, suspension or termination of grants, or government-wide suspension or debarment.

 

The grantee certifies that it will provide a drug-free workplace by:

 

1.	Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or use of a controlled substance is prohibited in the grantee’s workplace and specifying the actions that will be taken against employees for violation of such prohibition;

 

2.	Establishing a drug-free awareness program to inform employees about:

 

a)

The dangers of drug abuse in the workplace;

 

b)

The grantee’s policy of maintaining a drug-free workplace;

 

c)

Any available drug counseling, rehabilitation, and employee assistance programs; and

 

d)

The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;

 

3.	Making it a requirement that each employee who will be engaged in the performance of the grant be given a copy of the statement required by paragraph 1;

 

4.	Notifying the employee in the statement required by paragraph 1 that, as a Condition of employment under the grant, the employee will:

 

a)

Abide by the terms of the statement; and

 

b)

Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than five Days after such conviction;

 

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5.	Notifying the agency within ten Days after receiving notice under subparagraph 4. b) from an employee or otherwise receiving actual notice of such conviction;

 

6.	Taking one of the following actions, within 30 Days of receiving notice under subparagraph 4. b), with respect to any employee who is so convicted;

 

a)

Taking appropriate personnel action against such an employee, up to and including termination; or

 

b)

Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a federal, State, or local health, law enforcement, or other appropriate agency;

 

7.	Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs 1, 2, 3, 4, 5, and 6.

 

Peach State Health Plan, Inc.
Contractor

 

/s/ Illegible				7/15/2005
Signature				Date

 

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ATTACHMENT B

 

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED

DEBARMENT, AND OTHER RESPONSIBILITY MATTERS

 

 

Federal Acquisition Regulation 52.209-5, Certification Regarding Debarment, Suspension, Proposed Debarment, and Other Responsibility Matters (March 1996)

 

(a)	(1)     The Contractor certifies, to the best of its knowledge and belief, that—

 

(i)

The Contractor and/or any of its Principals—

 

A.

Are ¨ are not x presently debarred, suspended, proposed for debarment, or declared ineligible for award of Contracts by any Federal agency;

 

B.

Have ¨ have not x within a three-year period preceding this offer, been convicted of or had a civil judgment rendered against them for: commission of Fraud or criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, State, or local) Contract or subcontract; violation of federal or State antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, evasion, or receiving stolen property; and

 

C.

Are ¨ are not x presently indicted for, or otherwise criminally or civilly charged by a governmental entity with commission of any of the offenses enumerated in subdivision (a)(1)(i)(B) of this provision.

 

(ii)

The Contractor has ¨ has not x within a three-year period preceding this offer, had one or more Contracts terminated for default by any federal agency.

 

(2)

“Principals,” for purposes of this certification, means officers, directors, owners, partners, and, persons having primary management or supervisory responsibilities within a business entity (e.g., general manager, plant manager, head of a subsidiary, division, or business segment; and similar positions).

 

This certification concerns a matter within the jurisdiction of an Agency of the United States and the making of a false, fictitious, or Fraudulent certification may render the maker subject to prosecution under 18 U.S.C. § 1001.

 

(b)	The Contractor shall provide immediate written notice to the Contracting Officer if, at any time prior to Contract Award, the Contractor learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

 

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(c)

A certification that if any of the items in paragraph (a) of this provision exist will not necessarily result in Withholding of an award under this solicitation. However, the certification will be considered in connection with a determination of the Contractor’s responsibility. Failure of the Contractor to furnish a certification or provide such additional information as requested by the Contracting Officer may render the Contractor non- responsible.

 

(d)

Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render, in good faith, the certification required by paragraph (a) of this provision. The knowledge and information of an Contractor is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

 

(e)

The certification in paragraph (a) of this provision is a material representation of fact upon which reliance was placed when making award. If it is later determined that the Contractor knowingly rendered an erroneous certification, in addition to other remedies available to the Government, the Contracting Officer may terminate the Contract resulting from this solicitation for default.

 

Contractor:
By:		Peach State Health Plan, Inc.
		/S/    ▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇						7/15/2005
		Signature						Date
		▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇, Executive Administrator
		Name and Title

 

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ATTACHMENT C

 

GEORGIA DEPARTMENT OF COMMUNITY HEALTH

NONPROFIT ORGANIZATION DISCLOSURE FORM

 

Notice to all DCH Contractors: Pursuant to Georgia law, nonprofit organizations that receive funds from a State organization must comply with audit requirements as specified in O.C.G.A. § 50-20-1 et seq. (hereinafter “the Act”) to ensure appropriate use of public funds. “Nonprofit Organization” means any corporation, trust, association, cooperative, or other organization that is operated primarily for scientific, educational, service, charitable, or similar purposes in the public interest; is not organized primarily for profit; and uses its net proceeds to maintain, improve or expand its operations. The term nonprofit organization includes nonprofit institutions of higher education and hospitals. For financial reporting purposes, guidelines issued by the American Institute of Certified Public Accountants should be followed in determining nonprofit status.

 

The Department of Community Health (DCH) must report Contracts with nonprofit organizations to the Department of Audits and must ensure compliance with the other requirements of the Act. Prior to execution of any Contract, the potential Contractor shall complete this form disclosing its corporate status to DCH. This form must be returned, along with proof of corporate status, to: ▇▇▇▇▇▇ ▇▇▇▇▇▇▇, Director, Contract and Procurement Administration, Georgia Department of Community Health, 35^th Floor, ▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇.▇., ▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇.

 

Acceptable proof of corporate status includes, but is not limited to, the following documentation:

 

•

Financial statements for the previous year;

 

•

Employee list;

 

•

Employee salaries;

 

•

Employees’ reimbursable expenses; and

 

•

Corrective action plans.

 

Entities that meet the definition of nonprofit organization provided above and are subject the requirements of the Act will be contacted by DCH for further information.

 

COMPANY NAME: Peach State Health Plan, Inc.

 

ADDRESS: ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇ ▇▇

         ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇

 

PHONE: ▇▇▇-▇▇▇-▇▇▇▇            FAX: ▇▇▇-▇▇▇-▇▇▇▇

 

CORPORATE STATUS: (check one)    For Profit x            Non-Profit ¨

 

I, the undersigned duly Authorized Representative of Peach State Health Plan, Inc. do hereby attest that the above information is true and correct to the best of my knowledge.

 

/s/    Illegible				7/15/2005
Signature				Date

 

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ATTACHMENT D

 

STATE OF GEORGIA

THE GEORGIA DEPARTMENT OF COMMUNITY HEALTH

▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇.▇.

▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇

 

CONFIDENTIALITY STATEMENT

FOR SAFEGUARDING INFORMATION

 

I, the undersigned, understand, and by my signature agree to comply with Federal and State requirements (References: 42 CFR 431.300 – 431.306. Chapter 350-5 of Rules of Georgia Department of Community Health) regarding the safeguarding of Medicaid information in my possession, including but not limited to information which is electronically obtained from the Medicaid Management Information System (MMIS) while performing Contractual services with the Department of Community Health, its Agents or Contractors.

 

Individual’s Name: (typed or printed): ▇▇▇▇▇▇ ▇ ▇▇▇▇▇▇
Signature:		/s/    Illegible				Date:		7/15/2005
Telephone No.: ▇▇▇-▇▇▇-▇▇▇▇

 

Company or Agency Name and Address:				Peach State Health Plan, Inc. ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇

 

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ATTACHMENT E

 

BUSINESS ASSOCIATE AGREEMENT

 

This Business Associate Agreement (hereinafter referred to as “Agreement”), effective this 15 day of July, 2005 is made and entered into by and between the Georgia Department of Community Health (hereinafter referred to as “DCH”) and Peach State Health Plan, Inc. (hereinafter referred to as “Contractor”) as Amendment No.                      to Contract No. 0653 between DCH and Contractor dated July 15, 2005 (“Contract”).

 

WHEREAS, DCH is required by the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (“HIPAA”), to enter into a Business Associate Agreement with certain entities that provide functions, activities, or services involving the use of Protected Health Information (“PHI”);

 

WHEREAS, Contractor, under Contract No. 0653 (hereinafter referred to as “Contract”), may provide functions, activities, or services involving the use of PHI;

 

NOW, THEREFORE, for and in consideration of the mutual promises, covenants and agreements contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, DCH and Contractor (each individually a “Party” and collectively the “Parties”) hereby agree as follows:

 

1.	Terms used, but not otherwise defined, in this Agreement shall have the same meaning as those terms in the Privacy Rule, published as the Standards for Privacy of Individually Identifiable Health Information in 45 CFR Parts 160 and 164 (“Privacy Rule”):

 

2.	Except as limited in this Agreement, Contractor may use or disclose PHI only to extent necessary to meet its responsibilities as set forth in the Contract provided that such use or disclosure would not violate the Privacy Rule if done by DCH.

 

3.	Unless otherwise required by Law, Contractor agrees:

 

A.

That it will not request, create, receive, use or disclose PHI other than as permitted or required by this Agreement or as required by law.

 

B.

To establish, maintain and use appropriate safeguards to prevent use or disclosure of the PHI other than as provided for by this Agreement.

 

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C.

To mitigate, to the extent practicable, any harmful effect that is known to Contractor of a use or disclosure of PHI by Contractor in violation of the requirements of this Agreement.

 

D.

That its Agents or Subcontractors are subject to the same obligations that apply to Contractor under this Agreement and Contractor agrees to ensure that its Agents or Subcontractors comply with the Conditions, restrictions, prohibitions and other limitations regarding the request for, creation, receipt, use or disclosure of PHI, that are applicable to Contractor under this Agreement.

 

E.

To report to DCH any use or disclosure of PHI that is not provided for by this Agreement of which it becomes aware. Contractor agrees to make such report to DCH in writing in such form as DCH may require within twenty-four (24) hours after Contractor becomes aware.

 

F.

To make any amendment(s) to PHI in a Designated Record Set that DCH directs or agrees to pursuant to 45 CFR 164.526 at the request of DCH or an Individual, within five (5) Business Days after request of DCH or of the Individual. Contractor also agrees to provide DCH with written confirmation of the amendment in such format and within such time as DCH may require.

 

G.

To provide access to PHI in a Designated Record Set, to DCH upon request, within five (5) Business Days after such request, or, as directed by DCH, to an Individual Contractor also agrees to provide DCH with written confirmation that access has been granted in such format and within such time as DCH may require.

 

H.

To give DCH, the Secretary of the U.S. Department of Health and Human Services (the “Secretary”) or their designees access to Contractor’s books and records and policies, practices or procedures relating to the use and disclosure of PHI for or on behalf of DCH within five (5) Business Days after DCH, the Secretary or their designees request such access or otherwise as DCH, the Secretary or their designees may require. Contractor also agrees to make such information available for review, inspection and copying by DCH, the Secretary or their designees during normal business hours at the location or locations where such information is maintained or to otherwise provide such information to DCH, the Secretary or their designees in such form, format or manner as DCH, the Secretary or their designees may require.

 

I.

To document all disclosures of PHI and information related to such disclosures as would be required for DCH to respond to a request by an Individual or by the Secretary for an accounting of disclosures of PHI in accordance with the requirements of the Privacy Rule.

 

J.

To provide to DCH or to an Individual, information collected in accordance with Section 3. I. of this Agreement, above, to permit DCH to respond to a request by an Individual for an accounting of disclosures of PHI as provided in the Privacy Rule.

 

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4.	Unless otherwise required by Law, DCH agrees:

 

That it will notify Contractor of any new limitation in DCH’s Notice of Privacy Practices in accordance with the provisions of the Privacy Rule if, and to the extent that, DCH determines in the exercise of its sole discretion that such limitation will affect Contractor’s use or disclosure of PHI.

 

That it will notify Contractor of any change in, or revocation of, permission by an Individual for DCH to use or disclose PHI to the extent that DCH determines in the exercise of its sole discretion that such change or revocation will affect Contractor’s use or disclosure of PHI.

 

That it will notify Contractor of any restriction regarding its use or disclosure of PHI that DCH has agreed to in accordance with the Privacy Rule if, and to the extent that, DCH determines in the exercise of its sole discretion that such restriction will affect Contractor’s use or disclosure of PHI.

 

5.

The Term of this Agreement shall be effective as of July 15, 2005, and shall terminate when all of the PHI provided by DCH to Contractor, or created or received by Contractor on behalf of DCH, is destroyed or returned to DCH, or, if it is infeasible to return or destroy PHI, protections are extended to such information, in accordance with the termination provisions in this Section.

 

A.

Termination for Cause. Upon DCH’s knowledge of a material breach by Contractor, DCH will either:

 

(1)

Provide an opportunity for Contractor to cure the breach or end the violation, and terminate this Agreement if Contractor does not cure the breach or end the violation within the time specified by DCH;

 

(2)

Immediately terminate this Agreement if Contractor has breached a material term of this Agreement and cure is not possible; or

 

(3)

If neither termination nor cure is feasible, DCH will report the violation to the Secretary.

 

B.

Effect of Termination.

 

Except as provided in paragraph (A.) (2) of this Section, upon termination of this Agreement, for any reason, Contractor shall return or destroy all PHI received from DCH, or created or received by Contractor on behalf of DCH. This provision shall apply to PHI that is in the possession of Subcontractors or Agents of Contractor. Neither Contractor nor its Agents nor Subcontractors shall retain copies of the PHI.

 

(1)

In the event that Contractor determines that returning or destroying the PHI is not feasible, Contractor shall send DCH detailed written notice of the specific

 

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reasons why it believes such return or destruction not feasible and the factual basis for such determination, including the existence of any Conditions or circumstances which make such return or disclosure infeasible. If DCH determines, in the exercise of its sole discretion, that the return or destruction of such PHI is not feasible, Contractor agrees that it will limit its further use or disclosure of PHI only to those purposes DCH may, in the exercise of its sole discretion, deem to be in the public interest or necessary for the protection of such PHI, and will take such additional action as DCH may require for the protection of patient privacy or the safeguarding, security and protection of such PHI.

 

(2)

If neither termination nor cure is feasible, DCH will report the violation to the Secretary.

 

(3)

Section 5. B. of this Agreement, regarding the effect of termination or expiration, shall survive the termination of this Agreement.

 

C.

Conflicting Termination Provisions.

 

In the event of conflicting termination provisions or requirements, with respect to PHI, the termination provisions of Section 5 in this Business Associate Agreement shall control and supercede and control those in the underlying Contract.

 

6.

Interpretation. Any ambiguity in this Agreement shall be resolved to permit DCH to comply with applicable Medicaid laws, rules and regulations, and the Privacy Rule, and any rules, regulations, requirements, rulings, interpretations, procedures or other actions related thereto that are promulgated, issued or taken by or on behalf of the Secretary; provided that applicable Medicaid laws, rules and regulations and the laws of the State of Georgia shall supercede the Privacy Rule if, and to the extent that, they impose additional requirements, have requirements that are more stringent than or have been interpreted to provide greater protection of patient privacy or the security or safeguarding of PHI than those of HIPAA and its Privacy Rule.

 

7.	All other terms and Conditions contained in the Contract and any amendment thereto, not amended by this Amendment, shall remain in full force and effect.

 

Signatures on following page

 

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SIGNATURE PAGE

 

Individual’s Name: (typed or printed): ▇▇▇▇▇▇ ▇ ▇▇▇▇▇▇
* Signature:		/S/    ▇▇▇▇▇▇ ▇ ▇▇▇▇▇▇				Date: 7/15/2005
Title:		Executive Administrator
Telephone No.: ▇▇▇-▇▇▇-▇▇▇▇						Fax No.		▇▇▇-▇▇▇-▇▇▇▇
Company or Agency Name and Address:						Peach State Health Plan, Inc. ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇

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*	Must be President, Vice President, CEO or other authorized officer

 

**	Must be Corporate Secretary

 

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ATTACHMENT F

 

VENDOR LOBBYLIST DISCLOSURE AND REGISTRATION

CERTIFICATION FORM

 

 

Pursuant to Executive Order Number 10.01.03.01 (the “Order”), which was signed by Governor ▇▇▇▇▇ ▇▇▇▇▇▇ on October 1, 2003, Contractors with the State are required to complete this form. The Order requires “Vendor Lobbyists,” defined as those who lobby State officials on behalf of businesses that seek a Contract to sell goods or services to the State or those who oppose such a Contract, to certify that they have registered with the State Ethics Commission and filed the disclosures required by Article 4 of Chapter 5 of Title 21 of the Official Code of Georgia Annotated. Consequently, every vendor desiring to enter into a Contract with the State must complete this certification form. False, incomplete, or untimely registration, disclosure, or certification shall be grounds for termination of the award and Contract and may cause recoupment or refund actions against Contractor.

 

In order to be in compliance with Executive Order Number 10.01.03.01, please complete this Certification Form by designating only one of the following:

 

¨

Contractor does not have any lobbyist employed, retained, or affiliated with the Contractor who is seeking or opposing Contracts for it or its clients. Consequently, Contractor has not registered anyone with the State Ethics Commission as required by Executive Order Number 10.01.03.01 and any of its related rules, regulations, policies, or laws.

 

x	Contractor does have lobbyist(s) employed, retained, or affiliated with the Contractor who are seeking or opposing Contracts for it or its clients. The lobbyists are:

 

▇▇▇ ▇▇▇▇▇▇

 

▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇

 

Contractor states, represents, warrants, and certifies that it has registered the above named lobbyists with the State Ethics Commission as required by Executive Order Number 10.01.03.01 and any of its related rules, regulations, policies, or laws.

 

Signatures on the following page

 

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SIGNATURE PAGE

 

Peach State Health Plan, Inc.				7/15/2005
Contractor				Date
/S/    ▇▇▇▇▇▇ ▇ ▇▇▇▇▇▇				Executive Administrator
Signature				Title of Signatory

 

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ATTACHMENT G

 

PAYMENT BOND AND

IRREVOCABLE LETTER OF CREDIT

 

Signatures on the following page

 

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SIGNATURE PAGE

 

Signed and sealed this 15 day of July 2005 in the presence of:

 

Seal
		Witness						Contractor
		Title
Seal
		Witness						Surety

 

		By:
		Title
		COUNTERSIGNED
		By:

 

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ATTACHMENT H

 

CAPITATION PAYMENT

 

On the Following Page

 

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ATTACHMENT H

 

Attachment H is a table displaying the contracted rates by rate cell for each contracted region. These rates will be the basis for calculating capitation payments in each contracted Region.

 

Contracted Rates by Region

 

CMO NAME				Peach State
Rate Category				Atlanta			Central
LIM/RSM/Refugee
		0 - 2 Months Male & Female		$	1,104.24		$	1,103.50
		3 - 11 Months Male & Female		$	177.85		$	207.41
		1 - 5 Years Male & Female		$	106.42		$	115.05
		6 - 13 Years Male & Female		$	101.41		$	105.43
		14 - 20 Years Female		$	166.58		$	163.17
		14 - 20 Years Male		$	116.04		$	100.47
		21 - 44 Years Female		$	227.50		$	257.47
		21 - 44 Years Male		$	255.65		$	280.71
		45+ Years Female		$	388.74		$	467.06
		45+ Years Male		$	515.63		$	556.30
PeachCare
		0 - 2 Months Male & Female		$	181.55		$	187.38
		3 - 11 Months Male & Female		$	181.55		$	187.38
		1 - 5 Years Male & Female		$	109.87		$	124.44
		6 - 13 Years Male & Female		$	131.20		$	135.94
		14 - 20 Years Female		$	156.06		$	163.26
		14 - 20 Years Male		$	144.31		$	139.60
Female Services
		Breast and Cervical Cancer		$	1,756.82		$	1,606.62
Maternity and Delivery Services				Unit Cost			Unit Cost
Kick Payment				$	5,796.63		$	5,759.46

 

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ATTACHMENT I

 

NOTICE OF YOUR RIGHT TO A HEARING

 

You have the right to a hearing about this decision. To have a hearing, you must ask for one in writing. You should send a copy of the attached letter in thirty (30) Days or less from the date that the notice of action is mailed to this address:

 

Department of Community Health

Legal Services Section

Division of Medical Assistance

▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇-▇▇^▇▇ ▇▇▇▇▇

▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇ ▇▇▇▇▇-▇▇▇▇

 

If you want to keep your services, you must send a written request for a hearing before the date that your services change.

 

The Office of State Administrative Hearings will notify you of the time, place and date of your hearing. An Administrative Law Judge will hold the hearing. In the hearing, you may speak for yourself or let a friend or family member speak for you. You also may ask a lawyer to help you. You may be able to get legal help at no cost. If you want a lawyer to help you, you may call one of these numbers:

 

1.      Georgia Legal Services Program 1-800-498-9469 (Statewide legal services, EXCEPT for the counties served by Atlanta Legal Aid)		2.      Georgia Advocacy Office 1-800-537-2329 (Statewide advocacy for persons with disabilities or mental illness)
3.      Atlanta Legal Aid 404-377-0701 (Dekalb/Gwinnett Counties) 770-528-2565 (▇▇▇▇ County) 404-524-5811 (▇▇▇▇▇▇ County) 404-669-0233 (So. ▇▇▇▇▇▇/▇▇▇▇▇▇▇ County)		4.      State Ombudsman Office ▇-▇▇▇-▇▇▇-▇▇▇▇ (Nursing Home or Personal Care Home)

 

You may also ask for free mediation services by calling ▇▇▇-▇▇▇-▇▇▇▇. Mediation is another way to solve problems without a hearing. If you cannot solve the problem with mediation, you still have the right to a hearing.

 

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ATTACHMENT J

 

MAP OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS

 

Atlanta		Central		East		North		SE		▇▇
▇▇▇▇▇▇ Bartow ▇▇▇▇▇ ▇▇▇▇▇▇▇ Cherokee ▇▇▇▇▇▇▇ ▇▇▇▇ Coweta DeKalb ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Gwinnett ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇ Paulding ▇▇▇▇▇▇▇ Rockdale Spalding ▇▇▇▇▇▇		▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇ Chattahoochee Crawford Crisp Dodge ▇▇▇▇▇ ▇▇▇▇▇▇ Heard Houston ▇▇▇▇▇ ▇▇▇▇▇ Laurens ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Muscogee Peach Pike Pulaski Talbot ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ Treutlen ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇		▇▇▇▇▇ Columbia ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ Lincoln ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Richmond Screven ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Washington ▇▇▇▇▇▇		Banks Catoosa Chattooga Clarke Dade ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇ Oconee Oglethorpe Polk ▇▇▇▇▇ ▇▇▇▇▇▇▇▇ Towns Union Walker White ▇▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇ Camden ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ Chatham Effingham ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇ Liberty Long Mclntosh ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Tattnall ▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇		▇▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇ ▇▇▇▇ Berrien ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇ Coffee ▇▇▇▇▇▇▇▇ ▇▇▇▇ Decatur ▇▇▇▇▇▇▇▇▇ Early ▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ Seminole ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ Sumter ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ Worth

 

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ATTACHMENT K

 

APPLICABLE CO-PAYMENTS

 

Children under age twenty-one (21), pregnant women, nursing facility residents and Hospice care Members are exempted from co-payments.

 

There are no co-payments for family planning services and for emergency services except as defined below.

 

Services can not be denied to anyone based on the inability to pay these co-payments.

 

Service		Additional Exceptions		Co-Pay Amount
Ambulatory Surgical Centers				A $3 co-payment to be deducted from the surgical procedure code billed. In the case of multiple surgical procedures, only one $3 amount will be deducted per date of service.
FQHC/RHCs				A $2 co-payment on all FQHC and RHC.
Outpatient				A $3 member co-payment is required on all non-emergency outpatient hospital visits
Inpatient		Members who are admitted from an emergency department or following the receipt of urgent care or are transferred from a different hospital, from a skilled nursing facility, or from another health facility are exempted from the inpatient co-payment.		A co-payment of $12.50 will be imposed on hospital inpatient services
Emergency Department				A $6 co-payment will be imposed if the Condition is not an Emergency Medical Condition
Oral Maxiofacial Surgery				A $2 Member co-payment will be imposed on all evaluation and management procedure codes (99201 – 99499) billed by oral surgeons.
Prescription Drugs				Drug Cost: <$10.01 $10.01-$25.00 $25.01-$50.00 >$50.01		Co-pay Amount $.50 $1.00 $2.00 $3.00

 

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ATTACHMENT L

 

INFORMATION MANAGEMENT AND SYSTEMS

 

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Georgia Cares Program (GCS) Program

Care Management Organization (CMO) Contract

Attachment L.1: Data and Document Management Requirements by Major Information Type

 

In order to meet programmatic, reporting and management requirements, CMO systems will serve as either a) the authoritative host of key data and documents or b) the host of valid, replicated data and documents from other systems. The following table lays out the requirements for managing (capturing, storing and maintaining) data and documents for the major information types and subtypes associated with the aforementioned programmatic, reporting and management requirements:

 

L.1.1 Member Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
1.1		Unique member identifier (UMI)		Authoritative host; retain relationship to Fiscal Agent-assigned member identifier		The UMI should span member’s lifetime and should serve as an index to obtain member-specific information across multiple sub systems/databases of a single CMO
1.2		Fiscal Agent-assigned member identifier		Receive original record and updates from Fiscal Agent		Retain relationship to UMI
1.3		Member enrollment and enrollment status changes in Contractor’s CMO		Receive original record and updates from DCH and/or its agent		The CMO shall retain in its “live” systems the most recent 7-year history (or less if member dies within 7-year period) of enrollment status changes, including multiple re-enrollments and disenrollments of the same member, indexed by and linked to the member’s UMI and Fiscal Agent-assigned member identifier.
1.3		Member demographic profile		Reconcile as needed to data kept by DCH and/or its agent		Includes family relationships, age, sex, pregnancy and incarceration flags, standardized address linked to GCS service region and standard location codes (zip code, municipality, county, etc.)
1.5		Member financial, insurance and employment profile		TPL: exchange data with DCH and/or its agent. Other: reconcile as needed to data kept by DCH and/or its agent		Includes TPL data that may need to be provided to multiple CMOs and may include capitation rate cell to which the Member is associated
1.6		Member assignments to PCP and, if applicable, to CMO sub programs/”plan options”		Authoritative host

 

Special Considerations:

 

1.1 CMO system(s) shall conform to HIPAA-driven standards for individual and employer identification that are currently under development within 120 days of the standard’s effective date or, if earlier, the date stipulated by CMS.

 

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L.1.2 Provider Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
2.1		Unique provider identifier (UPI)		Authoritative host; retain relationship to Fiscal Agent-assigned Provider ID		The UPI will meet the requirements of the National Provider ID (NPI) standards of HIPAA and will retain relationships to existing GA IDs. NPI requirements include identifying providers using the NPI and/or utilizing standards consistent with NPI and HIPAA requirements that identify a unique number for a provider. Also, maintain an on-line cross-reference of all old provider #s to new provider #s and historical information linked to the NPI.
2.2		Provider CMO affiliation		Authoritative host		The CMO will retain a 7-year history (or less if member dies within 7-year period) of enrollment status changes, including multiple re-enrollments and disenrollments of the same provider; indexed by and linked to the provider’s UPI.
2.3		Contractor-Provider agreement document		Authoritative host		Signed; indexed by and linked to the provider’s UPI.
2.4		Provider location(s)		Reconcile as needed to data kept by DCH and/or its agent		Include location codes that enable map and GIS based renderings of network coverage and capacity by provider type and geographic area. Include standardized office/practice address (es).
2.5		Provider credentialing Information		Authoritative host for non-mandated Providers (year 1) - receive original record and updates from Fiscal Agent; Authoritative host for all Providers thereafter		At a minimum: licensure status, board eligibility/certification. Includes indexed images of applicable documents.
2.6		Provider specialties, affiliation and relation to other provider Information		Authoritative host; reconcile as needed to data kept by DCH and/or its agent		Specialties for which s/he is certified, professional affiliations, group/practice associations, hospital admitting privileges. Includes indexed images of applicable documents.
2.7		Provider descriptive		Authoritative host for non-mandated Providers (year 1) - receive original record and updates from Fiscal Agent; Authoritative host for all Providers thereafter		Race, sex, languages spoken by him/her and staff, education and training

 

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L.1.2 Provider Data and Related Documents (cont.)

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
2.8		Provider medical and service profile		Authoritative host; reconcile as needed to data kept by DCH and/or its agent		Member assessments, reported incidents, malpractice cases, etc. Includes indexed images of applicable documents.
2.9		Provider financial		Authoritative host; reconcile as needed to data kept by DCH and/or its agent		At a minimum: ▇▇▇▇▇/tax IDs, 1099s. Includes indexed images of applicable documents.

 

L.1.3 Service-Specific Utilization and Financial (“Encounter”) Data and Related Documents

 

Data to be extracted from claims management systems and other sources as needed.

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
3.1		Claim data including subsequent claim adjustment		Authoritative host; provide to State and/or its agent following format and procedure in Attachment L5.		Capture data elements per applicable standard format/layout to be adopted by all CMOs (UB-92, CMS-1500, ADA, NCPDP). Capture EPSDT flags where applicable; all claim adjustments shall be logically linked to the original claim (parent/child data relationship). Contractor shall retain up to seven (7) years of Claims history per Member (less if Member dies within 7-year period).
3.2		Encounter data from sub-capitated provider		Authoritative host; provide to State and/or its agent following format and procedure in Attachment L5.		Encounter data from sub-capitated provider shall be equivalent (in terms of fields captured per record) to data obtained from claim submissions (ref. 3.1). Contractor shall retain up to seven (7) years of history of this type of Encounter data per Member (less if Member dies within 7-year period).

 

Special Considerations:

 

3.1 CMO systems will flag all services related to Federal EPSDT requirements, including diagnostic and treatment services resulting from an EPSDT screening service, for the purposes of consolidated EPSDT activity reporting (e.g. CMS form 416) and other management applications.

 

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L.1.4 Utilization Management and Care Coordination Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
4.1		In-network specialist referrals		Authoritative host		7-year history (or less if member dies within 7-year period) of all medical management transactions by member. Capture and retain link/logical relationship to subsequent claim(s).
4.2		In-network authorizations		Authoritative host		7-year history (or less if member dies within 7-year period) of all medical management transactions by member. Capture and retain link/logical relationship to subsequent claim(s).
4.3		Out-of-network service referrals and authorizations		Authoritative host		7-year history (or less if member dies within 7-year period) of all medical management transactions by member. Capture and retain link/logical relationship to subsequent claim(s).
4.4		“Transition” service authorizations		Receive original record from DCH and/or its agent		Service authorizations issued by DCH and/or its agent during period prior to enrollment in CMO. Retain history of all of these authorizations. Capture and retain link/logical relationship to subsequent claim(s).

 

L.1.5 Health Status, Clinical and Outcomes Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
5.1		Focused studies		Authoritative host		Unique ID per study; codify results for summarization and analysis based on scheme TBD.
5.2		Member (clinical) safety – reported incidents/occurrences		Authoritative host		Unique ID per reported incident/occurrence; codify for summarization and analysis based on scheme TBD.

 

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L.1.6 Member Inquiry Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
6.1		Inquiry data (electronic or paper-based submission)		Authoritative host		Retain relationship to UMI; content of fields in online or paper-based forms codified for summarization and analysis according to CMO-specific scheme.
6.2		Inquiry processing status changes		Authoritative host		Maintain 7-year history (or less if member dies within 7-year period) of inquiry processing, the Contractor staff that have participated in addressing the inquiry and/or interacted with Member, date/time of interactions and any intermediate status changes or updates. Status of inquiry to be codified for summarization and analysis according to CMO-specific scheme.
6.3		Inquiry resolution		Authoritative host		Includes date of resolution; codify for summarization and analysis according to CMO-specific scheme.
6.4		Inquiry forms (paper-based submission)		Authoritative host		Retain relationship to UMI

 

L.1.7 Provider Inquiry Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
7.1		Inquiry data (electronic or paper-based submission)		Authoritative host		Retain relationship to UPI; content of fields in online or paper-based forms codified for summarization and analysis according to CMO-specific scheme.
7.2		Inquiry processing status changes		Authoritative host		Maintain 7-year history (or less if Provider dies within 7-year period) of inquiry processing, the Contractor staff that have participated in addressing the inquiry and/or interacted with Provider, date/time of interactions and any intermediate status changes or updates. Status of inquiry to be codified for summarization and analysis according to CMO-specific scheme.
7.3		Inquiry resolution		Authoritative host		Includes date of resolution; codify for summarization and analysis according to CMO-specific scheme.
7.4		Inquiry forms (paper-based submission)		Authoritative host		Retain relationship to UPI

 

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L.1.8 Member Grievance and Appeal Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
8.1		Unique grievance/appeal ID		Authoritative host		Scheme must not conflict or overlap with scheme used by Fiscal Agent
8.2		Grievance and appeal data including categorization - type/subtype (electronic or paper-based submission)		Authoritative host		Retain relationship to UMI; content of fields in online or paper-based forms codified for summarization and analysis according to scheme TBD.
8.3		Grievance and appeal processing status changes		Authoritative host		Maintain 7-year history (or less if Member dies within 7-year period) of transaction processing, the Contractor staff that have participated in addressing the issue(s) and/or interacted with Member, date/time of interactions and any intermediate status changes or updates. Status of grievance/appeal to be codified for summarization and analysis according to CMO-specific scheme.
8.4		Grievance and appeal resolution		Authoritative host		Includes date of resolution; codify for summarization and analysis according to CMO-specific scheme.
8.5		Grievance and appeal forms (paper-based submission)		Authoritative host		Retain relationship to UMI

 

L.1.9 Provider Complaint Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
9.1		Unique complaint ID		Authoritative host		Scheme must not conflict or overlap with scheme used by Fiscal Agent
9.2		Complaint data including categorization - type/subtype (electronic or paper-based submission)		Authoritative host		Content of fields in online or paper-based forms codified for summarization and analysis according to scheme TBD.
9.3		Complaint processing status changes		Authoritative host		Maintain 7-year history (or less if Provider dies within 7-year period) of transaction processing, the Contractor staff that have participated in addressing the issue(s) and/or interacted with Provider, date/time of interactions and any intermediate status changes or updates. Status of complaint to be codified for summarization and analysis according to CMO-specific scheme.
9.4		Complaint resolution		Authoritative host		Includes date of resolution; codify for summarization and analysis according to CMO-specific scheme.
9.5		Complaint forms (paper-based submission)		Authoritative host		Retain relationship to UPI

 

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L.1.10 Member and Provider Feedback Data and Related Documents

 

Results of satisfaction surveys and other studies and/or research vehicles.

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
10.1		Survey/study ID		Authoritative host		Maintain 7-year history of feedback obtained from surveys, studies, etc.
10.2		Survey/study question		Authoritative host		Retain relationship to survey/study ID
10.3		Survey/study response		Authoritative host		Where applicable, retain relationship to UMI/UPI. Codify as needed for summarization and analysis according to CMO-specific scheme.

 

L.1.11 Financial Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
11.1		Financial transaction		Authoritative host		Adhere where applicable to Generally Accepted Accounting Principles (GAAP). All financial transaction data as captured must also conform to State and Federal auditing standards and guidelines.
11.2		Medical loss ratio (MLR) and related		Authoritative host		Tie back to MLR requirement in contract

 

L.1.12 Claims Management and Related Financial Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
12.1		Unique claim ID (UCI)		Authoritative host		UCI scheme must not conflict or overlap with scheme used by Fiscal Agent
12.2		Claims processing and status		Authoritative host		Includes longitudinal record of claim’s date/time stamped multiple status changes (submitted, received, pended, denied, reopened, adjudicated, final settled, etc.) during its life.
12.3		Claims payments (all: initial, interim, final)		Authoritative host		Discrete, date/time stamped payments
12.4		Cost avoidance and post payment recovery		Authoritative host		Tie to individual claims (roll up as needed)

 

Special Considerations:

 

12.1 Contractor systems shall distinctly track payments made to FQHCs and RHCs.

 

12.2 Contractor systems shall track claims incurred but not paid by Member and capitation rate cell.

 

12.3 Contractor systems shall retain a 7-year history of changes in procedure pricing (basis for claims payments); where procedure pricing is tied to a particular provider, provider group or provider type, the appropriate linkages to these will be retained as well.

 

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L.1.13

Program Integrity and Compliance Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
13.1		Investigation ID		Authoritative host; reconcile as needed to data held by DCH and/or its agent		Refers to internal investigations; Where applicable, tie back to specific claim(s), provider(s), member(s)
13.2		Investigation type		Authoritative host		Codify as needed for summarization and analysis according to scheme TBD.
13.3		Investigation attributes		Authoritative host		Source of complaint; alleged persons or entities involved; nature of complaint (narrative); approximate dollars involved; etc. Codify as needed for summarization and analysis according to scheme TBD.
13.4		Investigation progress and status changes		Authoritative host		Codify as needed for summarization and analysis according to CMO-specific scheme.
13.5		Investigation resolution		Authoritative host		Includes corrective actions taken and, where applicable, referral to DCH. Codify as needed for summarization and analysis according to scheme TBD.

 

L.1.14

System Availability and Performance Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
14.1		Recorded/monitored response time by System/system function		Authoritative host		Based on statistically valid sampling methodology that covers appropriate # of users by user class. By system function (e.g. highlight ECM and CCE) if possible.
14.2		Reported unavailability events by System/system function		Authoritative host		Captured in IT service management system. Reconcile to data captured in 14.1. By system function if possible. Includes resolution and correction actions taken where applicable.
14.3		Business continuity-disaster recovery test results		Authoritative host		By system function where applicable. Includes resolution and correction actions taken where applicable.
14.4		System user interactions with SHD		Authoritative host		Capture and provide based on SHD performance measures laid out in Section 4.17.8
14.5		System change management activity		Authoritative host		Includes, where applicable, referral to DCH for review and approval

 

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L.1.15

System Activity Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
15.1		Call center metrics		Authoritative host		Maintain 1-year daily history of Hourly totals: call volume; e-mail volume Hourly averages: call length; hold time; call abandonment rate
15.2		Web site hits (non-interactive components)		Authoritative host		Maintain 1-year daily history of hourly hits
15.3		Web portal logins (interactive components/system functions)		Authoritative host		Maintain 1-year daily history of hourly logins and access to system functions (not only submitted transactions but every instance where the associated function is accessed) if possible

 

L.1.16

Information Security Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
16.1		System access security event		Authoritative host		Includes reports or identification of security breaches associated with System access. Capture by system function and/or data element/document type where applicable. Identify source/cause of breach and corrective actions taken where applicable. Tag as HIPAA-related violation when applicable.
16.2		Physical security event		Authoritative host		Includes reports or identification of security breaches associated with unauthorized access to specific facilities and access to documents within that facility. Capture by location and/or data element/document type where applicable. Identify source/cause of breach and corrective actions taken where applicable. Tag as HIPAA-related violation when applicable.

 

Special Considerations:

 

16.1 When applicable Contractor systems shall retain Federally or State mandated forms/reports/documents associated with these events.

 

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L.1.17

System Management Data and Related Documents

 

Subtype ID		Subtype Name/Description		Role of CMO System		Data Management Requirements
17.1		System problem or defect		Authoritative host		Maintain history of proactively identified or reported problems/defects and associated resolution/corrective action for the life of the contract. Capture by system function if possible and where applicable. Where the problem was the underlying cause of a system unavailability or performance event, establish a logical relationship between the problem/defect and the event.
17.2		System change		Authoritative host		Maintain history of changes for the life of the contract. Capture by system function if possible and where applicable. Where the change is part of the resolution/corrective action associated with a System problem/defect, establish a logical relationship between the change and the problem/defect.

 

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Georgia Cares Program (GCS)

Care Management Organization (CMO) Contract

Attachment L.2: Compliance with Standard Coding Schemes

 

A CMO system that is required to or otherwise contains the applicable data type shall conform to the following HIPAA-based standard code sets; the processes through which the data are generated should conform to the same standards as needed:

 

i.

Logical Observation Identifier Names and Codes (LOINC)

 

ii.

Health Care Financing Administration Common Procedural Coding System (HCPCS)

 

iii.

Home Infusion EDI Coalition (HEIC) Product Codes

 

iv.

National Drug Code (NDC)

 

v.

National Council for Prescription Drug Programs (NCPDP)

 

vi.

International Classification of Diseases (ICD-9)

 

vii.

American Dental Association Current Dental Terminology (CDT-4)

 

viii.

Diagnosis Related Group (DRG)

 

ix.

Claim Adjustment Reason Codes

 

x.

Remittance Remarks Codes

 

Additionally, CMO systems shall conform to the following Georgia-specific code sets:

 

xi.

GA SPECIFIC CODE SETS, IF ANY, TO BE SPECIFIED.

 

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Georgia Cares Program (GCS)

Care Management Organization (CMO) Contract

Attachment L.3: Batch and Online Transaction Specifications for Data Exchange

 

CMO systems must conform to the following HIPAA-compliant standards for information exchange effective the first day of CMO operations in the state of Georgia:

 

Batch transaction types

 

•

Premium Payment ASC X12N 820 (004010X061)

 

•

Eligibility ASC X12N 834 (004010X095)

 

•

Payment Remittance Advice ASC X12N 835 (004010X091)

 

•

Institutional Claims ASC X12N 837 (004010X096)

 

•

Professional Claims ASC X12N 837 (004010X097)

 

•

Dental Claims ASC X12N 837 (004010X098)

 

Online transaction types

 

•

Eligibility Inquiry ASC X12N 270/271 (004010X092)

 

•

Additional Claim Information ASC X12N 275 (004010X107)

 

•

Claims Status Inquiry ASC X12N 276 (004010X093)

 

•

Request for Additional Information ASC X12N 277 (004010X104)

 

•

Utilization Review Inquiry ASC X12N 278/279 (004010X094)

 

Page 12 of 13

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Georgia Cares Program (GCS)

Care Management Organization (CMO) Contract

Attachment L.4: Performance Data to Be Captured by Call Center Systems

 

Call center systems must be able to capture data required to create statistical profiles over a defined timeframe of the following industry-standard call center performance measures:

 

•

Speed of answer/hold time

 

•

Abandon rate

 

•

Response time

 

•

Call duration

 

•

Number of calls taken by call center resource

 

•

First contact resolution rates

 

Page 13 of 13

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Attachment L.5.1

 

ACS Fiscal Agent Electronic Claims Management (ACS acronym: EMC) Subsystem Interface Functionality

 

EMC Interface Record Layout Files

 

In the case of the PRIOR AUTHORIZATION EDI INTERFACE COPYBOOK X820V01, this IRL defines the format of the output data from SHCH to GMCF.

 

000010
000020
000030		PRIOR AUTHORIZATION EDI INTERFACE
000040		COPYBOOK X278V01
000050
000060		THE PRIOR AUTHORIZATION EDI INTERFACE COPYBOOK HAS THE
000070		SAME DATA CONTENT AS THE 278 PRIOR AUTHORIZATION/REFERRAL
000080		RESPONSE TRANSACTION. THE PRIOR AUTHORIZATION INTERFACE
000090		COPYBOOK CONTAINS ALL OF THE DATA CONTENT AS THE 278
000100		PRIOR AUTHORIZATION INQUIRY TRANSACTION. SOME SEGMENTS
000110		(AAA - UMO REQUEST VALIDATION) ARE IN THE RESPONSE, BUT
000120		NOT IN THE INQUIRY TRANSACTION.
000130
000140		AS SUGGESTED BY THE 278 PRIOR AUTHORIZATION/REFERRAL
000150		IMPLEMENTATION GUIDE, EACH 278 TRANSACTION APPLIES TO
000160		ONE PATIENT EVENT; I.E., EVEN IF THE INBOUND 278
000170		TRANSACTION APPLIED TO MULTIPLE PATIENTS, THE HIPAA
000180		CLEARINGHOUSE TRANSLATOR WILL DIVIDE THEM INTO
000190		SINGLE PATIENT EVENTS IN THE PRIOR AUTHORIZATION EDI
000200		INTERFACE FILE.
000210
000220
000230		RECORD		DESCRIPTION
000240
000250
000260		X278-TX-HEADER		CONTAINS TRANSACTION HEADER
000270				SEGMENTS
000280
000290		X278-UMO		CONTAINS LOOPS 2000A AND
000300				2010A (IDENTIFIES THE
000310				UTILIZATION MAINTENANCE
000320				ORGANIZATION)
000330
000340		X278-REQUESTOR		CONTAINS LOOPS 2000B AND 2010B

 

Page 1 of 326

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000350				(IDENTIFIES THE REQUESTOR)
000360
000370		X278-SUBSCRIBER		CONTAINS LOOPS 2000C AND 2010CA
000380				(IDENTIFIES THE SUBSCRIBER)
000390
000400		X278-DEPENDENT		CONTAINS LOOPS 2000D AND 2010DA
000410				(IDENTIFIES THE DEPENDENT)
000420
000430		X278-SVC-PROV		CONTAINS LOOPS 2000E AND 2010E
000440				(IDENTIFIES THE SERVICE PROVIDER)
000450
000460		X278-SVC-DETAIL		CONTAINS LOOP 2000F (IDENTIFIES
000470				THE SERVICE)
000480
000490		X278-TX-TRAILER		CONTAINS THE TRANSACTION
000500				TRAILER SEGMENT
000510
000520
000530		EACH RECORD BEGINS WITH A RECORD CODE AND A SORT KEY
000540		CONTAINING THE FOLLOWING FIELDS.
000550
000560		FIELD		DESCRIPTION
000570
000580
000590		X278-TX-CODE		IDENTIFIES EACH TYPE OF RECORD
000600
000610				00 FOR X278-TX-HEADER
000620				01 FOR X278-UMO
000630				02 FOR X278-REQUESTOR
000640				03 FOR X278-SUBSCRIBER
000650				04 FOR X278-DEPENDENT
000660				05 FOR X278-SVC-PROV
000670				06 FOR X278-SVC-DETAIL
000680				99 FOR X278-TX-TRAILER
000690
000700		X278-TX-CODE-SEQ-NUM		TO SEQUENCE RECORDS WITHIN A
000710				RECORD TYPE
000720
000730		THE FOLLOWING EXAMPLE SHOWS HOW THIS WORKS.
000740
000750				TX CODE		TX CODE SEQ
000760		RECORD
000770
000780
000790		TX HEADER		00		ZEROS
000800		UMO		01		ZEROS
000810		REQUESTOR		02		ZEROS
000820		SUBSCRIBER		03		ZEROS
000830		DEPENDENT		04		ZEROS
000840		SVC PROV		▇▇		▇▇▇-▇▇▇
000850		SVC DETAIL		▇▇		▇▇▇-▇▇▇

 

Page 2 of 326

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000860		TX TRAILER            99          9999999
000870
000880
000890
000900
000910
000920
000930		278 TRANSACTION HEADER RECORD (NO LOOP)
000940
000950
000960		01     X278-TX-HEADER.
000970
000980		05     X278-RECORD-CODE
000990		PIC X(02).
001000
001010		05     X278-SORT-KEY.
001020
001030
001040		USE‘00’ FOR THE TRANSACTION CODE
001050
001060
001070		10     X278-TX-CODE
001080		VALUE ‘00’
001090		PIC X(02).
001100
001110
001120		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
001130
001140
001150		10     X278-TX-CODE-SEQ-NUM
001160		VALUE ZEROES
001170		PIC 9(05).
001180
001190		05     X278-TX-HEADER-SEG.
001200
001210		10     X278-TX-ID
001220		VALUE ‘278’
001230		PIC X(03).
001240		10     X278-TX-CTL-NUM-HDR
001250		PIC X(09).
001260		10     FILLER
001270		PIC X(10).
001280
001290		05     X278-BEG-OF-TX-SEG.
001300
001310		10     X278-BEG-TX-HIER-CODE
001320		PIC X(04).
001330		10     X278-TX-SET-PURPOSE-CODE
001340		PIC X(02).
001350		10     X278-SUBMITTER-TX-ID
001360		PIC X(30).

 

Page 3 of 326

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001370		10     X278-TX-CREATION-DATE
001380		PIC X(08).
001390		10     X278-TX-CREATION-TIME
001400		PIC X(08).
001410		10     X278-TX-TYPE-CODE
001420		PIC X(02).
001430		10     FILLER
001440		PIC X(10).
001450
001460
001470
001480		278 UTILIZATION MAINTENANCE ORGANIZATION RECORD
001490
001500
001510		01     X278-UMO.
001520
001530		05     X278-RECORD-CODE
001540		PIC X(02).
001550
001560		05     X278-SORT-KEY.
001570
001580
001590		USE ‘01’ FOR THE TRANSACTION CODE
001600
001610
001620		10     X278-TX-CODE
001630		VALUE ‘01’
001640		PIC X(02).
001650
001660
001670		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
001680
001690
001700		10     X278-TX-CODE-SEQ-NUM
001710		VALUE ZEROES
001720		PIC 9 (05).
001730
001740		05     X278-UMO-LEVEL-SEG.
001750
001760		10     X278-UMO-HIER-ID-NUM
001770		PIC X(12).
001780		10     X278-UMO-HIER-PARENT
001790		PIC X(12).
001800		10     X278-UMO-HIER-LEVEL
001810		PIC. X(02).
001820		10     X278-UMO-HIER-CHILD
001830		PIC X(01).
001840		10     FILLER
001850		PIC X(10).
001860
001870		05     X278-UMO-RESPONSE-SEG

 

Page 4 of 326

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001880		OCCURS 9 TIMES
001890		INDEXED BY X278-UMO-RESPONSE-SEG-NDX.
001900
001910		10     X278-UMO-YES-NO-IND
001920		PIC X(01).
001930		10     X278-UMO-REJECT-REASON
001940		PIC X(02).
001950		10     X278-UMO-FOLLOW-UP-CODE
001960		PIC X(01).
001970		10     FILLER
001980		PIC X(10).
001990
002000		05     X278-UMO-NAME-SEG.
002010
002020		10     X278-UMO-IDENT-CODE
002030		PIC X(03).
002040		10     X278-UMO-PERSON-IND
002050		PIC X(01).
002060		10     X278-UMO-LAST-NAME
002070		PIC X(35).
002080		10     X278-UMO-FIRST-NAME
002090		PIC X(25).
002100		10     X278-UMO-MIDDLE-NAME
002110		PIC X(25).
002120		10     X278-UMO-NAME-SUFFIX
002130		PIC X(10).
002140		10     X278-UMO-ID-QUAL
002150		PIC X(02).
002160		10     X278-UMO-ID
002170		PIC X(80).
002180		10     FILLER
002190		PIC X(10).
002200
002210		05     X278-UMO-CONTACT-SEG.
002220
002230		10     X278-UMO-CONTACT-NAME
002240		PIC X(60).
002250		10     X278-UMO-COMM
002260		OCCURS 3 TIMES
002270		INDEXED BY X278-UMO-COMM-NDX.
002280
002290		15     X278-UMO-COMM-NUM-QUAL
002300		PIC X(02).
002310		15     X278-UMO-COMM-NUM
002320		PIC X(80).
002330		15     FILLER
002340		PIC X(10).
002350
002360		05     X278-UMO-NM-RESPONSE-SEG
002370		OCCURS 9 TIMES
002380		INDEXED BY X278-UMO-NM-RESPONSE-SEG-NDX.

 

Page 5 of 326

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002390
002400		10     X278-UMO-NM-YES-NO-IND
002410		PIC X(01).
002420		10     X278-UMO-NM-REJECT-REASON
002430		PIC X(02).
002440		10     X278-UMO-NM-FOLLOW-UP-CODE
002450		PIC X(01).
002460		10     FILLER
002470		PIC X(10).
002480
002490
002500
002510		278 REQUESTOR RECORD
002520
002530
002540		01     X278-REQUESTOR.
002550
002560		05     X278-RECORD-CODE
002570		PIC X(02).
002580
002590		05     X278-SORT-KEY.
002600
002610
002620		USE ‘02’ FOR THE TRANSACTION CODE
002630
002640
002650		10     X278-TX-CODE
002660		VALUE ‘02’
002670		PIC X(02).
002680
002690
002700		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
002710
002720
002730		10     X278-TX-CODE-SEQ-NUM
002740		VALUE ZEROES
002750		PIC 9 (05).
002760
002770		05     X278-REQUESTER-LEVEL-SEG.
002780
002790		10     X278-REQUESTER-HIER-ID-NUM
002800		PIC X(12).
002810		10     X278-REQUESTER-HIER-PARENT
002820		PIC X(12).
002830		10     X278-REQUESTER-HIER-LEVEL
002840		PIC X(02).
002850		10     X278-REQUESTER-HIER-CHILD
002860		PIC X(01).
002870		10     FILLER
002880		PIC X(10).
002890

 

Page 6 of 326

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002900		05     X278-REQUESTER-NAME-SEG.
002910
002920		10     X278-REQUESTER-IDENT-CODE
002930		PIC X(03).
002940		10     X278-REQUESTER-PERSON-IND
002950		PIC X(01).
002960		10     X278-REQUESTER-LAST-NAME
002970		PIC X(35).
002980		10     X278-REQUESTER-FIRST-NAME
002990		PIC X(25).
003000		10     X278-REQUESTER-MIDDLE-NAME
003010		PIC X(25).
003020		10     X278-REQUESTER-NAME-SUFFIX
003030		PIC X(10).
003040		10     X278-REQUESTER-ID-QUAL
003050		PIC X(02).
003060		10     X278-REQUESTER-ID
003070		PIC X(80).
003080		10     FILLER
003090		PIC X(10).
003100
003110		05     X278-REQUESTER-SUPPL-SEG
003120		OCCURS 8 TIMES
003130		INDEXED BY X278-REQUESTOR-SUPPL-SEG-NDX.
003140
003150		10     X278-REQUESTOR-SUPPL-ID-QUAL
003160		PIC X(03).
003170		10     X278-REQUESTOR-SUPPL-ID
003180		PIC X(30).
003190		10     FILLER
003200		PIC X(10).
003210
003220		05     X278-REQUEST-RESPONSE-SEG
003230		OCCURS 9 TIMES
003240		INDEXED BY X278-REQUEST-RESPONSE-SEG-NDX.
003250
003260		10     X278-REQUEST-YES-NO-IND
003270		PIC X(01).
003280		10     X278-REQUEST-REJECT-REASON
003290		PIC X(02).
003300		10     X278-REQUEST-FOLLOW-UP-CODE
003310		PIC X(01).
003320		10     FILLER
003330		PIC X(10).
003340
003350		05     X278-REQUEST-PROV-SEG.
003360
003370		10     X278-REQUEST-PROV-TYPE
003380		PIC X(03).
003390		10     X278-REQUEST-TAXONONMY-QUAL
003400		PIC X(03).

 

Page 7 of 326

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003410		10     X278-REQUEST-TAXONOMY
003420		PIC X(30).
003430		10     FILLER
003440		PIC X(10).
003450
003460
003470
003480		278  SUBSCRIBER RECORD
003490
003500
003510		01     X278-SUBSCRIBER.
003520
003530		05     X278-RECORD-CODE
003540		PIC X(02).
003550
003560		05     X278-SORT-KEY.
003570
003580
003590		USE ‘03’ FOR THE TRANSACTION CODE
003600
003610
003620		10     X278-TX-CODE
003630		VALUE ‘03’
003640		PIC X(02).
003650
003660
003670		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
003680
003690
003700		10     X278-TX-CODE-SEQ-NUM
003710		VALUE ZEROES
003720		PIC 9(05).
003730
003740		05     X278-SUBSCR-LEVEL-SEG.
003750
003760		10     X278-SUBSCR-HIER-ID-NUM
003770		PIC X(12).
003780		10     X278-SUBSCR-HIER-PARENT
003790		PIC X(12).
003800		10     X278-SUBSCR-HIER-LEVEL
003810		PIC X(02).
003820		10     X278-SUBSCR-HIER-CHILD
003830		PIC X(01).
003840		10     FILLER
003850		PIC X(10).
003860
003870		05     X278-SUBSCR-TRACE-SEG
003880		OCCURS 3 TIMES
003890		INDEXED BY X278-SUBSCR-TRACE-SEG-NDX.
003900
003910		10     X278-SUBSCR-TRACE-TYPE

 

Page 8 of 326

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003920		PIC X(02).
003930		10     X278-SUBSCR-TRACE-NUM
003940		PIC X(30).
003950		10     X278-SUBSCR-TRACE-ASSIGN-ID-1
003960		PIC X(10).
003970		10     X278-SUBSCR-TRACE-ASSIGN-ID-2
003980		PIC X(10).
003990		10     FILLER
004000		PIC X(10).
004010
004020		05     X278-SUBSCR-RESPONSE-SEG
004030		OCCURS 9 TIMES
004040		INDEXED BY X278-SUBSCR-RESPONSE-SEG-NDX.
004050
004060		10     X278-SUBSCR-YES-NO-IND
004070		PIC X(01).
004080		10     X278-SUBSCR-REJECT-REASON
004090		PIC X(02).
004100		10     X278-SUBSCR-FOLLOW-UP-CODE
004110		PIC X(01).
004120		10     FILLER
004130		PIC X(10).
004140
004150		05     X278-SUBSCR-ACCIDENT-SEG.
004160
004170		10     X278-SUBSCR-ACCIDENT-DATE
004180		PIC X(08).
004190		10     FILLER
004200		PIC X(10).
004210
004220		05     X278-SUBSCR-MENSTRUAL-SEG.
004230
004240		10     X278-SUBSCR-MENSTRUAL-DATE
004250		PIC X(08).
004260		10     FILLER
004270		PIC X(10).
004280
004290		05     X278-SUBSCR-EST-BIRTH-SEG.
004300
004310		10     X278-SUBSCR-EST-BIRTH-DATE
004320		PIC X(08).
004330		10     FILLER
004340		PIC X(10).
004350
004360		05     X278-SUBSCR-ILLNESS-SEG.
004370
004380		10     X278-SUBSCR-ILLNESS-DATE
004390		PIC X(08).
004400		10     FILLER
004410		PIC X(10).
004420

 

Page 9 of 326

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004430		05     X278-SUBSCR-DIAG-SEG.
004440
004450		10     X278-SUBSCR-DIAG-DATA
004460		OCCURS 12 TIMES
004470		INDEXED BY X278-SUBSCR-DIAG-DATA-NDX.
004480
004490		15     X278-SUBSCR-DIAG-TYPE
004500		PIC X(03).
004510		15     X278-SUBSCR-DIAG
004520		PIC X(30).
004530		15     X278-SUBSCR-DIAG-DATE
004540		PIC X(08).
004550		15     FILLER
004560		PIC X(10).
004570
004580		05     X278-SUBSCR-PWK-SEG
004590		OCCURS 10 TIMES
004600		INDEXED BY X278-SUBSCR-PWK-SEG-NDX.
004610
004620		10     X278-SUBSCR-PWK-TYPE
004630		PIC X(02).
004640		10     X278-SUBSCR-PWK-TRANSMIT-CODE
004650		PIC X(02).
004660		10     X278-SUBSCR-PWK-CTL-NUM-QUAL
004670		PIC X(02).
004680		10     X278-SUBSCR-PWK-CTL-NUM
004690		PIC X(80).
004700		10     X278-SUBSCR-PWK-DESC
004710		PIC X(80).
004720		10     FILLER
004730		PIC X(10).
004740
004750		05     X278-SUBSCR-NAME-SEG.
004760
004770		10     X278-SUBSCR-IDENT-CODE
004780		PIC X(03).
004790		10     X278-SUBSCR-PERSON-IND
004800		PIC X(01).
004810		10     X278-SUBSCR-LAST-NAME
004820		PIC X(35).
004830		10     X278-SUBSCR-FIRST-NAME
004840		PIC X(25).
004850		10     X278-SUBSCR-MIDDLE-NAME
004860		PIC X(25).
004870		10     X278-SUBSCR-NAME-SUFFIX
004880		PIC X(10).
004890		10     X278-SUBSCR-ID-QUAL
004900		PIC X(02).
004910		10     X278-SUBSCR-ID
004920		PIC X(80).
004930		10     FILLER

 

Page 10 of 326

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004940		PIC X(10).
004950
004960		05     X278-SUBSCR-SUPPL-SEG
004970		OCCURS 9 TIMES
004980		INDEXED BY X278-SUBSCR-SUPPL-SEG-NDX.
004990
005000		10     X278-SUBSCR-SUPPL-ID-QUAL
005010		PIC X(03).
005020		10     X278-SUBSCR-SUPPL-ID
005030		PIC X(30).
005040		10     FILLER
005050		PIC X(10).
005060
005070		05     X278-SUBSCR-NM-RESPONSE-SEG
005080		OCCURS 9 TIMES
005090		INDEXED BY X278-SUBSCR-NM-RESPONSE-NDX.
005100
005110		10     X278-SUBSCR-NM-YES-NO-IND
005120		PIC X(01).
005130		10     X278-SUBSCR-NM-REJECT-REASON
005140		PIC X(02).
005150		10     X278-SUBSCR-NM-FOLLOW-UP-CODE
005160		PIC X(01).
005170		10     FILLER
005180		PIC X(10).
005190
005200		05     X278-SUBSCR-DEMO-SEG.
005210
005220		10     X2 7 8-SUBSCR-BIRTH-DATE
005230		PIC X(08).
005240		10     X278-SUBSCR-SEX-CODE
005250		PIC X(01).
005260		10     FILLER
005270		PIC X(10).
005280
005290		05     X278-SUBSCR-CONTACT-NAME-SEG.
005300
005310		10     X278-SUBSCR-CONTACT-IDENT-CODE
005320		PIC X(03).
005330		10     X278-SUBSCR-CONTACT-PERSON-IND
005340		PIC X(01).
005350		10     X278-SUBSCR-CONTACT-LAST-NAME
005360		PIC X(35).
005370		10     X278-SUBSCR-CONTACT-FIRST-NAME
005380		PIC X(25).
005390		10     X278-SUBSCR-CONTACT-MIDDLE-NM
005400		PIC X(25).
005410		10     X278-SUBSCR-CONTACT-NM-SUFFIX
005420		PIC X(10).
005430		10     X278-SUBSCR-CONTACT-ID-QUAL
005440		PIC X(02).

 

Page 11 of 326

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005450		10     X278-SUBSCR-CONTACT-ID
005460		PIC X(80).
005470		10     FILLER
005480		PIC X(10).
005490
005500		05     X278-SUBSCR-CONTACT-ADDR-SEG.
005510
005520		10     X278-SUBSCR-CONTACT-ADDR-1
005530		PIC X(55).
005540		10     X278-SUBSCR-CONTACT-ADDR-2
005550		PIC X(55).
005560		10     FILLER
005570		PIC X(10).
005580
005590		05     X278-SUBSCR-CONTACT-CITY-SEG.
005600
005610		10     X278-SUBSCR-CONTACT-CITY
005620		PIC X(30).
005630		10     X278-SUBSCR-CONTACT-STATE
005640		PIC X(02).
005650		10     X278-SUBSCR-CONTACT-ZIP
005660		PIC X(15).
005670		10     X278-SUBSCR-CONTACT-COUNTRY
005680		PIC X (03).
005690		10     X278-SUBSCR-CONTACT-LOC-QUAL
005700		PIC X(02).
005710		10     X278-SUBSCR-CONTACT-LOC
005720		PIC X(30).
005730		10     FILLER
005740		PIC X(10).
005750
005760		05     X278-SUBSCR-OTHER-CONTACT-SEG.
005770
005780		10     X278-SUBSCR-OTHER-CONTACT-NAME
005790		PIC X(60).
005800		10     X278-SUBSCR-OTHER-COMM
005810		OCCURS 3 TIMES
005820		INDEXED BY X278-SUBSCR-OTHER-COMM-NDX.
005830
005840		15     X278-SUBSCR-COMM-NUM-QUAL
005850		PIC X(02).
005860		15     X278-SUBSCR-COMM-NUM
005870		PIC X(80).
005880		15     FILLER
005890		PIC X(10).
005900
005910
005920
005930		278 DEPENDENT RECORD
005940
005950

 

Page 12 of 326

---

005960		01     X278-DEPENDENT.
005970
005980		05     X278-RECORD-CODE
005990		PIC X(02).
006000
006010		05     X278-SORT-KEY.
006020
006040		USE ‘04’ FOR THE TRANSACTION CODE
006050
006060
006070		10     X278-TX-CODE
006080		VALUE ‘04’
006090		PIC X(02).
006100
006110
006120		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
006130
006140
006150		10     X278-TX-CODE-SEQ-NUM
006160		VALUE ZEROES
006170		PIC 9(05).
006180
006190		05     X278-DEPEND-LEVEL-SEG.
006200
006210		10     X278-DEPEND-HIER-ID-NUM
006220		PIC X(12).
006230		10     X278-DEPEND-HIER-PARENT
006240		PIC X(12).
006250		10     X278-DEPEND-HIER-LEVEL
006260		PIC X(02).
006270		10     X278-DEPEND-HIER-CHILD
006280		PIC X(01).
006290		10     FILLER
006300		PIC X(10).
006310
006320		05     X278-DEPEND-TRACE-SEG
006330		OCCURS 3 TIMES
006340		INDEXED BY X278-DEPEND-TRACE-SEG-NDX.
006350
006360		10     X278-DEPEND-TRACE-TYPE
006370		PIC X(02).
006380		10     X278-DEPEND-TRACE-NUM
006390		PIC X(30).
006400		10     X278-DEPEND-TRACE-ASSIGN-ID-1
006410		PIC X(10).
006420		10     X27 8-DEPEND-TRACE-ASSIGN-ID-2
006430		PIC X(10).
006440		10     FILLER
006450		PIC X(10).
006460

 

Page 13 of 326

---

006470		05     X278-DEPEND-RESPONSE-SEG
006480		OCCURS 9 TIMES
006490		INDEXED BY X278-DEPEND-RESPONSE-SEG-NDX.
006500
006510		10     X278-DEPEND-YES-NO-IND
006520		PIC X(01).
006530		10     X278-DEPEND-REJECT-REASON
006540		PIC X(02).
006550		10     X278-DEPEND-FOLLOW-UP-CODE
006560		PIC X(01).
006570		10     FILLER
006580		PIC X(10).
006590
006600		05     X278-DEPEND-ACCIDENT-SEG.
006610
006620		10     X278-DEPEND-ACCIDEND-DATE
006630		PIC X(08).
006640		10     FILLER
006650		PIC X(10).
006660
006670		05     X278-DEPEND-MENSTRUAL-SEG.
006680
006690		10     X278-DEPEND-MENSTRUAL-DATE
006700		PIC X(08).
006710		10     FILLER
006720		PIC X(10).
006730
006740		05     X278-DEPEND-EST-BIRTH-SEG.
006750
006760		10     X278-DEPEND-EST-BIRTH-DATE
006770		PIC X(08).
006780		10     FILLER
006790		PIC X(10).
006800
006810		05     X278-DEPEND-ILLNESS-SEG.
006820
006830		10     X278-DEPEND-ILLNESS-DATE
006840		PIC X(08).
006850		10     FILLER
006860		PIC X(10).
006870
006880		05     X278-DEPEND-DIAG-SEG.
006890
006900		10     X278-DEPEND-DIAG-DATA
006910		OCCURS 12 TIMES
006920		INDEXED BY X278-DEPEND-DIAG-DATA.
006930
006940		15     X278-DEPEND-DIAG-TYPE
006950		PIC X(03).
006960		15     X278-DEPEND-DIAG
006970		PIC X(30).

 

Page 14 of 326

---

006980		15     X278-DEPEND-DIAG-DATE
006990		PIC X(08).
007000		15     FILLER
007010		PIC X(10).
007020
007030		05     X278-DEPEND-PWK-SEG
007040		OCCURS 10 TIMES
007050		INDEXED BY X278-DEPEND-PWK-SEG-NDX.
007060
007070		10     X278-DEPEND-PWK-TYPE
007080		PIC X(02).
007090		10     X278-DEPEND-PWK-TRANSMIT-CODE
007100		PIC X(02).
007110		10     X278-DEPEND-PWK-CTL-NUM-QUAL
007120		PIC X(02).
007130		10     X278-DEPEND-PWK-CTL-NUM
007140		PIC X(80).
007150		10     X278-DEPEND-PWK-DESC
007160		PIC X(80).
007170		10     FILLER
007180		PIC X(10).
007190
007200		05     X278-DEPEND-NAME-SEG.
007210
007220		10     X278-DEPEND-IDENT-CODE
007230		PIC X(03).
007240		10     X278-DEPEND-PERSON-IND
007250		PIC X(01).
007260		10     X278-DEPEND-LAST-NAME
007270		PIC X(35).
007280		10     X278-DEPEND-FIRST-NAME
007290		PIC X(25).
007300		10     X278-DEPEND-MIDDLE-NAME
007310		PIC X(25).
007320		10     X278-DEPEND-NAME-SUFFIX
007330		PIC X(10).
007340		10     X278-DEPEND-ID-QUAL
007350		PIC X(02).
007360		10     X278-DEPEND-ID
007370		PIC X(80).
007380		10     FILLER
007390		PIC X(10).
007400
007410		05     X278-DEPEND-SUPPL-SEG
007420		OCCURS 3 TIMES
007430		INDEXED BY X278-DEPEND-SUPPL-SEG-NDX.
007440
007450		10     X278-DEPEND-SUPPL-ID-QUAL
007460		PIC X(03).
007470		10     X278-DEPEND-SUPPL-ID
007480		PIC X(30).

 

Page 15 of 326

---

007490		10     FILLER
007500		PIC X(10).
007510
007520		05     X278-DEPEND-NM-RESPONSE-SEG.
007530		OCCURS 9 TIMES
007540		INDEXED BY X278-DEPEND-NM-RESPONSE-NDX.
007550
007560		10     X278-DEPEND-NM-YES-NO-IND
007570		PIC X(01).
007580		10     X278-DEPEND-NM-REJECT-REASON
007590		PIC X(02).
007600		10     X278-DEPEND-NM-FOLLOW-UP-CODE
007610		PIC X(01).
007620		10     FILLER
007630		PIC X(10).
007640
007650		05     X278-DEPEND-DEMO-SEG.
007660
007670		10     X278-DEPEND-BIRTH-DATE
007680		PIC X(08).
007690		10     X278-DEPEND-SEX-CODE
007700		PIC X(01).
007710		10     FILLER
007720		PIC X(10).
007730
007740		05     X278-DEPEND-RELATIONSHIP-SEG.
007750
007760		10     X278-DEPEND-INSURED-IND
007770		PIC X(01).
007780		10     X278-DEPEND-RELATIONSHIP
007790		PIC X(02).
007800		10     X278-DEPEND-BIRTH-SEQ-NUM
007810		PIC 9(09).
007820		10     FILLER
007830		PIC X(10).
007840
007850		05     X278-DEPEND-CONTACT-NAME-SEG.
007860
007870		10     X278-DEPEND-CONTACT-IDENT-CODE
007880		PIC X(03).
007890		10     X278-DEPEND-CONTACT-PERSON-IND
007900		PIC X(01).
007910		10     X278-DEPEND-CONTACT-LAST-NAME
007920		PIC X(35).
007930		10     X278-DEPEND-CONTACT-FIRST-NAME
007940		PIC X(25).
007950		10     X278-DEPEND-CONTACT-MIDDLE-NM
007960		PIC X(25).
007970		10     X278-DEPEND-CONTACT-NM-SUFFIX
007980		PIC X(10).
007990		10     X278-DEPEND-CONTACT-ID-QUAL

 

Page 16 of 326

---

008000		PIC X(02).
008010		10     X278-DEPEND-CONTACT-ID
008020		PIC X(80).
008030		10     FILLER
008040		PIC X(10).
008050
008060		05     X278-DEPEND-CONTACT-ADDR-SEG.
008070
008080		10     X278-DEPEND-CONTACT-ADDR-1
008090		PIC X(55).
008100		10     X278-DEPEND-CONTACT-ADDR-2
008110		PIC X(55).
008120		10     FILLER
008130		PIC X(10).
008140
008150		05     X278-DEPEND-CONTACT-CITY-SEG.
008160
008170		10     X278-DEPEND-CONTACT-CITY
008180		PIC X(30).
008190		10     X278-DEPEND-CONTACT-STATE
008200		PIC X(02).
008210		10     X278-DEPEND-CONTACT-ZIP
008220		PIC X(15).
008230		10     X278-DEPEND-CONTACT-COUNTRY
008240		PIC X(03).
008250		10     X278-DEPEND-CONTACT-LOC-QUAL
008260		PIC X(02).
008270		10     X278-DEPEND-CONTACT-LOC
008280		PIC X(30).
008290		10     FILLER
008300		PIC X(10).
008310
008320		05     X278-DEPEND-CONTACT-INFO-SEG.
008330
008340		10     X278-DEPEND-OTHER-CONTACT-NAME
008350		PIC X(60).
008360		10     X278-DEPEND-OTHER-COMM
008370		OCCURS 3 TIMES
008380		INDEXED BY X278-DEPEND-OTHER-COMM-NDX.
008390
008400		15     X278-DEPEND-COMM-NUM-QUAL
008410		PIC X(02).
008420		15     X278-DEPEND-COMM-NUM
008430		PIC X(80).
008440		15     FILLER
008450		PIC X(10).
008460
008470
008480
008490		278 SERVICE PROVIDER RECORD
008500

 

Page 17 of 326

---

008510
008520		01     X278-SVC-PROV.
008530
008540		05     X278-RECORD-CODE
008550		PIC X(02).
008560
008570		05     X278-SORT-KEY.
008580
008590
008600		USE ‘05’ FOR THE TRANSACTION CODE
008610
008620
008630		10     X278-TX-CODE
008640		VALUE ‘05’
008650		PIC X(02).
008660
008670
008680		USE A UNIQUE SEQUENCE NUMBER FOR EACH SERVICE PROVIDER
008690		RECORD
008700
008710
008720		10     X278-TX-CODE-SEQ-NUM
008730		PIC 9(05).
008740
008750		05     X278-SVC-PROV-LEVEL-SEG.
008760
008770		10     X278-SVC-PROV-HIER-ID-NUM
008780		PIC X(12).
008790		10     X278-SVC-PROV-HIER-PARENT
008800		PIC X(12).
008810		10     X278-SVC-PROV-HIER-LEVEL
008820		PIC X(02).
008830		10     X278-SVC-PROV-HIER-CHILD
008840		PIC X(01).
008850		10     FILLER
008860		PIC X(10).
008870
008880		05     X278-SVC-PROV-MSG-SEG.
008890
008900		10     X278-SVC-PROV-MSG
008910		PIC X(264).
008920		10     FILLER
008930		PIC X(10).
008940
008950		05     X278-SVC-PROV-NAME-SEG.
008960
008970		10     X278-SVC-PROV-IDENT-CODE
008980		PIC X(03).
008990		10     X278-SVC-PROV-PERSON-IND
009000		PIC X(01).
009010		10     X278-SVC-PROV-LAST-NAME

 

Page 18 of 326

---

009020		PIC X(35).
009030		10     X278-SVC-PROV-FIRST-NAME
009040		PIC X(25).
009050		10     X278-SVC-PROV-MIDDLE-NAME
009060		PIC X(25).
009070		10     X278-SVC-PROV-NAME-SUFFIX
009080		PIC X(10).
009090		10     X278-SVC-PROV-ID-QUAL
009100		PIC X(02).
009110		10     X278-SVC-PROV-ID
009120		PIC X(80).
009130		10     FILLER
009140		PIC X(10).
009150
009160		05     X278-SVC-PROV-SUPPL-SEG
009170		OCCURS 7 TIMES
009180		INDEXED BY X278-SVC-PROV-SUPPL-SEG-NDX.
009190
009200		10     X278-SVC-PROV-SUPPL-ID-QUAL
009210		PIC X(03).
009220		10     X278-SVC-PROV-SUPPL-ID
009230		PIC X(30).
009240		10     FILLER
009250		PIC X(10).
009260
009270		05     X278-SVC-PROV-ADDR-SEG.
009280
009290		10     X278-SVC-PROV-CONTACT-ADDR-1
009300		PIC X(55).
009310		10     X278-SVC-PROV-CONTACT-ADDR-2
009320		PIC X(55).
009330		10     FILLER
009340		PIC X(10).
009350
009360		05     X278-SVC-PROV-CITY-SEG.
009370
009380		10     X278-SVC-PROV-CONTACT-CITY
009390		PIC X(30).
009400		10     X278-SVC-PROV-CONTACT-STATE
009410		PIC X(02).
009420		10     X278-SVC-PROV-CONTACT-ZIP
009430		PIC X(15).
009440		10     X278-SVC-PROV-CONTACT-COUNTRY
009450		PIC X(03).
009460		10     FILLER
009470		PIC X(10).
009480
009490		05     X278-SVC-PROV-CONTACT-SEG.
009500
009510		10     X278-SVC-PROV-OTHER-CONTACT-NM
009520		PIC X(60).

 

Page 19 of 326

---

009530		10     X278-SVC-PROV-OTHER-COMM
009540		OCCURS 3 TIMES
009550		INDEXED BY X278-SVC-PROV-OTHER-COMM-NDX.
009560
009570		15     X278-SVC-PROV-COMM-NUM-QUAL
009580		PIC X(02).
009590		15     X278-SVC-PROV-COMM-NUM
009600		PIC X(80).
009610		15     FILLER
009620		PIC X(10).
009630
009640		05     X278-SVC-PROV-RESPONSE-SEG
009650		OCCURS 9 TIMES
009660		INDEXED BY X278-SVC-PROV-RESPONSE-SEG-NDX.
009670
009680		10     X278-SVC-PROV-YES-NO-IND
009690		PIC X(01).
009700		10     X278-SVC-PROV-REJECT-REASON
009710		PIC X(02).
009720		10     X278-SVC-PROV-FOLLOW-UP-CODE
009730		PIC X(01).
009740		10     FILLER
009750		PIC X(10).
009760
009770		05     X278-SVC-PROV-INFO-SEG.
009780
009790		10     X278-SVC-PROV-TYPE
009800		PIC X(03).
009810		10     X278-SVC-PROV-TAXONOMY-QUAL
009820		PIC X(03).
009830		10     X278-SVC-PROV-TAXONOMY
009840		PIC X(30).
009850		10     FILLER
009860		PIC X(10).
009870
009880
009890
009900		278 SERVICE DETAIL RECORD
009910
009920
009930		01     X278-SVC-DETAIL.
009940
009950		05     X278-RECORD-CODE
009960		PIC X(02).
009970
009980		05     X278-SORT-KEY.
009990
010000
010010		USE ‘06’ FOR THE TRANSACTION CODE
010020
010030

 

Page 20 of 326

---

010040		10     X278-TX-CODE
010050		VALUE ‘06’
010060		PIC X(02).
010070
010080
010090		USE A UNIQUE SEQUENCE NUMBER FOR EACH SERVICE DETAIL
010100		RECORD
010110
010120
010130		10     X278-TX-CODE-SEQ-NUM
010140		PIC 9(05).
010150
010160		05     X278-SVC-LEVEL-SEG.
010170
010180		10     X278-SVC-HIER-ID-NUM
010190		PIC X(12).
010200		10     X278-SVC-HIER-PARENT
010210		PIC X(12).
010220		10     X278-SVC-HIER-LEVEL
010230		PIC X(02).
010240		10     X278-SVC-HIER-CHILD
010250		PIC X(01).
010260		10     FILLER
010270		PIC X(10).
010280
010290		05     X278-SVC-TRACE-NUM-SEG
010300		OCCURS 3 TIMES
010310		INDEXED BY X278-SVC-TRACE-NUM-SEG-NDX.
010320
010330		10     X278-SVC-TRACE-TYPE
010340		PIC X(02).
010350		10     X278-SVC-TRACE-NUM
010360		PIC X(30).
010370		10     X278-SVC-TRACE-ASSIGN-ID-1
010380		PIC X(10).
010390		10     X278-SVC-TRACE-ASSIGN-ID-2
010400		PIC X(10).
010410		10     FILLER
010420		PIC X(10).
010430
010440		05     X278-SVC-RESPONSE-SEG
010450		OCCURS 9 TIMES
010460		INDEXED BY X278-SVC-RESPONSE-SEG-NDX.
010470
010480		10     X278-SVC-YES-NO-IND
010490		PIC X(01).
010500		10     X278-SVC-REJECT-REASON
010510		PIC X(02).
010520		10     X278-SVC-FOLLOW-UP-CODE
010530		PIC X(01).
010540		10     FILLER

 

Page 21 of 326

---

010550		PIC X(10).
010560
010570		05     X278-CARE-REVIEW-INFO-SEG.
010580
010590		10     X278-REQUEST-CAT-CODE
010600		PIC X(02).
010610		10     X278-CERT-TYPE-CODE
010620		PIC X(01).
010630		10     X278-SVC-TYPE-CODE
010640		PIC X(02).
010650		10     X278-PLACE-OF-SVC
010660		PIC X(02).
010670		10     X278-PLACE-OF-SVC-QUAL
010680		PIC X(02).
010690		10     X278-LEVEL-OF-SVC-CODE
010700		PIC X(03).
010710		10     FILLER
010720		PIC X(10).
010730
010740		05     X278-CARE-REVIEW-SEG.
010750
010760		10     X278-CERT-ACTION-CODE
010770		PIC X(02).
010780		10     X278-CERTIFICATION-NUM
010790		PIC X(30).
010800		10     X278-REJECT-REASON-CODE
010810		PIC X(02).
010820		10     X278-SECOND-SURG-OPINION-IND
010830		PIC X(01).
010840		10     FILLER
010850		PIC X(10).
010860
010870		05     X278-PREV-CERT-IDENT-SEG.
010880
010890		10     X278-PREV-CERTIFICATION-NUM
010900		PIC X(30).
010910		10     FILLER
010920		PIC X(10).
010930
010940		05     X278-SVC-DATES-SEG.
010950
010960		10     X278-DATES-OF-SVC.
010970
010980		15     X278-FIRST-DATE-OF-SVC
010990		PIC X(08).
011000		15     X278-LAST-DATE-OF-SVC
011010		PIC X(08).
011020
011030		10     FILLER
011040		PIC X(10).
011050

 

Page 22 of 326

---

011060		05     X278-ADMIN-DATE-SEG.
011070
011080		10     X278-ADMIN-DATE
011090		PIC X(08).
011100		10     FILLER
011110		PIC X(10).
011120
011130		05     X278-DISCHARGE-DATE-SEG.
011140
011150		10     X278-DISCHARGE-DATE
011160		PIC X(08).
011170		10     FILLER
011180		PIC X(10).
011190
011200		05     X278-SURGERY-DATE-SEG.
011210
011220		10     X278-SURGERY-DATE
011230		PIC X(08).
011240		10     FILLER
011250		PIC X(10).
011260
011270		05     X278-CERT-ISSUE-DATE-SEG.
011280
011290		10     X278-CERT-ISSUE-DATE
011300		PIC X(08).
011310		10     FILLER
011320		PIC X(10).
011330
011340		05     X278-CERT-EXPIRE-DATE-SEG.
011350
011360		10     X278-CERT-EXPIRE-DATE
011370		PIC X(08).
011380		10     FILLER
011390		PIC X(10).
011400
011410		05     X278-CERT-EFF-DATES-SEG.
011420
011430		10     X278-CERT-EFF-DATES.
011440		15     X278-CERT-EFF-DATE-BEGIN
011450		PIC X(08).
011460		15     X278-CERT-EFF-DATE-END
011470		PIC X(08).
011480		10     FILLER
011490		PIC X(10).
011500
011510		05     X278-SERVICE-SEG.
011520
011530		10     X278-SVC-DATA
011540		OCCURS 12 TIMES
011550		INDEXED BY X278-SVC-DATA-NDX.
011560

 

Page 23 of 326

---

011570		15     X278-SVC-CODE-QUAL
011580		PIC X(03).
011590		15     X278-SVC-CODE
011600		PIC X(30).
011610		15     X278-SVC-DATES.
011620		20     X278-SVC-FIRST-DATE
011630		PIC X(08).
011640		20     X278-SVC-LAST-DATE
011650		PIC X(08).
011660		15     X278-SVC-AMT
011670		PIC 9(11)V99.
011680		15     X278-SVC-QTY
011690		PIC 9(07)V99.
011700		15     X278-SVC-VERSION
011710		PIC X(30).
011720		15     FILLER
011730		PIC X(10).
011740
011750		05     X278-DELIVERY-SEG.
011760
011770		10     X278-DELIVERY-QTY-QUAL
011780		PIC X(02).
011790		10     X278-DELIVERY-QTY
011800		PIC 9(07)V99.
011810		10     X278-DELIVERY-PER-QUAL
011820		PIC X(02).
011830		10     X278-DELIVERY-PER-FREQ
011840		PIC 9(06).
011850		10     X278-DELIVERY-PERIOD-QUAL
011860		PIC X(02).
011870		10     X278-DELIVERY-NUM-OF-PERIODS
011880		PIC 9(03).
011890		10     X278-DELIVERY-PATTERN
011900		PIC X(02).
011910		10     X278-DELIVERY-TIME
011920		PIC X(01).
011930		10     FILLER
011940		PIC X(10).
011950
011960		05     X278-INSTIT-CLAIM-SEG.
011970
011980		10     X278-ADMIN-TYPE
011990		PIC X(01).
012000		10     X278-ADMIN-SOURCE-CODE
012010		PIC X(01).
012020		10     X278-PATIENT-STATUS-CODE
012030		PIC X(02).
012040		10     X278-NH-RESIDENTIAL-STATUS
012050		PIC X(01).
012060		10     FILLER
012070		PIC X(10).

 

Page 24 of 326

---

012080
012090		05     X278-AMBULANCE-SEG.
012100
012110		10     X278-AMBULANCE-TRANSPORT-CODE
012120		PIC X(01).
012130		10     X278-AMBULANCE-UNIT-OF-MEASURE
012140		PIC X(02).
012150		10     X278-AMBULANCE-DISTANCE
012160		PIC 9(09).
012170		10     X278-AMBULANCE-ORGIN
012180		PIC X(55).
012190		10     X278-AMBULANCE-DESTINATION
012200		PIC X(55).
012210		10     FILLER
012220		PIC X(10).
012230
012240		05     X278-SPINAL-SEG.
012250
012260		10     X278-TREATMENT-SERIES-NUM
012270		PIC 9(09).
012280		10     X278-TREATMENT-COUNT
012290		PIC 9(11).
012300		10     X278-SUBLUXATION-LEVEL
012310		PIC X(03).
012320		10     X278-END-LEVEL-OF-SUBLUXATION
012330		PIC X(03).
012340		10     X278-TREATMENT-PERIOD-QUAL
012350		PIC X(02).
012360		10     X278-TREATMENT-PERIOD
012370		PIC 9(09).
012380		10     X278-TREATMENT-MONTHLY-QTY
012390		PIC 9(09).
012400		10     FILLER
012410		PIC X(10).
012420
012430		05     X278-HOME-OXYGEN-THERAPY-SEG.
012440
012450		10     X278-EQUIPMENT-TYPE
012460		PIC X(01).
012470		10     X278-ADDLN-EQUIPMENT-TYPE
012480		PIC X(01).
012490		10     X278-EQUIPMENT-REASON-DESC
012500		PIC X(80).
012510		10     X278-OXYGEN-FLOW-RATE
012520		PIC 9(15).
012530		10     X278-DAILY-OXYGEN-USED
012540		PIC 9(15).
012550		10     X278-NUM-HOURS-PER-PERIOD
012560		PIC 9(15).
012570		10     X278-RESPIRATORY-TEXT
012580		PIC X(80).

 

Page 25 of 326

---

012590		10     X278-PORTABLE-OXYGEN-FLOW-RATE
012600		PIC 9(15).
012610		10     X278-OXYGEN-DELIVERY-CODE
012620		PIC X(01).
012630		10     X278-OXYGEN-EQUIPMENT-TYPE
012640		PIC X(01).
012650		10     FILLER
012660		PIC X(10).
012670
012680		05     X278-HOME-HEALTH-CARE-SEG.
012690
012700		10     X278-HH-PROGNOSIS-CODE
012710		PIC X(01).
012720		10     X278-HH-START-DATE
012730		PIC X(08).
012740		10     X278-HH-CERT-DATES.
012750		15     X278-HH-CERT-START-DATE
012760		PIC X(08).
012770		15     X278-HH-CERT-END-DATE
012780		PIC X(08).
012790		10     X278-MEDICARE-COVERAGE-IND
012800		PIC X(01).
012810		10     X278-HH-CERT-TYPE-CODE
012820		PIC X(01).
012830		10     FILLER
012840		PIC X(10).
012850
012860		05     X278-SVC-PWK-SEG.
012870		OCCURS 10 TIMES
012880		INDEXED BY X278-SVC-PWK-SEG-NDX.
012890
012900		10     X278-SVC-PWK-TYPE
012910		PIC X(02).
012920		10     X278-SVC-PWK-TRANSMIT-CODE
012930		PIC X(02).
012940		10     X278-SVC-PWK-CTL-NUM-QUAL.
012950		PIC X(02).
012960		10     X278-SVC-PWK-CTL-NUM
012970		PIC X(80).
012980		10     X278-SVC-PWK-DESC
012990		PIC X(80).
013000		10     FILLER
013010		PIC X(10).
013020
013030		05     X278-SVC-MSG-SEG.
013040
013050		10     X278-SVC-MSG
013060		PIC X(264).
013070		10     FILLER
013080		PIC X(10).
013090		¦

 

Page 26 of 326

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013100		05     X278-SVC-CONTACT-NAME-SEG.
013110
013120		10     X278-SVC-CONTACT-IDENT-CODE
013130		PIC X(03).
013140		10     X278-SVC-CONTACT-PERSON-IND
013150		PIC X(01).
013160		10     X278-SVC-CONTACT-LAST-NAME
013170		PIC X(35).
013180		10     X278-SVC-CONTACT-FIRST-NAME
013190		PIC X(25).
013200		10     X278-SVC-CONTACT-MIDDLE-NM
013210		PIC X(25).
013220		10     X278-SVC-CONTACT-NM-SUFFIX
013230		PIC X(10).
013240		10     X278-SVC-CONTACT-ID-QUAL
013250		PIC X(02).
013260		10     X278-SVC-CONTACT-ID
013270		PIC X(80).
013280		10     FILLER
013290		PIC X(10).
013300
013310		05     X278-SVC-CONTACT-ADDR-SEG.
013320
013330		10     X278-SVC-CONTACT-ADDR-1
013340		PIC X(55).
013350		10     X278-SVC-CONTACT-ADDR-2
013360		PIC X(55).
013370		10     FILLER
013380		PIC X(10).
013390
013400		05     X278-SVC-CONTACT-CITY-SEG.
013410
013420		10     X278-SVC-CONTACT-CITY
013430		PIC X(30).
013440		10     X278-SVC-CONTACT-STATE
013450		PIC X(02).
013460		10     X278-SVC-CONTACT-ZIP
013470		PIC X(15).
013480		10     X278-SVC-CONTACT-COUNTRY
013490		PIC X(03).
013500		10     X278-SVC-CONTACT-LOC-QUAL
013510		PIC X(02).
013520		10     X278-SVC-CONTACT-LOC
013530		PIC X(30).
013540		10     FILLER
013550		PIC X(10).
013560
013570		05     X278-SVC-CONTACT-INFO-SEG.
013580
013590		10     X278-SVC-OTHER-CONTACT-NAME
013600		PIC X(60).

 

Page 27 of 326

---

013610		10     X278-SVC-OTHER-COMM
013620		OCCURS 3 TIMES
013630		INDEXED BY X278-SVC-OTHER-COMM-NDX.
013640
013650		15     X278-SVC-COMM-NUM-QUAL
013660		PIC X(02).
013670		15     X278-SVC-COMM-NUM
013680		PIC X(80).
013690		15     FILLER
013700		PIC X(10).
013710
013720
013730
013740		278 TRANSACTION TRAILER RECORD
013750
013760
013770		01     X278-TX-TRAILER.
013780
013790		05     X278-RECORD-CODE
013800		PIC X(02).
013810
013820		05     X278-SORT-KEY.
013830
013840
013850		USE ‘99’ FOR THE TRANSACTION CODE
013860
013870
013880		10     X278-TX-CODE
013890		VALUE ‘99’
013900		PIC X(02).
013910
013920
013930		USE ALL 9’S FOR THE TRANSACTION CODE SEQUENCE NUMBER
013940
013950
013960		10     X278-TX-CODE-SEQ-NUM
013970		VALUE 99999
013980		PIC 9(05).
013990
014000		05     X278-TX-TRAILER-SEG.
014010
014020		10     X278-TX-NUM-OF-SEG
014030		PIC 9(10).
014040		10     X278-TX-CTL-NUM-TLR
014050		PIC X(09).
014060		10     FILLER
014070		PIC X(10).

 

Page 28 of 326

---

000010
000020
000030		PREMIUM PAYMENT EDI INTERFACE
000040		COPYBOOK X820V01
000050
000060
000070		THE PREMIUM PAYMENT EDI INTERFACE COPYBOOK HAS THE SAME
000080		DATA CONTENT AS THE 820 PREMIUM PAYMENT TRANSACTION.
000090
000100		THE PAYMENT EDI INTERFACE COPYBOOK CONTAINS THE
000110		FOLLOWING RECORDS.
000120
000130
000140		RECORD		DESCRIPTION
000150
000160
000170		X820-TX-HEADER		CONTAINS TRANSACTION HEADER
000180				SEGMENTS
000190
000200		X820-ORG-OR-INDIV-IDENT		CONTAINS LOOP 2000A (FOR
000210				ORGANIZATIONAL ▇▇▇▇▇▇▇) ▇▇
▇▇▇▇▇▇				LOOPS 2000B AND 2100B (FOR
000230				INDIVIDUAL)
000240
000250		X820-ORG-OR-INDIV-DTL		CONTAINS LOOP 2300A (FOR
000260				ORGANIZATIONAL ▇▇▇▇▇▇▇) ▇▇
▇▇▇▇▇▇				LOOP 2300B (FOR INDIVIDUAL)
000280
000290		X820-ORG-COUNTS		CONTAINS LOOPS 2310A AND 2315A
000300				(FOR ORGANIZATIONAL SUMMARY)
000310
000320		X820-ADJUSTMENT		CONTAINS LOOP 2320A (FOR
000330				ORGANIZATIONAL ▇▇▇▇▇▇▇) ▇▇
▇▇▇▇▇▇				LOOP 2320B (FOR INDIVIDUAL)
000350
000360		X820-TX-TRAILER		CONTAINS THE TRANSACTION
000370				TRAILER SEGMENT
000380
000390
000400		EACH RECORD BEGINS WITH A RECORD CODE AND A SORT KEY
000410		CONTAINING THE FOLLOWING FIELDS.
000420
000430		FIELD		DESCRIPTION
000440
000450
000460		X820-IDENT-SEQ-NUM		PURPOSE IS TO UNIQUELY IDENTIFY
000470				EACH ORGANIZATIONAL OR
000480				INDIVIDUAL
000490
000500		X820-DETAIL-SEQ-NUM		PURPOSE IS TO UNIQUELY IDENTIFY

 

Page 29 of 326

---

000510				EACH ORGANIZATION’S OR
000520				INDIVIDUAL’S DETAIL RECORDS
000530
000540		X820-TX-CODE		IDENTIFIES EACH TYPE OF RECORD
000550
000560				00 FOR X820-TX-HEADER
000570				01 FOR X820-ORG-OR-INDIV-IDENT
000580				02 FOR X820-ORG-OR-INDIV-DTL
000590				03 FOR X820-ORG-COUNTS
000600				04 FOR X820-ADJSUTMENT
000610				99 FOR X820-TX-TRAILER
000620
000630		X820-TX-CODE-SEQ-NUM		TO SEQUENCE RECORDS WITHIN A
000640				RECORD TYPE
000650
000660		THE FOLLOWING EXAMPLE SHOWS HOW THIS WORKS, WHERE
000670		IIIII IS A UNIQUE NUMBER FOR EACH ORGANIZATION OR
000680		INDIVIDUAL AND DDDDD IS A UNIQUE NUMBER FOR EACH
000690		ORGANIZATION’S CR INDIVIDUAL’S PAYMENT DETAIL.
000700

 

000710				IDENT		DETAIL		TX		TX CODE
000720		RECORD		SEQ		SEQ		CODE		SEQ
000730
000740
000750		TX HEADER		▇▇▇▇▇		▇▇▇▇▇		▇▇		▇▇▇▇▇
▇▇▇▇▇▇		ORG/INDIV IDENT		IIIII		▇▇▇▇▇		▇▇		▇▇▇▇▇
▇▇▇▇▇▇		ORG/INDIV DTL		IIIII		DDDDD		02		ZEROS
000780		ORG COUNTS		IIIII		DDDDD		03		01-999999
000790		ADJUSTMENT		IIIII		DDDDD		04		01-999999
000800		TX TRAILER		99999		99999		99		999999
000810
000820
000830
000840
000850
000860
000870
000880

000890		820  TRANSACTION HEADER RECORD (NO LOOP)
000900
000910
000920		01     X820-TX-HEADER.
000930
000940		05     X820-RECORD-CODE
000950		PIC X(02).
000960
000970		05     X820-SORT-KEY.
000980
000990
001000		USE ZEROES FOR THE IDENTIFICATION SEQUENCE NUMBER
001010

 

Page 30 of 326

---

001020
001030		10     X820-IDENT-SEQ-NUM
001040		VALUE ZEROES
001050		PIC 9(11).
001060
001070
001080		USE ZEROES FOR THE DETAIL SEQUENCE NUMBER
001090
001100
001110		10     X820-DETAIL-SEQ-NUM
001120		VALUE ZEROES
001130		PIC 9(11).
001140
001150
001160		USE ‘00’ FOR THE TRANSACTION CODE
001170
001180
001190		10     X820-TX-CODE
001200		VALUE ‘00’
001210		PIC X(02).
001220
001230
001240		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
001250
001260
001270		10     X820-TX-CODE-SEQ-NUM
001280		VALUE ZEROES
001290		PIC 9(05).
001300
001310		05     X820-TX-HEADER-SEG.
001320
001330		10     X820-TX-ID
001340		VALUE ‘820’
001350		PIC X(03).
001360		10     X820-TX-CTL-NUM-HDR
001370		PIC X(09).
001380		10     FILLER
001390		PIC X(10).
001400
001410		05     X820-FINANCIAL-INFO-SEG.
001420
001430		10     X820-TX-HANDLING-CODE
001440		PIC X(02).
001450		10     X820-TOTAL-PREMIUM-AMT
001460		PIC S9(11)V99.
001470		10     X820-DEBIT-CREDIT-FLAG
001480		PIC X(01).
001490		10     X820-PAYMENT-METHOD-CODE
001500		PIC X(03).
001510		10     X820-PAYMENT-FORMAT-CODE
001520		PIC X(10).

 

Page 31 of 326

---

001530		10     X820-SENDER-DFI-ID-QUAL
001540		PIC X(02).
001550		10     X820-SENDER-DFI-ID
001560		PIC X(12).
001570		10     X820-SENDER-ACCT-QUAL
001580		PIC X(03).
001590		10     X820-SENDER-ACCT
001600		PIC X(35).
001610		10     X820-SENDER-ID
001620		PIC X(10).
001630		10     X820-SENDER-SUPPL-CODE
001640		PIC X(09).
001650		10     X820-RECEIVER-DFI-ID-QUAL
001660		PIC X(02).
001670		10     X820-RECEIVER-DFI-ID
001680		PIC X(12).
001690		10     X820-SENDER-ACCT-QUAL
001700		PIC X(03).
001710		10     X820-SENDER-ACCT
001720		PIC X(35).
001730		10     X820-CHECK-EFT-DATE
001740		PIC X(08).
001750		10     FILLER
001760		PIC X(10).
001770
001780		05     X820-REASSOCIATION-SEG.
001790
C01800		10     X820-CHECK-EFT-TRACE-TYPE
001810		PIC X(02).
001820		10     X820-CHECK-EFT-TRACE-NUM
001830		PIC X(30).
001840		10     X820-PAYER-ID
001850		PIC X(10).
001860		10     X820-PAYER-SUPPL-CODE
001870		PIC X(30).
001880		10     FILLER
001890		PIC X(10).
001900
001910		05     X820-CURRENCY-SEG.
001920
001930		10     FILLER
001940		PIC X(10).
001950
001960		05     X820-RECEIVER-IDENT-SEG
001970		OCCURS 5 TIMES
001980		INDEXED BY X820-RECEIVER-IDENT-SEG-NDX.
001990
002000		10     X820-RECIEVER-ID-QUAL
002010		PIC X(03).
002020		10     X820-RECIEVER-ID
002030		PIC X(30).

 

Page 32 of 326

---

002040		10     FILLER
002050		PIC X(10).
002060
002070		05     X820-PROCESS-DATE-SEG.
002080
002090		10     X820-PROCESS-DATE
002100		PIC X(08).
002110		10     FILLER
002120		PIC X(10).
002130
002140		05     X820-DELIVERY-DATE-SEG.
002150
002160		10     X820-DELIVERY-DATE
002170		PIC X(08).
002180		10     FILLER
002190		PIC X(10).
002200
002210		05     X820-COVERAGE-PERIOD-SEG.
002220
002230		10     X820-COVERAGE-START-DATE
002240		PIC X(08).
002250		10     X820-COVERAGE-END-DATE
002260		PIC X(08).
002270		10     FILLER
002280		PIC X(10).
002290
002300		05     X820-RECEIVER-NAME-SEG.
002310
002320		10     X820-RECEIVER-NAME
002330		PIC X(60).
002340		10     X820-RECEIVER-ID-QUAL
002350		PIC X(02).
002360		10     X820-RECEIVER-ID
002370		PIC X(80).
002380		10     FILLER
002390		PIC X(10).
002400
002410		05     X820-RECEIVER-OTHER-NAME-SEG.
002420
002430		10     X820-RECEIVER-OTHER-NAME
002440		PIC X(60).
002450		10     FILLER
002460		PIC X(10).
002470
002480		05     X820-RECEIVER-ADDRESS-SEG.
002490
002500		10     X820-RECEIVER-ADDR-1
002510		PIC X(55).
002520		10     X820-RECEIVER-ADDR-2
002530		PIC X(55).
002540		10     FILLER

 

Page 33 of 326

---

002550		PIC X(10).
002560
002570		05     X820-RECEIVER-CITY-STATE-SEG.
002580
002590		10     X820-RECEIVER-CITY
002600		PIC X(30).
002610		10     X820-RECEIVER-STATE
002620		PIC X(02).
002630		10     X820-RECEIVER-ZIP
002640		PIC X(15).
002650		10     X820-RECEIVER-COUNTRY
002660		PIC X(03).
002670		10     FILLER
002680		PIC X(10).
002690
002700		05     X820-PAYER-NAME-SEG.
002710
002720		10     X820-PAYER-NAME
002730		PIC X(60).
002740		10     X820-PAYER-ID-QUAL
002750		PIC X(02).
002760		10     X820-PAYER-ID
002770		PIC X(80).
002780		10     FILLER
002790		PIC X(10).
002800
002810		05     X820-PAYER-OTHER-NAME-SEG.
002820
002830		10     X820-PAYER-OTHER-NAME
002840		PIC X(60).
002850		10     FILLER
002860		PIC X(10).
002870
002880		05     X820-PAYER-ADDRESS-SEG.
002890
002900		10     X820-PAYER-ADDR-1
002910		PIC X(55).
002920		10     X820-PAYER-ADDR-2
002930		PIC X(55).
002940		10     FILLER
002950		PIC X(10).
002960
002970		05     X820-PAYER-CITY-STATE-SEG.
002980
002990		10     X820-PAYER-CITY
003000		PIC X(30).
003010		10     X820-PAYER-STATE
003020		PIC X(02).
003030		10     X820-PAYER-ZIP
003040		PIC X(15).
003050		10     X820-PAYER-COUNTRY

 

Page 34 of 326

---

003060		PIC X(03).
003070		10     FILLER
003080		PIC X(10).
003090
003100		05     X820-PAYER-CONTACT-SEG
003110		OCCURS 5 TIMES
003120		INDEXED BY X820-PAYER-CONTACT-SEG-NDX.
003130
003140		10     X820-PAYER-CONTACT-NAME
003150		PIC X(60).
003160		10     X820-PAYER-COMM
003170		OCCURS 3 TIMES
003180		INDEXED BY X820-PAYER-COMM-NDX.
003190		15     X820-PAYER-COMM-QUAL
003200		PIC X(02).
003210		15     X820-PAYER-COMM-NUM
003220		PIC X(80).
003230		10     FILLER
003240		PIC X(10).
003250
003260
003270
003280		820 ORGANIZATION/INDIVIDUAL IDENTIFICATION RECORD
003290
003300
003310		01     X820-ORG-OR-INDIV-IDENT.
003320
003330		05     X820-RECORD-CODE
003340		PIC X(02).
003350
003360		05     X820-SORT-KEY.
003370
003380
003390		USE SAME IDENTIFICATION SEQUENCE NUMBER FOR EACH
003400		ORGANIZATION OR INDIVIDUAL
003410
003420
003430		10     X820-IDENT-SEQ-NUM
003440		PIC 9(11).
003450
003460
003470		USE ZEROES FOR THE DETAIL SEQUENCE NUMBER
003480
003490
003500		10     X820-DETAIL-SEQ-NUM
003510		VALUE ZEROES
003520		PIC 9(11).
003530
003540
003550		USE ‘01’ FOR THE TRANSACTION CODE
003560

 

Page 35 of 326

---

003570
003580		10     X820-TX-CODE
003590		VALUE ‘01’
003600		PIC X(02).
003610
003620
003630		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
003640
003650
003660		10     X820-TX-CODE-SEQ-NUM
003670		VALUE ZEROES
003680		PIC 9(05).
003690
003700		05     X820-ORG-OR-INDIV-IDENT-SEG.
003710
003720		10     X820-ASSIGNED-NUMBER
003730		PIC 9(06).
003740		10     X820-ORG-OR-INDIV-IND
003750		PIC X(03).
003760		10     X820-ORG-OR-INDIV-ID-QUAL
003770		PIC X(02).
003780		10     X820-ORG-OR-INDIV-ID
003790		PIC X(80).
003800		10     FILLER
003810		PIC X(10).
003820
003830		05     X820-INDIV-NAME-SEG.
003840
003850		10     X820-INDIV-LAST-NAME
003860		PIC X(35).
003870		10     X820-INDIV-FIRST-NAME
003880		PIC X(25).
003890		10     X820-INDIV-MIDDLE-NAME
003900		PIC X(25).
003910		10     X820-INDIV-NAME-PREFIX
003920		PIC X(10).
003930		10     X820-INDIV-NAME-SUFFIX
003940		PIC X(10).
003950		10     X820-INDIV-ID-QUAL
003960		PIC X(02).
003970		10     X820-INDIV-ID
003980		PIC X(80).
003990		10     FILLER
004000		PIC X(10).
004010
004020
004030
004040		820 ORGANIZATION/INDIVIDUAL DETAIL RECORD
004050
004060
004070		01     X820-ORG-OR-INDIV-DTL.

 

Page 36 of 326

---

004080
004090		05     X820-RECORD-CODE
004100		PIC X(02).
004110
004120		05     X820-SORT-KEY.
004130
004140
004150		USE SAME IDENTIFICATION SEQUENCE NUMBER FOR EACH
004160		ORGANIZATION OR INDIVIDUAL
004170
004180
004190		10     X820-IDENT-SEQ-NUM
004200		PIC 9(11).
004210
004220
004230		USE UNIQUE SEQUENCE NUMBER FOR EACH ORGANIZATION’S OR
004240		INDIVIDUAL’S DETAIL
004250
004260
004270		10     X820-DETAIL-SEQ-NUM
004280		PIC 9(11).
004290
004300
004310		USE ‘02’ FOR THE TRANSACTION CODE
004320
004330
004340		10     X820-TX-CODE
004350		VALUE ‘02’
004360		PIC X(02).
004370
004380
004390		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
004400
004410
004420		10     X820-TX-CODE-SEQ-NUM
004430		VALUE ZEROES
004440		PIC 9(05).
004450
004460		05     X820-ORG-OR-INDIV-DTL-SEG.
004470
004480		10     X820-CONTRACT-QUAL
004490		PIC X(03).
004500		10     X820-CONTRACT-NUM
004510		PIC X(30).
004520		10     X820-PMT-ACTION-CODE
004530		PIC X(02).
004540		10     X820-PMT-AMT
004550		PIC S9(11)V99.
004560		10     X820-BILLED-AMT
004570		PIC S9(11)V99.
004580		10     FILLER

 

Page 37 of 326

---

004590		PIC X(10).
004600
004610		05     X820-INDIV-COV-PERIOD-SEG.
004620
004630		10     X820-INDIV-COV-START-DATE
004640		PIC X(08).
004650		10     X820-INDIV-COV-END-DATE
004660		PIC X(08).
004670		10     FILLER
004680		PIC X(10).
004690
004700
004710
004720		820 ORGANIZATIONAL COUNT RECORD
004730
004740
004750		01     X820-ORG-COUNTS.
004760
004770		05     X820-RECORD-CODE
004780		PIC X(02).
004790
004800		05     X820-SORT-KEY.
004810
004820
004830		USE SAME IDENTIFICATION SEQUENCE NUMBER FOR EACH
004840		ORGANIZATION OR INDIVIDUAL
004850
004860
004870		10     X820-IDENT-SEQ-NUM
004880		PIC 9(11).
004890
004900
004910		USE UNIQUE SEQUENCE NUMBER FOR EACH ORGANIZATION’S OR
004920		INDIVIDUAL’S DETAILS
004930
004940
004950		10     X820-DETAIL-SEQ-NUM
004960		PIC 9 (11).
004970
004980
004990		USE ‘03’ FOR THE TRANSACTION CODE
005000
005010
005020		10     X820-TX-CODE
005030		VALUE ‘03’
005040		PIC X(02).
005050
005060
005070		USE UNIQUE SEQUENCE NUMBER FOR EACH ORGANIZATION’S
005080		COUNT RECORDS
005090

 

Page 38 of 326

---

005100
005110		10     X820-TX-CODE-SEQ-NUM
005120		VALUE ZEROES
005130		PIC 9(05).
005140
005150		05     X820-LI-BASELINE-SEG.
005160
005170		10     X820-LI-BASELINE
005180		PIC X(20).
005190		10     FILLER
005200		PIC X(10).
005210
005220		05     X820-ORG-COUNTS-SEG.
005230
005240		10     X820-LI-CTL-NUM
005250		PIC X(20).
005260		10     X820-HEAD-COUNT
005270		PIC S9(9).
005280		10     X820-TYPE-OF-HEAD-COUNT
005290		PIC X(02).
005300		10     FILLER
005310		PIC X(10).
005320
005330
005340
005350		820 ADJUSTMENT RECORD
005360
005370
005380		01     X820-ADJUSTMENT.
005390
005400		05     X820-RECORD-CODE
005410		PIC X(02).
005420
005430		05     X820-SORT-KEY.
005440
005450
005460		USE SAME IDENTIFICATION SEQUENCE NUMBER FOR EACH
005470		ORGANIZATION OR INDIVIDUAL
005480
005490
005500		10     X820-IDENT-SEQ-NUM
005510		PIC 9(11).
005520
005530
005540		USE UNIQUE SEQUENCE NUMBER FOR EACH ORGANIZATION’S OR
005550		INDIVIDUAL’S DETAILS
005560
005570
005580		10     X820-DETAIL-SEQ-NUM
005590		PIC 9(11).
005600

 

Page 39 of 326

---

005610
005620		USE ‘04’ FOR THE TRANSACTION CODE
005630
005640
005650		10     X820-TX-CODE
005660		VALUE ‘04’
005670		PIC X(02).
005680
005690
005700		USE UNIQUE SEQUENCE NUMBER FOR EACH ORGANIZATION’S OR
005710		INDIVIDUAL’S ADJUSTMENT RECORD
005720
005730
005740		10     X820-TX-CODE-SEQ-NUM
005750		VALUE ZEROES
005760		PIC 9(05).
005770
005780		05     X820-ADJUSTMENT-SEG.
005790
005800		10     X820-ADJUSTMENT-AMT
005810		PIC S9(11)V99.
005820		10     X820-ADJUSTMENT-REASON
005830		PIC X(02).
005840		10     FILLER
005850		PIC X(10).
005860
005870
005880
005890		820 TRANSACTION TRAILER RECORD
005900
005910
005920		01     X820-TX-TRAILER.
005930
005940		05     X820-RECORD-CODE
005950		PIC X(02).
005960
005970		05     X820-SORT-KEY.
005980
005990
006000		USE ALL 9’S FOR THE INDENTIFICATION SEQUENCE NUMBER
006010
006020
006030		10     X820-IDENT-SEQ-NUM
006040		VALUE 99999999999
006050		PIC 9(11).
006060
006070
006080		USE ALL 9’S FOR THE DETAIL SEQUENCE NUMBER
006090
006100
006110		10     X820-DETAIL-SEQ-NUM

 

Page 40 of 326

---

006120		VALUE 99999999999
006130		PIC 9(11).
006140
006150
006160		USE ‘99’ FOR THE TRANSACTION CODE
006170
006180
006190		10     X820-TX-CODE
006200		VALUE ‘99’
006210		PIC X(02).
006220
006230
006240		USE ALL 9’S FOR THE TRANSACTION CODE SEQUENCE NUMBER
006250
006260
006270		10     X820-TX-CODE-SEQ-NUM
006280		VALUE 99999
006290		PIC 9(05).
006300
006310		05     X820-TX-TRAILER-SEG.
006320
006330		10     X820-TX-NUM-OF-SEG
006340		PIC 9(10).
006350		10     X820-TX-CTL-NUM-TLR
006360		PIC X(09).
006370		10     FILLER
006380		PIC X(10).
000010
000020
000030		ENROLLMENT EDI INTERFACE FILE
000040		COPYBOOK X834V01
000050
000060
000070		THE ENROLLMENT EDI INTERFACE COPYBOOK HAS THE SAME
000080		DATA CONTENT AS THE 834 ENROLLMENT TRANSACTION.
000090
000100		THE ENROLLMENT EDI INTERFACE COPYBOOK CONTAINS 5 RECORDS:
000110

 

000120		RECORD		DESCRIPTION
000130
000140
000150		X834-TX-HEADER		CONTAINS TRANSACTION HEADER
000160				SEGMENTS
000170
000180		X834-MEMBER-DETAIL		CONTAINS MEMBER DETAIL
000190				LOOP 2000 SEGMENTS
000200
000210		X834-MEMBER-NAME		CONTAINS MEMBER NAME
000220				SEGMENTS FROM LOOPS 2100A,
000230				2100B, 2100C, 2100D, 2100E,
000240				2100F, 2100G, AND 2200

 

Page 41 of 326

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000250
000260				X834-HEALTH-COVERAGE		CONTAINS HEALTH COVERAGE
000270						SEGMENTS FROM LOOPS 2300,
000280						2100, AND 2320
000290
000300				X834-TX-TRAILER		CONTAINS TRANSACTION TRAILER
000310						SEGMENTS
000320
000330				EACH RECORD BEGINS WITH A RECORD CODE AND A SORT KEY
000340				CONTAINING THE FOLLOWING FIELDS.
000350
000360				FIELD		DESCRIPTION
000370
000380
000390				X834-MEMBER-SEQ-NUM		PURPOSE IS TO UNIQUELY IDENTIFY
000400						EACH MEMBER’S DATA. THE MEMBER
000410						SEQUENCE NUMBER FOR THE
000420						X834-TX-HEADER RECORD IS ALL
000430						ZEROES AND ALL NINES FOR THE
000440						X834-TX-TRAILER RECORD.
000450
000460
000470						EACH MEMBER’S DETAIL, MEMBER
000480						NAME AND HEALTH COVERAGE RECORDS
000490						WILL HAVE THE SAME MEMBER
000500						SEQUENCE NUMBER
000510
000520				X834-TX-CODE		IDENTIFIES EACH TYPE OF RECORD
000530
000540						00 FOR X834-TX-HEADER
000550						01 FOR X834-MEMBER-DETAIL
000560						02 FOR X834-MEMBER-NAME
000570						03 FOR X834-HEALTH-COVERAGE
000580						99 FOR X834-TX-TRAILER
000590
000600
000610				X834-TX-CODE-SEQ-NUM		TO SEQUENCE RECORDS WITHIN A
000620						RECORD TYPE (NECESSARY ONLY
000630						FOR THE X834-TX-HEALTH-COVERAGE
000640						RECORDS). THE SEQUENCE NUMBER
000650						FOR A MEMBER’S FIRST HEALTH
000660						COVERAGE RECORD IS ‘001’, FOR
000670						THE SECOND ‘002’, ETC.
000680
000690

 

Page 42 of 326

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000700		THE FOLLOWING EXAMPLE SHOWS HOW THIS WORKS, WHERE
000710		MMMMM IS A UNIQUE NUMBER FOR EACH MEMBER.
000720
000730
000740		RECORD		MEMBER SEQ		TX CODE		TX CODE SEQ
000750
000760
000770		TX HEADER		▇▇▇▇▇		▇▇		▇▇▇▇▇
▇▇▇▇▇▇		MEMBER DETAIL		MMMMM		01		ZEROS
000790		MEMBER NAME		MMMMM		02		ZEROS
000800		HEALTH COVERAGE		MMMMM		03		01 - 99
000810		TX TRAILER		99999		99		99999
000820

 

000830
000840		WARNING!!!!  THE ENROLLMENT EDI INTERFACE FILE HAS ONLY
000850		FIVE (5) OCCURRENCES OF PROVIDER DATA WITHIN
000860		EACH OCCURRENCE OF HEALTH COVERAGE (WHICH
000870		SHOULD BE MORE THAN ENOUGH). THE 834
000880		IMPLEMENTATION ON GUIDE SAYS THERE COULD BE
000890		AS MANY AS THIRTY (30) OCCURRENCES OF
000900		PROVIDER DATA WITHIN EACH HEALTH COVERAGE.
000910
000920
000930
000940
000950
000960
000970		834 - TRANSACTION HEADER RECORD
000980
000990
001000		01     X834-TX-HEADER.
001010
001020		05     X834-RECORD-CODE
001030		PIC X(02).
001040
001050		05     X834-TX-SORT-KEY.
001060
001070
001080		USE ZEROES FOR MEMBER SEQUENCE NUMBER
001090
001100
001110		10     X834-MEMBER-SEQ-NUM
001120		VALUE ZEROS
001130		PIC 9(11).
001140
001150
001160		USE ZEROES FOR TRANSACTION CODE
001170
001180
001190		10     X834-TX-CODE
001200		VALUE ZEROS
001210		PIC X(02) .
001220
001230
001240		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER.
001250
001260

 

Page 43 of 326

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001270		10     X834-TX-CODE-SEQ-NUM
001280		VALUE ZEROES
001290		PIC 9(03).
001300
001310		05     X834-TX-HEADER-SEG.
001320		10     X834-TX-ID
001330		VALUE ‘834’
001340		PIC X(03).
001350		10     X834-TX-CTL-NUM
001360		PIC X(09).
001370		10     FILLER
001380		PIC X(10).
001390
001400		05     X834-BEG-SEGMENT.
001410		10     X834-TX-PURPOSE-CODE
001420		PIC X(02).
001430		10     X834-TX-ID-CODE
001440		PIC X(30).
001450		10     X834-TX-CREATION-DATE
001460		PIC X(08).
001470		10     X834-TX-CREATION-TIME
001480		PIC X(08).
001490		10     X834-TX-TIME-ZONE
001500		PIC X(02).
001510		10     X834-PREV-TX-ID-CODE
001520		PIC X(30).
001530		10     X834-TX-ACTION-CODE
001540		PIC X(02).
001550		10     FILLER
001560		PIC X(10).
001570
001580		05     X834-TX-POLILCY-SEG.
001590		10     X834-MASTER-POLICY-NUM
001600		PIC X(30).
001610		10     FILLER
001620		PIC X(10).
001630
001640		05     X834-TX-EFF-DTE-SEG.
001650		10     X834-TX-FILE-EFF-DTE-QUAL
001660		PIC X(03).
001670		10     X834-TX-FILE-EFF-DTE
001680		PIC X(08).
001690		10     FILLER
001700		PIC X(10).
001710
001720		▇▇▇ ▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇ NAME
001730
001740		05     X834-SPONSOR-SEG.
001750		10     X834-SPONSOR-NAME
001760		PIC X(60).
001770		10     X834-SPONSOR-ID-QUAL

 

Page 44 of 326

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001780		PIC X(02).
001790		10     X834-SPONSOR-ID
001800		PIC X(80).
001810		10     FILLER
001820		PIC X (10).
001830
001840		834 LOOP 1000B PAYER
001850
001860		05     X834-PAYER-SEG.
001870		10     X834-PAYER-NAME
001880		PIC X(60).
001890		10     X834-PAYER-ID-QUAL
001900		PIC X(02).
001910		10     X834-PAYER-ID
001920		PIC X(80).
001930		10     FILLER
001940		PIC X(10).
001950
001960		▇▇▇ ▇▇▇▇ ▇▇▇▇▇ ▇▇▇/▇▇▇▇▇▇ NAME
001970
001980		05     X834-TPA-BROKER-SEG
001990		OCCURS 2 TIMES
002000		INDEXED BY X834-TPA-BROKER-SEG-NDX.
002010		10     X834-TPA-BROKER-IND
002020		PIC X(03).
002030		10     X834-TPA-BROKER-NAME
002040		PIC X(60).
002050		10     X834-TPA-BROKER-ID-QUAL
002060		PIC X(02).
002070		10     X834-TPA-BROKER-ID
002080		PIC X(80).
002090		10     FILLER
002100		PIC X(10).
002110
002120		▇▇▇ ▇▇▇▇ ▇▇▇▇▇ ▇▇▇/▇▇▇▇▇▇ ACCOUNT
002130
002140		10     X834-TPA-BROKER-ACCT-NUM
002150		OCCURS 2 TIMES
002160		INDEXED BY X834-TPA-BROKER-ACCT-NUM-NDX
002170		PIC X(35).
002180
002190
002200
002210		834 - MEMBER DETAIL RECORD
002220
002230
002240
002250		834 LOOP 2000 MEMBER LEVEL DETAIL
002260
002270		01     X834-MEMBER-DETAIL.
002280

 

Page 45 of 326

---

002290		05     X834-RECORD-CODE
002300		PIC X(02).
002310
002320		05     X834-TX-SORT-KEY.
002330
002340
002350		USE SAME MEMBER SEQUENCE NUMBER FOR EACH MEMBER
002360
002370
002380		10     X834-MEMBER-SEQ-NUM
002390		PIC 9(11).
002400
002410
002420		USE ‘01’ FOR TRANSACTION CODE
002430
002440
002450		10     X834-TX-CODE
002460		VALUE ‘01’
002470		PIC X(02).
002480
002490
002500		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
002510
002520
002530		10     X834-TX-CODE-SEQ-NUM
002540		VALUE ZEROES
002550		PIC 9(03).
002560
002570		05     X834-INSURED-BENEFIT-SEG.
002580		10     X834-INSURED-IND
002590		PIC X(01).
002600		10     X834-RELATIONSHIP-CODE
002610		PIC X(02).
002620		10     X834-MAINT-TYPE-CODE
002630		PIC X(03).
002640		10     X834-MAINT-REASON-CODE
002650		PIC X(03).
002660		10     X834-BENEFIT-STATUS-CODE
002670		PIC X(01).
002680		10     X834-MEDICARE-PLAN-CODE
002690		PIC X(01).
002700		10     X834-COBRA-QUAL-CODE
002710		PIC X(02).
002720		10     X834-EMPLOY-STATUS-CODE
002730		PIC X(02).
002740		10     X834-STUDENT-STATUS-CODE
002750		PIC X(01).
002760		10     X834-HANDICAP-IND
002770		PIC X(01).
002780		10     X834-DATE-OF-DEATH
002790		PIC X(08).

 

Page 46 of 326

---

002800		10     X834-BIRTH-SEQ-NUM
002810		PIC 9(09).
002820		10     FILLER
002830		PIC X(30).
002840
002850		05     X834-SUBSCRIBER-SEG.
002860		10     X834-SUBSCRIBER-ID
002870		PIC X(30).
002880		10     FILLER
002890		PIC X(10).
002900
002910		05     X834-MBR-POLICY-SEG.
002920		10     X834-POLICY-NUMBER
002930		PIC X(30).
002940		10     FILLER
002950		PIC X(10).
002960
002970		05     X834-MBR-ID-SEG
002980		OCCURS 5 TIMES
002990		INDEXED BY X834-MBR-ID-SEG-NDX.
003000		10     X834-MBR-ID-QUAL
003010		PIC X(03).
003020		10     X834-SUBSCR-SUPPL-ID
003030		PIC X(30).
003040		10     FILLER
003050		PIC X(10).
003060
003070		05     X834-PRIOR-COV-MONTHS-SEG.
003080		10     X834-NUM-PRIOR-COV-MONTH
003090		PIC 9(03).
003100		10     FILLER
003110		PIC X(10).
003120		05     X834-MEMBER-LEVEL-DATE
003130		OCCURS 20 TIMES
003140		INDEXED BY X834-MEMBER-LEVEL-DATE-NDX.
003150		10     X834-MBR-EFF-DTE-QUAL
003160		PIC X(03).
003170		10     X834-MBR-EFF-DTE
003180		PIC X(08).
003190		10     FILLER
003200		PIC X(10).
003210
003220
003230
003240		834 – MEMBER NAME RECORD
003250
003260
003270		834 LOOP 2100A MEMBER NAME
003280
003290		01     X834-MEMBER-NAME.
003300

 

Page 47 of 326

---

003310		05     X834-RECORD-CODE
003320		PIC X(02).
003330
003340		05     X834-TX-SORT-KEY.
003350
003360
003370		USE SAME MEMBER SEQUENCE NUMBER FOR EACH MEMBER
003390
003400		10     X834-MEMBER-SEQ-NUM
003410		PIC 9(11).
003420
003430
003440		USE ‘02’ FOR TRANSACTION CODE
003460
003470		10     X834-TX-CODE
003480		VALUE ‘02’
003490		PIC X(02).
003500
003510
003520		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
003530
003540
003550		10     X834-TX-CODE-SEQ-NUM
003560		VALUE ZEROES
003570		PIC 9(03).
003580
003590		05     X834-MEMBER-NAME-SEG.
003600		10     X834-ENROLL-IND
003610		PIC X(03).
003620		10     X834-MEMBER-LAST-NAME
003630		PIC X(35).
003640		10     X834-MEMBER-FIRST-NAME
003650		PIC X(25).
003660		10     X834-MEMBER-MIDDLE-NAME
003670		PIC X(25).
003680		10     X834-MEMBER-NAME-SUFFIX
003690		PIC X(10).
003700		10     X834-MEMBER-ID-QUAL
003710		PIC X(02).
003720		10     X834-MEMBER-ID
003730		PIC X(80).
003740		10     FILLER
003750		PIC X(30).
003760
003770		05     X834-COMM-NUM-SEG
003780		OCCURS 3 TIMES
003790		INDEXED BY X834-COMM-NUM-SEG-NDX.
003800		10     X834-COMM-NUM-QUAL
003810		PIC X(02).

 

Page 48 of 326

---

003820		10     X834-COMM-NUM
003830		PIC X(80).
003840		10     FILLER
003850		PIC X(10).
003860
003870		05     X834-RESIDENCE-STREET-SEG.
003880		10     X834-MEMBER-ADDR-1
003890		PIC X(55).
003900		10     X834-MEMBER-ADDR-2
003910		PIC X(55).
003920		10     FILLER
003930		PIC X(10).
003940
003950		05     X834-RESIDENCE-CITY-STATE-SEG.
003960		10     X834-MEMBER-CITY
003970		PIC X(30).
003980		10     X834-MEMBER-STATE
003990		PIC X(02).
004000		10     X834-MEMBER-ZIP-CODE
004010		PIC X(15).
004020		10     X834-MEMBER-COUNTRY
004030		PIC X(03).
004040		10     X834-MEMBER-LOC-QUAL
004050		PIC X(02).
004060		10     X834-MEMBER-LOC-CODE
004070		PIC X(30).
004080		10     FILLER
004090		PIC X(10).
004100
004110		05     X834-DEMOGRAPHICS-SEG.
004120		10     X834-MEMBER-DATE-OF-BIRTH
004130		PIC X(08).
004140		10     X834-MEMBER-SEX-CODE
004150		PIC X(01).
004160		10     X834-MEMBER-MARITAL-STAT
004170		PIC X(01).
004180		10     X834-MEMBER-RACE
004190		PIC X (01).
004200		10     X834-MEMBER-CITIZENSHIP
004210		PIC X(02).
004220		10     FILLER
004230		PIC X(10).
004240
004250		05     X834-INCOME-SEG.
004260		10     X834-INCOME-FREQ-CODE
004270		PIC X(01).
004280		10     X834-WAGE-AMOUNT
004290		PIC 9(11)V99.
004300		10     X834-WORK-HOURS-COUNT
004310		PIC 9(03).
004320		10     X834-WORK-LOC-ID-CODE

 

Page 49 of 326

---

004330		PIC X(30).
004340		10     X834-SALARY-GRADE
004350		PIC X(05).
004360		10     FILLER
004370		PIC X(10).
004380
004390		05     X834-POLICY-AMT-SEG.
004400		OCCURS 5 TIMES
004410		INDEXED BY X834-POLICY-AMT-SEG-NDX.
004420		10     X834-POLICY-AMT-QUAL
004430		PIC X(03).
004440		10     X834-POLICY-AMT
004450		PIC 9(11)V99.
004460		10     FILLER
004470		PIC X(10).
004480
004490		05     X834-HEALTH-INFO-SEG.
004500		10     X834-HEALTH-REL-CODE
004510		PIC X(01).
004520		10     X834-HEIGHT
004530		PIC 9(08).
004540		10     X834-WEIGHT
004550		PIC 9(10).
004560		10     FILLER
004570		PIC X(10).
004580
004590		05     X834-LANGUAGE-SEG.
004600		OCCURS 5 TIMES
004610		INDEXED BY X834-LANGUAGE-SEG-NDX.
004620		10     X834-LANG-CODE-QUAL
004630		PIC X(02).
004640		10     X834-LANG-CODE
004650		PIC X(80).
004660		10     X834-LANG-DESC
004670		PIC X(80).
004680		10     X834-LANG-USE-IND
004690		PIC X(02).
004700		10     X834-LANG-PROFICIENCY-IND
004710		PIC X(01).
004720		10     FILLER
004730		PIC X(10).
004740
004750		834 LOOP 2100B INCORRECT MEMBER NAME
004760
004770		05     X834-INCORRECT-NAME-SEG.
004780		10     X834-PRIOR-LAST-NAME
004790		PIC X(35).
004800		10     X834-PRIOR-FIRST-NAME
004810		PIC X(25).
004820		10     X834-PRIOR-MIDDLE-NAME
004830		PIC X(25).

 

Page 50 of 326

---

004840		10     X834-PRIOR-NAME-SUFFEX
004850		PIC X(10).
004860		10     X834-PRIOR-MEMBER-ID-QUAL
004870		PIC X(02).
004880		10     X834-PRIOR-MEMBER-ID
004890		PIC X(80).
004900		10     FILLER
004910		PIC X(10).
004920
004930		05     X834-INCORRECT-DEMO-SEG.
004940		10     X834-PRIOR-DATE-OF-BIRTH
004950		PIC X(08).
004960		10     X834-PRIOR-SEX-CODE
004970		PIC X(01).
004980		10     FILLER
004990		PIC X(10).
005000
005010		834 LOOP 2100C MEMBER MAILING ADDRESS
005020
005030		05     X834-MAIL-STREET-SEG.
005040		10     X834-MAIL-ADDR-1
005050		PIC X(55).
005060		10     X834-MAIL-ADDR-2
005070		PIC X(55).
005080		10     FILLER
005090		PIC X(10).
005100
005110		05     X834-MAIL-CITY-STATE-SEG.
005120		10     X834-MAIL-CITY
005130		PIC X(30).
005140		10     X834-MAIL-STATE
005150		PIC X(02).
005160		10     X834-MAIL-ZIP-CODE
005170		PIC X(15).
005180		10     X834-MAIL-COUNTRY
005190		PIC X(03).
005200		10     FILLER
005210		PIC X(10).
005220
005230		834 LOOP 2100D MEMBER EMPLOYER
005240
005250		05     X834-EMPLOYER-NAME-SEG.
005260		10     X834-EMPLOYER-TYPE-IND
005270		PIC X(03).
005280		10     X834-EMPLOYER-LAST-NAME
005290		PIC X(35).
005300		10     X834-EMPLOYER-FIRST-NAME
005310		PIC X(25).
005320		10     X834-EMPLOYER-MIDDLE-NAME
005330		PIC X(25).
005340		10     X834-EMPLOYER-NAME-SUFFIX

 

Page 51 of 326

---

005350		PIC X(10).
005360		10     X834-EMPLOYER-ID-QUAL
005370		PIC X(02).
005380		10     X834-EMPLOYER-ID
005390		PIC X(80).
005400		10     FILLER
005410		PIC X(10).
005420
005430		05     X834-EMPLOYER-COMM-NUM-SEG.
005440		OCCURS 3 TIMES
005450		INDEXED BY X834-EMPLOYER-COMM-NUM-SEG-NDX.
005460		10     X834-EMPLOYER-COMM-QUAL
005470		PIC X(02).
005480		10     X834-EMPLOYER-COMM-NUM
005490		PIC X(80).
005500		10     FILLER
005510		PIC X(10).
005520
005530		05     X834-EMPLOYER-STREET-SEG.
005540		10     X834-EMPLOYER-ADDR-1
005550		PIC X(55).
005560		10     X834-EMPLOYER-ADDR-2
005570		PIC X(55).
005580		10     FILLER
005590		PIC X(10).
005600
005610		05     X834-EMPLOYER-CITY-STATE-SEG.
005620		10     X834-EMPLOYER-CITY
005630		PIC X(30).
005640		10     X834-EMPLOYER-STATE
005650		PIC X(02).
005660		10     X834-EMPLOYER-ZIP-CODE
005670		PIC X(15).
005680		10     X834-EMPLOYER-COUNTRY
005690		PIC X(03).
005700		10     FILLER
005710		PIC X(10).
005720
005730		834 LOOP 2100E MEMBER SCHOOL
005740
005750		05     X834-SCHOOL-NAME-SEG.
005760		10     X834-SCHOOL-NAME
005770		PIC X(35).
005780		10     FILLER
005790		PIC X(10).
005800
005810		05     X834-SCHOOL-COMM-SEG.
005820		OCCURS 3 TIMES
005830		INDEXED BY X834-SCHOOL-COMM-SEG-NDX.
005840		10     X834-SCHOOL-COMM-QUAL
005850		PIC X(02).

 

Page 52 of 326

---

005860		10     X834-SCHOOL-COMM-NUM
005870		PIC X(80).
005880		10     FILLER
005890		PIC X(10).
005900
005910		05     X834-SCHOOL-STREET-SEG.
005920		10     X834-SCHOOL-APDR-1
005930		PIC X(55).
005940		10     X834-SCHOOL-ADDR-2
005950		PIC X(55).
005960		10     FILLER
005970		PIC X(10).
005980
005990		05     X834-SCHOOL-CITY-STATE-SEG.
006000		10     X834-SCHOOL-CITY
006010		PIC X(30).
006020		10     X834-SCHOOL-STATE
006030		PIC X(02).
006040		10     X834-SCHOOL-ZIP-CODE
006050		PIC X(15).
006060		10     X834-SCHOOL-COUNTRY
006070		PIC X(03).
006080		10     FILLER
006090		PIC X(10).
006100
006110		834 LOOP 2100F CUSTODIAL PARENT
006120
006130		05     X834-PARENT-NAME-SEG.
006140		10     X834-PARENT-LAST-NAME
006150		PIC X(35).
006160		10     X834-PARENT-FIRST-NAME.
006170		PIC X(25).
006180		10     X834-PARENT-MIDDLE-NAME
006190		PIC X(25).
006200		10     X834-PARENT-NAME-SUFFIX
006210		PIC X(10).
006220		10     X834-PARENT-ID-QUAL
006230		PIC X(02).
006240		10     X834-PARENT-ID
006250		PIC X(80).
006260		10     FILLER
006270		PIC X(10).
006280
006290		05     X834-PARENT-COMM-SEG.
006300		OCCURS 3 TIMES
006310		INDEXED BY X834-PARENT-COMM-SEG-NDX.
006320		10     X834-PARENT-COMM-QUAL
006330		PIC X(02).
006340		10     X834-PARENT-COMM-NUM
006350		PIC X(80)
006360		10     FILLER

 

Page 53 of 326

---

006370		PIC X(10).
006380
006390		05     X834-PARENT-STREET-SEG.
006400		10     X834-PARENT-ADDR-1
006410		PIC X(55).
006420		10     X834-PARENT-ADDR-2
006430		PIC X(55).
006440		10     FILLER
006450		PIC X(10).
006460
006470		05     X834-PARENT-CITY-STATE-SEG.
006480		10     X834-PARENT-CITY
006490		PIC X(30).
006500		10     X834-PARENT-STATE
006510		PIC X(02).
006520		10     X834-PARENT-ZIP-CODE
006530		PIC X(15).
006540		10     X834-PARENT-COUNTRY
006550		PIC X(03).
006560		10     FILLER
006570		PIC X(10).
006580
006590		834 LOOP 2100G RESPONSIBLE PERSON
006600
006610		05     X834-RESP-NAME-SEG.
006620		10     X834-RESP-TYPE-IND
006630		PIC X(03).
006640		10     X834-RESP-LAST-NAME
006650		PIC X(35).
006660		10     X834-RESP-FIRST-NAME
006670		PIC X(25).
006680		10     X834-RESP-MIDDLE-NAME
006690		PIC X(25).
006700		10     X834-RESP-NAME-SUFFIX
006710		PIC X(10).
006720		10     X834-RESP-ID-QUAL
006730		PIC X(02).
006740		10     X834-RESP-ID
006750		PIC X(80).
006760		10     FILLER
006770		PIC X(10).
006780
006790		05     X834-RESP-COMM-SEG
006800		OCCURS 3 TIMES
006810		INDEXED BY X834-RESP-COMM-SEG-NDX.
006820		10     X834-RESP-COMM-QUAL
006830		PIC X(02).
006840		10     X834-RESP-COMM-NUM
006850		PIC X(80).
006860		10     FILLER
006870		PIC X(10).

 

Page 54 of 326

---

006880
006890		05     X834-RESP-STREET-SEG.
006900		10     X834-RESP-ADDR-2
006910		PIC X(55).
006920		10     X834-RESP-ADDR-2
006930		PIC X(55).
006940
006950		05     X834-RESP-CITY-STATE-SEG.
006960		10     X834-RESP-CITY
006970		PIC X(30).
006980		10     X834-RESP-STATE
006990		PIC X(02).
007000		10     X834-RESP-ZIP-CODE
007010		PIC X(15).
007020		10     X834-RESP-COUNTRY
007030		PIC X(03).
007040		10     FILLER
007050		PIC X(10).
007060
007070		834 LOOP 2200 DISABILITY INFORMATION
007080
007090		05     X834-DISABL-INFO-SEG.
007100		10     X834-DISABL-TYPE-CODE
007110		PIC X(01).
007120		10     X834-DISABL-DIAG-CODE
007130		PIC X(15).
007140		10     FILLER
007150		PIC X(10).
007160
007170		05     X834-DISABL-DATES-SEG
007180		OCCURS 10 TIMES
007190		INDEXED BY X834-DISABL-DATES-SEG-NDX.
007200		10     X834-DISABL-DATE-QUAL
007210		PIC X(03).
007220		10     X834-DISABL-DATE
007230		PIC X(08).
007240		10     FILLER
007250		PIC X(10).
007260
007270
007280
007290		834 - MEMBER HEALTH COVERAGE RECORD(S)
007300
007310
007320		834 LOOP 2300 HEALTH COVERAGE
007330
007340		01     X834-HEALTH-COVERAGE.
007350
007360		05     X834-RECORD-CODE
007370		PIC X(02).
007380

 

Page 55 of 326

---

007390		05     X834-TX-SORT-KEY.
007400
007410
007420		USE SAME MEMBER SEQUENCE NUMBER FOR EACH MEMBER
007430
007440
007450		10     X8 34-MEMBER-SEQ-NUM
007460		PIC 9(11).
007470
007480
007490		USE ‘03’ FOR TRANSACTION CODE
007500
007510
007520		10     X834-TX-CODE
007530		VALUE ‘03’
007540		PIC X(02).
007550
007560
007570		USE 01 - 99 TO UNIQUELY IDENTIFY EACH HEALTH COVERAGE
007580		RECORD FOR A MEMBER
007590
007600
007610		05     X834-TX-CODE-SEQ-NUM
007620		PIC 9(03).
007630
007640		05     X834-HEALTH-COV-SEG.
007650		10     X834-COV-TYPE-CODE
007660		PIC X(03).
007670		10     X834-COV-INS-LINE-CODE
007680		PIC X(03).
007690		10     X834-COV-PLAN-DESC
007700		PIC X(50).
007710		10     X834-COV-LEVEL-CODE
007720		PIC X(03).
007730		10     FILLER
007740		PIC X(10).
007750
007760		05     X834-HEALTH-COV-DATES-SEG
007770		OCCURS 10 TIMES
007780		INDEXED BY X834-HEALTH-COV-DATES-SEG-NDX.
007790		10     X834-COV-DATE-QUAL
007800		PIC X(03).
007810		10     X834-COV-DATE
007820		PIC X(08).
007830		10     FILLER
007840		PIC X(10).
007850
007860		05     X834-HEALTH-COV-AMT-SEG
007870		OCCURS 4 TIMES
007880		INDEXED BY X834-HEALTH-COV-AMT-SEG-NDX.
007890		10     X834-CONTRACT-AMT-QUAL

 

Page 56 of 326

---

007900		PIC X(03).
007910		10     X834-CONTRACT-AMT
007920		PIC 9(11)V99.
007930		10     FILLER
007940		PIC X(10).
007950
007960		05     X834-POLICY-NUM-SEG
007970		OCCURS 2 TIMES
007980		INDEXED BY X834-POLICY-NUM-SEG-NDX.
007990		10     X834-POLICY-NUM-QUAL
008000		PIC X(03).
008010		10     X834-POLICY-NUM
008020		PIC X(30).
008030		10     FILLER
008040		PIC X(10).
008050
008060		05     X834-HEALTH-COV-ID-CARD
008070		OCCURS 10 TIMES
008080		INDEXED BY X834-HEALTH-COV-ID-CARD-NDX.
008090		10     X834-ID-CARD-PLAN-DESC
008100		PIC X(50).
008110		10     X834-ID-CARD-TYPE-CODE
008120		PIC X(01).
008130		10     X834-ID-CARD-COUNT
008140		PIC 9(03).
008150		10     X834-ID-CARD-ACTION-CODE
008160		PIC X(02).
008170		10     FILLER
008180		PIC X(10).
008190
008200		834 LOOP 2310 PROVIDER INFORMATION
008210
008220		NOTE:  PROVIDER DATA OCCURS ONLY 5 TIMES IN THE COPYBOOK.
008230		THE IMPLEMENATION GUIDE SAYS PROVIDER DATA CAN
008240		OCCUR AS MANY AS 30 TIMES.
008250
008260		05     X834-PROV-DATA
008270		OCCURS 5 TIMES
008280		INDEXED BY X834-PROV-DATA-NDX.
008290
008300		10     X834-PROV-INFO-SEG.
008310		15     X834-PROV-LX-NUMBER
008320		PIC 9(06).
008330
008340		10     X834-PROV-NAME-SEG.
008350		15     X834-PROV-TYPE-CODE
008360		PIC X(03).
008370		15     X834-PROV-TYPE-QUAL
008380		PIC X(01).
008390		15     X834-PROV-LAST-NAME
008400		PIC X(35).

 

Page 57 of 326

---

008410		15     X834-PROV-FIRST-NAME
008420		PIC X(25).
008430		15     X834-PROV-MIDDLE-NAME
008440		PIC X(25).
008450		15     X834-PROV-NAME-PREFIX
008460		PIC X(10).
008470		15     X834-PROV-NAME-SUFFIX
008480		PIC X(10).
008490		15     X834-PROV-ID-QUAL
008500		PIC X(02).
008510		15     X834-PROV-ID
008520		PIC X(80).
008530		15     X834-PATIENT-RELATIONSHIP
008540		PIC X(02).
008550		15     FILLER
008560		PIC X(10).
008570
008580		10     X834-PROV-CITY-STATE-SEG.
008590		15     X834-PROV-CITY
008600		PIC X(30).
008610		15     X834-PROV-STATE
008620		PIC X(02).
008630		15     X834-PROV-ZIP-CODE
008640		PIC X(15).
008650		15     X834-PROV-COUNTRY
008660		PIC X(03).
008670		15     X834-PROV-LOC-ID-QUAL
008680		PIC X(02).
008690		15     X834-PROV-LOC-ID
008700		PIC X(30).
008710		15     FILLER
008720		PIC X(10).
008730
008740		10     X834-PROV-COMM-NUM-SEG
008750		OCCURS 6 TIMES
008760		INDEXED BY X834-PROV-COMM-NUM-SEG-NDX.
008770		15     X834-PROV-COMM-NUM-QUAL
008780		PIC X(02).
008790		15     X834-PROV-COMM-NUM
008800		PIC X(80).
008810		15     FILLER
008820		PIC X(10).
008830
008840		10     X834-PCP-CHANGE-REASON-SEG.
008850		15     X834-PCP-EFF-DATE
008860		PIC X(08).
008870		15     X834-PCP-MAINT-REASON
008880		PIC X(03).
008890		15     FILLER
008900		PIC X(10).
008910

 

Page 58 of 326

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008920		834  LOOP 2320 COORDINATION OF BENEFITS
008930
008940		05     X834-COB-DATA
008950		OCCURS 5 TIMES
008960		INDEXED BY X834-COB-DATA-NDX.
008970
008980		10     X834-COB-SEG.
008990		15     X834-PAYER-RESP-SEQ-NUM
009000		PIC X(01).
009010		15     X834-PAYER-ID
009020		PIC X(30).
009030		15     X834-COB-CODE
009040		PIC X(01).
009050		15     FILLER
009060		PIC X(10).
009070
009080		10     X834-OTHER-COB-ID-SEG
009090		OCCURS 5 TIMES
009100		INDEXED BY X834-OTHER-COB-ID-SEG-NDX.
009110		15     X834-COB-ID-QUAL
009120		PIC X(03).
009130		15     X834-COB-POLICY-NUM
009140		PIC X(30).
009150		15     FILLER
009160		PIC X(10).
009170
009180		10     X834-OTHER-INS-NAME-SEG.
009190		15     X834-OTHER-INS-NAME
009200		PIC X(60).
009210		15     X834-OTHER-INS-ID-QUAL
009220		PIC X(02).
009230		15     X834-OTHER-INS-ID
009240		PIC X(80).
009250		15     FILLER
009260		PIC X(10).
009270
009280		10     X834-COB-ELIG-DATES-SEG
009290		OCCURS 2 TIMES
009300		INDEXED BY X834-COB-ELIG-DATES-SEG-NDX.
009310		15     X834-COB-ELIG-DATE-QUAL
009320		PIC X(03).
009330		15     X834-COB-ELIG-DATE
009340		PIC X(08).
009350		15     FILLER
009360		PIC X(10).
009370/
009380
009390
009400		834 - TRANSACTION TRAILER RECORD
009410
009420

 

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009430		01     X834-TX-TRAILER.
009440
009450		05     X834-RECORD-CODE
009460		PIC X(02).
009470
009480		05     X834-TX-SORT-KEY.
009490
009500
009510		USE ALL 9’S FOR MEMBER SEQUENCE NUMBER
009520
009530
009540		10     X834-MEMBER-SEQ-NUM
009550		VALUE 99999999999
009560		PIC 9 (11).
009570
009580
009590		USE ‘99’ FOR TRANSACTION CODE
009600
009610
009620		10     X834-TX-CODE
009630		VALUE ‘99’
009640		PIC X(02).
009650
009660
009670		USE ALL 9’S FOR TRANSACTION CODE SEQUENCE NUMBER
009680
009690
009700		10     X834-TX-CODE-SEQ-NUM
009710		VALUE 999
009720		PIC 9(03).
009730
009740		05     X834-TX-TRAILER-SEG.
009750		10     X834-TRAILER-NUM-OF-SEG
009760		PIC 9(10).
009770		10     X834-TRAILER-CTL-NUM
009780		PIC X(09).
009790		10     FILLER
009800		PIC X(10).

 

Page 60 of 326

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000010
000020
000030		REMITTANCE ADVICE EDI INTERFACE
000040		COPYBOOK X835V01
000050
000060
000070		THE REMITTANCE ADVICE EDI INTERFACE COPYBOOK HAS THE
000080		SAME DATA CONTENT AS THE 835 REMITTANCE ADVICE
000090		TRANSACTION.
000100
000110		THE REMITTANCE ADVICE INTERFACE COPYBOOK CONTAINS X
000120		RECORDS:
000130
000140		RECORD		DESCRIPTION
000150
000160
000170		X835-TX-HEADER		CONTAINS TRANSACTION HEADER
000180				SEGMENTS
000190
000200		X835-PAYER-IDENT		CONTAINS LOOP 1000A SEGMENTS
000210
000220		X835-PAYEE-IDENT		CONTAINS LOOP 1000B SEGMENTS
000230
000240		X835-PROV-SUMMARY		CONTAINS PROVIDER SUMMARY
000250				LOOP 2000 SEGMENTS
000260
000270		X835-CLM-PMT		CONTAINS CLAIM PAYMENT
000280				LOOP 2100 SEGMENTS
000290
000300		X835-CLM-CAS		CONTAINS CLAIM ADJUSTMENT
000310				CAS SEGMENTS FROM LOOP 2110
000320
000330		X835-CLM-TREAT-PROV		CONTAINS TREATING PROVIDER
000340				REF SEGMENTS FROM LOOP 2110
000350
000360		X835-CLM-SUPPL-INFO		CONTAINS CLAIM SUPPLEMENTAL
000370				AMT SEGMENTS FROM LOOP 2110
000380
000390		X835-CLM-SUPPL-QTY		CONTAINS CLAIM SUPPLEMENTAL
000400				QTY SEGMENTS FROM LOOP 2110
000410
000420		X835-SVC-PMT		CONTAINS SERVICE PAYMENT
000430				LOOP 2110 SEGMENTS
000440
000450		X835-SVC-CAS		CONTAINS SERVICE ADJUSTMENT
000460				CAS SEGMENTS FROM LOOP 2110
000470
000480		X835-SVC-TREAT-PROV		CONTAINS SERVICE TREATING PROV
000490				REF SEGMENTS FROM LOOP 2110
000500
000510		X835-SVC-SUPPL-INFO		CONTAINS SERVICE SUPPLEMENTAL

 

Page 61 of 326

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000520				AMT SEGMENTS FROM LOOP 2110
000530
000540		X835-SVC-SUPPL-QTY		CONTAINS SERVICE SUPPLEMENTAL
000550				QTY SEGMENTS FROM LOOP 2110
000560
000570		X835-SVC-REMARKS		CONTAINS SERVICE REMARKS
000580				LQ SEGMENTS FROM LOOP 2110
000590
000600		X835-PROV-ADJUST		CONTAINS PROVIDER ADJUSTMENT
000610				PLB SEGMENTS
000620
000630		X835-TX-TRAILER		CONTAINS THE TRANSACTION
000640				TRAILER SEGMENT
000650
000660
000670		EACH RECORD BEGINS WITH A RECORD CODE AND A SORT KEY
000680		CONTAINING THE FOLLOWING FIELDS.
000690
000700		FIELD		DESCRIPTION
000710
000720
000730		X835-PROV-SEQ-NUM		PURPOSE IS TO UNIQUELY IDENTIFY
000740				EACH PROVIDER’S DATA.
000750
000760		X835-CLM-SEQ-NUM		PURPOSE IS TO UNIQUELY IDENTIFY
000770				EACH CLAIM FOR A PROVIDER.
000780
000790		X835-SVC-SEQ-NUM		PURPOSE IS TO UNIQUELY IDENTIFY
000800				EACH SERVICE (LINE ITEM) IN A
000810				CLAIM.
000820
000830		X835-TX-CODE		PURPOSE IS TO UNIQUELY IDENTIFY
000840				THE FOLLOWING TYPES OF RECORDS
000850
000860				00 FOR X835-TX-HEADER
000870				01 FOR X835-PAYER-IDENT
000880				02 FOR X835-PAYEE-IDENT
000890				03 FOR X835-PROV-SUMMARY
000900				04 FOR X835-CLM-PMT
000910				05 FOR X835-CLM-CAS
000920				0 6 FOR X835-CLM-TREAT-PROV
000930				07 FOR X835-CLM-SUPPL-INFO
000940				08 FOR X835-CLM-SUPPL-QTY
000950				09 FOR X835-SVC-PMT
000960				10 FOR X835-SVC-CAS
000970				11 FOR X835-SVC-TREAT-PROV
000980				12 FOR X835-SVC-SUPPL-INFO
000990				13 FOR X835-SVC-SUPPL-QTY
001000				14 FOR X835-SVC-REMARKS
001010				15 FOR X835-PROV-ADJUST
001020				99 FOR X835-TX-TRAILER

 

Page 62 of 326

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001030
001040		X835-TX-CODE-SEQ-NUM				TO SEQUENCE RECORDS WITHIN A
001050						RECORD TYPE
001060
001070		THE FOLLOWING EXAMPLE SHOWS HOW THIS WORKS, WHERE
001080		PPPPP IS A UNIQUE NUMBER FOR EACH PROVIDER, CCCCC IS
001090		A UNIQUE NUMBER FOR EACH PROVIDER’S CLAIMS, AND SSSSS
001100		UNIQUELY IDENTIFIES EACH LINE ITEM IN A CLAIM.
001110
001120				PROV		CLAIM		SVC		REC		REC CODE
001130		RECORD		SEQ		SEQ		SEQ		CODE		SEQ
001140
001150
001160		TX HEADER		ZEROS		▇▇▇▇▇		▇▇▇▇▇		▇▇		▇▇▇▇▇
▇▇▇▇▇▇		PAYER IDENT		ZEROS		▇▇▇▇▇		▇▇▇▇▇		▇▇		▇▇▇▇▇
▇▇▇▇▇▇		PAYEE IDENT		ZEROS		▇▇▇▇▇		▇▇▇▇▇		▇▇		▇▇▇▇▇
▇▇▇▇▇▇		PROV SUMMARY		PPPPP		▇▇▇▇▇		▇▇▇▇▇		▇▇		▇▇▇▇▇
▇▇▇▇▇▇		CLM PMT		PPPPP		CCCCC		ZEROS		04		ZEROS
001210		CLM CAS		PPPPP		CCCCC		ZEROS		05		01-99
001220		CLM TREAT PROV		PPPPP		CCCCC		ZEROS		06		01-10
001230		CLM SUPPL INFO		PPPPP		CCCCC		ZEROS		07		01-14
001240		CLM SUPPL QTY		PPPPP		CCCCC		ZEROS		08		01-15
001250		SVC PMT		PPPPP		CCCCC		SSSSS		09		ZEROS
001260		SVC CAS		PPPPP		CCCCC		SSSSS		10		01-99
001270		SVC TREAT PROV		PPPPP		CCCCC		SSSSS		11		01-10
001280		SVC SUPPL INFO		PPPPP		CCCCC		SSSSS		12		01-12
001290		SVC SUPPL QTY		PPPPP		CCCCC		SSSSS		13		01-06
001300		SVC REMARKS		PPPPP		CCCCC		SSSSS		14		01-99
001310		PROV ADJUST		PPPPP		99999		99999		15		01-999
001320		TX TRAILER		99999		99999		99999		99		99999
001330
001340
001350		WARNING!!!    THE REMITTANCE ADVICE EDI INTERFACE FILE HAS
001360		ONLY TEN (10) OCCURRENCES FOR THE ADDITIONAL
001370		PAYEE SEGMENTS.THE IMPLEMENTATION GUIDE
001380		ALLOWS AN UNLIMITED NUMBER OF OCCURRENCES.
001390
001400
001410
001420
001430
001440
001450		835  TRANSACTION HEADER RECORD (NO LOOP)
001460
001470
001480		01     X835-TX-HEADER.
001490
001500		05     X835-RECORD-CODE
001510		PIC X(02) .
001520		05     X835-SORT-KEY.
001530

 

Page 63 of 326

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001540
001550		USE ZEROES FOR PROVIDER SEQUENCE NUMBER
001560
001570
001580		10     X835-PROV-SEQ-NUM
001590		VALUE ZEROES
001600		PIC 9(11).
001610
001620
001630		USE ZEROES FOR CLAIM SEQUENCE NUMBER
001640
001650
001660		10     X835-CLM-SEQ-NUM
001670		VALUE ZEROES
001680		PIC 9(11).
001690
001700
001710		USE ZEROES FOR SERVICE SEQUENCE NUMBER
001720
001730
001740		10     X835-SVC-SEQ-NUM
001750		VALUE ZEROES
001760		PIC 9(03).
001770
001780
001790		USE ‘00’ FOR THE TRANSACTION CODE
001800
001810
001820		10     X835-TX-CODE
001830		VALUE ZEROES
001840		PIC X(02).
001850
001860
001870		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
001880
001890
001900		10     X835-TX-CODE-SEQ-NUM
001910		VALUE ZEROES
001920		PIC 9(03).
001930
001940		05     X835-TX-HEADER-SEG.
001950
001960		10     X835-TX-ID
001970		VALUE ‘835’
001980		PIC X(03).
001990		10     X835-TX-CTL-NUM-HDR
002000		PIC X(09).
002010		10     FILLER
002020		PIC X(10).
002030
002040		05     X835-BPR-SEG.

 

Page 64 of 326

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002050
002060		10     X835-TRANS-HANDLING-CODE
002070		PIC X(02).
002080		10     X835-REIMBURSEMENT-AMT
002090		PIC S9(11)V99.
002100		10     X835-CREDIT-DEBIT-CODE
002110		PIC X(01).
002120		10     X835-PMT-METHOD-CODE
002130		PIC X(03).
002140		10     X835-PMT-FORMAT-CODE
002150		PIC X(10).
002160		10     X835-SENDER-DFI-ID-QUAL
002170		PIC X(02).
002180		10     X835-SENDER-DFI-ID
002190		PIC X(12).
002200		10     X835-SENDER-ACCT-QUAL
002210		PIC X(03).
002220		10     X835-SENDER-ACCT
002230		PIC X(35).
002240		10     X835-SENDER-ID
002250		PIC X(10).
002260		10     X835-SENDER-SUPPL-CODE
002270		PIC X(09).
002280		10     X835-RECEIVER-DFI-ID-QUAL
002290		PIC X(02).
002300		10     X835-RECEIVER-DFI-ID
002310		PIC X(12).
002320		10     X835-RECEIVER-ACCT-QUAL
002330		PIC X(03).
002340		10     X835-RECEIVER-ACCT
002350		PIC X(35).
002360		10     X835-CHECK-EFT-DATE
002370		PIC X(08).
002380		10     FILLER
002390		PIC X(10).
002400
002410		05     X835-REASSOC-TRACE-SEG.
002420
002430		10     X835-CHECK-EFT-TRACE-NUM
002440		PIC X(30).
002450		10     X835-PAYER-ID
002460		PIC X(10).
002470		10     X835-PAYER-SUPPL-CODE
002480		PIC X(30).
002490		10     FILLER
002500		PIC X(10).
002510
002520		05     X835-FOREIGN-CURR-SEG.
002530
002540		10     FILLER
002550		PIC X(10).

 

Page 65 of 326

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002560
002570		05     X835-RECEIVER-IDENT-SEG.
002580
002590		10     X835-RECEIVER-ID
002600		PIC X(30).
002610		10     FILLER
002620		PIC X(10).
002630
002640		05     X835-VERSION-IDENT-SEG.
002650
002660		10     X835-VERSION-ID
002670		PIC X(30).
002680		10     FILLER
002690		PIC X(10).
002700
002710		05     X835-PRODUCTION-DATE-SEG.
002720
002730		10     X835-PRODUCTION-DATE
002740		PIC X(08).
002750		10     FILLER
002760		PIC X(10).
002770
002780
002790
002800		▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ (▇▇▇▇ ▇▇▇▇▇)
002810
002820
002830		01     X835-PAYER-IDENT.
002840
002850		05     X835-RECORD-CODE
002860		PIC X(02).
002870		05     X835-SORT-KEY.
002880
002890
002900		USE ZEROES FOR PROVIDER SEQUENCE NUMBER
002910
002920
002930		10     X835-PROV-SEQ-NUM
002940		VALUE ZEROES
002950		PIC 9(11).
002960
002970
002980		USE ZEROES FOR CLAIM SEQUENCE NUMBER
002990
003000
003010		10     X835-CLM-SEQ-NUM
003020		VALUE ZEROES
003030		PIC 9(11) .
003040
003050
003060		USE ZEROES FOR SERVICE SEQUENCE NUMBER

 

Page 66 of 326

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003070
003080
003090		10     X835-SVC-SEQ-NUM
003100		VALUE ZEROES
003110		PIC 9(03).
003120
003130
003140		USE ‘01’ FOR THE TRANSACTION CODE
003150
003160
003170		10     X835-TX-CODE
003180		VALUE ‘01’
003190		PIC X(02).
003200
003210
003220		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
003230
003240
003250		10     X835-TX-CODE-SEQ-NUM
003260		VALUE ZEROES
003270		PIC 9(03).
003280
003290		05     X835-PAYER-IDENT-SEG.
003300
003310		10     X835-PAYER-NAME
003320		PIC X(60).
003330		10     X835-PAYER-PLAN-ID-QUAL
003340		PIC X(02).
003350		10     X835-PAYER-PLAN-ID
003360		PIC X(80).
003370		10     FILLER
003380		PIC X(10).
003390
003400		05     X835-PAYER-ADDRESS-SEG.
003410
003420		10     X835-PAYER-ADDR-1
003430		PIC X(55).
003440		10     X835-PAYER-ADDR-2
003450		PIC X(55).
003460		10     FILLER
003470		PIC X(10).
003480
003490		05     X835-PAYER-CITY-STATE-SEG.
003500
003510		10     X835-PAYER-CITY
003520		PIC X(30).
003530		10     X835-PAYER-STATE
003540		PIC X(02).
003550		10     X835-PAYER-ZIP
003560		PIC X(15).
003570		10     FILLER

 

Page 67 of 326

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003580		PIC X(10).
003590
003600		05     X835-OTHER-PAYER-ID-SEG
003610		OCCURS 4 TIMES
003620		INDEXED BY X835-OTHER-PAYER-ID-SEG-NDX.
003630
003640		10     X835-OTHER-PAYER-ID-QUAL
003650		PIC X(03).
003660		10     X835-OTHER-PAYER-ID
003670		PIC X(30).
003680		10     FILLER
003690		PIC X(10).
003700
003710		05     X835-PAYER-CONTACT-INFO-SEG.
003720
003730		10     X835-PAYER-CONTACT-NAME
003740		PIC X(60).
003750		10     X835-PAYER-COMM
003760		OCCURS 3 TIMES
003770		INDEXED BY X835-PAYER-COM-NDX.
003780		15     X835-PAYER-COMM-QUAL
003790		PIC X(02).
003800		15     X835-PAYER-COMM-NUM
003810		PIC X(80).
003820		10     FILLER
003830		PIC X(10).
003840
003850
003860
003870		▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ (▇▇▇▇ ▇▇▇▇▇)
003880
003890
003900		01     X835-PAYEE-IDENT.
003910
003920		05     X835-RECORD-CODE
003930		PIC X(02).
003940		05     X835-SORT-KEY.
003950
003960
003970		USE ZEROES FOR PROVIDER SEQUENCE NUMBER
003980
003990
004000		10     X835-PROV-SEQ-NUM
004010		VALUE ZEROES
004020		PIC 9(11).
004030
004040
004050		USE ZEROES FOR CLAIM SEQUENCE NUMBER
004060
004070
004080		10     X835-CLM-SEQ-NUM

 

Page 68 of 326

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004090		VALUE ZEROES
004100		PIC 9(11).
004110
004120
004130		USE ZEROES FOR SERVICE SEQUENCE NUMBER
004140
004150
004160		10     X835-SVC-SEQ-NUM
004170		VALUE ZEROES
004180		PIC 9(03).
004190
004200
004210		USE ‘02’ FOR THE TRANSACTION CODE
004220
004230
004240		10     X835-TX-CODE
004250		VALUE ‘02’
004260		PIC X(02).
004270
004280
004290		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
004300
004310
004320		10     X835-TX-CODE-SEQ-NUM
004330		VALUE ZEROES
004340		PIC 9(03).
004350
004360		05     X835-PAYEE-IDENT-SEG.
004370
004380		10     X835-PAYEE-NAME
004390		PIC X(60).
004400		10     X835-PAYEE-ID-QUAL
004410		PIC X(02).
004420		10     X835-PAYEE-PLAN-ID
004430		PIC X(80).
004440		10     FILLER
004450		PIC X(10).
004460
004470		05     X835-PAYEE-ADDRESS-SEG.
004480
004490		10     X835-PAYEE-ADDR-1
004500		PIC X(55).
004510		10     X835-PAYEE-ADDR-2
004520		PIC X(55).
004530		10     FILLER
004540		PIC X(10).
004550
004560		05     X835-PAYEE-CITY-STATE-SEG.
004570
004580		10     X835-PAYEE-CITY
004590		PIC X(30).

 

Page 69 of 326

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004600		10     X835-PAYEE-STATE
004610		PIC X(02).
004620		10     X835-PAYEE-ZIP
004630		PIC X(15).
004640		10     X835-PAYEE-COUNTRY
004650		PIC X(03).
004660		10     FILLER
004670		PIC X(10).
004680
004690		05     X835-ADDITIONAL-PAYEE-SEG
004700		OCCURS 10 TIMES
004710		INDEXED BY X835-ADDITIONAL-PAYEE-SEG-NDX.’
004720
004730		10     X835-ADDNL-PAYEE-ID-QUAL
004740		PIC X(03).
004750		10     X835-ADDNL-PAYEE-ID
004760		PIC X(30).
004770		10     FILLER
004780		PIC X(10).
004790/
004800
004810
004820		835 PROVIDER SUMMARY RECORD - LOOP 2000
004830
004840
004850		01     X835-PROV-SUMMARY.
004860
004870		05     X835-RECORD-CODE
004880		PIC X(02).
004890		05     X835-SORT-KEY.
004900
004910
004920		USE SAME PROVIDER SEQUENCE NUMBER FOR EACH PROVIDER
004930
004940
004950		10     X835-PROV-SEQ-NUM
004960		PIC 9(11).
004970
004980
004990		USE ZEROES FOR CLAIM SEQUENCE NUMBER
005000
005010
005020		10     X835-CLM-SEQ-NUM
005030		VALUE ZEROES
005040		PIC 9(11).
005050
005060
005070		USE ZEROES FOR SERVICE SEQUENCE NUMBER
005080
005090
005100		10     X835-SVC-SEQ-NUM

 

Page 70 of 326

---

005110		VALUE ZEROES
005120		PIC 9(03).
005130
005140
005150		USE ‘03’ FOR THE TRANSACTION CODE
005160
005170
005180		10     X835-TX-CODE
005190		VALUE ‘03’
005200		PIC X(02).
005210
005220
005230		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
005240
005250
005260		10     X835-TX-CODE-SEQ-NUM
005270		VALUE ZEROES
005280		PIC 9(03).
005290
005300		05     X835-PROV-LX-SEG.
005310
005320		10     X835-PROV-LX-NUMBER
005330		PIC 9(06).
005340		10     FILLER
005350		PIC X(10).
005360
005370		05     X835-PROV-SUMMARY-SEG.
005380
005390		10     X835-PROV-ID
005400		PIC X(30).
005410		10     X835-TYPE-FACILITY
005420		PIC X(02).
005430		10     X835-FISCAL-YR-END-DATE
005440		PIC X(08).
005450		10     X835-NUM-OF-CLAIMS
005460		PIC 9(09).
005470		10     X835-TOT-CHRGS
005480		PIC S9(11)V99.
005490		10     X835-TOT-COV-CHRGS
005500		PIC S9(11)V99.
005510		10     X835-TOT-NON-COV-CHRGS
005520		PIC S9(11)V99.
005530		10     X835-TOT-DENIED-CHRGS
005540		PIC S9 (11)V99.
005550		10     X835-TOT-REIMB-AMT
005560		PIC S9(11)V99.
005570		10     X835-TOT-INTEREST-AMT
005580		PIC S9(11)V99.
005590		10     X835-TOT-ADJUST-AMT
005600		PIC S9(11)V99.
005610		10     X835-TOT-▇▇▇▇▇-▇▇▇▇-AMT

 

Page 71 of 326

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005620		PIC S9(11)V99.
005630		10     X835-TOT-MSP-PAYER-AMT
005640		PIC S9(11)V99.
005650		10     X835-TOT-BLOOD-DEDUCT
005660		PIC S9(11)V99.
005670		10     X835-TOT-NON-LAB-AMT
005680		PIC S9(11)V99.
005690		10     X835-TOT-COINS
005700		PIC S9(11JV99.
005710		10     X835-TOT-HCPCS-CHRG
005720		PIC S9(11)V99.
005730		10     X835-TOT-HCPCS-REIMB
005740		PIC S9(11)V99.
005750		10     X835-TOT-DEDUCT
005760		PIC S9(11)V99.
005770		10     X835-TOT-PROF-COMP
005780		PIC S9(11)V99.
005790		10     X835-TOT-MSP-▇▇▇-LIAB-MET
005800		PIC S9(11)V99.
005810		10     X835-TOT-PATIENT-REIMB
005820		PIC S9(11)V99.
005830		10     X835-TOT-PIP-CLM-COUNT
005840		PIC 9(09).
005850		10     X835-TOT-PIP-ADJUST-AMT
005860		PIC S9(11)V99.
005870
005880		05     X835-PROV-SUPPL-SEG.
005890
005900		10     X835-TOT-DRG-AMT
005910		PIC S9(11)V99.
005920		10     X835-TOT-FED-SPECIFIC
005930		PIC S9(11)V99.
005940		10     X835-TOT-HOSP-SPECIFIC
005950		PIC S9(11)V99.
005960		10     X835-TOT-DISPROP-SHARE
005970		PIC S9(11)V99.
005980		10     X835-TOT-CAPITAL-AMT
005990		PIC S9(11)V99.
006000		10     X835-TOT-INDIR-MED-EDUC
006010		PIC S9(11)V99.
006020		10     X835-TOT-OUTLIER-DAYS
006030		PIC S9(09).
006040		10     X835-TOT-DAY-OUTLIER-AMT
006050		PIC S9(11)V99.
006060		10     X835-TOT-COST-OUTLIER-AMT
006070		PIC S9(11)V99.
006080		10     X835-AVG-DRG-LOS
006090		PIC S9(09).
006100		10     X835-TOT-DISCHARGE-COUNT
006110		PIC S9(09).
006120		10     X835-TOT-COST-RPT-DAYS

 

Page 72 of 326

---

006130		PIC S9(09).
006140		10     X835-TOT-COV-DAYS
006150		PIC S9(09).
006160		10     X835-TOT-NON-COV-DAYS
006170		PIC S9(09).
006180		10     X835-TOT-MSP-PASS-THRU
006190		PIC S9(11)V99.
006200		10     X835-AVG-DRG-WEIGHT
006210		PIC S9(09).
006220		10     X835-TOT-PPS-CAPITAL-FSP
006230		PIC S9(11)V99.
006240		10     X835-TOT-PPS-CAPITAL-HSP
006250		PIC S9(11)V99.
006260		10     X835-TOT-PPS-DSH
006270		PIC 39(11)V99.
006280		10     FILLER
006290		PIC X(10).
006300
006310
006320
006330		835 CLAIM PAYMENT RECORD - LOOP 2100
006340
006350
006360		01     X835-CLM-PMT.
006370
006380		05     X835-RECORD-CODE
006390		PIC X (02).
006400		05     X835-SORT-KEY.
006410
006420
006430		USE SAME PROVIDER SEQUENCE NUMBER FOR EACH PROVIDER
006440
006450
006460		10     X835-PROV-SEQ-NUM
006470		PIC 9(11).
006480
006490
006500		USE SAME CLAIM SEQUENCE NUMBER FOR EACH PROVIDER’S CLAIM
006510
006520
006530		10     X835-CLM-SEQ-NUM
006540		PIC 9(11).
006550
006560
006570		USE ZEROES FOR SERVICE SEQUENCE NUMBER
006580
006590
006600		10     X835-SVC-SEQ-NUM
006610		VALUE ZEROES
006620		PIC 9(03).
006630

 

Page 73 of 326

---

006640
006650		USE ‘04’ FOR THE TRANSACTION CODE
006660
006670
006680		10     X835-TX-CODE
006690		VALUE ‘04’
006700		PIC X(02).
006710
006720
006730		USE ZEROES FOR TRANSACTION CODE SEQUENCE NUMBER
006740
006750
006760		10     X835-TX-CODE-SEQ-NUM
006770		VALUE ZEROES
006780		PIC 9(03).
006790
006800		05     X835-CLM-PMT-SEG.
006810
006820		10     X835-PATIENT-CTL-NUM
006830		PIC X(38).
006840		10     X835-CLM-STATUS-CODE
006850		PIC X(02).
006860		10     X835-TOT-CLM-CHARGE-AMT
006870		PIC S9(11)V99.
006880		10     X835-CLM-REIMB-AMT
006890		PIC S9(11)V99.
006900		10     X835-PATIENT-RESP-AMT
006910		PIC S9(11)V99.
006920		10     X835-CLM-FILING-IND-CODE
006930		PIC X(02).
006940		10     X835-PAYER-CLM-CTL-NUM
006950		PIC X(30).
006960		10     X835-FACILITY-TYPE
006970		PIC X(02).
006980		10     X835-CLM-FREQ-TYPE-CODE
006990		PIC X(01).
007000		10     X835-DRG-CODE
007010		PIC X(04).
007020		10     X835-DRG-WEIGHT
007030		PIC X(15).
007040		10     X835-DISCHARGE-FRACTION
007050		PIC 999V99.
007060		10     FILLER
007070		PIC X(10).
007080
007090		05     X835-PATIENT-NAME-SEG.
007100
007110		10     X835-PATIENT-LAST-NAME
007120		PIC X(35).
007130		10     X835-PATIENT-FIRST-NAME
007140		PIC X(25).

 

Page 74 of 326

---

007150		10     X835-PATIENT-MIDDLE-NAME
007160		PIC X(25).
007170		10     X835-PATIENT-NAME-SUFFIX
007180		PIC X(10).
007190		10     X835-PATIENT-ID-QUAL
007200		PIC X(02).
007210		10     X835-PATIENT-ID
007220		PIC X(80).
007230		10     FILLER
007240		PIC X(10).
007250
007260		NOTE: THE INSURED IS ANOTHER NAME FOR SUBSCRIBER
007270
007280		05     X835-INSURED-NAME-SEG.
007290
007300		10     X835-PERSON-IND
007310		PIC X(01).
007320		10     X835-INSURED-LAST-NAME
007330		PIC X(35).
007340		10     X835-INSURED-FIRST-NAME
007350		PIC X(25).
007360		10     X835-INSURED-MIDDLE-NAME
007370		PIC X(25).
007380		10     X835-INSURED-NAME-SUFFIX
007390		PIC X(10).
007400		10     X835-INSURED-ID-QUAL
007410		PIC X(02).
007420		10     X835-INSURED-ID
007430		PIC X(80).
007440		10     FILLER
007450		PIC X(10).
007460
007470		05     X835-CORR-NAME-SEG.
007480
007490		10     X835-CORR-PERSON-IND
007500		PIC X(01).
007510		10     X835-CORR-LAST-NAME
007520		PIC X(35).
007530		10     X835-CORR-FIRST-NAME
007540		PIC X(25).
007550		10     X835-CORR-MIDDLE-NAME
007560		PIC X(25).
007570		10     X835-CORR-NAME-SUFFIX
007580		PIC X(10).
007590		10     X835-CORR-ID-QUAL
007600		PIC X(02).
007610		10     X835-CORR-ID
007620		PIC X(80).
007630		10     FILLER
007640		PIC X(10).
007650

 

Page 75 of 326

---

007660		05     X835-SVC-PROV-NAME-SEG.
007670
007680		10     X835-SVC-PROV-IND
007690		PIC X(01).
007700		10     X835-SVC-PROV-LAST-NAME
007710		PIC X(35).
007720		10     X835-SVC-PROV-FIRST-NAME
007730		PIC X(25).
007740		10     X835-SVC-PROV-MIDDLE-NAME
007750		PIC X(25).
007760		10     X835-SVC-PROV-NAME-SUFFIX
007770		PIC X(10).
007780		10     X835-SVC-PROV-ID-QUAL
007790		PIC X(02).
007800		10     X835-SVC-PROV-ID
007810		PIC X(80).
007820		10     FILLER
007830		PIC X(10).
007840
007850		05     X835-XOVER-CARRIER-NAME-SEG.
007860
007870		10     X835-XOVER-CARRIER-NAME
007880		PIC X(35).
007890		10     X835-XOVER-CARRIER-ID-QUAL
007900		PIC X(02).
007910		10     X835-XOVER-CARRIER-ID
007920		PIC X(80).
007930		10     FILLER
007940		PIC X(10).
007950
007960		05     X835-CORR-PAYER-SEG.
007970		OCCURS 2 TIMES
007980		INDEXED BY X835-CORR-PAYER-SEG-NDX.
007990
008000		10     X835-CORR-PAYER-NAME
008010		PIC X(35).
008020		10     X835-CORR-PAYER-ID-QUAL
008030		PIC X(02).
008040		10     X835-CORR-PAYER-ID
008050		PIC X(80).
008060		10     FILLER
008070		PIC X(10).
008080
008090		05     X835-MIA-ADJUD-SEG.
008100
008110		10     X835-MIA-COV-DAYS-VISITS
008120		PIC S9(09).
008130		10     X835-MIA-PPS-OUTLIER-AMT
008140		PIC S9(11)V99.
008150		10     X835-MIA-PYSC-DAYS
008160		PIC S9(09).

 

Page 76 of 326

---

008170		10     X835-MIA-CLM-DRG-AMT
008180		PIC S9(11)V99.
008190		10     X835-MIA-REMARK-CODE
008200		PIC X(30).
008210		10     X835-MIA-CLM-DISPROP-SHR
008220		PIC S9(11)V99.
008230		10     X835-MIA-CLM-MSP-PASSTHRU
008240		PIC S9(11)V99.
008250		10     X835-MIA-CLM-PPS-CAP
008260		PIC S9(11)V99.
008270		10     X835-MIA-PPS-CAP-FSP-DRG
008280		PIC S9(11)V99.
008290		10     X835-MIA-PPS-CAP-HSP-DRG
008300		PIC S9(11)V99.
008310		10     X835-MIA-PPS-CAP-DSH-DRG
008320		PIC S9(11)V99.
008330		10     X835-MIA-OLD-CAPITAL-AMT
008340		PIC S9(11)V99.
008350		10     X835-MIA-PPS-CAP-IME-AMT
008360		PIC S9(11)V99.
008370		10     X835-MIA-PPS-OP-HOSP-DRG
008380		PIC S9(11)V99.
008390		10     X835-MIA-COST-RPT-DAYS
008400		PIC S9(09).
008410		10     X835-MIA-PPS-OPER-FED-DRG
008420		PIC S9(11)V99.
008430		10     X835-MIA-CLM-PPS-CAP-OUT
008440		PIC S9(11)V99.
008450		10     X835-MIA-CLM-INDIR-TEACH
008460		PIC S9(11)V99.
008470		10     X835-MIA-NONPAY-PROF-COMP
008480		PIC S9(11)V99.
008490		10     X835-MIA-ADDNL-REMARK
008500		OCCURS 4 TIMES
008510		INDEXED BY X835-MIA-ADDNL-REMARK-NDX
008520		PIC X(30).
008530		10     X835-MIA-PPS-CAP-EXEP-AMT
008540		PIC S9(11)V99.
008550		10     FILLER
008560		PIC X(10).
008570
008580		05     X835-MOA-ADJUD-SEG.
008590
008600		10     X835-MOA-REIMB-RATE
008610		PIC S999V999.
008620		10     X835-MOA-CLM-HCPCS-PMT
008630		PIC S9(11)V99.
008640		10     X835-MOA-REMARK-CODE
008650		OCCURS 5 TIMES
008660		INDEXED BY X835-MOA-REMARK-NDX
008670		PIC X(30).

 

Page 77 of 326

---

008680		10     X835-MOA-CLM-ESRD-PMT
008690		PIC S9(11)V99.
008700		10     X835-MOA-NONPAY-PROF-COMP
008710		PIC S9(11)V99.
008720		10     FILLER
008730		PIC X(10).
008740
008750		05     X835-OTHER-CLM-SEG
008760		OCCURS 5 TIMES
008770		INDEXED BY X835-OTHER-CLM-SEG-NDX.
008780
008790		10     X835-OTHER-CLM-ID-QUAL
008800		PIC X(03).
008810		10     X835-OTHER-CLM-ID
008820		PIC X(30).
008830		10     FILLER
008840		PIC X(10).
008850
008860		05     X835-CLAIM-DATE-SEG
008870		OCCURS 4 TIMES
008880		INDEXED BY X835-CLAIM-DATE-SEG-NDX.
008890
008900		10     X835-CLM-DATE-QUAL
008910		PIC X(03).
008920		10     X835-CLM-DATE
008930		PIC X(08).
008940		10     FILLER
008950		PIC X(10).
008960
008970		05     X835-CLAIM-CONTACT-SEG
008980		OCCURS 9 TIMES
008990		INDEXED BY X835-CLAIM-CONTACT-SEG-NDX.
009000
009010		10     X835-CLM-CONT-NAME
009020		PIC X(60).
009030		10     X835-CLM-CONT-COMM-QUAL
009040		PIC X(02).
009050		10     X835-CLM-CONT-COMM
009060		PIC X(80).
009070		10     FILLER
009080		PIC X(10).
009090
009100
009110
009120		835 CLAIM ADJUSTMENT RECORD - CAS SEGMENT,
009130		LOOP 2100
009140
009150
009160		01     X835-CLM-CAS.
009170
009180		05     X835-RECORD-CODE

 

Page 78 of 326

---

009190		PIC X(02).
009200		05     X835-SORT-KEY.
009210
009220
009230		USE SAME PROVIDER SEQUENCE NUMBER FOR EACH PROVIDER
009240
009250
009260		10     X835-PROV-SEQ-NUM
009270		PIC 9(11).
009280
009290
009300		USE SAME CLAIM SEQUENCE NUMBER FOR EACH PROVIDER’S CLAIM
009310
009320
009330		10     X835-CLM-SEQ-NUM
009340		PIC 9(11).
009350
009360
009370		USE ZEROES FOR SERVICE SEQUENCE NUMBER
009380
009390
009400		10     X835-SVC-SEQ-NUM
009410		VALUE ZEROES
009420		PIC 9(03).
009430
009440
009450		USE ‘05’ FOR THE TRANSACTION CODE
009460
009470
009480		10     X835-TX-CODE
009490		VALUE ‘05’
009500		PIC X(02).
009510
009520
009530		USE SAME TRANACTION CODE SEQUENCE NUMBER FOR EACH CLAIM’S
009540		CLAIM LEVEL ADJUSTMENT RECORDS
009550
009560
009570		10     X835-TX-CODE-SEQ-NUM
009580		PIC 9(03).
009590
009600		05     X835-CLM-CAS-SEG.
009610
009620		10     X835-CLM-ADJUST-GROUP
009630		PIC X(02).
009640		10     X835-CLM-ADJUST-DATA
009650		OCCURS 6 TIMES
009660		INDEXED BY X835-CLAIM-AJUST-DATA-NDX.
009670		15     X835-CLM-ADJUST-REASON
009680		PIC X(05).
009690		15     X835-CLM-ADJUST-AMT

 

Page 79 of 326

---

009700		PIC S9(11)V99.
009710		15     X835-CLM-ADJUST-QTY
009720		PIC S9(07)V9999.
009730		10     FILLER
009740		PIC X(10).
009750
009760
009770
009780		835 CLAIM TREATING PROV RECORD - REF SEGMENT,
009790		LOOP 2100
009800
009810
009820		01     X835-CLM-TREAT-PROV.
009830
009840		05     X835-RECORD-CODE
009850		PIC X(02).
009860		05     X835-SORT-KEY.
009870
009880
009890		USE SAME PROVIDER SEQUENCE NUMBER FOR EACH PROVIDER
009900
009910
009920		10     X835-PROV-SEQ-NUM
009930		PIC 9(11).
009940
009950
009960		USE SAME CLAIM SEQUENCE NUMBER FOR EACH PROVIDER’S CLAIM
009970
009980
009990		10     X835-CLM-SEQ-NUM
010000		PIC 9(11).
010010
010020
010030		USE ZEROES FOR SERVICE SEQUENCE NUMBER
010040
010050
010060		10     X835-SVC-SEQ-NUM
010070		VALUE ZEROES
010080		PIC 9(03).
010090
010100
010110		USE ‘06’ FOR THE TRANSACTION CODE
010120
010130
010140		10     X835-TX-CODE
010150		VALUE ‘06’
010160		PIC X(02).
010170
010180		:
010190		ASSIGN A UNIQUE SEQUENCE NUMBER FOR EACH CLAIM’S
010200		TREATING PROVIDER SEGMENTS

 

Page 80 to 326

---

010210
010220
010230		10     X835-TX-CODE-SEQ-NUM
010240		PIC 9(03).
010250
010260		05     X835-CLM-TREAT-PROV-SEG.
010270
010280		10     X835-CLM-TREAT-ID-QUAL
010290		PIC X(03).
010300		10     X835-CLM-TREAT-ID
010310		PIC X(30).
010320		10     FILLER
010330		PIC X(10).
010340
010350
010360
010370		835 CLAIM SUPPLEMENTAL INFORMATION RECORD,
010380		AMT SEGMENT IN LOOP 2100
010390
010400
010410		01     X835-CLM-SUPPL-INFO.
010420
010430		05     X835-RECORD-CODE
010440		PIC X(02).
010450		05     X835-SORT-KEY.
010460
010470
010480		USE SAME PROVIDER SEQUENCE NUMBER FOR EACH PROVIDER
010490
010500
010510		10     X835-PROV-SEQ-NUM
010520		PIC 9(11).
010530
010540
010550		USE SAME CLAIM SEQUENCE NUMBER FOR EACH PROVIDER’S CLAIM
010560
010570
010580		10     X835-CLM-SEQ-NUM
010590		PIC 9(11).
010600
010610
010620		USE ZEROES FOR SERVICE SEQUENCE NUMBER
010630
010640
010650		10     X835-SVC-SEQ-NUM
010660		VALUE ZEROES
010670		PIC 9(03).
010680
010690
010700		USE ‘07’ FOR THE TRANSACTION CODE
010710

 

Page 81 of 326

---

010720
010730		10     X835-TX-CODE
010740		VALUE ‘07’
010750		PIC X(02).
010760
010770
010780		ASSIGN A UNIQUE SEQUENCE NUMBER FOR EACH CLAIM’S
010790		SUPPLEMENTAL INFORMATION SEGEMENTS
010800
010810
010820		10     X835-TX-CODE-SEQ-NUM
010830		PIC 9(03).
010840
010850		05     X835-CLM-SUPPL-INFO-SEG.
010860
010870		10     X835-CLM-SUPPL-AMT-QUAL
010880		PIC X(03).
010890		10     X835-CLM-SUPPL-AMT
010900		PIC S9(11)V99.
010910		10     FILLER
010920		PIC X(10).
010930
010940
010950
010960		835 CLAIM SUPPLEMENTAL QUANTITY RECORD
010970		QTY SEGMENT IN LOOP 2100
010980
010990
011000		01     X835-CLM-SUPPL-QTY.
011010
011020		05     X835-RECORD-CODE
011030		PIC X(02).
011040		05     X835-SORT-KEY.
011050
011060
011070		USE SAME PROVIDER SEQUENCE NUMBER FOR EACH PROVIDER
011080
011090
011100		10     X835-PROV-SEQ-NUM
011110		PIC 9(11).
011120
011130
011140		USE SAME CLAIM SEQUENCE NUMBER FOR EACH PROVIDER’S CLAIM
011150
011160
011170		10     X835-CLM-SEQ-NUM
011180		PIC 9(11).
011190
011200
011210		USE ZEROES FOR SERVICE SEQUENCE NUMBER
011220

 

Page 82 of 326

---

011230
011240		10     X835-SVC-SEQ-NUM
011250		VALUE ZEROES
011260		PIC 9(03).
011270
011280
011290		USE ‘08’ FOR THE TRANSACTION CODE
011300
011310
011320		10     X835-TX-CODE
011330		VALUE ‘08’
011340		PIC X(02).
011350
011360
011370		ASSIGN A UNIQUE SEQUENCE NUMBER FOR EACH CLAIM’S
011380		SUPPLEMENTAL QUANTITY SEGMENTS
011390
011400
011410		10     X835-TX-CODE-SEQ-NUM
011420		PIC 9(03).
011430
011440		05     X835-CLM-SUPPL-QTY-SEG.
011450
011460		10     X835-CLM-SUPP-QTY-QUAL
011470		PIC X(02).
011480		10     X835-CLM-SUPP-QTY
011490		PIC S9(07)V9999.
011500		10     FILLER
011510		PIC X(10).
011520
011530
011540
011550		835 SERVICE PAYMENT RECORD - LOOP 2110
011560
011570
011580		01     X835-SVC-PMT.
011590
011600		05     X835-RECORD-CODE
011610		PIC X(02).
011620		05     X835-SORT-KEY.
011630
011640
011650		USE SAME PROVIDER SEQUENCE NUMBER FOR EACH PROVIDER
011660
011670
011680		10     X835-PROV-SEQ-NUM
011690.		PIC 9(11).
011700
011710
011720		USE SAME CLAIM SEQUENCE NUMBER FOR EACH PROVIDER’S CLAIM
011730

 

Page 83 to 326

---

011740
011750		10     X835-CLM-SEQ-NUM
011760		PIC 9(11).
011770
011780
011790		USE SAME SERVICE SEQUENCE NBR FOR EACH CLAIM’S LINE ITEM
011800
011810
011820		10     X835-SVC-SEQ-NUM
011830		PIC 9(03).
011840
011850
011860		USE ‘09’ FOR THE TRANSACTION CODE
011870
011880
011890		10     X835-TX-CODE
011900		VALUE ‘09’
011910		PIC X(02).
011920
011930
011940		USE ZEROES FOR THE CLAIM’S SERVICE PAYMENT SEGMENT
011950
011960
011970		10     X835-TX-CODE-SEQ-NUM
011980		VALUE ZEROES
011990		PIC 9(03).
012000
012010		05     X835-SVC-PMT-SEG.
012020
012030		10     X835-PROC-CODE-QUAL
012040		PIC X(02).
012050		10     X835-PROC-CODE
012060		PIC X(48).
012070		10     X835-MODIFIER
012080		OCCURS 4 TIMES
012090		INDEXED BY X835-MODIFIER-NDX
012100		PIC X(02).
012110		10     X835-PROC-DESC
012120		PIC X(80).
012130		10     X835-LI-CHARGE-AMT
012140		PIC S9(11)V99.
012150		10     X835-LI-REIMB-AMT
012160		PIC S9(11)V99.
012170		10     X835-REVENUE-CODE
012180		PIC X(48).
012190		10     X835-UNITS-OF-SVC
012200		PIC S9(07)V9999.
012210		10     X835-SUB-PROC-CODE-QUAL
012220		PIC X(02).
012230		10     X835-SUB-PROC-CODE
012240		PIC X(48).

 

Page 84 of 326

---

012250		10     X835-SUB-MODIFIER
012260		OCCURS 4 TIMES
012270		INDEXED BY X835-SUB-MODIFIER-NDX
012280		PIC X(02).
012290		10     X835-SUB-PROC-DESC
012300		PIC X(80).
012310		10     X835-SUB-UNITS-OF-SVC
012320		PIC S9(07)V9999.
012330		10     FILLER
012340		PIC X(10).
012350
012360		05     X835-SVC-DATE-SEG
012370		OCCURS 3 TIMES
012380		INDEXED BY X835-SVC-DATE-SEG-NDX.
012390
012400		10     X835-SVC-DATE-QUAL
012410		PIC X(03).
012420		10     X835-SVC-DATE
012430		PIC X(08).
012440		10     FILLER
012450		PIC X(10).
012460
012470		05     X835-SVC-IDENT-SEG
012480		OCCURS 7 TIMES
012490		INDEXED BY X835-SVC-IDENT-SEG-NDX.
012500
012510		10     X835-SVC-IDENT-QUAL
012520		PIC X(03).
012530		10     X835-SVC-IDENT
012540		PIC X(30).
012550		10     FILLER
012560		PIC X(10).
012570
012580
012590
012600		835 SERVICE ADJUSTMENT RECORD - CAS SEGMENT,
012610		LOOP 2110
012620
012630
012640		01     X835-SVC-CAS.
012650
012660		05     X835-RECORD-CODE
012670		PIC X(02).
012680		05     X835-SORT-KEY.
012690
012700
012710		USE SAME PROVIDER SEQUENCE NUMBER FOR EACH PROVIDER
012720
012730
012740		10     X835-PROV-SEQ-NUM
012750		PIC 9(11).

 

Page 85 of 326

---

012760
012770
012780		USE SAME CLAIM SEQUENCE NUMBER FOR EACH PROVIDER’S CLAIM
012790
012800
012810		10     X835-CLM-SEQ-NUM
012820		PIC 9(11).
012830
012840
012850		USE SAME SERVICE SEQUENCE NBR FOR EACH CLAIM’S LINE ITEM
012860
012870
012880		10     X835-SVC-SEQ-NUM
012890		PIC 9(03).
012900
012910
012920		USE ‘10’ FOR THE TRANSACTION CODE
012930
012940
012950		10     X835-TX-CODE
012960		VALUE ‘10’
012970		PIC X(02).
012980
012990
013000		ASSIGN A UNIQUE SEQUENCE NUMBER FOR EACH SERVICE LINE’S
013010		ADJUSTMENT SEGMENTS
013020
013030
013040		10     X835-TX-CODE-SEQ-NUM
013050		PIC 9(03).
013060
013070		05     X835-SVC-CAS-SEG.
013080
013090		10     X835-SVC-ADJUST-GROUP
013100		PIC X(02).
013110		10     X835-SVC-ADJUST-DATA
013120		OCCURS 6 TIMES
013130		INDEXED BY X835-SVC-ADJUST-DATA-NDX.
013140		15     X835-SVC-ADJUST-REASON
013150		PIC X(05).
013160		15     X835-SVC-ADJUST-AMT
013170		PIC S9(11)V99.
013180		15     X835-SVC-ADJUST-QTY
013190		PIC S9(07)V9999.
013200		10     FILLER
013210		PIC X(10).
013220
013230
013240
013250		835 SERVICE TREATING PROVIDER RECORD
013260		REF SEGMENT IN LOOP 2110

 

Page 86 of 326

---

013270
013280
013290		01     X835-SVC-TREAT-PROV.
013300
013310		05     X835-RECORD-CODE
013320		PIC X(02).
013330		05     X835-SORT-KEY.
013340
013350
013360		USE SAME PROVIDER SEQUENCE NUMBER FOR EACH PROVIDER
013370
013380
013390		10     X835-PROV-SEQ-NUM
013400		PIC 9(11).
013410
013420
013430		USE SAME CLAIM SEQUENCE NUMBER FOR EACH PROVIDER’S CLAIM
013440
013450
013460		10     X835-CLM-SEQ-NUM
013470		PIC 9(11).
013480
013490
013500		USE SAME SERVICE SEQUENCE NBR FOR EACH CLAIM’S LINE ITEM
013510
013520
013530		10     X835-SVC-SEQ-NUM
013540		PIC 9(03).
013550
013560
013570		USE ‘11’ FOR THE TRANSACTION CODE
013580
013590
013600		10     X835-TX-CODE
013610		VALUE ‘11’
013620		PIC X(02).
013630
013640
013650		ASSIGN A UNIQUE SEQUENCE NUMBER FOR EACH SERVICE LINE’S
013660		TREATING PROVIDER SEGMENTS
013670
013680
013690		10     X835-TX-CODE-SEQ-NUM
013700		PIC 9(03).
013710
013720		05     X835-SVC-TREAT-PROV-SEG.
013730
013740		10     X835-SVC-TREAT-ID-QUAL
013750		PIC X(03).
013760		10     X835-SVC-TREAT-ID
013770		PIC X(30).

 

Page 87 of 326

---

013780		10     FILLER
013790		PIC X(10).
013800
013810		.
013820
013830		835 SERVICE SUPPLEMENTAL INFORMATION RECORD
013840		AMT SEGMENT IN LOOP 2110
013850
013860
013870		01     X835-SVC-SUPPL-INFO.
013880
013890		05     X835-RECORD-CODE
013900		PIC X(02).
013910		05     X835-SORT-KEY.
013920
013930
013940		USE SAME PROVIDER SEQUENCE NUMBER FOR EACH PROVIDER
013950
013960
013970		10     X835-PROV-SEQ-NUM
013980		PIC 9(11).
013990
014000
014010		USE SAME CLAIM SEQUENCE NUMBER FOR EACH PROVIDER’S CLAIM
014020
014030
014040		10     X835-CLM-SEQ-NUM
014050		PIC 9(11).
014060
014070
014080		USE SAME SERVICE SEQUENCE NBR FOR EACH CLAIM’S LINE ITEM
014090
014100
014110		10     X835-SVC-SEQ-NUM
014120		PIC 9(03).
014130
014140
014150		USE ‘12’ FOR THE TRANSACTION CODE
014160
014170
014180		10     X835-TX-CODE
014190		VALUE ‘12’
014200		PIC X(02).
014210
014220
014230		ASSIGN A UNIQUE SEQUENCE NUMBER FOR EACH SERVICE LINE’S
014240		SUPPLEMENTAL INFORMATION SEGMENTS
014250
014260
014270		10     X835-TX-CODE-SEQ-NUM
014280		PIC 9(03).

 

Page 88 of 326

---

014290
014300		05     X835-SVC-SUPPL-INFO-SEG.
014310
014320		10     X835-SVC-SUPPL-AMT-QUAL
014330		PIC X(03).
014340		10     X835-SVC-SUPPL-AMT
014350		PIC S9(11)V99.
014360		10     FILLER
014370		PIC X(10).
014380
014390
014400
014410		835  SERVICE SUPPLEMENTAL QUANTITY RECORD
014420		QTY SEGMENT IN LOOP 2110
014430
014440
014450		01     X835-SVC-SUPPL-QTY.
014460
014470		05     X835-RECORD-CODE
014480		PIC X(02).
014490		05     X835-SORT-KEY.
014500
014510
014520		USE SAME PROVIDER SEQUENCE NUMBER FOR EACH PROVIDER
014530
014540
014550		10     X835-PROV-SEQ-NUM
014560		PIC 9(11).
014570
014580
014590		USE SAME CLAIM SEQUENCE NUMBER FOR EACH PROVIDER’S CLAIM
014600
014610
014620		10     X835-CLM-SEQ-NUM
014630		PIC 9(11).
014640
014650
014660		USE SAME SERVICE SEQUENCE NBR FOR EACH CLAIM’S LINE ITEM
014670
014680
014690		10     X835-SVC-SEQ-NUM
014700		PIC 9(03).
014710
014720
014730		USE ‘13’ FOR THE TRANSACTION CODE .
014740
014750
014760		10     X835-TX-CODE
014770		VALUE ‘13’
014780		PIC X(02).
014790

 

Page 89 of 326

---

014800
014810		ASSIGN A UNIQUE SEQUENCE NUMBER FOR EACH SERVICE LINE’S
014820		SUPPLEMENTAL QUANTITY SEGMENTS
014830
014840
014850		10     X835-TX-CODE-SEQ-NUM
014860		PIC 9(03).
014870
014880		05     X835-SVC-SUPPL-QTY-SEG.
014890
014900		10     X835-SVC-SUPPL-QTY-QUAL
014910		PIC X(02).
014920		10     X835-SVC-SUPPL-QUANTITY
014930		PIC S9(07)V9999.
014940		10     FILLER
014950		PIC X(10).
014960
014970
014980
014990		835  SERVICE REMARKS RECORD
015000		RMK SEGMENT IN LOOP 2110
015010
015020
015030		01     X835-SVC-REMARKS.
015040
015050		05     X835-RECORD-CODE
015060		PIC X(02).
015070		05     X835-SORT-KEY.
015080
015090
015100		USE SAME PROVIDER SEQUENCE NUMBER FOR EACH PROVIDER
015110
015120
015130		10     X835-PROV-SEQ-NUM
015140		PIC 9(11).
015150
015160
015170		USE SAME CLAIM SEQUENCE NUMBER FOR EACH PROVIDER’S CLAIM
015180
015190
015200		10     X835-CLM-SEQ-NUM
015210		PIC 9(11).
015220
015230
015240		USE SAME SERVICE SEQUENCE NBR FOR EACH CLAIM’S LINE ITEM
015250
015260
015270		10     X835-SVC-SEQ-NUM
015280		PIC 9(03).
015290
015300

 

Page 90 of 326

---

015310		USE ‘14’ FOR THE TRANSACTION CODE
015320
015330
015340		10     X835-TX-CODE
015350		VALUE ‘14’
015360		PIC X(02).
015370
015380
015390		ASSIGN A UNIQUE SEQUENCE NUMBER FOR EACH SERVICE LINE’S
015400		REMARKS SEGMENTS
015410
015420
015430		10     X835-TX-CODE-SEQ-NUM
015440		PIC 9(03).
015450
015460		05     X835-SVC-REMARKS-SEG.
015470
015480		10     X835-SVC-REMARK-QUAL
015490		PIC X(03).
015500		10     X835-SVC-REMARK
015510		PIC X(30).
015520
015530
015540
015550		83▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ - ▇▇▇ ▇EGMENT,
015560		NO LOOP
015570
015580
015590		01     X835-PROV-ADJUST.
015600
015610		05     X835-RECORD-CODE
015620		PIC X(02).
015630		05     X835-SORT-KEY.
015640
015650
015660		USE SAME PROVIDER SEQUENCE NUMBER FOR EACH PROVIDER
015670
015680
015690		10     X835-PROV-SEQ-NUM
015700		PIC 9(11).
015710
015720
015730		USE ZEROES FOR THE CLAIM SEQUENCE NUMBER
015740
015750
015760		10     X835-CLM-SEQ-NUM
015770		PIC 9(11).
015780
015790
015800		USE ZEROES FOR THE SERVICE SEQUENCE NUMBER
015810

 

Page 91 of 326

---

015820
015830		10     X835-SVC-SEQ-NUM
015840		VALUE ZEROES
015850		PIC 9(03).
015860
015870
015880		USE ‘15’ FOR THE TRANSACTION CODE
015890
015900
015910		10     X835-TX-CODE
015920		VALUE ‘15’
015930		PIC X(02).
015940
015950
015960		ASSIGN A UNIQUE SEQUENCE NUMBER FOR EACH PROVIDER’S
015970		ADJUSTMENT (GROSS ADJUSTMENT) SEGMENTS
015980
015990
016000		10     X835-TX-CODE-SEQ-NUM
016010		PIC 9(03).
016020
016030		05     X835-PROV-ADJUST-SEG.
016040
016050		10     X835-PROV-CLM-ID
016060		PIC X(30).
016070		10     X835-PROV-FISCAL-YR-END
016080		PIC X(08).
016090		10     X835-PROV-ADJUSTMENT
016100		OCCURS 6 TIMES
016110		INDEXED BY X835-PROV-ADJUSTMENT-NDX.
016120		15     X835-PROV-ADJUST-REASON
016130		PIC X(02).
016140		15     X835-GROSS-ADJUST-TCN
016150		PIC X(30).
016160		15     X835-ADJUSTMENT-AMT
016170		PIC S9(11)V99.
016180
016190
016200		83▇ ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ - ▇▇ ▇EGMENT,
016210		NO LOOP
016220
016230
016240		01     X835-TX-TRAILER.
016250
016260		05     X835-RECORD-CODE
016270		PIC X(02).
016280		05     X835-SORT-KEY.
016290
016300
016310		USE ALL 9’S FOR THE PROVIDER SEQUENCE NUMBER
016320

 

Page 92 of 326

---

016330
016340		10     X835-PROV-SEQ-NUM
016350		VALUE 99999999999
016360		PIC 9(11).
016370
016380
016390		USE ALL 9’S FOR THE CLAIM SEQUENCE NUMBER
016400
016410
016420		10     X835-CLM-SEQ-NUM
016430		VALUE 99999999999
016440		PIC 9(11).
016450
016460
016470		USE ALL 9’S FOR THE SERVICE SEQUENCE NUMBER
016480
016490
016500		10     X835-SVC-SEQ-NUM
016510		VALUE 999
016520		PIC 9(03).
016530
016540
016550		USE ALL 9’S FOR THE TRANSACTION CODE
016560
016570
016580		10     X835-TX-CODE
016590		VALUE ‘99’
016600		PIC X(02).
016610
016620
016630		USE ALL 9’S FOR THE TRANSACTION CODE SEQUENCE NUMBER
016640
016650
016660		10     X835-TX-CODE-SEQ-NUM
016670		VALUE 999
016680		PIC 9(03).
016690
016700		05     X835-TX-TRAILER-SEG.
016710		10     X835-TX-NUM-OF-SEG
016720		PIC 9(10).
016730		10     X835-TX-CTL-NUM-TLR
016740		PIC X(09).
016750		10     FILLER
016760		PIC X(10).

 

Page 93 of 326

---

000010
000020
000030		DENTAL CLAIM EDI INTERFACE FILE
000040		COPYBOOK X837DV01
000050
000060
000070		THE HEALTH CARE DENTAL CLAIM EDI INTERFACE
000080		HAS THE SAME DATA CONTENT AS THE
000090		837 HEALTH CARE DENTAL CLAIM TRANSACTION
000100
000110		THE HEALTH CARE DENTAL CLAIM INTERFACE
000120		COPYBOOK CONTAINS 10 RECORDS :
000130
000140		RECORD		DESCRIPTION
000150
000160
000170		X837D-TX-HEADER		CONTAINS TRANSACTION HEADER
000180
000190		X837D-PROVIDER		CONTAINS LOOP 2000A, 2010AA
000200				AND 2010AB SEGMENTS
000210
000220		X837D-SUBSCRIBER		CONTAINS LOOP 2000B, 2010BA, 2010BB
000230				2010BC SEGMENTS.
000240
000250		X837D-PATIENT		CONTAINS LOOP 2000C AND 2010CA
000260				SEGMENTS.
000270
000280		X837D-CLAIM		CONTAINS LOOP 2300, 2310A, 2310B
000290				2310C, AND 2310D SEGMENTS.
000300
000310		X837D-OTHER-SUBSCRIBER		CONTAINS LOOP
000320				2320 (MINUS CLAIM-LVL-ADJ) ,
000330				2330A, 2330B, 2330C, 2330D,
000340				2330E SEGMENTS
000350
000360		X837D-CLAIM-LVL-ADJ		CONTAINS CLAIM-LVL-ADJ ONLY
000370				SEGMENTS FROM LOOP 2320.
000380
000390		X837D-SVC-LINE		CONTAINS LOOP 2400, 2420A, 2420B
000400				2420C SEGMENTS.
000410
000420		X837D-LINE-LVL-ADJ		CONTAINS LOOP 2430 SEGMENTS.
000430
000440		X837D-TX-TRAILER		CONTAINS TRANSACTION TRAILER
000450				SEGMENTS
000460
000470		EACH RECORD BEGINS WITH THE SAME 8 FIELDS, THE SORT-KEY.
000480
000490		FIELD		DESCRIPTION
000500

 

Page 94 of 326

---

000510
000520		X837D-PROV-SEQ-NUM		PURPOSE IS TO UNIQUELY IDENTIFY
000530				EACH PROVIDER’S DATA.
000540				ZERO FOR HEADER AND 9’S FOR
000550				TRAILER.
000560
000570		X837D-SUBSCRIBER-SEQ-NUM		PURPOSE IS TO UNIQUELY IDENTIFY
000580				EACH SUBSCRIBER’S DATA FOR A
000590				PROVIDER
000600
000610		X837D-PATIENT-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
000620				EACH PATIENT’S DATA FOR A
000630				PROVIDER
000640
000650		X837D-CLAIM-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
000660				EACH CLAIM’S DATA FOR A PATIENT
000670
000680		X837D-SUB-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
000690				EACH OTHER-SUBSCRIBER’S DATA
000700				FOR A CLAIM -OR-
000710				CLAIM-LVL-ADJUSTMENTS
000720
000730		X837D-CLAIM-LVL-ADJ-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
000740				EACH SET OF CLAIM LVL ADJUSTMENTS
000750				FOR A CLAIM
000760
000770		X837D-SVC-LINE-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
000780				EACH SVC-LINE’S DATA FOR A CLAIM
000790
000800		X837D-LINE-LVL-ADJ-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
000810				EACH SET OF LINE LVL ADJUSTMENTS
000820				FOR A CLAIM
000830
000840		X837D-TX-CODE		IDENTIFIES EACH TYPE OF RECORD
000850				00 FOR X837D-TX-HEADER
000860				01 FOR X837D-PROVIDER
000870				02 FOR X837D-SUBSCRIBER
000880				03 FOR X837D-PATIENT
000890				04 FOR X837D-CLAIM
000900				05 FOR X837D-OTHER-SUBS-INFO
000910				06 FOR X837D-CLAIM-LVL-ADJ
000920				07 FOR X837D-SVC-LINE
000930				08 FOR X837D-LINE-LVL-ADJ
000940				99 FOR X837D-TX-TRAILER
000950
000960
000970		X837D-TX-CODE-SEQ-NUM		TO SEQUENCE RECORDS WITHIN A
000980				RECORD TYPE. THE SEQUENCE NUMBER
000990				FOR THE FIRST RECORD IF ‘0001’,
001000				FOR THE SECOND ‘002’, ETC.
001010

 

Page 95 of 326

---

001020

001030

001040

THE FOLLOWING EXAMPLE SHOWS HOW THIS WORKS, WHERE

001050

PPPPP   = PROVIDER-SEQ

CCCCC     = CLAIM-SEQ

001060

SSSSS   = SUBSCRIBER-SEQ

LLLLL       = LINE-SEQ

001070

TTTTT = PATIENT-SEQ

HHHHHH = SUB-SEQ

001080

001090

PROV

SUBS

▇▇▇

CLM

SVC

SUB

TX

TX

001100

RECORD

SEQ

SEQ

SEQ

SEQ

SEQ

SEQ

CDE

SEQ

001110

001120

TX-HEADER

ZERO

ZERO

ZERO

ZERO

ZERO

ZERO

00

ZERO

001130

PROVIDER

PPPPP

ZERO

ZERO

ZERO

ZERO

ZERO

01

ZERO

001140

SUBSCRIBER

PPPPP

SSSSS

ZERO

ZERO

ZERO

ZERO

02

ZERO

001150

PATIENT

PPPPP

SSSSS

TTTTT

ZERO

ZERO

ZERO

03

ZERO

001160

CLAIM

PPPPP

SSSSS

TTTTT

CCCCC

ZERO

ZERO

04

ZERO

001170

OTHER-SUBS-INFO

PPPPP

SSSSS

TTTTT

CCCCC

ZERO

HHHHH

05

ZERO

001180

CLAIM-LVL-ADJ

PPPPP

SSSSS

TTTTT

CCCCC

ZERO

HHHHH

06

1-999

001190

SVC-LINE

PPPPP

SSSSS

TTTTT

CCCCC

LLLLL

ZERO

07

ZERO

001200

LINE-LVL-ADJ

PPPPP

SSSSS

TTTTT

CCCCC

LLLLL

ZERO

08

1-999

001210

TX-TRAILER

99999

SSSSS

TTTTT

CCCCC

ZERO

ZERO

99

99999

001220

001230

001240

001250

001260

83ZD - TRANSACTION HEADER RECORD

001270

001280

001290

01     X837D-TX-HEADER.

001300

001310

05     X837D-RECORD-CODE

001320

PIC X(02).

001330

001340

05     X837D-SORT-KEY.

001350

001360

10     X837D-PROV-SEQ-NUM

001370

VALUE ZEROES

001380

PIC 9(11).

001390

001400

10     X837D-SUBSCRIBER-SEQ-NUM

001410

VALUE ZEROES

001420

PIC 9(11).

001430

001440

10     X837D-PATIENT-SEQ

001450

VALUE ZEROES

001460

PIC 9(11).

001470

001480

10     X837D-CLAIM-SEQ

001490

VALUE ZEROES

001500

PIC 9(11).

001510

001520

10     X837D-SVC-LINE-SEC

 

Page 96 of 326

---

001530		VALUE ZEROES
001540		PIC 9(11).
001550
001560
001570		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
001580		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
001590
001600
001610		10     X837D-SUB-SEQ
001620		VALUE ZEROES
001630		PIC 9(11).
001640
001650		10     X837D-TX-CODE
001660		VALUE ‘00’
001670		PIC X(02) .
001680
001690		10     X837D-TX-CODE-SEQ-NUM
001700		VALUE ZEROES
001710		PIC 9(07).
001720
001730		END OF HDR SORT-KEY
001740
001750
001760
001770		05     X837D-TX-HEADER-SEG.
001780
001790		10     X837D-TX-ID
001800		VALUE ‘837’
001810		PIC X(03).
001820		10     X837D-TX-CTL-NUM
001830		PIC X(09).
001840		10     FILLER
001850		PIC X(10).
001860
001870		05     X837D-BEG-SEGMENT.
001880
001890		10     X837D-TX-HIERACH-STRUCT-CODE
001900		PIC X(04).
001910		10     X837D-TX-PURPOSE-CODE
001920		PIC X(02).
001930		10     X837D-TX-ID-CODE
001940		PIC X(30).
001950		10     X837D-TX-CREATION-DATE
001960		PIC X(08).
001970		10     X837D-TX-CREATION-TIME
001980		PIC X(08).
001990		10     X837D-TX-TYPE-CODE
002000		PIC X(02).
002010		10     FILLER
002020		PIC X(10).
002030

 

Page 97 0f 326

---

002040		05     X837D-XMIT-TYPE-ID-SEG.
002050		10     X837D-XMIT-REF-ID-CODE
002060		PIC X(03).
002070		10     X837D-XMIT-REF-ID
002080		PIC X(30).
002090		10     FILLER
002100		PIC X(10).
002110
002120		05     X837D-SUBMITTER-NAME-SEG.
002130
002140		10     X837D-SUBMITTER-ENTITY-QUAL
002150		PIC X(01).
002160		10     X837D-SUBMITTER-NAME-LAST
002170		PIC X(35).
002180		10     X837D-SUBMITTER-NAME-FIRST
002190		PIC X(25).
002200		10     X837D-SUBMITTER-NAME-MIDDLE
002210		PIC X(25).
002220		10     X837D-SUBMITTER-ID-CODE
002230		PIC X(80).
002240		10     FILLER
002250		PIC X(10).
002260
002270		05     X837D-SUBMITTER-CONTACT-SEG
002280		OCCURS 2 TIMES
002290		INDEXED BY X837D-SUBMITTER-CONTACT-NDX.
002300
002310		10     X837D-CONTACT-NAME
002320		PIC X(60).
002330		10     X837D-COMMUNICATION-INFO
002340		OCCURS 4 TIMES
002350		INDEXED BY X837D-COMMUNICATION-INFO-NDX.
002360		15     X837D-COMMUNICATION-QUAL
002370		PIC X(02).
002380		15     X837D-COMMUNICATION-NUMBER
002390		PIC X(80).
002400		10     FILLER
002410		PIC X(10).
002420
002430		05     X837D-RECEIVER-NAME-SEG.
002440
002450		10     X837D-RECEIVER-NAME-LAST
002460		PIC X(35).
002470		10     X837D-RECEIVER-ID-CODE
002480		PIC X(80).
002490		10     FILLER
002500		PIC X(10).
002510
002520
002530
002540

 

Page 98 of 326

---

002550		837D - DETAIL, BILLING/PAY-TO PROVIDER
002560
002570
002580		837D LOOP 2000A DETAIL, BILLING/PAY-TO PROVIDER
002590
002600		01     X837D-PROVIDER.
002610
002620		05     X837D-RECORD-CODE
002630		PIC X(02).
002640
002650		05     X837D-SORT-KEY.
002660
002670		10     X837D-PROV-SEQ-NUM
002680		VALUE ZEROES
002690		PIC 9(11).
002700
002710		10     X837D-SUBSCRIBER-SEQ-NUM
002720		VALUE ZEROES
002730		PIC 9(11).
002740
002750		10     X837D-PATIENT-SEQ
002760		VALUE ZEROES
002770		PIC 9(11).
002780
002790		10     X837D-CLAIM-SEQ
002800		VALUE ZEROES
002810		PIC 9(11).
002820
002830		10     X837D-SVC-LINE-SEQ
002840		VALUE ZEROES
002850		PIC 9(11).
002860
002870
002880		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
002890		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
002900
002910
002920		10     X837D-SUB-SEQ
002930		VALUE ZEROES
002940		PIC 9(11).
002950
002960		10     X837D-TX-CODE
002970		VALUE ‘01’
002980		PIC X(02).
002990
003000		10     X837D-TX-CODE-SEQ-NUM
003010		VALUE ZEROES
003020		PIC 9(07).
003030
003040		END OF HDR SORT-KEY
003050

 

Page 99 of 326

---

003060
003070
003080		LOOP-ID-2000A
003090
003100		05     X837D-PROV-HIERACHICAL-LVL-SEG.
003110
003120		10     X837D-PROV-HIER-NBR
003130		PIC X(12).
003140		10     X837D-PROV-HIER-LVL-CODE
003150		PIC X(02).
003160		10     X837D-PROV-HIER-CHILD-CODE
003170		PIC X(01).
003180		10     FILLER
003190		PIC X(10).
003200
003210		05     X837D-PROV-SPECIALTY-INFO-SEG.
003220
003230		10     X837D-PROV-TYPE-CODE
003240		PIC X(03).
003250		10     X837D-PROV-SPECIALTY-CODE
003260		PIC X(30).
003270		10     FILLER
003280		PIC X(10).
003290
003300		05     X837D-CURRENCY-INFO-SEG.
003310
003320		10     X837D-CURRENCY-CODE
003330		PIC X(03).
003340		10     FILLER
003350		PIC X(10).
003360
003370		LOOP-ID-2010AA
003380
003390		05     X837D-BILLING-PROV-NAME-SEG.
003400
003410		10     X83ZD-▇▇▇▇-PROV-TYPE-CODE
003420		PIC X(01).
003430		10     X83ZD-▇▇▇▇-PROV-NAME-LAST
003440		PIC X(35).
003450		10     X83ZD-▇▇▇▇-PROV-NAME-FIRST
003460		PIC X(25).
003470		10     X83ZD-▇▇▇▇-PROV-NAME-MIDDLE
003480		PIC X(25).
003490		10     X83ZD-▇▇▇▇-PROV-NAME-SFX
003500		PIC X(10).
003510		10     X83ZD-▇▇▇▇-PROV-ID-CODE-TYPE
003520		PIC X(02).
003530		10     X83ZD-▇▇▇▇-PROV-ID-CODE
003540		PIC X(80).
003550		10     FILLER
003560		PIC X(10).

 

Page 100 of 326

---

003570
003580		05     X837D-▇▇▇▇-PROV- ADDR-SEG.
003590
003600		10     X837D-▇▇▇▇-PROV-ADDR1
003610		PIC X(55).
003620		10     X837D-▇▇▇▇-PROV-ADDR2
003630		PIC X(55).
003640		10     FILLER
003650		PIC X(10).
003660
003670		05     X837D-▇▇▇▇-PROV- LOC-SEG.
003680
003690		10     X837D-▇▇▇▇-PROV- CITY
003700		PIC X(30).
003710		10     X837D-▇▇▇▇-PROV-STATE
003720		PIC X(02).
003730		10     X837D-▇▇▇▇-PROV-ZIP
003740		PIC X(15).
003750		10     X837D-▇▇▇▇-PROV-COUNTRY
003760		PIC X(03).
003770		10     FILLER
003780		PIC X(10).
003790
003800		05     X837D-▇▇▇▇-PROV-2ND-IDENT-SEG
003810		OCCURS 5 TIMES
003820		INDEXED BY X837D-▇▇▇▇-PROV-2ND-IDENT-NDX.
003830
003840		10     X837D-▇▇▇▇-PROV-2ND-ID-CODE
003850		PIC X(03).
003860		10     X837D-▇▇▇▇-PROV-2ND-ID
003870		PIC X(30).
003880		10     FILLER
003890		PIC X(10).
003900
003910		05     X837D-SUBMITTER-BANK-CARD-SEG
003920		OCCURS 8 TIMES
003930		INDEXED BY X837D-SUBMITTER-BANK-CARD-NDX.
003940
003950		10     X837D-SUBMITTER-CRDT-CRD-ID-TP
003960		PIC X(03).
003970		10     X837D-SUBMITTER-CRDT-CRD-ID
003980		PIC X(30).
003990		10     FILLER
004000		PIC X(10).
004010
004020		LOOP-ID-2010AB
004030
004040		05     X8 3ZD-PAYTO-PROV-NAME-SEG.
004050
004060		10     X8 3ZD-PAYTO-PROV-TYPE-CODE
004070		PIC X(01).

 

Page 101 of 326

---

004080		10     X83ZD-PAYTO-PROV-NAME-LAST
004090		PIC X(35).
004100		10     X83ZD-PAYTO-PROV-NAME-FIRST
004110		PIC X(25).
004120		10     X83ZD-PAYTO-PROV-NAME-MIDDLE
004130		PIC X(25).
004140		10     X83ZD-PAYTO-PROV-NAME-SFX
004150		PIC X(10).
004160		10     X83ZD-PAYTO-PROV-ID-CODE-TYPE
004170		PIC X(02).
004180		10     X83ZD-PAYTO-PROV-ID-CODE
004190		PIC X(80).
004200		10     FILLER
004210		PIC X(10).
004220
004230		05     X837D-PAYTO-PROV-ADDR-SEG.
004240
004250		10     X837D-PAYTO-PROV-ADDR1
004260		PIC X(55).
004270		10     X837D-PAYTO-PROV-ADDR2
004280		PIC X(55).
004290		10     FILLER
004300		PIC X(10).
004310
004320		05     X837D-PAYTO-PROV-LOC-SEG.
004330
004340		10     X837D-PAYTO-PROV-CITY
004350		PIC X(30).
004360		10     X837D-PAYTO-PROV-STATE
004370		PIC X(02).
004380		10     X837D-PAYTO-PROV-ZIP
004390		PIC X(15).
004400		10     X837D-PAYTO-PROV-COUNTRY
004410		PIC X(03).
004420		10     FILLER
004430		PIC X(10).
004440
004450		05     X837D-PAYTO-PROV-2ND-ID-SEG.
004460		OCCURS 5 TIMES
004470		INDEXED BY X837D-PAYTO-PROV-2ND-ID-NDX.
004480
004490		10     X837D-PAYTO-PROV-2ND-ID-CODE
004500		PIC X(03).
004510		10     X837D-PAYTO-PROV-2ND-ID
004520		PIC X(30).
004530		10     FILLER
004540		PIC X(10).
004550
004560
004570
004580		837D - SUBSCRIBER

 

Page 102 of 326

---

004590
004600
004610
004620		837D DETAIL, SUBSCRIBER HIERARCHAL LEVEL
004630
004640		01     X837D-SUBSCRIBER.
004650
004660		05     X837D-RECORD-CODE
004670		PIC X(02).
004680
004690		05     X837D-SORT-KEY.
004700
004710		10     X837D-PROV-SEQ-NUM
004720		VALUE ZEROES
004730		PIC 9(11).
004740
004750		10     X837D-SUBSCRIBER-SEQ-NUM
004760		VALUE ZEROES
004770		PIC 9(11).
004780
004790		10     X837D-PATIENT-SEQ
004800		VALUE ZEROES
004810		PIC 9(11).
004820
004830		10     X837D-CLAIM-SEQ
004840		VALUE ZEROES
004850		PIC 9(11).
004860
004870		10     X837D-SVC-LINE-SEQ
004880		VALUE ZEROES
004890		PIC 9(11).
004900
004910
004920		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
004930		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
004940
004950
004960		10     X837D-SUB-SEQ
004970		VALUE ZEROES
004980		PIC 9(11).
004990
005000		10     X837D-TX-CODE
005010		VALUE ‘02’
005020		PIC X(02).
005030
005040		10     X837D-TX-CODE-SEQ-NUM
005050		VALUE ZEROES
005060		PIC 9(07).
005070
005080		END OF HDR SORT-KEY
005090

 

Page 103 of 326

---

005110
005120		LOOP-ID-2000B
005130
005140		05     X837D-SUBS-HIERACHICAL-LVL-SEG.
005150
005160		10     X837D-SUBS-HIER-NBR
005170		PIC X(12).
005180		10     X837D-SUBS-HIER-PARENT-NBR
005190		PIC X(12).
005200		10     X837D-SUBS-HIER-LVL-CODE
005210		PIC X(02).
005220		10     X837D-SUBS-HIER-CHILD-CODE
005230		PIC X(01).
005240		10     FILLER
005250		PIC X(10).
005260
005270		05     X837D-SUBSCRIBER-INFO-SEG.
005280
005290		10     X837D-SUBS-PYR-RESPONS-SEQ-CD
005300		PIC X(01).
005310		10     X837D-SUBS-RELATIONSHIP-CODE
005320		PIC X(02).
005330		10     X837D-SUBS-POLICY-NBR
005340		PIC X(30).
005350		10     X837D-SUBS-PLAN-NAME
005360		PIC X(60).
005370		10     X837D-SUBS-COB-CODE
005380		PIC X(01).
005390		10     X837D-SUBS-CLAIM-FILING-IND-CD
005400		PIC X(02).
005410		10     FILLER
005420		PIC X(10).
005430
005440		LOOP-ID-2010BA
005450
005460		05     X837D-SUBS-NAME-SEG.
005470
005480		10     X837D-SUBS-TYPE-CODE
005490		PIC X(01).
005500		10     X837D-SUBS-NAME-LAST
005510		PIC X(35).
005520		10     X837D-SUBS-NAME-FIRST
005530		PIC X(25).
005540		10     X837D-SUBS-NAME-MIDDLE
005550		PIC X(25).
005560		10     X837D-SUBS-NAME-SFX
005570		PIC X(10).
005580		10     X837D-SUBS-ID-CODE-TYPE
005590		PIC X(02).
005600		10     X837D-SUBS-ID-CODE

 

Page 104 of 326

---

005610		PIC X(80).
005620		10     FILLER
005630		PIC X(10).
005640
005650		05     X837D-SUBS-ADDR-SEG.
005660
005670		10     X837D-SUBS-ADDR1
005680		PIC X(55).
005690		10     X837D-SUBS-ADDR2
005700		PIC X(55).
005710		10     FILLER
005720		PIC X(10).
005730
005740		05     X837D-SUBS-CITY-STATE-SEG.
005750
005760		10     X837D-SUBS-CITY
005770		PIC X(30).
005780		10     X837D-SUBS-STATE-CODE
005790		PIC X(02).
005800		10     X837D-SUBS-ZIP-CODE
005810		PIC X(15).
005820		10     X837D-SUBS-COUNTRY-CODE
005830		PIC X(03).
005840		10     FILLER
005850		PIC X(10).
005860
005870		05     X837D-SUBS-DEMOGRAPHIC-SEG.
005880
005890		10     X837D-SUBS-DOB
005900		PIC X (08).
005910		10     X837D-SUBS-GENDER-CODE
005920		PIC X(01).
005930		10     FILLER
005940		PIC X(10).
005950
005960		05     X837D-SUBS-2ND-ID-SEG
005970		OCCURS 4 TIMES
005980		INDEXED BY X837D-SUBS-2ND-ID-NDX.
005990
006000		10     X837D-SUBS-2ND-ID-TYPE
006010		PIC X(03).
006020		10     X837D-SUBS-2ND-ID
006030		PIC X(30).
006040		10     FILLER
006050		PIC X(10).
006060
006070		05     X837D-SUBS-PROP-CLAIM-NBR-SEG.
006080
006090		10     X837D-SUBS-PROP-CLAIM-NBR
006100		PIC X(30).
006110		10     FILLER

 

Page 105 of 326

---

006120		PIC X(10).
006130
006140		LOOP-ID-2010BB
006150
006160		05     X837D-PAYER-NAME-SEG.
006170
006180		10     X837D-PAYER-NAME
006190		PIC X(35).
006200		10     X837D-PAYER-ID-CODE-TYPE
006210		PIC X(02).
006220		10     X837D-PAYER-ID-CODE
006230		PIC X(80).
006240		10     FILLER
006250		PIC X(10).
006260
006270		05     X837D-PAYER-ADDR-SEG.
006280
006290		10     X837D-PAYER-ADDR1
006300		PIC X(55).
006310		10     X837D-PAYER-ADDR2
006320		PIC X(55).
006330		10     FILLER
006340		PIC X(10).
006350
006360		05     X837D-PAYER-CITY-STATE-SEG.
006370
006380		10     X837D-PAYER-CITY
006390		PIC X(30).
006400		10     X837D-PAYER-STATE-CODE
006410		PIC X(02).
006420		10     X837D-PAYER-ZIP-CODE
006430		PIC X(15).
006440		10     X837D-PAYER-COUNTRY-CODE
006450		PIC X(03).
006460		10     FILLER
006470		PIC X(10).
006480
006490		05     X837D-PAYER-2ND-ID-SEG
006500		OCCURS 3 TIMES
006510		INDEXED BY X837D-PAYER-2ND-ID-NDX.
006520
006530		10     X837D-PAYER-2ND-ID-TYPE
006540		PIC X(03).
006550		10     X837D-PAYER-2ND-ID
006560		PIC X(30).
006570		10     FILLER
006580		PIC X(10).
006590
006600		LOOP-ID-2010BC
006610
006620		05     X837D-SUBS-CARD-NAME-SEG.

 

Page 106 of 326

---

006630
006640		10     X837D-SUBS-CARD-TYPE-CODE
006650		PIC X(01).
006660		10     X837D-SUBS-CARD-NAME-LAST
006670		PIC X(35).
006680		10     X837D-SUBS-CARD-NAME-FIRST
006690		PIC X(25).
006700		10     X837D-SUBS-CARD-NAME-MIDDLE
006710		PIC X(25).
006720		10     X837D-SUBS-CARD-NAME-SFX
006730		PIC X(10).
006740		10     X837D-SUBS-CARD-ID-CODE-TYPE
006750		PIC X(02).
006760		10     X837D-SUBS-CARD-ID-CODE
006770		PIC X(80).
006780		10     FILLER
006790		PIC X(10).
006800
006810		05     X837D-SUBS-BANK-CARD-SEG
006820		OCCURS 3 TIMES
006830		INDEXED BY X837D-SUBS-BANK-CARD-NDX.
006840
006850		10     X837D-SUBS-CRDT-CARD-AUTH-NBR
006860		PIC X(30).
006870		10     FILLER
006880		PIC X(10).
006890
006900
006910
006920
006930		837S - PATIENT
006940
006950
006960
006970		837S DETAIL, PATIENT HIERARCHAL LEVEL
006980
006990		01     X837D-PATIENT.
007000
007010		05     X837D-RECORD-CODE
007020		PIC X(02).
007030
007040		05     X837D-SORT-KEY.
007050
007060		10     X837D-PROV-SEQ-NUM
007070		VALUE ZEROES
007080		PIC 9(11).
007090
007100		10     X837D-SUBSCRIBER-SEQ-NUM
007110		VALUE ZEROES
007120		PIC 9(11).
007130

 

Page 107 of 326

---

007140		10     X837D-PATIENT-SEQ
007150		VALUE ZEROES
007160		PIC 9(11).
007170
007180		10     X837D-CLAIM-SEQ
007190		VALUE ZEROES
007200		PIC 9(11).
007210
007220		10     X837D-SVC-LINE-SEQ
007230		VALUE ZEROES
007240		PIC 9(11).
007250
007260
007270		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
007280		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORD.
007290
007300
007310		10     X837D-SUB-SEQ
007320		VALUE ZEROES
007330		PIC 9(11).
007340
007350		10     X837D-TX-CODE
007360		VALUE ‘03’
007370		PIC X(02).
007380
007390		10     X837D-TX-CODE-SEQ-NUM
007400		VALUE ZEROES
007410		PIC 9(07).
007420
007430		END OF HDR SORT-KEY
007440
007450
007460
007470		LOOP-ID-2000C
007480
007490		05     X837D-▇▇▇-HIERACHICAL-LVL-SEG.
007500
007510		10     X837D-▇▇▇-HIER-NBR
007520		PIC X(12).
007530		10     X837D-▇▇▇-HIER-PARENT-NBR
007540		PIC X(12).
007550		10     X837D-▇▇▇-HIER-LVL-CODE
007560		PIC X(02).
007570		10     X837D-▇▇▇-HIER-CHILD-CODE
007580		PIC X(01).
007590		10     FILLER
007600		PIC X(10).
007610
007620		05     X837D-PATIENT-INFO-SEG.
007630
007640		10     X837D-▇▇▇-RELATIONSHIP-CODE

 

Page 108 of 326

---

007650		PIC X(02).
007660		10     X837D-▇▇▇-STUDENT-STATUS-CD
007670		PIC X(01).
007680		10     FILLER
007690		PIC X(10).
007700
007710		LOOP-ID-2010CA
007720
007730		05     X837D-▇▇▇-NAME-SEG.
007740
007750		10     X837D-▇▇▇-TYPE-CODE
007760		PIC X(01).
007770		10     X837D-▇▇▇-NAME-LAST
007780		PIC X(35).
007790		10     X837D-▇▇▇-NAME-FIRST
007800		PIC X(25).
007810		10     X837D-▇▇▇-NAME-MIDDLE
007820		PIC X(25).
007830		10     X837D-▇▇▇-NAME-SFX
007840		PIC X(10).
007850		10     X837D-▇▇▇-ID-CODE-TYPE
007860		PIC X(02).
007870		10     X837D-▇▇▇-ID-CODE
007880		PIC X(80).
007890		10     FILLER
007900		PIC X(10).
007910
007920		05     X837D-▇▇▇-ADDR-SEG.
007930
007940		10     X837D-▇▇▇-ADDR1
007950		PIC X(55).
007960		10     X837D-▇▇▇-ADDR2
007970		PIC X(55).
007980		10     FILLER
007990		PIC X(10).
008000
008010		05     X837D-▇▇▇-CITY-STATE-SEG.
008020
008030		10     X837D-▇▇▇-CITY
008040		PIC X(30).
008050		10     X837D-▇▇▇-STATE-CODE
008060		PIC X(02).
008070		10     X837D-▇▇▇-ZIP-CODE
008080		PIC X(15).
008090		10     X837D-▇▇▇-COUNTRY-CODE
008100		PIC X(03).
008110		10     FILLER
008120		PIC X(10).
008130
008140		05     X837D-▇▇▇-DEMOGRAPHIC-SEG.
008150

 

Page 109 of 326

---

008160		10     X837D-▇▇▇-DOB
008170		PIC X(08).
008180		10     X837D-▇▇▇-GENDER-CODE
008190		PIC X(01).
008200		10     FILLER
008210		PIC X(10).
008220
008230		05     X837D-▇▇▇-2ND-ID-SEG
008240		OCCURS 5 TIMES
008250		INDEXED BY X837D-▇▇▇-2ND-ID-NDX.
008260
008270		10     X837D-▇▇▇-2ND-ID-TYPE
008280		PIC X(03).
008290		10     X837D-▇▇▇-2ND-ID
008300		PIC X(30).
008310		10     FILLER
008320		PIC X(10).
008330
008340		05     X837D-▇▇▇-PROP-CLAIM-NBR-SEG.
008350		10     X837D-▇▇▇-PROP-CLAIM-NBR
008360		PIC X(30).
008370		10     FILLER
008380		PIC X(10).
008390
008400
008410
008420		837D - CLAIM-INFO
008430
008440
008450
008460		837D CLAIM INFORMATION
008470
008480		01     X837D-CLAIM-INFO.
008490
008500		05     X837D-RECORD-CODE
008510		PIC X(02).
008520
008530		05     X837D-SORT-KEY.
008540
008550		10     X837D-PROV-SEQ-NUM
008560		VALUE ZEROES
008570		PIC 9(11).
008580
008590		10     X837D-SUBSCRIBER-SEQ-NUM
008600		VALUE ZEROES
008610		PIC 9(11).
008620
008630		10     X837D-PATIENT-SEQ
008640		VALUE ZEROES
008650		PIC 9(11).
008660

 

Page 110 of 326

---

008670		10     X837D-CLAIM-SEQ
008680		VALUE ZEROES
008690		PIC 9(11).
008700
008710		10     X837D-SVC-LINE-SEQ
008720		VALUE ZEROES
008730		PIC 9(11).
008740
008750
008760		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
008770		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
008780
008790
008800		10     X837D-SUB-SEQ
008810		VALUE ZEROES
008820		PIC 9(11).
008830
008840		10     X837D-TX-CODE
008850		VALUE ‘04’
008860		PIC X(02).
008870
008880		10     X837D-TX-CODE-SEQ-NUM
008890		VALUE ZEROES
008900		PIC 9(07).
008910
008920		END OF HDR SORT-KEY
008930
008940
008950
008960		LOOP-ID-2300
008970
008980		05     X837D-CLM-INFO-SEG.
008990
009000		10     X837D-CLM-PATIENT-CTL-NUM
009010		PIC X(38).
009020		10     X837D-CLM-TOT-CHARGE-AMOUNT
009030		PIC S9(11)V99.
009040		10     X837D-CLM-PLACE-OF-SVC-CODE
009050		PIC X(02).
009060		10     X837D-CLM-FREQ-TYPE-CODE
009070		PIC X(01).
009080		10     X837D-CLM-PROV-SIG-ON-FILE
009090		PIC X(01).
009100		10     X837D-CLM-MCARE-ASSIGNMENT-IND
009110		PIC X(01).
009120		10     X837D-CLM-ASSIGN-BENE-IND
009130		PIC X(01).
009140		10     X837D-CLM-RELEASE-OF-INFO-IND
009150		PIC X(01).
009160		10     X837D-CLM-RELATED-CAUSE-CD-1
009170		PIC X(03).

 

Page 111 of 326

---

009180		10     X837D-CLM-RELATED-CAUSE-CD-2
009190		PIC X(03).
009200		10     X837D-CLM-RELATED-CAUSE-CD-3
009210		PIC X(03).
009220		10     X837D-CLM-ACCIDENT-STATE
009230		PIC X(02).
009240		10     X837D-CLM-COUNTRY-CODE
009250		PIC X(03).
009260		10     X837D-CLM-SPECIAL-PROG-IND
009270		PIC X(03).
009280		10     X837D-CLM-SUBMISSION-REAS
009290		PIC X(02).
009300		10     X837D-CLM-▇▇▇▇▇-▇▇▇▇-CODE
009310		PIC X(03).
009320		10     FILLER
009330		PIC X(10).
009340
009350		05     X837D-CLM-ADMISSION-DATE-SEG.
009360
009370		10     X837D-CLM-ADMISSION-DATE
009380		PIC X(08).
009390		10     FILLER
009400		PIC X(10).
009410
009420		05     X837D-CLM-DISCHARGE-DATE-SEG.
009430
009440		10     X837D-CLM-DISCHARGE-DATE
009450		PIC X(08).
009460		10     FILLER
009470		PIC X(10).
009480
009490		05     X837D-CLM-REFERRAL-DATE-SEG.
009500
009510		10     X837D-CLM-REFERRAL-DATE
009520		PIC X(08).
009530		10     FILLER
009540		PIC X(10).
009550
009560		05     X837D-CLM-ACCIDENT-DATE-SEG.
009570		10     X837D-CLM-ACCIDENT-DATE
009580		PIC X(08).
009590		10     FILLER
009600		PIC X(10).
009610
009620		05     X837D-CLM-APPL-PLACE-DT-SEG
009630		OCCURS 5 TIMES
009640		INDEXED BY X837D-CLM-APPL-PLACET-DT-NDX.
009650
009660		10     X837D-CLM-APPL-PLACE-DT
009670		PIC X(08).
009680		10     FILLER

 

Page 112 of 326

---

009690		PIC X(10).
009700
009710		05     X837D-CLM-SERVICE-DATE-SEG.
009720
009730		10     X837D-CLM-SERVICE-DATE
009740		PIC X(08).
009750		10     FILLER
009760		PIC X(10).
009770
009780		05     X837D-CLM-ORTHO-MM-TREAT-SEG.
009790
009800		10     X837D-CLM-ORTHO-MONTHS-REMAIN
009810		PIC S9(7)V99.
009820		10     X837D-CLM-XTR-ORAL-TRAC-DEVICE
009830		PIC X(01).
009840		10     FILLER
009850		PIC X(10).
009860
009870		05     X837D-CLM-TOOTH-STATUS
009880		OCCURS 35 TIMES
009890		INDEXED BY X837D-CLM-TOOTH-STATUS-NDX.
009900
009910		10     X837D-CLM-TOOTH-NBR
009920		PIC X(30).
009930		10     X837D-CLM-TOOTH-STATUS-CD
009940		PIC X(02).
009950
009960		05     X837D-CLM-SUPPLMENT-INFO-SEG
009970		OCCURS 10 TIMES
009980		INDEXED BY X837D-CLM-SUPPLMENT-INFO-NDX.
009990
010000		10     X837D-CLM-ATTACHMENT-TYPE
010010		PIC X(02).
010020		10     X837D-CLM-ATTCH-TRANSMIT-CODE
010030		PIC X(02).
010040		10     X837D-CLM-ATTACHMENT-CNTL-NBR
010050		PIC X(80).
010060		10     FILLER
010070		PIC X(10).
010080
010090		05     X837D-CLM-▇▇▇-PAID-AMT-SEG.
010100
010110		10     X837D-CLM-▇▇▇-PAID-AMT
010120		PIC S9(11)V99.
010130		10     FILLER
010140		PIC X(10).
010150
010160		05     X837D-CLM-CARD-MAX-AMT-SEG.
010170
010180		10     X837D-CLM-CARD-MAX-AMT
010190		PIC S9(11)V99.

 

Page 113 of 326

---

010200		10     FILLER
010210		PIC X(10).
010220
010230		05     X837D-CLM-PREDETERMINE-ID-SEG
010240		OCCURS 5 TIMES
010250		INDEXED BY X837D-CLM-PREDETERMINE-ID-NDX.
010260
010270		10     X837D-CLM-PREDETERM-BENE-IND
010280		PIC X(30).
010290		10     FILLER
010300		PIC X(10).
010310
010320		05     X837D-CLM-SVC-AUTH-EXCEP-SEG.
010330		10     X837D-CLM-SVC-AUTH-EXCEP-CD
010340		PIC X(30).
010350		10     FILLER
010360		PIC X(10).
010370
010380		05     X837D-CLM-ORIG-REF-NBR-SEG.
010390		10     X837D-CLM-ORIG-REF-NBR
010400		PIC X(30).
010410		10     FILLER
010420		PIC X(10).
010430
010440		05     X837D-CLM-PA-REF-NBR-SEG
010450		OCCURS 2 TIMES
010460		INDEXED BY X837D-CLM-PA-REF-NBR-NDX.
010470
010480		10     X837D-CLM-PA-REF-QUAL
010490		PIC X(03).
010500		10     X837D-CLM-PA-REF-NBR
010510		PIC X(30).
010520		10     FILLER
010530		PIC X(10).
010540
010550		05     X837D-CLM-CLRHSE-TRACE-SEG.
010560		10     X837D-CLM-CLRHSE-TRACE-NBR.
010570		PIC X(30).
010580		10     FILLER
010590		PIC X(10).
010600
010610		05     X837D-CLM-NOTE-SEG
010620		OCCURS 20 TIMES
010630		INDEXED BY X837D-CLM-NOTE-NDX.
010640
010650		10     X837D-CLM-NOTE-REF-CODE
010660		PIC X(03).
010670		10     X837D-CLM-NOTE-TEXT
010680		PIC X(80).
010690		10     FILLER
010700		PIC X(10).

 

Page 114 of 326

---

010710
010720		LOOP-ID-2310A
010730
010740		05     X837D-CLM-REF-PROV-NAME-LOOP
010750		OCCURS 2 TIMES
010760		INDEXED BY X837D-CLM-REF-PROV-NAME-NDX.
010770
010780		10     X837D-CLM-REF-PROV-NAME-SEG.
010790
010800		15     X837D-CLM-REF-PROV-ENTITY-CD
010810		PIC X(03).
010820		15     X837D-CLM-REF-PROV-NME-QUAL
010830		PIC X(01).
010840		15     X837D-CLM-REF-PROV-NM-LAST
010850		PIC X(35).
010860		15     X837D-CLM-REF-PROV-NM-FIRST
010870		PIC X(25).
010880		15     X837D-CLM-REF-PROV-NM-MIDDLE
010890		PIC X(25).
010900		15     X837D-CLM-REF-PROV-NM-SFX
010910		PIC X(10).
010920		15     X837D-CLM-REF-PROV-ID-QUAL
010930		PIC X(02).
010940		15     X837D-CLM-REF-PROV-ID-NBR
010950		PIC X(80).
010960		15     FILLER
010970		PIC X(10).
010980
010990		10     X837D-CLM-REF-PROV-SPEC-SEG.
011000
011010		15     X837D-CLM-REF-PROV-SPEC-CODE
011020		PIC X(30).
011030		15     FILLER
011040		PIC X(10).
011050
011060		10     X837D-CLM-REF-PROV-2ND-ID-SEG
011070		OCCURS 5 TIMES
011080		INDEXED BY X837D-CLM-REF-PROV-2ND-ID-NDX.
011090
011100		15     X837D-CLM-REF-PROV-2ND-ID-CODE
011110		PIC X(03).
011120		15     X837D-CLM-REF-PROV-2ND-ID
011130		PIC X(30).
011140		15     FILLER
011150		PIC X(10).
011160
011170		LOOP-ID-2310B
011180
011190		05     X837D-CLM-REND-PROV-NAME-SEG.
011200
011210		10     X837D-CLM-REND-PROV-ENTITY-CD

 

Page 115 of 326

---

011220		PIC X(03).
011230		10     X837D-CLM-REND-PROV-NME-QUAL
011240		PIC X(01).
011250		10     X837D-CLM-REND-PROV-NM-LAST
011260		PIC X(35).
011270		10     X837D-CLM-REND-PROV-NM-FIRST
011280		PIC X(25).
011290		10     X837D-CLM-REND-PROV-NM-MIDDLE
011300		PIC X(25).
011310		10     X837D-CLM-REND-PROV-NM-SFX
011320		PIC X(10).
011330		10     X837D-CLM-REND-PROV-ID-QUAL
011340		PIC X(02).
011350		10     X837D-CLM-REND-PROV-ID-NBR
011360		PIC X(80).
011370		10     FILLER
011380		PIC X(10).
011390
011400		05     X837D-CLM-REND-PROV-SPEC-SEG.
011410
011420		10     X837D-CLM-REND-PROV-SPEC-CODE
011430		PIC X(30).
011440		10     FILLER
011450		PIC X(10).
011460
011470		05     X837D-CLM-REND-PROV-2ND-ID-SEG
011480		OCCURS 5 TIMES
011490		INDEXED BY X837D-CLM-REND-PROV-2ND-ID-NDX.
011500
011510		10     X837D-CLM-REND-PROV-2ND-ID-CD
011520		PIC X(03).
011530		10     X837D-CLM-REND-PROV-2ND-ID
011540		PIC X(30).
011550		10     FILLER
011560		PIC X(10).
011570
011580		LOOP-ID-2310C
011590
011600		05     X837D-CLM-SVC-FAC-LOC-SEG.
011610
011620		10     X837D-CLM-SVC-FAC-NAME
011630		PIC X(35).
011640		10     X837D-CLM-SVC-FAC-ID-QUAL
011650		PIC X(02).
011660		10     X837D-CLM-SVC-FAC-ID
011670		PIC X(80).
011680		10     FILLER
011690		PIC X(10).
011700
011710		05     X837D-CLM-SVC-FAC-2ND-ID-SEG
011720		OCCURS 5 TIMES

 

Page 116 of 326

---

011730		INDEXED BY X837D-CLM-SVC-FAC-2ND-ID-NDX.
011740
011750		10     X837D-CLM-SVC-FAC-2ND-ID-TYPE
011760		PIC X(03).
011770		10     X837D-CLM-SVC-FAC-2ND-ID
011780		PIC X(30).
011790		10     FILLER
011800		PIC X(10).
011810
011820		LOOP-ID-2310D
011830
011840		05     X837D-CLM-AST-SURG-NAME-SEG.
011850
011860		10     X837D-CLM-AST-SURG-ENTITY-CD
011870		PIC X(03).
011880		10     X837D-CLM-AST-SURG-NME-QUAL
011890		PIC X(01).
011900		10     X837D-CLM-AST-SURG-NM-LAST
011910		PIC X(35).
011920		10     X837D-CLM-AST-SURG-NM-FIRST
011930		PIC X(25).
011940		10     X837D-CLM-AST-SURG-NM-MIDDLE
011950		PIC X(25).
011960		10     X837D-CLM-AST-SURG-NM-SFX
011970		PIC X(10).
011980		10     X837D-CLM-AST-SURG-ID-QUAL
011990		PIC X(02).
012000		10     X837D-CLM-AST-SURG-ID-NBR
012010		PIC X(80).
012020		10     FILLER
012030		PIC X(10).
012040
012050		05     X837D-CLM-AST-SURG-SPEC-SEG.
012060
012070		10     X837D-CLM-AST-SURG-SPEC-CODE
012080		PIC X(30).
012090		10     FILLER
012100		PIC X(10).
012110
012120		05     X837D-CLM-AST-SURG-2ND-ID-SEG.
012130
012140		10     X837D-CLM-AST-SURG-2ND-ID-CODE
012150		PIC X(03).
012160		10     X837D-CLM-AST-SURG-2ND-ID
012170		PIC X(30).
012180		10     FILLER
012190		PIC X(10).
012200
012210
012220
012230

 

Page 117 of 326

---

012240
012250		837D - OTHER SUBSCRIBER INFORMATION
012260
012270
012280
012290		837D OTHER SUBSCRIBER INFORMATION
012300
012310		01     X837D-OTHER-SUBSCRIBER-INFO.
012320
012330		05     X837D-RECORD-CODE
012340		PIC X(02).
012350
012360		05     X837D-SORT-KEY.
012370
012380		10     X837D-PROV-SEQ-NUM
012390		VALUE ZEROES
012400		PIC 9(11).
012410
012420		10     X837D-SUBSCRIBER-SEQ-NUM
012430		VALUE ZEROES
012440		PIC 9(11).
012450
012460		10     X837D-PATIENT-SEQ
012470		VALUE ZEROES
012480		PIC 9(11).
012490
012500		10     X837D-CLAIM-SEQ
012510		VALUE ZEROES
012520		PIC 9(11).
012530
012540		10     X837D-SVC-LINE-SEQ
012550		VALUE ZEROES
012560		PIC 9(11).
012570
012580
012590		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
012600		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
012610
012620
012630		10     X837D-SUB-SEQ
012640		VALUE ZEROES
012650		PIC 9(11).
012660
012670		10     X837D-TX-CODE
012680		VALUE ‘05’
012690		PIC X(02).
012700
012710		10     X837D-TX-CODE-SEQ-NUM
012720		VALUE ZEROES
012730		PIC 9(07).
012740

 

Page 118 of 326

---

012750		END OF HDR SORT-KEY
012760
012770
012780
012790		LOOP-2320 OTHER SUBSCRIBER INFORMATION-START
012800
012810		05     X837D-OTHR-SUBS-INFO-SEG.
012820
012830		10     X837D-PAYER-RESPONS-CODE
012840		PIC 9(01).
012850		10     X837D-INDIVIDUAL-RELAT-CODE
012860		PIC 9(02).
012870		10     X837D-OTHR-SUBS-POLICY-NBR
012880		PIC X(30).
012890		10     X837D-OTHR-SUBS-PLAN-NAME
012900		PIC X(60).
012910		10     X837D-OTHR-SUBS-FILING-IND-CD
012920		PIC 9(02).
012930		10     FILLER
012940		PIC X(10).
012950
012960		CLAIM LEVEL ADJUSTMENTS ON SEPARATE RECORD
012970
012980		05     X837D-COB-PAYER-PAID-SEG.
012990
013000		10     X837D-COB-PAYER-PAID-AMT
013010		PIC S9(11)V99.
013020		10     FILLER
013030		PIC X(10).
013040
013050		05     X837D-COB-APPROVED-SEG.
013060
013070		10     X837D-COB-APPROVED-AMT
013080		PIC S9(11)V99.
013090		10     FILLER
013100		PIC X(10).
013110
013120		05     X837D-COB-ALLOWED-SEG.
013130
013140		10     X837D-COB-ALLOWED-AMT
013150		PIC S9(11)V99.
013160		10     FILLER
013170		PIC X(10).
013180
013190		05     X837D-COB-▇▇▇-RESPON-SEG.
013200
013210		10     X837D-COB-▇▇▇-RESPON-AMT
013220		PIC S9(11)V99.
013230		10     FILLER
013240		PIC X(10).
013250

 

Page 119 of 326

---

013260		05     X837D-COB-COVERED-SEG.
013270
013280		10     X837D-COB-COVERED-AMT
013290		PIC S9(11)V99.
013300		10     FILLER
013310		PIC X(10).
013320		‘
013330		05     X837D-COB-DISCOUNT-SEG
013340
013350		10     X837D-COB-DISCOUNT-AMT
013360		PIC S9(11)V99.
013370		10     FILLER
013380		PIC X(10).
013390
013400		05     X837D-COB-PATIENT-PAID-SEG.
013410
013420		10     X837D-COB-PATIENT-PAID-AMT
013430		PIC S9(11)V99.
013440
013450		10     FILLER
013460		PIC X(10).
013470
013480		05     X837D-OTHR-SUBS-DEMO-SEG.
013490
013500		10     X837D-OTH-SUBS-OTHR-INSRD-DOB
013510		PIC X(08).
013520		10     X837D-OTH-SUBS-OTHR-GENDER-CD
013530		PIC X(01).
013540		10     FILLER
013550		PIC X(10).
013560
013570		05     X837D-OTHR-INS-COVRG-INFO-SEG.
013580
013590		10     X837D-ASSIGNMENT-OF-BENE-IND
013600		PIC X(01).
013610		10     X837D-RELEASE-INFO-CODE
013620		PIC X(01).
013630		10     FILLER
013640		PIC X(10).
013650
013660
013670		LOOP-2330A OTHR SUBSCRIBER NAME
013680
013690		05     X837D-OTHR-SUBS-NAME-SEG.
013700
013710		10     X837D-OTHR-SUBS-TYPE-CODE
013720		PIC X(01).
013730		10     X837D-OTHR-SUBS-NAME-LAST
013740		PIC X(35).
013750		10     X837D-OTHR-SUBS-NAME-FIRST
013760		PIC X(25).

 

Page 120 of 326

---

013770		10     X837D-OTHR-SUBS-NAME-MIDDLE
013780		PIC X(25).
013790		10     X837D-OTHR-SUBS-NAME-SFX
013800		PIC X(10).
013810		10     X837D-OTHR-SUBS-ID-CODE-TYPE
013820		PIC X(02).
013830		10     X837D-OTHR-SUBS-ID-CODE
013840		PIC X (80).
013850		10     FILLER
013860		PIC X(10).
013870
013880		05     X837D-OTHR-SUBS-ADDR-SEG.
013890
013900		10     X837D-OTHR-SUBS-ADDR1
013910		PIC X(55).
013920		10     X837D-OTHR-SUBS-ADDR2
013930		PIC X(55).
013940		10     FILLER
013950		PIC X(10).
013960
013970		05     X837D-OTHR-SUBS-CITY-STATE-SEG.
013980
013990		10     X837D-OTHR-SUBS-CITY
014000		PIC X(30).
014010		10     X837D-OTHR-SUBS-STATE-CODE
014020		PIC X(02).
014030		10     X837D-OTHR-SUBS-ZIP-CODE
014040		PIC X(15).
014050		10     X837D-OTHR-SUBS-COUNTRY-CODE
014060		PIC X(03).
014070		10     FILLER
014080		PIC X(10).
014090
014100		05     X837D-OTHR-SUBS-2ND-ID-SEG
014110		OCCURS 3 TIMES
014120		INDEXED BY X837D-OTHR-SUBS-2ND-ID-NDX.
014130
014140		10     X837D-OTHR-SUBS-2ND-ID-TYPE
014150		PIC X(03).
014160		10     X837D-OTHR-SUBS-2ND-ID
014170		PIC X(30).
014180		10     FILLER
014190		PIC X(10).
014200
014210		LOOP-2330B OTHR PAYER NAME
014220
014230		05     X837D-OTHR-PAYER-NAME-SEG.
014240
014250		10     X837D-OTHR-PAYER-NAME
014260		PIC X(35).
014270		10     X837D-OTHR-PAYER-ID-CODE-TYPE

 

Page 121 of 326

---

014280		PIC X(02).
014290		10     X837D-OTHR-PAYER-ID-CODE
014300		PIC X(80).
014310		10     FILLER
014320		PIC X(10).
014330
014340		05     X837D-OTHR-PYR-CONTACT-SEG
014350		OCCURS 2 TIMES
014360		INDEXED BY X837D-OTHR-PYR-CONTACT-NDX.
014370
014380		10     X837D-OTHR-PYR-CONTACT-NAME
014390		PIC X(60).
014400		10     X837D-OTHR-PYR-COMM-INFO
014410		OCCURS 3 TIMES
014420		INDEXED BY X837D-OTHR-PYR-COMM-INFO-NDX.
014430		15     X837D-OTHR-PYR-COMM-QUAL
014440		PIC X(02).
014450		15     X837D-OTHR-PYR-COMM-NUMBER
014460		PIC X(80).
014470		10     FILLER
014480		PIC X(10).
014490
014500		05     X837D-CLAIM-PAID-DATE-SEG.
014510
014520		10     X837D-CLAIM-PAID-DATE
014530		PIC X(08).
014540
014550		05     X837D-OTHR-PAYER-2ND-IDENT-SEG
014560		OCCURS 3 TIMES
014570		INDEXED BY X837D-OTHR-PAYER-2ND-IDENT-NDX.
014580
014590		10     X837D-OTHR-PAYER-2ND-ID-TYPE
014600		PIC X(03).
014610		10     X837D-OTHR-PAYER-2ND-ID
014620		PIC X(30).
014630		10     FILLER
014640		PIC X(10).
014650
014660		05     X837D-OTHR-PAYER-PA-REF-SEG.
014670
014680		10     X837D-OTHR-PAYER-PA-REF-IND
014690		PIC X(03).
014700		10     X837D-OTHR-PAYER-PA-REF-NUMBER
014710		PIC X(30).
014720		10     FILLER
014730		PIC X(10).
014740
014750		05     X837D-OTHR-PYR-CLM-ADJ-IND-SEG.
014760
014770		10     X837D-OTHR-PAYER-ADJ-QUAL
014780		PIC X(03).

 

Page 122 of 326

---

014790		10     X837D-OTHR-PAYER-ADJ-IND
014800		PIC X(30).
014810		10     FILLER
014820		PIC X(10).
014830
014840		LOOP-2330C OTHR PAYER PATIENT
014850
014860		05     X837D-OTHR-PYR-▇▇▇-INFO-SEG.
014870
014880		10     X837D-OTHR-PYR-▇▇▇-NAME
014890		PIC X(35).
014900		10     X837D-OTHR-PYR-▇▇▇-PRIME-QUAL
014910		PIC X(02).
014920		10     X837D-OTHR-PYR-▇▇▇-PRIME-ID
014930		PIC X(30).
014940		10     FILLER
014950		PIC X(10).
014960
014970		05     X837D-OTHR-PAYER-▇▇▇-ID-SEG
014980		OCCURS 3 TIMES
014990		INDEXED BY X837D-OTHR-PAYER-▇▇▇-ID-NDX.
015000
015010		10     X837D-OTHR-PAYER-▇▇▇-ID-QUAL
015020		PIC X(03).
015030		10     X837D-OTHR-PAYER-▇▇▇-ID-NBR
015040		PIC X(30).
015050		10     FILLER
015060		PIC X(10).
015070
015080		LOOP-2330D OTHR PAYER REFERRING PROVIDER
015090
015100		05     X837D-OTHR-PYR-REF-PROV-SEG.
015110
015120		10     X837D-OTHR-PYR-REF-PROV-CD
015130		PIC X(03).
015140		10     X837D-OTHR-PYR-REF-PROV-QUAL
015150		PIC X(01).
015160		10     FILLER
015170		PIC X(10).
015180
015190		05     X837D-OTHR-PYR-REF-PRV-ID-SEG
015200		OCCURS 3 TIMES
015210		INDEXED BY X837D-OTHR-PYR-REF-PRV-ID-NDX.
015220
015230		10     X837D-OTHR-PYR-REF-PRV-ID-QL
015240		PIC X(03).
015250		10     X837D-OTHR-PYR-REF-PRV-ID
015260		PIC X(30).
015270		10     FILLER
015280		PIC X(10).
015290

 

Page 123 of 326

---

015300		LOOP-2330E OTHR PAYER RENDERING PROVIDER
015310
015320		05     X837D-OTHR-PYR-REND-PROV-SEG.
015330
015340		10     X837D-OTHR-PYR-REND-PROV-QUAL
015350		PIC X(01).
015360		10     FILLER
015370		PIC X(10).
015380
015390		05     X837D-OTHR-PYR-REND-PRV-ID-SEG
015400		OCCURS 3 TIMES
015410		INDEXED BY X837D-OTHR-PYR-REND-PRV-ID-NDX.
015420
015430		10     X837D-OTHR-PYR-REND-PRV-ID-QL
015440		PIC X(03).
015450		10     X837D-OTHR-PYR-REND-PRV-ID
015460		PIC X(30).
015470		10     FILLER
015480		PIC X(10).
015490
015500
015510
015520
015530		837D - CLAIM LEVEL-ADJUSTMENT (99)
015540
015550
015560
015570		837D CLAIM LEVEL ADJUSTMENT
015580
015590		01     X837D-CLAIM-LVL-ADJUSTMENT.
015600
015610		05     X837D-RECORD-CODE
015620		PIC X(02).
015630
015640		05     X837D-SORT-KEY.
015650
015660		10     X837D-PROV-SEQ-NUM
015670		VALUE ZEROES
015680		PIC 9(11).
015690
015700		10     X837D-SUBSCRIBER-SEQ-NUM
015710		VALUE ZEROES
015720		PIC 9(11).
015730
015740		10     X837D-PATIENT-SEQ
015750		VALUE ZEROES
015760		PIC 9(11).
015770
015780		10     X837D-CLAIM-SEQ
015790		VALUE ZEROES
015800		PIC 9(11).

 

Page 124 of 326

---

015810
015820		10     X837D-SVC-LINE-SEQ
015830		VALUE ZEROES
015840		PIC 9(11).
015850
015860
015870		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
015880		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORD.
015890
015900
015910		10     X837D-SUB-SEQ
015920		VALUE ZEROES
015930		PIC 9(11).
015940
015950		10     X837D-TX-CODE
015960		VALUE ‘06’
015970		PIC X(02).
015980
015990		10     X837D-TX-CODE-SEQ-NUM
016000		VALUE ZEROES
016010		PIC 9(07).
016020
016030		END OF HDR SORT-KEY
016040
016050
016060
016070		05     X837D-CLAIM-ADJ-SEG
016080		OCCURS 05 TIMES
016090		INDEXED BY X837D-CLAIM-ADJ-NDX.
016100
016110		10     X837D-CLAIM-ADJ-GROUP-CODE
016120		PIC X(02).
016130		10     X837D-CLAIM-ADJ
016140		OCCURS 6 TIMES
016150		INDEXED BY X837D-CLAIM-ADJ-NDX.
016160		15     X837D-CLAIM-ADJ-REASON-CD
016170		PIC X(05).
016180		15     X837D-CLAIM-ADJ-AMOUNT
016190		PIC S9(11)V99.
016200		15     X837D-CLAIM-ADJ-UNITS
016210		PIC S9(7)V9(4).
016220
016230
016240
016250
016260		837D - CLAIM-SERVICE-LINE (MAX 50)
016270
016280
016290
016300		837D CLAIM SERVICE LINE
016310

 

Page 125 of 326

---

016320		01     X837D-CLAIM-SVC-LINE.
016330
016340		05     X837D-RECORD-CODE
016350		PIC X(02).
016360
016370		05     X837D-SORT-KEY.
016380
016390		10     X837D-PROV-SEQ-NUM
016400		VALUE ZEROES
016410		PIC 9(11).
016420
016430		10     X837D-SUBSCRIBER-SEQ-NUM
016440		VALUE ZEROES
016450		PIC 9(11).
016460
016470		10     X837D-PATIENT-SEQ
016480		VALUE ZEROES
016490		PIC 9(11).
016500
016510		10     X837D-CLAIM-SEQ
016520		VALUE ZEROES
016530		PIC 9(11).
016540
016550		10     X837D-SVC-LINE-SEQ
016560		VALUE ZEROES
016570		PIC 9(11).
016580
016590
016600		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
016610		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORD.
016620
016630
016640		10     X837D-SUB-SEQ
016650		VALUE ZEROES
016660		PIC 9(11).
016670
016680		10     X837D-TX-CODE
016690		VALUE ‘07’
016700		PIC X(02).
016710
016720		10     X837D-TX-CODE-SEQ-NUM
016730		VALUE ZEROES
016740		PIC 9(07).
016750
016760		END OF HDR SORT-KEY
016770
016780
016790
016800		LOOP-ID-2400
016810
016820		05     X837D-LN-ASSIGNED-NBR-SEG.

 

Page 126 of 326

---

016830
016840		10     X837D-LN-ASSIGNED-NBR
016850		PIC S9(9).
016860
016870		05     X837D-LN-DENTAL-SVC-SEG.
016880
016890		10     X837D-LN-PROC-CODE
016900		PIC X(48).
016910		10     X837D-LN-PROC-MOD-1
016920		PIC X(02).
016930		10     X837D-LN-PROC-MOD-2
016940		PIC X(02).
016950		10     X837D-LN-PROC-MOD-3
016960		PIC X(02).
016970		10     X837D-LN-PROC-MOD-4
016980		PIC X(02).
016990		10     X837D-LN-SUBMITTED-CHRG
017000		PIC S9(11)V99.
017010		10     X837D-LN-PLACE-OF-SVC-CODE
017020		PIC X(02).
017030		10     X837D-LN-ORAL-CAVITY-CD
017040		OCCURS 5 TIMES
017050		INDEXED BY X837D-LN-ORAL-CAVITY-CD-NDX
017060		PIC X(03).
017070		10     X837D-LN-INIT-REPLACE-PROTH
017080		PIC X(01).
017090		10     X837D-LN-PROC-COUNT
017100		PIC S9(9).
017110		10     FILLER
017120		PIC X(10).
017130
017140		05     X837D-LN-TOOTH-INFO-SEG
017150		OCCURS 32 TIMES
017160		INDEXED BY X837D-LN-TOOTH-INFO-NDX.
017170
017180		10     X837D-LN-TOOTH-CODE
017190		PIC X(30).
017200		10     X837D-LN-TOOTH-SURFACE-CD
017210		OCCURS 5 TIMES
017220		INDEXED BY X837D-LN-TOOTH-SURFACE-NDX
017230		PIC X(02).
017240		10     FILLER
017250		PIC X(10).
017260
017270		05     X837D-LN-SVC-DATE-SEG
017280		PIC X(08).
017290
017300		05     X837D-LN-PRIOR-PLACE-DATE-SEG
017310		PIC X(08).
017320
017330		05     X837D-LN-APPL-PLACE-DATE-SEG

 

Page 127 of 326

---

017340		PIC X(08).
017350
017360		05     X837D-LN-REPLACEMENT-DATE-SEG
017370		PIC X(08).
017380
017390		05     X837D-LN-ANESTHESIA-QTY-SEG
017400		OCCURS 5 TIMES
017410		INDEXED BY X837D-LN-ANESTHESIA-QTY-NDX.
017420
017430		10     X837D-LN-ANESTHESIA-QTY-QUAL
017440		PIC X(02).
017450		10     X837D-LN-ANESTHESIA-QTY
017460		PIC S9(9)V99.
017470
017480		05     X837D-LN-PREDETERMINE-ID-SEG.
017490
017500		10     X837D-LN-PREDETERM-BENE-IND
017510		PIC X(30).
017520		10     FILLER
017530		PIC X(10).
017540
017550		05     X837D-LN-PA-REF-NBR-SEG
017560		OCCURS 2 TIMES
017570		INDEXED BY X837D-LN-PA-REF-NBR-NDX.
017580
017590		10     X837D-LN-PA-REF-QUAL
017600		PIC X(03).
017610		10     X837D-LN-PA-REF-NBR
017620		PIC X(30).
017630		10     FILLER
017640		PIC X(10).
017650
017660
017670		05     X837D-LN-ITEM-CNTL-NBR-SEG.
017680
017690		10     X837D-LN-ITEM-CNTL-NBR
017700		PIC X(30).
017710		10     FILLER
017720		PIC X(10).
017730
017740		05     X837D-LN-APPROVED-AMT-SEG.
017750
017760		10     X837D-LN-APPROVED-AMT
017770		PIC S9(11)V99.
017780
017790		05     X837D-LN-SALES-TAX-AMT-SEG.
017800
017810		10     X837D-LN-SALES-TAX-AMT
017820		PIC S9(11)V99.
017830
017840		05     X837D-LN-NOTE-SEG

 

Page 128 of 326

---

017850		OCCURS 20 TIMES
017860		INDEXED BY X837D-LN-NOTE-NDX.
017870
017880		10     X837D-LN-NOTE-TEXT
017890		PIC X(80).
017900		10     FILLER
017910		PIC X(10).
017920
017930		LOOP-ID-2420A
017940
017950		05     X837D-LN-REND-PROV-NAME-SEG.
017960
017970		10     X837D-LN-REND-PROV-ENTITY-CD
017980		PIC X(03).
017990		10     X837D-LN-REND-PROV-NME-QUAL
018000		PIC X(01).
018010		10     X837D-LN-REND-PROV-NM-LAST
018020		PIC X(35).
018030		10     X837D-LN-REND-PROV-NM-FIRST
018040		PIC X(25).
018050		10     X837D-LN-REND-PROV-NM-MIDDLE
018060		PIC X(25).
018070		10     X837D-LN-REND-PROV-NM-SFX
018080		PIC X(10).
018090		10     X837D-LN-REND-PROV-ID-QUAL
018100		PIC X(02).
018110		10     X837D-LN-REND-PROV-ID-NBR
018120		PIC X(80).
018130		10     FILLER
018140		PIC X(10).
018150
018160		05     X837D-LN-REND-PROV-SPEC-SEG.
018170
018180		10     X837D-LN-REND-PROV-SPEC-CODE
018190		PIC X(30).
018200		10     FILLER
018210		PIC X(10).
018220
018230		05     X837D-LN-REND-PROV-2ND-ID-SEG
018240		OCCURS 5 TIMES
018250		INDEXED BY X837D-LN-REND-PROV-2ND-ID-NDX.
018260
018270		10     X837D-LN-REND-PROV-2ND-ID-CODE
018280		PIC X(03).
018290		10     X837D-LN-REND-PROV-2ND-ID
018300		PIC X(30).
018310		10     FILLER
018320		PIC X(10).
018330
018340		05     X837D-LN-OTH-PYR-REF-NBR-SEG.
018350		10     X837D-LN-OTH-PYR-REF-NAME

 

Page 129 of 326

---

018360		PIC X(35).
018370		10     FILLER
018380		PIC X(10).
018390
018400		05     X837D-LN-OTH-PYR-PA-REF-NB-SEG
018410		OCCURS 2 TIMES
018420		INDEXED BY X837D-LN-OTH-PYR-PA-REF-NB-NDX.
018430
018440		10     X837D-LN-OTH-PYR-PA-REF-QUAL
018450		PIC X(03).
018460		10     X837D-LN-OTH-PYR-PA-REF-NB
018470		PIC X(30).
018480		10     FILLER
018490		PIC X(10).
018500
018510		LOOP-ID-2420C
018520
018530		05     X837D-LN-AST-SURG-NAME-SEG.
018540
018550		10     X837D-LN-AST-SURG-ENTITY-CD
018560		PIC X(03).
018570		10     X837D-LN-AST-SURG-NME-QUAL
018580		PIC X(01).
018590		10     X837D-LN-AST-SURG-NM-LAST
018600		PIC X(35).
018610		10     X837D-LN-AST-SURG-NM-FIRST
018620		PIC X(25).
018630		10     X837D-LN-AST-SURG-NM-MIDDLE
018640		PIC X(25).
018650		10     X837D-LN-AST-SURG-NM-SFX
018660		PIC X(10).
018670		10     X837D-LN-AST-SURG-ID-QUAL
018680		PIC X(02).
018690		10     X837D-LN-AST-SURG-ID-NBR
018700		PIC X(80).
018710		10     FILLER
018720		PIC X(10).
018730
018740		05     X837D-LN-AST-SURG-SPEC-SEG.
018750
018760		10     X837D-LN-AST-SURG-SPEC-CODE
018770		PIC X(30).
018780		10     FILLER
018790		PIC X(10).
018800
018810		05     X837D-LN-AST-SURG-2ND-ID-SEG.
018820
018830		10     X837D-LN-AST-SURG-2ND-ID-CODE
018840		PIC X(03).
018850		10     X837D-LN-AST-SURG-2ND-ID
018860		PIC X(30).

 

Page 130 of 326

---

018870		10     FILLER
018880		PIC X(10).
018890
018900
018910
018920
018930		837D - LINE-LVL-ADJUSTMENT (MAX 99)
018940
018950
018960
018970		837D-LINE-LEVEL-ADJUSTMENTS
018980
018990		01     X837D-LINE-LVL-ADJUSTMENTS.
019000
019010		05     X837D-RECORD-CODE
019020		PIC X(02).
019030
019040		05     X837D-SORT-KEY.
019050
019060		10     X837D-PROV-SEQ-NUM
019070		VALUE ZEROES
019080		PIC 9(11).
019090
019100		10     X837D-SUBSCRIBER-SEQ-NUM
019110		VALUE ZEROES
019120		PIC 9(11).
019130
019140		10     X837D-PATIENT-SEQ
019150		VALUE ZEROES
019160		PIC 9(11).
019170
019180		10     X837D-CLAIM-SEQ
019190		VALUE ZEROES
019200		PIC 9(11).
019210
019220		10     X837D-SVC-LINE-SEQ
019230		VALUE ZEROES
019240		PIC 9(11).
019250
019260
019270		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
019280		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORD.
019290
019300
019310		10     X837D-SUB-SEQ
019320		VALUE ZEROES
019330		PIC 9(11).
019340
019350		10     X837D-TX-CODE
019360		VALUE ‘08’
019370		PIC X(02).

 

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---

019380
019390		10     X837D-TX-CODE-SEQ-NUM
019400		VALUE ZEROES
019410		PIC 9(07).
019420
019430		END OF HDR SORT-KEY
019440
019450
019460
019470		LOOP-ID-2430
019480
019490		05     X837D-LINE-LVL-ADJ-SEG.
019500
019510		10     X837D-LINE-ADJ-PYR-ID
019520		PIC X(80).
019530		10     X837D-LINE-ADJ-AMOUNT-PAID
019540		PIC S9(11)V99.
019550		10     X837D-LINE-ADJ-SVC-ID-QUAL
019560		PIC X(02).
019570		10     X837D-LINE-ADJ-SVC-ID
019580		PIC X(48).
019590		10     X837D-LINE-ADJ-SVC-MOD-1
019600		PIC X(02).
019610		10     X837D-LINE-ADJ-SVC-MOD-2
019620		PIC X(02).
019630		10     X837D-LINE-ADJ-SVC-MOD-3
019640		PIC X(02).
019650		10     X837D-LINE-ADJ-SVC-MOD-4
019660		PIC X(02).
019670		10     X837D-LINE-ADJ-SVC-CD-DESC
019680		PIC X(80).
019690		10     X837D-LINE-ADJ-UNITS-OF-SVC
019700		PIC S9(7)V9(4).
019710		10     X837D-LINE-ADJ-BUNDLE-LINE-NBR
019720		PIC S9(4).
019730		10     FILLER
019740		PIC X(10).
019750
019760		05     X837D-LINE-ADJ-SEG
019770		OCCURS 9 9 TIMES
019780		INDEXED BY X837D-LINE-ADJ-NDX.
019790
019800		10     X837D-LINE-ADJ-GROUP-CODE
019810		PIC X(02).
019820		10     X837D-LINE-ADJ
019830		OCCURS 6 TIMES
019840		INDEXED BY X837D-LINE-ADJ-NDX.
019850		15     X837D-LINE-ADJ-REASON-CD
019860		PIC X(05).
019870		15     X837D-LINE-ADJ-AMOUNT
019880		PIC S9(11)V99.

 

Page 132 of 326

---

019890		15     X837D-LINE-ADJ-UNITS
019900		PIC S9(7)V9(4).
019910
019920		05     X837D-LINE-ADJ-DATE-SEG.
019930
019940		10     X837D-LINE-DATE-CLAIM-PAID
019950		PIC X(08).
019960
019970
019980
019990
020000		▇▇▇▇ - ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇
▇▇▇▇▇▇
020020
020030		01     X837D-TX-TRAILER.
020040
020050		05     X837D-RECORD-CODE
020060		PIC X(02).
020070
020080		05     X837D-SORT-KEY.
020090
020100		10     X837D-PROV-SEQ-NUM
020110		VALUE ZEROES
020120		PIC 9(11).
020130
020140		10     X837D-SUBSCRIBER-SEQ-NUM
020150		VALUE ZEROES
020160		PIC 9(11).
020170
020180		10     X837D-PATIENT-SEQ
020190		VALUE ZEROES
020200		PIC 9(11).
020210
020220		10     X837D-CLAIM-SEQ
020230		VALUE ZEROES
020240		PIC 9(11).
020250
020260		10     X837D-SVC-LINE-SEQ
020270		VALUE ZEROES
020280		PIC 9(11).
020290
020300
020310		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
020320		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
020330
020340
020350		10     X837D-SUB-SEQ
020360		VALUE ZEROES
020370		PIC 9(11).
020380
020390		10     X837D-TX-CODE

 

Page 133 of 326

---

020400		VALUE ‘99’
020410		PIC X(02).
020420
020430		10     X837D-TX-CODE-SEQ-NUM
020440		VALUE ZEROES
020450		PIC 9(07).
020460
020470		END OF HDR SORT-KEY
020480
020490
020500
020510		05     X837D-TX-TRAILER-SEG.
020520
020530		10     X837D-TRAILER-NUM-OF-SEG
020540		PIC 9(10).
020550		10     X837D-TRAILER-CTL-NUM
020560		PIC X(09).
020570		10     FILLER
020580		PIC X(10).

 

Page 134 of 326

---

000100
000200
000300		INSTITUTIONAL CLAIM EDI INTERFACE FILE
000400		COPYBOOK X837IV01
000500
000600
000700		THE HEALTH CARE INSTITUTIONAL CLAIM EDI INTERFACE
000800		HAS THE SAME DATA CONTENT AS THE
000900		837 HEALTH CARE INSTITUTIONAL CLAIM TRANSACTION
001000
001100		THE HEALTH CARE INSTITUTIONAL CLAIM INTERFACE
001200		COPYBOOK CONTAINS 11 RECORDS:
001300
001400		RECORD		DESCRIPTION
001500
001600
001700		X837I-TX-HEADER		CONTAINS TRANSACTION HEADER
001800
001900		X837I-PROVIDER		CONTAINS LOOP 2000A, 2010AA
002000				AND 2010AB SEGMENTS
002100
002200		X837I-SUBSCRIBER		CONTAINS LOOP 2000B, 2010BA, 2010BB
002300				2010BC AND 2010BD SEGMENTS.
002400
002500		X837I-PATIENT		CONTAINS LOOP 2000C AND 2010CA
002600				SEGMENTS.
002700
002800		X837I-CLAIM		CONTAINS LOOP 2300, 2305, 2310A,
002900				2310B, 2310C, AND 2310E
003000				SEGMENTS.
003100
003200		X837I-OTHER-SUBSCRIBER		CONTAINS LOOP
003300				2320 (MINUS CLAIM-LVL-ADJ),
003400				2330A, 2330B, 2330C, 2330D,
003500				2330E, 2330F
003600				AND 2330H SEGMENTS.
003700
003800		X837I-CLAIM-LVL-ADJ		CONTAINS CLAIM-LVL-ADJ ONLY
003900				SEGMENTS FROM LOOP 2320.
004000
004100		X837I-SVC-LINE		CONTAINS LOOP 2400, 2410, 2420A,
004200				2420B, 2420C SEGMENTS.
004300
004400		X837I-LINE-DRUG-ID		CONTAINS LOOP 2410 SEGMENTS.
004500
004600		X837I-LINE-LVL-ADJ		CONTAINS LOOP 2430 SEGMENTS.
004700
004800		X837I-TX-TRAILER		CONTAINS TRANSACTION TRAILER ’
004900				SEGMENTS
005000
005100		EACH RECORD BEGINS WITH THE SAME 8 FIELDS, THE SORT-KEY.

 

Page 135 of 326

---

005200
005300		FIELD		DESCRIPTION
005400
005500
005600		X837I-PROV-SEQ-NUM		PURPOSE IS TO UNIQUELY IDENTIFY
005700				EACH PROVIDER’S DATA.
005800				ZERO FOR HEADER AND 9’S FOR
005900				TRAILER.
006000
006100		X837I-SUBSCRIBER-SEQ-NUM		PURPOSE IS TO UNIQUELY IDENTIFY
006200				EACH SUBSCRIBER’S DATA FOR A
006300				PROVIDER
006400
006500		X837I-PATIENT-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
006600				EACH PATIENT’S DATA FOR A
006700				PROVIDER
006800
006900		X837I-CLAIM-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
007000				EACH CLAIM’S DATA FOR A PATIENT
007100
007200		X837I-SUB-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
007300				EACH OTHER-SUBSCRIBER’S DATA
007400				FOR A CLAIM -OR-
007500				CLAIM-LVL-ADJUSTMENTS
007600
007700		X837I-CLAIM-LVL-ADJ-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
007800				EACH SET OF CLAIM LVL ADJUSTMENTS
007900				FOR A CLAIM
008000
008100		X837I-SVC-LINE-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
008200				EACH SVC-LINE’S DATA FOR A CLAIM
008300
008400		X837I-LINE-LVL-ADJ-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
008500				EACH SET OF LINE LVL ADJUSTMENTS
008600				FOR A CLAIM
008700
008800		X837I-TX-CODE		IDENTIFIES EACH TYPE OF RECORD
008900				00     FOR X837I-TX-HEADER
009000				01     FOR X837I-PROVIDER
009100				02     FOR X837I-SUBSCRIBER
009200				03     FOR X837I-PATIENT
009300				04     FOR X837I-CLAIM
009400				08     FOR X837I-OTHER-SUBS-INFO
009500				06     FOR X837I-CLAIM-LVL-ADJ
009600				07     FOR X837I-SVC-LINE
009700				08     FOR X837I-LINE-DRUG-ID
009800				09     FOR X837I-LINE-LVL-ADJ
009900				99     FOR X837I-TX-TRAILER
010000
010100
010200		X837I-TX-CODE-SEQ-NUM		TO SEQUENCE RECORDS WITHIN A

 

Page 136 of 326

---

010300

RECORD TYPE. THE SEQUENCE NUMBER

010400

FOR THE FIRST RECORD IF ‘0001’,

010500

FOR THE SECOND ‘002’, ETC.

010600

010700

010800

010900

THE FOLLOWING EXAMPLE SHOWS HOW THIS WORKS, WHERE

011000

PPPPP

=

PROVIDER-SEQ

CCCCC

=

CLAIM-SEQ

011100

SSSSS

=

SUBSCRIBER-SEQ

LLLLL

=

LINE-SEQ

011200

TTTTT

=

PATIENT-SEQ

HHHHHH

=

SUB-SEQ

011300

011400

PROV

SUBS

▇▇▇

CLM

SVC

SUB

TX

TX

011500

RECORD

SEQ

SEQ

SEQ

SEQ

SEQ

SEQ

CDE

SEQ

011600

011700

TX-HEADER

ZERO

ZERO

ZERO

ZERO

ZERO

ZERO

00

ZERO

011800

PROVIDER

PPPPP

ZERO

ZERO

ZERO

ZERO

ZERO

01

ZERO

011900

SUBSCRIBER

PPPPP

SSSSS

ZERO

ZERO

ZERO

ZERO

02

ZERO

012000

PATIENT

PPPPP

SSSSS

TTTTT

ZERO

ZERO

ZERO

03

ZERO

012100

CLAIM

PPPPP

SSSSS

TTTTT

CCCCC

ZERO

ZERO

04

ZERO

012200

OTHER-SUBS-INFO

PPPPP

SSSSS

TTTTT

CCCCC

ZERO

HHHHH

05

ZERO

012300

CLAIM-LVL-ADJ

PPPPP

SSSSS

TTTTT

CCCCC

ZERO

HHHHH

06

1-999

012400

SVC-LINE

PPPPP

SSSSS

TTTTT

CCCCC

LLLLL

ZERO

07

ZERO

012500

LINE-DRUG-ID

PPPPP

SSSSS

TTTTT

CCCCC

LLLLL

ZERO

09

1-25

012600

LINE-LVL-ADJ

PPPPP

SSSSS

TTTTT

CCCCC

LLLLL

ZERO

08

1-999

012700

TX-TRAILER

99999

SSSSS

TTTTT

CCCCC

ZERO

ZERO

99

99999

012800
012900
013000
013100
013200		837I – TRANSACTION HEADER RECORD
013300
013400
013500		01     X837I-TX-HEADER.
013600
013700		05     X837I-RECORD-CODE
013800		PIC X(02).
013900
014000		05     X837I-SORT-KEY.
014100
014200		10     X837I-PROV-SEQ-NUM
014300		VALUE ZEROES
014400		PIC 9(11).
014500
014600		10     X837I-SUBSCRIBER-SEQ-NUM
014700		VALUE ZEROES
014800		PIC 9(11).
014900
015000		10     X837I-PATIENT-SEQ
015100		VALUE ZEROES
015200		PIC 9(11).
015300

 

Page 137 of 326

---

015400		10     X837I-CLAIM-SEQ
015500		VALUE ZEROES
015600		PIC 9(11).
015700
015800		10     X837I-SVC-LINE-SEQ
015900		VALUE ZEROES
016000		PIC 9(11).
016100
016200
016300		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
016400		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORD.
016500
016600
016700		10     X837I-SUB-SEQ
016800		VALUE ZEROES
016900		PIC 9(11).
017000
017100		10     X837I-TX-CODE
017200		VALUE ‘00’
017300		PIC X(02).
017400
017500		10     X837I-TX-CODE-SEQ-NUM
017600		VALUE ZEROES
017700		PIC 9(07).
017800
017900		END OF HDR SORT-KEY.
018000
018100
018200
018300		05     X837I-TX-HEADER-SEG.
018400
018500		10     X837I-TX-ID
018600		VALUE ‘837’
018700		PIC X(03).
018800		10     X837I-TX-CTL-NUM
018900		PIC X(09).
019000		10     FILLER
019100		PIC X(10).
019200
019300		05     X837I-SEG-SEGMENT.
019400
019500		10     X837I-TX-HIERACH-STRUCT-CODE
019600		PIC X(04).
019700		10     X837I-TX-PURPOSE-CODE
019800		PIC X(02).
019900		10     X837I-TX-ID-CODE
020000		PIC X(30).
020100		10     X837I-TX-CREATION-DATE
020200		PIC X(08).
020300		10     X837I-TX-CREATION-TIME
020400		PIC X(08).

 

Page 138 of 326

---

020500		10     X837I-TX-TYPE-CODE
020600		PIC X(02).
020700		10     FILLER
020800		PIC X(10).
020900
021000		05     X837I-XMIT-TYPE-ID-SEG.
021100		10     X837I-XMIT-REF-ID-CODE
021200		PIC X(02).
021300		10     X837I-XMIT-REF-ID
021400		PIC X(30).
021500		10     FILLER
021600		PIC X(10).
021700
021800		05     X837I-SUBMITTER-NAME-SEG.
021900
022000		10     X837I-SUBMITTER-ENTITY-CODE
022100		PIC X(03).
022200		10     X837I-SUBMITTER-ENTITY-QUAL
022300		PIC X(01).
022400		10     X837I-SUBMITTER-NAME-LAST
022500		PIC X(35).
022600		10     X837I-SUBMITTER-NAME-FIRST
022700		PIC X(25).
022800		10     X837I-SUBMITTER-NAME-MIDDLE
022900		PIC X(25).
023000		10     X837I-SUBMITTER-ID-CODE
023100		PIC X(80).
023200		10     FILLER
023300		PIC X(10).
023400
023500		05     X837I-SUBMITTER-CONTACT-SEG
023600		OCCURS 2 TIMES
023700		INDEXED BY X837I-SUBMITTER-CONTACT-NDX.
023800
023900		10     X837I-CONTACT-NAME
024000		PIC X(60).
024100		10     X837I-COMMUNICATION-INFO
024200		OCCURS 3 TIMES
024300		INDEXED BY X837I-COMMUNICATION-INFO-NDX.
024400		15     X837I-COMMUNICATION-QUAL
024500		PIC X(02).
024600		15     X837I-COMMUNICATION-NUMBER
024700		PIC X(80).
024800		10     FILLER
024900		PIC X(10).
025000
025100		05     X837I-RECEIVER-NAME-SEG.
025200
025300		10     X837I-RECEIVER-NAME-LAST
025400		PIC X(35).
025500		10     X837I-RECEIVER-ID-CODE

 

Page 139 of 326

---

025600		PIC X(80).
025700		10     FILLER
025800		PIC X(10).
025900
026000
026100
026200
026300		837I - DETAIL, BILLING/PAY-TO PROVIDER
026400
026500
026600		837I LOOP 2000A DETAIL, BILLING/PAY-TO PROVIDER
026700
026800		01     X837I-PROVIDER.
026900
027000		05     X837I-RECORD-CODE
027100		PIC X(02).
027200
027300		05     X837I-SORT-KEY.
027400
027500		10     X837I-PROV-SEQ-NUM
027600		VALUE ZEROES
027700		PIC 9(11).
027800
027900		10     X837I-SUBSCRIBER-SEQ-NUM
028000		VALUE ZEROES
028100		PIC 9(11).
028200
028300		10     X837I-PATIENT-SEQ
028400		VALUE ZEROES
028500		PIC 9(11).
028600
028700		10     X837I-CLAIM-SEQ
028800		VALUE ZEROES
028900		PIC 9(11).
029000
029100		10     X837I-SVC-LINE-SEQ
029200		VALUE ZEROES
029300		PIC 9(11).
029400
029500
029600		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
029700		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORD.
029800
029900
030000		10     X837I-SUB-SEQ
030100		VALUE ZEROES
030200		PIC 9(11).
030300
030400		10     X837I-TX-CODE
030500		VALUE ‘01’
030600		PIC X(02).

 

Page 140 of 326

---

030700
030800		10     X837I-TX-CODE-SEQ-NUM
030900		VALUE ZEROES
031000		PIC 9(07).
031100
031200		END OF HDR SORT-KEY
031300
031400
031500
031600		LOOP-ID-2000A
031700
031800		05     X837I-PROV-HIERACHICAL-LVL-SEG.
031900
032000		10     X837I-PROV-HIER-NBR
032100		PIC X(12).
032200		10     X837I-PROV-HIER-LVL-CODE
032300		PIC X(02).
032400		10     X837I-PROV-HIER-CHILD-CODE
032500		PIC X(01).
032600		10     FILLER
032700		PIC X(10).
032800
032900		05     X837I-PROV-SPECIALTY-INFO-SEG.
033000
033100		10     X837I-PROV-TYPE-CODE
033200		PIC X(03).
033300		10     X837I-PROV-SPECIALTY-CODE
033400		PIC X(30).
033500		10     FILLER
033600		PIC X(10).
033700
033800		05     X837I-CURRENCY-INFO-SEG.
033900
034000		10     X837I-CURRENCY-CODE
034100		PIC X(03).
034200		10     FILLER
034300		PIC X(10).
034400
034500		LOOP-ID-2010AA
034600
034700		05     X837I-BILLING-PROV-NAME-SEG.
034800
034900		10     X837I-▇▇▇▇-PROV-ENTITY-CODE
035000		PIC X(01).
035100		10     X837I-▇▇▇▇-PROV-NAME-LAST
035200		PIC X(35).
035300		10     X837I-▇▇▇▇-PROV-ID-CODE
035400		PIC X(02).
035500		10     X837I-▇▇▇▇-PROV-ID-NBR
035600		PIC X(80).
035700		10     FILLER

 

Page 141 of 326

---

035800		PIC X(10).
035900
036000		05     X837I-▇▇▇▇-PROV-ADDR-SEG.
036100
036200		10     X837I-▇▇▇▇-PROV-ADDR1
036300		PIC X(55).
036400		10     X837I-▇▇▇▇-PROV-ADDR2
036500		PIC X(55).
036600		10     FILLER
036700		PIC X(10).
036800
036900		05     X837I-▇▇▇▇-PROV-LOC-SEG.
037000
037100		10     X837I-▇▇▇▇-PROV-CITY
037200		PIC X(30).
037300		10     X837I-▇▇▇▇-PROV-STATE
037400		PIC X(02).
037500		10     X837I-▇▇▇▇-PROV-ZIP
037600		PIC X(15).
037700		10     X837I-▇▇▇▇-PROV-COUNTRY
037800		PIC X(03).
037900		10     FILLER
038000		PIC X(10).
038100
038200		05     X837I-▇▇▇▇-PROV-2ND-IDENT-SEG
038300		OCCURS 8 TIMES
038400		INDEXED BY X837I-▇▇▇▇-PROV-2ND-IDENT-NDX.
038500
038600		10     X837I-▇▇▇▇-PROV-2ND-ID-CODE
038700		PIC X(03).
038800		10     X837I-▇▇▇▇-PROV-2ND-ID
038900		PIC X(30).
039000		10     FILLER
039100		PIC X(10).
039200
039300		05     X837I-▇▇▇▇-PROV-BANK-CARD-SEG
039400		OCCURS 8 TIMES
039500		INDEXED BY X837I-▇▇▇▇-PROV-BANK-CARD-NDX.
039600
039700		10     X837I-▇▇▇▇-PROV-CRDT-CRD-ID-TP
039800		PIC X(03).
039900		10     X837I-▇▇▇▇-PROV-CRDT-CRD-ID
040000		PIC X(30).
040100		10     FILLER
040200		PIC X(10).
040300
040400		05     X837I-▇▇▇▇-PROV-CONTACT-SEG
040500		OCCURS 2 TIMES
040600		INDEXED BY X837I-▇▇▇▇-PROV-CONTACT-NDX.
040700
040800		10     X837I-▇▇▇▇-PRV-CONTACT-NAME

 

Page 142 of 326

---

040900		PIC X(60).
041000		10     X837I-▇▇▇▇-PROV-COMM-INFO
041100		OCCURS 3 TIMES
041200		INDEXED BY X837I-▇▇▇▇-PROV-COMM-INFO-NDX.
041300		15     X837I-▇▇▇▇-PROV-COMM-QUAL
041400		PIC X(02).
041500		15     X837I-▇▇▇▇-PROV-COMM-NUMBER
041600		PIC X(80).
041700		10     FILLER
041800		PIC X(10).
041900
042000		LOOP-ID-2010AB
042100
042200		05     X837I-PAY-TO-PROV-NAME-SEG.
042300
042400		10     X837I-PAYTO-PROV-ENTITY-CODE
042500		PIC X(01).
042600		10     X837I-PAYTO-PROV-NAME-LAST
042700		PIC X(35).
042800		10     X837I-PAYTO-PROV-ID-CODE
042900		PIC X(02).
043000		10     X837I-PAYTO-PROV-ID-NBR
043100		PIC X(80).
043200		10     FILLER
043300		PIC X(10).
043400
043500		05     X837I-PAYTO-PROV-ADDR-SEG.
043600
043700		10     X837I-PAYTO-PROV-ADDR1
043800		PIC X(55).
043900		10     X837I-PAYTO-PROV-ADDR2
044000		PIC X(55).
044100		10     FILLER
044200		PIC X(10).
044300
044400		05     X837I-PAYTO-PROV-LOC-SEG.
044500
044600		10     X837I-PAYTO-PROV-CITY
044700		PIC X(30).
044800		10     X837I-PAYTO-PROV-STATE
044900		PIC X(02).
045000		10     X837I-PAYTO-PROV-ZIP
045100		PIC X(15).
045200		10     X837I-PAYTO-PROV-COUNTRY
045300		PIC X(03).
045400		10     FILLER
045500		PIC X(10).
045600
045700		05     X837I-PAYTO-PROV-2ND-ID-SEG
045800		OCCURS 5 TIMES
045900		INDEXED BY X837I-PAYTO-PROV-2ND-ID-NDX.

 

Page 143 of 326

---

046000
046100		10     X837I-PAYTO-PROV-2ND-ID-CODE
046200		PIC X(03).
046300		10     X837I-PAYTO-PROV-2ND-ID
046400		PIC X(30).
046500		10     FILLER
046600		PIC X(10).
046700
046800
046900
047000		837I - SUBSCRIBER
047100
047200
047300
047400		837I DETAIL, SUBSCRIBER HIERARCHAL LEVEL
047500
047600		01     X837I-SUBSCRIBER.
047700
047800		05     X837I-RECORD-CODE
047900		PIC X(02).
048000
048100		05     X837I-SORT-KEY.
048200
048300		10     X837I-PROV-SEQ-NUM
048400		VALUE ZEROES
048500		PIC 9(11).
048600
048700		10     X837I-SUBSCRIBER-SEQ-NUM
048800		VALUE ZEROES
048900		PIC 9(11).
049000
049100		10     X837I-PATIENT-SEQ
049200		VALUE ZEROES
049300		PIC 9(11).
049400
049500		10     X837I-CLAIM-SEQ
049600		VALUE ZEROES
049700		PIC 9(11).
049800
049900		10     X837I-SVC-LINE-SEQ
050000		VALUE ZEROES
050100		PIC 9(11).
050200
050300
050400		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
050500		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
050600
050700
050800		10     X837I-SUB-SEQ
050900		VALUE ZEROES
051000		PIC 9(11).

 

Page 144 of 326

---

051100
051200		10     X837I-TX-CODE
051300		VALUE ‘02’
051400		PIC X(02).
051500
051600		10     X837I-TX-CODE-SEQ-NUM
051700		VALUE ZEROES
051800		PIC 9(07).
051900
052000		END OF HDR SORT-KEY
052100
052200
052300
052400		LOOP-ID-2000B
052500
052600		05     X837I-SUBS-HIERACHICAL-LVL-SEG.
052700
052800		10     X837I-SUBS-HIER-NBR
052900		PIC X(12).
053000		10     X837I-SUBS-HIER-PARENT-NBR
053100		PIC X(12).
053200		10     X837I-SUBS-HIER-LVL-CODE
053300		PIC X(02).
053400		10     X837I-SUBS-HIER-CHILD-CODE
053500		PIC X(01).
053600		10     FILLER
053700		PIC X(10).
053800
053900		05     X837I-SUBSCRIBER-INFO-SEG.
054000
054100		10     X837I-SUBS-PYR-RESPONS-SEQ-CD
054200		PIC X(01).
054300		10     X837I-SUBS-RELATIONSHIP-CODE
054400		PIC X(02).
054500		10     X837I-SUBS-POLICY-NBR
054600		PIC X(30).
054700		10     X837I-SUBS-PLAN-NAME
054800		PIC X(60).
054900		10     X837I-SUBS-CLAIM-FILING-IND-CD
055000		PIC X(02).
055100		10     FILLER
055200		PIC X(10).
055300
055400		05     X837I-SUBS-PATIENT-INFO-SEG.
055500
055600		10     X837I-SUBS-WEIGHT-CODE
055700		PIC X(02).
055800		10     X837I-SUBS-WEIGHT
055900		PIC 9(5).
056000		10     X837I-SUBS-PREGNANCY-INDICATOR
056100		PIC X(01).

 

Page 145 of 326

---

056200		10     FILLER
056300		PIC X(10).
056400
056500		LOOP-ID-2010BA
056600
056700		05     X837I-SUBS-NAME-SEG.
056800
056900		10     X837I-SUBS-TYPE-CODE
057000		PIC X(01).
057100		10     X837I-SUBS-NAME-LAST
057200		PIC X(35).
057300		10     X837I-SUBS-NAME-FIRST
057400		PIC X(25).
057500		10     X837I-SUBS-NAME-MIDDLE
057600		PIC X(25).
057700		10     X837I-SUBS-NAME-SFX
057800		PIC X(10).
057900		10     X837I-SUBS-ID-CODE-TYPE
058000		PIC X(02).
058100		10     X837I-SUBS-ID-CODE
058200		PIC X(8.0).
058300		10     FILLER
058400		PIC X(10).
058500
058600		05     X837I-SUBS-ADDR-SEG.
058700
058800		10     X837I-SUBS-ADDR1
058900		PIC X(55).
059000		10     X837I-SUBS-ADDR2
059100		PIC X(55).
059200		10     FILLER
059300		PIC X(10).
059400
059500		05     X837I-SUBS-CITY-STATE-SEG.
059600
059700		10     X837I-SUBS-CITY
059800		PIC X(30).
059900		10     X837I-SUBS-STATE-CODE
060000		PIC X(02).
060100		10     X837I-SUBS-ZIP-CODE
060200		PIC X(15).
060300		10     X837I-SUBS-COUNTRY-CODE
060400		PIC X(03).
060500		10     FILLER-
060600		PIC X(10).
060700
060800		05     X837I-SUBS-DEMOGRAPHIC-SEG.
060900
061000		10     X837I-SUBS-OTHR-INSURED-DOB
061100		PIC X(08).
061200		10     X837I-SUBS-OTHR-GENDER-CODE.

 

Page 146 of 326

---

061300		PIC X(01).
061400		10     FILLER
061500		PIC X(10).
061600
061700		05     X837I-SUBS-2ND-ID-SEG
061800		OCCURS 4 TIMES
061900		INDEXED BY X837I-SUBS-2ND-ID-NDX.
062000
062100		10     X837I-SUBS-2ND-ID-TYPE
062200		PIC X(03).
062300		10     X837I-SUBS-2ND-ID
062400		PIC X(30).
062500		10     FILLER
062600		PIC X(10).
062700
062800		05     X837I-SUBS-PROP-CLAIM-NBR-SEG.
062900
063000		10     X837I-SUBS-PROP-CLAIM-NBR
063100		PIC X(30).
063200		10     FILLER
063300		PIC X(10).
063400
063500		LOOP-ID-2010BB
063600
063700		05     X837I-SUBS-CARD-NAME-SEG.
063800
063900		10     X837I-SUBS-CARD-TYPE-CODE
064000		PIC X(01).
064100		10     X837I-SUBS-CARD-NAME-LAST
064200		PIC X(35).
064300		10     X837I-SUBS-CARD-NAME-FIRST
064400		PIC X(25).
064500		10     X837I-SUBS-CARD-NAME-MIDDLE
064600		PIC X(25).
064700		10     X837I-SUBS-CARD-NAME-SFX
064800		PIC X(10).
064900		10     X837I-SUBS-CARD-ID-CODE-TYPE
065000		PIC X(02).
065100		10     X837I-SUBS-CARD-ID-CODE
065200		PIC X(80).
065300		10     FILLER
065400		PIC X(10).
065500
065600		05     X837I-SUBS-BANK-CARD-SEG
065700		OCCURS 2 TIMES
065800		INDEXED BY X837I-SUBS-BANK-CARD-NDX.
065900
066000		10     X837I-SUBS-CRDT-CRD-ID-TP
066100		PIC X(03).
066200		10     X837I-SUBS-CRDT-CRD-ID
066300		PIC X(30).

 

Page 147 of 326

---

066400		10     FILLER
066500		PIC X(10).
066600
066700		LOOP-ID-2010BC
066800
066900		05     X837I-PAYER-NAME-SEG.
067000
067100		10     X837I-PAYER-NAME
067200		PIC X(35).
067300		10     X837I-PAYER-ID-CODE-TYPE
067400		PIC X(02).
067500		10     X837I-PAYER-ID-CODE
067600		PIC X(80).
067700		10     FILLER
067800		PIC X(10).
067900
068000		05     X837I-PAYER-ADDR-SEG.
068100
068200		10     X837I-PAYER-ADDR1
068300		PIC X(55).
068400		10     X837I-PAYER-ADDR2
068500		PIC X(55).
068600		10     FILLER
068700		PIC X(10).
068800
068900		05     X837I-PAYER-CITY-STATE-SEG.
069000
069100		10     X837I-PAYER-CITY
069200		PIC X(30).
069300		10     X837I-PAYER-STATE-CODE
069400		PIC X(02).
069500		10     X837I-PAYER-ZIP-CODE
069600		PIC X(15).
069700		10     X837I-PAYER-COUNTRY-CODE
069800		PIC X(03).
069900		10     FILLER
070000		PIC X(10).
070100
070200		05     X837I-PAYER-2ND-ID-SEG
070300		OCCURS 3 TIMES
070400		INDEXED BY X837I-PAYER-2ND-ID-NDX.
070500
070600		10     X837I-PAYER-2ND-ID-TYPE
070700		PIC X(03).
070800		10     X837I-PAYER-2ND-ID
070900		PIC X(30).
071000		10     FILLER
071100		PIC X(10).
071200
071300		LOOP-ID-2010BD
071400

 

Page 148 of 326

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071500		05     X837I-RESPON-PARTY-NAME-SEG.
071600
071700		10     X837I-RESP-PARTY-ENTITY-CODE
071800		PIC X(01).
071900		10     X837I-RESP-PARTY-NAME-LAST
072000		PIC X(35).
072100		10     X837I-RESP-PARTY-NAME-FIRST
072200		PIC X(25).
072300		10     X837I-RESP-PARTY-NAME-MIDDLE
072400		PIC X(25).
072500		10     X837I-RESP-PARTY-NAME-SFX
072600		PIC X(10).
072700		10     FILLER
072800		PIC X(10).
072900
073000		05     X837I-RESPON-PARTY-ADDR-SEG.
073100
073200		10     X837I-RESP-PARTY-ADDR1
073300		PIC X(55).
073400		10     X837I-RESP-PARTY-ADDR2
073500		PIC X(55).
073600		10     FILLER
073700		PIC X(10).
073800
073900		05     X837I-RESPON-PARTY-LOC-SEG.
074000
074100		10     X837I-RESP-PARTY-CITY
074200		PIC X(30).
074300		10     X837I-RESP-PARTY-STATE
074400		PIC X(02).
074500		10     X837I-RESP-PARTY-ZIP
074600		PIC X(15).
074700		10     X837I-RESP-PARTY-COUNTRY
074800		PIC X(03).
074900		10     FILLER
075000		PIC X(10).
075100
075200
075300
075400
075500		837I - PATIENT
075600
075700
075800
075900		837I DETAIL, PATIENT HIERARCHAL LEVEL
076000
076100		01     X837I-PATIENT.
076200
076300		05     X837I-RECORD-CODE
076400		PIC X(02).
076500

 

Page 149 of 326

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076600		05     X837I-SORT-KEY.
076700
076800		10     X837I-PROV-SEQ-NUM
076900		VALUE ZEROES
077000		PIC 9(11).
077100
077200		10     X837I-SUBSCRIBER-SEQ-NUM
077300		VALUE ZEROES
077400		PIC 9(11).
077500
077600		10     X837I-PATIENT-SEQ
077700		VALUE ZEROES
077800		PIC 9(11).
077900
078000		10     X837I-CLAIM-SEQ
078100		VALUE ZEROES
078200		PIC 9(11).
078300
078400		10     X837I-SVC-LINE-SEQ
078500		VALUE ZEROES
078600		PIC 9(11).
078700
078800
078900		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
079000		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORD.
079100
079200
079300		10     X837I-SUB-SEQ
079400		VALUE ZEROES
079500		PIC 9(11).
079600
079700		10     X837I-TX-CODE
079800		VALUE ‘03’
079900		PIC X(02).
080000
080100		10     X837I-TX-CODE-SEQ-NUM
080200		VALUE ZEROES
080300		PIC 9(07).
080400
080500		END OF HDR SORT-KEY
080600
080800
080700
080900		LOOP-ID-2000C
081000
081100		05     X837I-▇▇▇-HIERACHICAL-LVL-SEG.
081200
081300		10     X837I-▇▇▇-HIER-NBR
081400		PIC X(12).
081500		10     X837I-▇▇▇-HIER-PARENT-NBR
081600		PIC X(12).

 

Page 150 of 326

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081700		10     X837I-▇▇▇-HIER-LVL-CODE
081800		PIC X(02).
081900		10     X837I-▇▇▇-HIER-CHILD-CODE
082000		PIC X(01).
082100		10     FILLER
082200		PIC X(10).
082300
082400		05     X837I-PATIENT-INFO-SEG.
082500
082600		10     X837I-▇▇▇-RELATIONSHIP-CODE
082700		PIC X(02).
082800		10     FILLER
082900		PIC X(10).
083000
083100		LOOP-ID-2010CA
083200
083300		05     X837I-▇▇▇-NAME-SEG.
083400
083500		10     X837I-▇▇▇-TYPE-CODE
083600		PIC X(01).
083700		10     X837I-▇▇▇-NAME-LAST
083800		PIC X(35).
083900		10     X837I-▇▇▇-NAME-FIRST
084000		PIC X(25).
084100		10     X837I-▇▇▇-NAME-MIDDLE
084200		PIC X(25).
084300		10     X837I-▇▇▇-NAME-SFX
084400		PIC X(10).
084500		10     X837I-▇▇▇-ID-CODE-TYPE
084600		PIC X(02).
084700		10     X837I-▇▇▇-ID-CODE
084800		PIC X(80).
084900		10     FILLER
085000		PIC X(10).
085100
085200		05     X837I-▇▇▇-ADDR-SEG.
085300
085400		10     X837I-▇▇▇-ADDR1
085500		PIC X(55).
085600		10     X837I-▇▇▇-ADDR2
085700		PIC X(55).
085800		10     FILLER
085900		PIC X(10).
086000
086100		05     X837I-▇▇▇-CITY-STATE-SEG.
086200
086300		10     X837I-▇▇▇-CITY
086400		PIC X(30).
086500		10     X837I-▇▇▇-STATE-CODE
086600		PIC X(02).
086700		10     X837I-▇▇▇-ZIP-CODE

 

Page 151 of 326

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086800		PIC X(15).
086900		10     X837I-▇▇▇-COUNTRY-CODE
087000		PIC X(03).
087100		10     FILLER
087200		PIC X(10).
087300
087400		05     X837I-▇▇▇-DEMOGRAPHIC-SEG.
087500
087600		10     X837I-▇▇▇-DOB
087700		PIC X(08).
087800		10     X837I-▇▇▇-GENDER-CODE
087900		PIC X(01).
088000		10     FILLER
088100		PIC X(10).
088200
088300		05     X837I-▇▇▇-2ND-ID-SEG
088400		OCCURS 5 TIMES
088500		INDEXED BY X837I-▇▇▇-2ND-ID-NDX.
088600
088700		10     X837I-▇▇▇-2ND-ID-TYPE
088800		PIC X(03).
088900		10     X837I-▇▇▇-2ND-ID
089000		PIC X(30).
089100		10     FILLER
089200		PIC X(10).
089300
089400		05     X837I-▇▇▇-PROP-CLAIM-NBR-SEG.
089500		10     X837I-▇▇▇-PROP-CLAIM-NBR
089600		PIC X(30).
089700		10     FILLER
089800		PIC X(10).
089900
090000
090100
090200		837I – CLAIM-INFO
090300
090400
090500
090600		837I CLAIM INFORMATION
090700
090800		01     X837I-CLAIM-INFO.
090900
091000		05     X837I-RECORD-CODE
091100		PIC X(02).
091200
091300		05     X837I-SORT-KEY.
091400
091500		10     X837I-PROV-SEQ-NUM
091600		VALUE ZEROES
091700		PIC 9(11).
091800

 

Page 152 of 326

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091900		10     X837I-SUBSCRIBER-SEQ-NUM
092000		VALUE ZEROES
092100		PIC 9(11).
092200
092300		10     X837I-PATIENT-SEQ
092400		VALUE ZEROES
092500		PIC 9(11).
092600
092700		10     X837I-CLAIM-SEQ
092800		VALUE ZEROES
092900		PIC 9(11).
093000
093100		10     X837I-SVC-LINE-SEQ
093200		VALUE ZEROES
093300		PIC 9(11).
093400
093500
093600		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
093700		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
093800
093900
094000		10     X837I-SUB-SEQ
094100		VALUE ZEROES
094200		PIC 9(11).
094300
094400		10     X837I-TX-CODE
094500		VALUE ‘04’
094600		PIC X(02).
094700
094800		10     X837I-TX-CODE-SEQ-NUM
094900		VALUE ZEROES
095000		PIC 9(07).
095100
095200		END OF HDR SORT-KEY
095300
095400
095500
095600		LOOP-ID-2300
095700
095800		05     X837I-CLM-INFO-SEG.
095900
096000		10     X837I-CLM-PATIENT-CTL-NUM
096100		PIC X(38).
096200		10     X837I-CLM-TOT-CHARGE-AMOUNT
096300		PIC S9(11)V99.
096400		10     X837I-CLM-PLACE-OF-SVC-CODE
096500		PIC X(02).
096600		10     X837I-CLM-FREQ-TYPE-CODE
096700		PIC X(01).
096800		10     X837I-CLM-PROV-SIG-ON-FILE
096900		PIC X(01).

 

Page 153 of 326

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097000		10     X837I-CLM-MCARE-ASSIGNMENT-IND
097100		PIC X(01).
097200		10     X837I-CLM-ASSIGN-BENE-IND
097300		PIC X(01).
097400		10     X837I-CLM-RELEASE-OF-INFO-IND
097500		PIC X(01).
097600		10     X837I-CLM-EOB-IND
097700		PIC X(01).
097800		10     X837I-CLM-▇▇▇▇▇-▇▇▇▇-CD
097900		PIC X(02).
098000		10     FILLER
098100		PIC X(10).
098200
098300		05     X837I-CLM-DISCHARGE-HOUR-SEG.
098400
098500		10     X837I-CLM-DISCHARGE-TIME
098600		PIC 9(04).
098700		10     FILLER
098800		PIC X(10).
098900
099000		05     X837I-CLM-STATEMENT-DATES-SEG.
099100
099200		10     X837I-CLM-STATEMENT-START-DATE
099300		PIC 9(08).
099400		10     X837I-CLM-STATEMENT-END-DATE
099500		PIC 9(08).
099600		10     FILLER
099700		PIC X(10).
099800
099900		05     X837I-CLM-ADMITT-DATES-SEG.
100000
100100		10     X837I-CLM-ADMITT-DATE
100200		PIC 9(08).
100300		10     X837I-CLM-ADMITT-HOUR
100400		PIC 9(04).
100500		10     FILLER
100600		PIC X(10).
100700
100800		05     X837I-CLM-INIST-CLM-CD-SEG.
100900
101000		10     X837I-CLM-ADMITT-SOURCE
101100		PIC X (01).
101200		10     X837I-CLM-▇▇▇-STATUS-CD
101300		PIC X(02).
101400		10     FILLER
101500		PIC X(10).
101600
101700		05     X837I-CLM-SUPPLMENT-INFO-SEG.
101800		OCCURS 10 TIMES
101900		INDEXED BY X837I-CLM-SUPPLMENT-INFO-NDX.
102000

 

Page 154 of 326

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102100		10     X837I-CLM-ATTACHMENT-TYPE
102200		PIC X(02).
102300		10     X837I-CLM-ATTCH-TRANSMIT-CODE
102400		PIC X(02).
102500		10     X837I-CLM-ATTACHMENT-CNTL-NBR
102600		PIC X(80).
102700		10     X837I-CLM-ATTACHMENT-DESC
102800		PIC X(80).
102900		10     FILLER
103000		PIC X(10).
103100
103200		05     X837I-CLM-CONTRACT-INFO-SEG.
103300
103400		10     X837I-CLM-CONTRACT-TYPE
103500		PIC X(02).
103600		10     X837I-CLM-CONTRACT-AMOUNT
103700		PIC S9(11)V99.
103800		10     X837I-CLM-CONTRACT-PERCENT
103900		PIC S9(4)V9(4).
104000		10     X837I-CLM-CONTRACT-CODE
104100		PIC X(30).
104200		10     X837I-CLM-CONTRACT-DISC-PCT
104300		PIC S9(4)V9(4).
104400		10     X837I-CLM-CONTRACT-VERSION
104500		PIC X(30).
104600		10     FILLER
104700		PIC X(10).
104800
104900		05     X837I-CLM-PYR-EST-AMT-DUE-SEG.
105000
105100		10     X837I-CLM-PYR-EST-AMT-DUE
105200		PIC S9(11)V99.
105300		10     FILLER
105400		PIC X(10).
105500
105600		05     X837I-CLM-▇▇▇-PAID-AMT-SEG.
105700
105800		10     X837I-CLM-▇▇▇-APID-AMT
105900		PIC S9(11)V99.
106000		10     FILLER
106100		PIC X(10).
106200
106300		05     X837I-CLM-CARD-MAX-AMT-SEG.
106400		10     X837I-CLM-CARD-MAX-AMT
106500		PIC S9(11)V99.
106600		10     FILLER
106700		PIC X(10).
106800
106900		05     X837I-CLM-ADJ-REPRICED-CLM-SEG.
107000		10     X837I-CLM-ADJ-REPRICED-CLM-NBR
107100		PIC X(30).

 

Page 155 of 326

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107200		10     FILLER
107300		PIC X(10).
107400
107500		05     X837I-CLM-REPRICED-CLM-SEG.
107600		10     X837I-CLM-REPRICED-CLM-NBR
107700		PIC X(30).
107800		10     FILLER
107900		PIC X(10).
108000
108100		05     X837I-CLM-CLRHSE-TRACE-SEG.
108200		10     X837I-CLM-CLRHSE-TRACE-NBR
108300		PIC X(30).
108400		10     FILLER
108500		PIC X(10).
108600
108700		05     X837I-CLM-DOC-ID-CD-SEG.
108800		10     X837I-CLM-DOC-ID-CD
108900		PIC X(30).
109000		10     FILLER
109100		PIC X(10).
109200
109300		05     X837I-CLM-ORIG-REF-NBR-SEG.
109400		10     X837I-CLM-ORIG-REF-NBR
109500		PIC X(30).
109600		10     FILLER
109700		PIC X(10).
109800
109900		05     X837I-CLM-INVEST-DEV-SEG.
110000		10     X837I-CLM-INVEST-DEV-EXEMPTN
110100		PIC X(30).
110200		10     FILLER
110300		PIC X(10).
110400
110500		05     X837I-CLM-SVC-AUTH-EXCEP-SEG.
110600		10     X837I-CLM-SVC-AUTH-EXCEP-CD
110700		PIC X(30).
110800		10     FILLER
110900		PIC X(10).
111000
111100		05     X837I-CLM-PEER-REV-ORG-SEG.
111200		10     X837I-CLM-PEER-REV-AUTH-NBR
111300		PIC X(30).
111400		10     FILLER
111500		PIC X(10).
111600
111700		05     X837I-CLM-PA-REF-NBR-SEG.
111800		OCCURS 2 TIMES
111900		INDEXED BY X837I-CLM-PA-REF-NBR-NDX.
112000
112100		10     X837I-CLM-PA-REF-QUAL
112200		PIC X(03).

 

Page 156 of 326

---

112300		10     X837I-CLM-PA-REF-NBR
112400		PIC X(30).
112500		10     FILLER
112600		PIC X(10).
112700
112800		05     X837I-CLM-MEDICAL-REC-NBR-SEG.
112900		10     X837I-CLM-MEDICAL-REC-NBR
113000		PIC X(30).
113100		10     FILLER
113200		PIC X(10).
113300
113400		05     X837I-CLM-DEMO-PROJ-SEG.
113500		10     X837I-CLM-DEMO-PROJ-ID
113600		PIC X(30).
113700		10     FILLER
113800		PIC X(10).
113900
114000		05     X837I-CLM-FILE-INFO-SEG
114100		OCCURS 10 TIMES
114200		INDEXED BY X837I-CLM-FILE-INFO-NDX.
114300		10     X837I-CLM-FUTURE-REQUITEMENT
114400		PIC X(80).
114500		10     FILLER
114600		PIC X(10).
114700
114800		05     X837I-CLM-NOTE-SEG
114900		OCCURS 10 TIMES
115000		INDEXED BY X837I-CLM-NOTE-NDX.
115100
115200		10     X837I-CLM-NOTE-REF-CODE
115300		PIC X(03).
115400		10     X837I-CLM-NOTE-TEXT
115500		PIC X(80).
115600		10     FILLER
115700		PIC X(10).
115800
115900		05     X837I-CLM-BILLING-NOTE-SEG.
116000
116100		10     X837I-CLM-BILLING-NOTE-TEXT
116200		PIC X(80).
116300		10     FILLER
116400		PIC X(10).
116500
116600		05     X837I-CLM-HOME-HLTH-INFO-SEG.
116700
116800		10     X837I-CLM-HH-PROGNOSIS-IND
116900		PIC X(01).
117000		10     X837I-CLM-HH-SVC-FROM-DATE
117100		PIC X(08).
117200		10     X837I-CLM-HH-CERT-FROM-DATE
117300		PIC X(08).

 

Page 157 of 326

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117400		10     X837I-CLM-HH-CERT-TO-DATE
117500		PIC X(08).
117600		10     X837I-CLM-HH-DIAG-DATE
117700		PIC X(08).
117800		10     X837I-CLM-HH-SKILL-NURSE-FAC
117900		PIC X(01).
118000		10     X837I-CLM-HH-MCARE-CVRD-IND
118100		PIC X(01).
118200		10     X837I-CLM-HH-CERT-TYPE-IND
118300		PIC X(01).
118400		10     X837I-CLM-HH-SURGERY-DATE
118500		PIC X(08).
118600		10     X837I-CLM-HH-SVC-QUAL
118700		PIC X(02).
118800		10     X837I-CLM-HH-SURG-PROC-CD
118900		PIC X(05).
119000		10     X837I-CLM-HH-PHYS-ORDER-DT
119100		PIC X(08).
119200		10     X837I-CLM-HH-LAST-VISIT-DT
119300		PIC X (08).
119400		10     X837I-CLM-HH-LAST-PHYS-CONTACT
119500		PIC X(08).
119600		10     X837I-CLM-HH-LAST-ADMIT-FRM-DT
119700		PIC X(08).
119800		10     X837I-CLM-HH-LAST-ADMIT-TO-DT
119900		PIC X(08).
120000		10     X837I-CLM-HH-TYPE-OF-FAC
120100		PIC X(01).
120200		10     X837I-CLM-HH-DIAG-2ND-DATE
120300		PIC X(08).
120400		10     X837I-CLM-HH-DIAG-2-DATE
120500		PIC X(08).
120600		10     X837I-CLM-HH-DIAG-3-DATE
120700		PIC X(08).
120800		10     X837I-CLM-HH-DIAG-4-DATE
120900		PIC X(08).
121000		10     FILLER
121100		PIC X(10).
121200
121300		05     X837I-CLM-HOME-HL-FUNC-LMT-SEG
121400		OCCURS 3 TIMES
121500		INDEXED BY X837I-CLM-HOME-HL-FUNC-LMT-NDX.
121600
121700		10     X837I-CLM-HH-LMT-IND
121800		PIC X(01).
121900		10     X837I-CLM-HH-LMT-CODE
122000		OCCURS 5 TIMES
122100		INDEXED BY X837I-CLM-HH-LMT-CODE-NDX
122200		PIC X(02).
122300		10     FILLER
122400		PIC X(10).

 

Page 158 of 326

---

122500
122600		05     X837I-CLM-HOME-HL-ACT-PERM-SEG
122700		OCCURS 3 TIMES
122800		INDEXED BY X837I-CLM-HOME-HL-ACT-PERM-NDX.
122900
123000		10     X837I-CLM-HH-ACT-PERMITTED-IND
123100		PIC X(01).
123200		10     X837I-CLM-HH-ACT-PERMIT-CD
123300		OCCURS 5 TIMES
123400		INDEXED BY X837I-CLM-HH-ACT-PERMIT-CD-NDX
123500		PIC X(02).
123600		10     FILLER
123700		PIC X(10).
123800
123900		05     X837I-CLM-HOME-HL-MENTAL-SEG
124000		OCCURS 2 TIMES
124100		INDEXED BY X837I-CLM-HOME-HL-MENTA-NDX.
124200
124300		10     X837I-CLM-HH-MENTAL-STAT-IND
124400		PIC X(01).
124500		10     X837I-CLM-HH-MENTAL-ST-CD
124600		OCCURS 5 TIMES
124700		INDEXED BY X837I-CLM-HH-MENTAL-ST-CD-NDX
124800		PIC X(02).
124900		10     FILLER
125000		PIC X(10).
125100
125200		05     X837I-CLM-DIAG-CODES-SEG.
125300
125400		10     X837I-CLM-DIAG-CODS
125500		OCCURS 3 TIMES
125600		INDEXED BY X837I-CLM-DIAG-CODES-NDX.
125700		15     X837I-CLM-DIAG-QUAL
125800		PIC X(03).
125900		15     X837I-CLM-DIAG-CODE ‘
126000		PIC X(30).
126100
126200		05     X837I-CLM-DRG-INFO-SEG.
126300
126400		10     X837I-CLM-DRG-CODE
126500		PIC X(30).
126600		10     FILLER
126700		PIC X(10).
126800
126900		05     X837I-CLM-OTHR-DIAG-INFO-SEG
127000		OCCURS 2 TIMES
127100		INDEXED BY X837I-CLM-OTHR-DIAG-INFO-NDX.
127200
127300		10     X837I-CLM-OTHR-DIAG-CODE
127400		OCCURS 12 TIMES
127500		INDEXED BY X837I-CLM-OTHR-DIAG-NDX

 

Page 159 of 326

---

127600		PIC X(30).
127700
127800		05     X837I-CLM-PRIN-PROC-INFO-SEG
127900		OCCURS 2 TIMES
128000		INDEXED BY X837I-CLM-PRIN-PROC-INFO-NDX.
128100
128200		10     X837I-CLM-PRIN-PROC-CD
128300		PIC X(30).
128400		10     FILLER
128500		PIC X(10).
128600
128700		05     X837I-CLM-OTHR-PROC-INFO-SEG
128800		OCCURS 2 TIMES
128900		INDEXED BY X837I-CLM-OTHR-PROC-INFO-NDX.
129000
129100		10     X837I-CLM-OTHR-PROC-CODE
129200		OCCURS 12 TIMES
129300		INDEXED BY X837I-CLM-OTHR-PROC-NDX.
129400		15     X837I-CLM-OTHR-PROC-QUAL
129500		PIC X(03).
129600		15     X837I-CLM-OTHR-PROC-CODE
129700		PIC X(30).
129800		15     X837I-CLM-OTHR-PROC-DATE
129900		PIC X(08).
130000
130100		05     X837I-CLM-OCC-SPAN-INFO-SEG
130200		OCCURS 2 TIMES
130300		INDEXED BY X837I-CLM-OCC-SPAN-INFO-NDX.
130400
130500		10     X837I-CLM-OCC-SPAN-CODE
130600		OCCURS 12 TIMES
130700		INDEXED BY X837I-CLM-OCC-SPAN-NDX.
130800		15     X837I-CLM-OCC-SPAN-QUAL
130900		PIC X(03).
131000		15     X837I-CLM-OCC-SPAN-CODE
131100		PIC X(30).
131200		15     X837I-CLM-OCC-SPAN-FROM-DATE
131300		PIC X(08).
131400		15     X837I-CLM-OCC-SPAN-TO-DATE
131500		PIC X(08).
131600
131700		05     X837I-CLM-OCCURRENCE-INFO-SEG
131800		OCCURS 2 TIMES
131900		INDEXED BY X837I-CLM-OCCURRENCE-INFO-NDX.
132000
132100		10     X837I-CLM-OCCURRENCE-CODE
132200		OCCURS 12 TIMES
132300		INDEXED BY X837I-CLM-OCCURRENCE-CODE-NDX.
132400		15     X837I-CLM-OCCURRENCE-QUAL
132500		PIC X (03).
132600		15     X837I-CLM-OCCURRENCE-CODE.

 

Page 160 of 326

---

132700		PIC X(30).
132800		15     X837I-CLM-OCCURRENCE-DATE
132900		PIC X(08).
133000
133100		05     X837I-CLM-VALUE-INFO-SEG
133200		OCCURS 2 TIMES
133300		INDEXED BY X837I-CLM-VALUE-INFO-NDX.
133400
133500		10     X837I-CLM-VALUE-CODE
133600		OCCURS 12 TIMES
133700		INDEXED BY X837I-CLM-VALUE-CODE-NDX.
133800		15     X837I-CLM-VALUE-QUAL
133900		PIC X(03).
134000		15     X837I-CLM-VALUE-CODE
134100		PIC X(30).
134200		15     X837I-CLM-VALUE-CD-AMT
134300		PIC S9(11)V99.
134400
134500		05     X837I-CLM-CONDITION-INFO-SEG
134600		OCCURS 2 TIMES
134700		INDEXED BY X837I-CLM-CONDITION-INFO-NDX.
134800
134900		10     X837I-CLM-CONDITION-CODE
135000		OCCURS 12 TIMES
135100		INDEXED BY X837I-CLM-CONDITION-CODE-NDX.
135200		15     X837I-CLM-CONDITION-QUAL
135300		PIC X(03).
135400		15     X837I-CLM-CONDITION-CODE
135500		PIC X(30).
135600
135700		05     X837I-CLM-TREAT-CODE-INFO-SEG
135800		OCCURS 2 TIMES
135900		INDEXED BY X837I-CLM-TREAT-CODE-INFO-NDX.
136000
136100		10     X837I-CLM-TREAT-CODE-CODE
136200		OCCURS 12 TIMES
136300		INDEXED BY X837I-CLM-TREAT-CODE-CODE-NDX.
136400		15     X837I-CLM-TREAT-CODE-CODE
136500		PIC X(30).
136600
136700		05     X837I-CLM-QUANTITY-SEG
136800		OCCURS 4 TIMES
136900		INDEXED BY X837I-CLM-QUANTITY-NDX.
137000
137100		10     X837I-CLM-QUANTITY-DAYS
137200		PIC S9(11)V99.
137300
137400		05     X837I-CLM-PRICE-REPRICE-SEG.
137500
137600		10     X837I-CLM-PRICE-METHOD
137700		PIC X(02).

 

Page 161 of 326

---

137800		10     X837I-CLM-PRICE-ALLOWED
137900		PIC S9(11)V99.
138000		10     X837I-CLM-PRICE-SAVINGS
138100		PIC S9(11)V99.
138200		10     X837I-CLM-REPRICE-ORG-ID
138300		PIC X(30).
138400		10     X837I-CLM-PRICE-RATE
138500		PIC S9(11)V9 (4).
138600		10     X837I-CLM-PRICE-APPRV-DRG-CD
138700		PIC X(30).
138800		10     X837I-CLM-PRICE-APPRV-DRG-AMT
138900		PIC S9(11)V99.
139000		10     X837I-CLM-PRICE-APPRV-REV-CD
139100		PIC X(48).
139200		10     X837I-CLM-PRICE-APPRV-PROC-CD
139300		PIC X(48).
139400		10     X837I-CLM-PRICE-MEAS-CODE
139500		PIC X(02).
139600		10     X837I-CLM-PRICE-APPRV-UNITS
139700		PIC S9(11)V99.
139800		10     X837I-CLM-PRICE-REJECT-REA
139900		PIC X(02).
140000		10     X837I-CLM-PRICE-COMPLIANCE-CD
140100		PIC X(02).
140200		10     X837I-CLM-PRICE-EXCEPTION-CD
140300		PIC X(02).
140400		10     FILLER
140500		PIC X(10).
140600
140700		LOOP-ID-2305
140800
140900		05     X837I-CLM-HOME-HEALTH-INFO
141000		OCCURS 6 TIMES
141100		INDEXED BY X837I-CLM-HOME-HEALTH-INFO-NDX.
141200
141300		10     X837I-CLM-HOME-HEALTH-INFO-SEG.
141400
141500		15     X837I-CLM-HH-DISCIPLINE-CODE
141600		PIC X(02).
141700		15     X837I-CLM-HH-TOT-VISITS
141800		PIC S9(9).
141900		15     X837I-CLM-HH-TOT-VISITS-PROJ
142000		PIC S9(9).
142100
142200		10     X837I-CLM-HOME-HEALTH-DELV-SEG
142300		OCCURS 12 TIMES
142400		INDEXED BY X837I-CLM-HOME-HEALTH-DELV-NDX.
142500
142600		15     X837I-CLM-HH-NBR-VISITS
142700		PIC S9(09).
142800		15     X837I-CLM-HH-VISIT-FREQ

 

Page 162 of 326

---

142900		PIC X(02).
143000		15     X837I-CLM-HH-FREQ-COUNT
143100		PIC S9(5).
143200		15     X837I-CLM-HH-VISIT-UNITS
143300		PIC X(02).
143400		15     X837I-CLM-HH-NBR-OF-UNITS
143500		PIC S9(9).
143600		15     X837I-CLM-HH-VISIT-PATTERN
143700		PIC X(02).
143800		15     X837I-CLM-HH-TIME-CODE
143900		PIC X(01).
144000
144100		10     FILLER
144200		PIC X(10).
144300
144400		LOOP-ID-2310A
144500
144600		05     X837I-CLM-ATND-PHY-NAME-SEG.
144700
144800		10     X837I-CLM-ATND-PHY-NME-QUAL
144900		PIC X(01).
145000		10     X837I-CLM-ATND-PHY-NM-LAST
145100		PIC X(35).
145200		10     X837I-CLM-ATND-PHY-NM-FIRST
145300		PIC X(25).
145400		10     X837I-CLM-ATND-PHY-NM-MIDDLE
145500		PIC X(25).
145600		10     X837I-CLM-ATND-PHY-NM-SFX
145700		PIC X(10).
145800		10     X837I-CLM-ATND-PHY-ID-QUAL
145900		PIC X(02).
146000		10     X837I-CLM-ATND-PHY-ID-NBR
146100		PIC X(80).
146200		10     FILLER
146300		PIC X(10).
146400
146500		05     X837I-CLM-ATND-PHY-SPEC-SEG.
146600
146700		10     X837I-CLM-ATND-PHY-PROV-CODE
146800		PIC X(03).
146900		10     X837I-CLM-ATND-PHY-SPEC-CODE
147000		PIC X(30).
147100		10     FILLER
147200		PIC X(10).
147300
147400		05     X837I-CLM-ATND-PHY-2ND-ID-SEG
147500		OCCURS 5 TIMES
147600		INDEXED BY X837I-CLM-ATND-PHY-2ND-ID-NDX.
147700
147800		10     X837I-CLM-ATND-PHY-2ND-ID-CODE
147900		PIC X(03).

 

Page 163 of 326

---

148000		10     X837I-CLM-ATND-PHY-2ND-ID
148100		PIC X(30).
148200		10     FILLER
148300		PIC X(10).
148400
148500		LOOP-ID-2310B
148600
148700		05     X837I-CLM-OPER-PHY-NAME-SEG.
148800
148900		10     X837I-CLM-OPER-PHY-NME-QUAL
149000		PIC X(01).
149100		10     X837I-CLM-OPER-PHY-NM-LAST
149200		PIC X(35).
149300		10     X837I-CLM-OPER-PHY-NM-FIRST
149400		PIC X(25).
149500		10     X837I-CLM-OPER-PHY-NM-MIDDLE
149600		PIC X(25).
149700		10     X837I-CLM-OPER-PHY-NM-SFX
149800		PIC X(10).
149900		10     X837I-CLM-OPER-PHY-ID-QUAL.
150000		PIC X(02).
150100		10     X837I-CLM-OPER-PHY-ID-NBR
150200		PIC X(80).
150300		10     FILLER
150400		PIC X(10).
150500
150600		05     X837I-CLM-OPER-PHY-SPEC-SEG.
150700
150800		10     X837I-CLM-OPER-PHY-PROV-CODE
150900		PIC X(03).
151000		10     X837I-CLM-OPER-PHY-SPEC-CODE
151100		PIC X(30).
151200		10     FILLER
151300		PIC X(10).
151400
151500		05     X837I-CLM-OPER-PHY-2ND-ID-SEG
151600		OCCURS 5 TIMES
151700		INDEXED BY X837I-CLM-OPER-PHY-2ND-ID-NDX.
151800
151900		10     X837I-CLM-OPER-PHY-2ND-ID-CODE
152000		PIC X(03).
152100		10     X837I-CLM-OPER-PHY-2ND-ID
152200		PIC X(30).
152300		10     FILLER
152400		PIC X(10).
152500
152600		LOOP-ID-2310C
152700
152800		05     X837I-CLM-OTHR-PROV-NAME-SEG.
152900
153000		10     X837I-CLM-OTHR-PROV-NME-QUAL

 

Page 164 of 326

---

153100		PIC X(01).
153200		10     X837I-CLM-OTHR-PROV-NM-LAST
153300		PIC X(35).
153400		10     X837I-CLM-OTHR-PROV-NM-FIRST
153500		PIC X(25).
153600		10     X837I-CLM-OTHR-PROV-NM-MIDDLE
153700		PIC X(25).
153800		10     X837I-CLM-OTHR-PROV-NM-SFX
153900		PIC X(10).
154000		10     X837I-CLM-OTHR-PROV-ID-QUAL
154100		PIC X(02).
154200		10     X837I-CLM-OTHR-PROV-ID-NBR
154300		PIC X(80).
154400		10     FILLER
154500		PIC X(10).
154600
154700		05     X837I-CLM-OTHR-PROV-SPEC-SEG.
154800
154900		10     X837I-CLM-OTHR-PROV-PROV-CODE
155000		PIC X(03).
155100		10     X837I-CLM-OTHR-PROV-SPEC-CODE
155200		PIC X(30).
155300		10     FILLER
155400		PIC X(10).
155500
155600		05     X837I-CLM-OTHR-PROV-2ND-ID-SEG
155700		OCCURS 5 TIMES
155800		INDEXED BY X837I-CLM-OTHR-PROV-2ND-ID-NDX.
155900
156000		10     X837I-CLM-OTHR-PROV-2ND-ID-CD
156100		PIC X(03).
156200		10     X837I-CLM-OTHR-PROV-2ND-ID
156300		PIC X(30).
156400		10     FILLER
156500		PIC X(10).
156600
156700		LOOP-ID-2310E
156800		05     X837I-CLM-SVC-FAC-LOC-SEG.
156900
157000		10     X837I-CLM-SVC-FAC-NAME
157100		PIC X(35).
157200		10     X837I-CLM-SVC-FAC-ID-QUAL
157300		PIC X(02).
157400		10     X837I-CLM-SVC-FAC-ID
157500		PIC X(80).
157600		10     FILLER
157700		PIC X(10).
157800
157900		05     X837I-CLM-SVC-FAC-SPEC-SEG.
158000
158100		10     X837I-CLM-SVC-FAC-SPEC-CODE

 

Page 165 of 326

---

158200		PIC X(30).
158300		10     FILLER
158400		PIC X(10).
158500
158600		05     X837I-CLM-SVC-FAC-LOC-ADDR-SEG.
158700
158800		10     X837I-CLM-SVC-FAC-ADDR1
158900		PIC X(55).
159000		10     X837I-CLM-SVC-FAC-ADDR2
159100		PIC X(55).
159200		10     FILLER
159300		PIC X(10).
159400
159500		05     X837I-CLM-SVC-FAC-CTY-ST-SEG.
159600
159700		10     X837I-CLM-SVC-FAC-CITY
159800		PIC X(30).
159900		10     X837I-CLM-SVC-FAC-STATE-CODE
160000		PIC X(02).
160100		10     X837I-CLM-SVC-FAC-ZIP-CODE
160200		PIC X(15).
160300		10     X837I-CLM-SVC-FAC-COUNTRY-CODE
160400		PIC X(03).
160500		10     FILLER
160600		PIC X(10).
160700
160800		05     X837I-CLM-SVC-FAC-2ND-ID-SEG
160900		OCCURS 5 TIMES
161000		INDEXED BY X837I-CLM-SVC-FAC-2ND-ID-NDX.
161100
161200		10     X837I-CLM-SVC-FAC-2ND-ID-TYPE
161300		PIC X(03).
161400		10     X837I-CLM-SVC-FAC-2ND-ID
161500		PIC X(30).
161600		10     FILLER
161700		PIC X(10).
161800
161900		OTHER SUBSCRIBER INFORMATION IN SEPARATE RECORD
162000		CLAIM LEVEL ADJUSTMENTS IN SEPARATE RECORD
162100
162200
162300
162400		837I-OTHER SUBSCRIBER INFORMAION
162500
162600
162700
162800		837I OTHER SUBSCRIBER INFORMATION
162900
163000		01     X837I-OTHER-SUBSCRIBER-INFO.
163100
163200		05     X837I-RECORD-CODE

 

Page 166 of 326

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163300		PIC X(02).
163400
163500		05     X837I-SORT-KEY.
163600
163700		10     X837I-PROV-SEQ-NUM
163800		VALUE ZEROES
163900		PIC 9(11).
164000
164100		10     X837I-SUBSCRIBER-SEQ-NUM
164200		VALUE ZEROES
164300		PIC 9(11).
164400
164500		10     X837I-PATIENT-SEQ
164600		VALUE ZEROES
164700		PIC 9(11).
164800
164900		10     X837I-CLAIM-SEQ
165000		VALUE ZEROES
165100		PIC 9(11).
165200
165300		10     X837I-SVC-LINE-SEQ
165400		VALUE ZEROES
165500		PIC 9(11).
165600
165700
165800		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
165900		‘OTHER-SUBSCRIBER-INFO RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
166000		:
166100
166200		10     X837I-SUB-SEQ
166300		VALUE ZEROES
166400		PIC 9(11).
166500
166600		10     X837I-TX-CODE
166700		VALUE ‘05’
166800		PIC X(02).
166900
167000		10     X837I-TX-CODE-SEQ-NUM
167100		VALUE ZEROES.
167200		PIC 9(07).
167300
167400		END OF HDR SORT-KEY
167500
167700
167800		LOOP-2320 OTHER SUBSCRIBER INFORMATION – START
167900
168000		05     X837I-OTHR-SUBS-INFO-SEG.
168100
168200		10     X837I-PAYER-RESPONS-CODE
168300		PIC 9(01).

 

Page 167 of 326

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168400		10     X837I-INDIVIDUAL-RELAT-CODE
168500		PIC 9(02).
168600		10     X837I-OTHR-SUBS-POLICY-NBR
168700		PIC X(30).
168800		10     X837I-OTHR-SUBS-PLAN-NAME
168900		PIC X(60).
169000		10     X837I-OTHR-SUBS-FILING-IND-CD
169100		PIC 9(02).
169200		10     FILLER
169300		PIC X(10).
169400
169500		05     X837I-PAYER-PRIOR-PAY-AMT
169600		PIC S9(11)V99.
169700
169800		05     X837I-COB-TOT-ALLOWED-AMT
169900		PIC S9(11)V99.
170000
170100		05     X837I-COB-TOT-SUBMITTED-AMT
170200		PIC S9(11)V99.
170300
170400		05     X837I-DRG-OUTLIER-AMT
170500		PIC S9(11)V99.
170600
170700		05     X837I-COB-TOT-MCARE-PAID-AMT
170800		PIC S9(11)V99.
170900
171000		05     X837I-MCARE-PAID-AT-100-PCT
171100		PIC S9(11)V99.
171200
171300		05     X837I-MCARE-PAID-AT-80-PCT
171400		PIC S9(11)V99.
171500
171600		05     X837I-COB-MCARE-A-PAID-AMT
171700		PIC S9(11)V99.
171800
171900		05     X837I-COB-MCARE-B-PAID-AMT
172000		PIC S9(11)V99.
172100
172200		05     X837I-COB-NON-COVERED-AMT
172300		PIC S9(11)V99.
172400
172500		05     X837I-COB-TOT-DENIED-AMT
172600		PIC S9(11)V99.
172700
172800		05     X837I-OTHR-SUBS-DEMO-SEG.
172900
173000		10     X837I-OTH-SUBS-OTHR-INSRD-DOB
173100		PIC X(08).
173200		10     X837I-OTH-SUBS-OTHR-GENDER-CD
173300		PIC X(01).
173400		10     FILLER

 

Page 168 of 326

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173500		PIC X(10).
173600
173700		05     X837I-OTHR-INS-COVRG-INFO-SEG.
173800
173900		10     X837I-ASSIGNMENT-OF-BENE-IND
174000		PIC X(01).
174100		10     X837I-RELEASE-INFO-CODE
174200		PIC X(01).
174300		10     FILLER
174400		PIC X(10).
174500
174600		05     X837I-MCARE-IP-AJUDICATION-SEG.
174700
174800		10     X837I-IP-COVERED-DAYS
174900		PIC S9(6)V99.
175000		10     X837I-IP-LIFETIME-RSRV-DAYS
175100		PIC S9(6)V99.
175200		10     X837I-IP-LIFETIME-PSYC-DAYS
175300		PIC S9(6)V99.
175400		10     X837I-IP-DRG-AMT-DAYS
175500		PIC S9(11)V99.
175600		10     X837I-IP-REMARK-CODE
175700		PIC X(30).
175800		10     X837I-IP-DISPROPORT-SHARE-AMT
175900		PIC S9(11)V99.
176000		10     X837I-IP-MSP-PASS-THRU-AMT
176100		PIC S9(11)V99.
176200		10     X837I-IP-PPS-CAPITAL-AMT
176300		PIC S9(11)V99.
176400		10     X837I-IP-PPS-FSP-DRG-AMT
176500		PIC S9(11)V99.
176600		10     X837I-IP-PPS-HSP-DRG-AMT
176700		PIC S9(11)V99.
176800		10     X837I-IP-PPS-DSH-DRG-AMT
176900		PIC S9(11)V99.
177000		10     X837I-IP-OLD-CAPITAL-AMT
177100		PIC S9(11)V99.
177200		10     X837I-IP-PPS-IME-AMT
177300		PIC S9(11)V99.
177400		10     X837I-IP-PPS-OPER-HOSP-DRG-AMT
177500		PIC S9(11)V99.
177600		10     X837I-IP-COST-RTP-DAY-COUNT
177700		PIC S9(9)V99.
177800		10     X837I-IP-PPS-OPER-FED-DRG-AMT
177900		PIC S9(11)V99.
178000		10     X837I-IP-PPS-CAP-OUTLIER-AMT
178100		PIC S9(11)V99.
178200		10     X837I-IP-INDIRECT-TEACH-AMT
178300		PIC S9(11)V99.
178400		10     X837I-IP-NONPAY-PROF-CMPNT-AMT
178500		PIC S9(11)V99.

 

Page 169 of 326

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178600		10     X837I-IP-RMARK-CODE-1
178700		PIC X(30).
178800		10     X837I-IP-RMARK-CODE-2
178900		PIC X(30).
179000		10     X837I-IP-RMARK-CODE-3
179100		PIC X(30).
179200		10     X837I-IP-RMARK-CODE-4
179300		PIC X(30).
179400		10     X837I-IP-PPS-CAP-EXCEPT-AMT
179500		PIC S9(11)V99.
179600
179700		05     X837I-MCARE-OP-AJUDICATION-SEG.
179800
179900		10     X837I-OP-REIMBURSEMENT-RATE
180000		PIC S9(4)V9(4).
180100		10     X837I-HCPCS-PAYABLE-AMOUNT
180200		PIC S9(11)V99.
180300		10     X837I-MCARE-OP-REMARKS
180400		OCCURS 5 TIMES
180500		INDEXED BY X837I-MCARE-OP-REMARKS-NDX.
180600		15     X837I-MCARE-OP-REMARKS-CODE
180700		PIC X(30).
180800		10     X837I-ESRD-PAID-AMOUNT
180900		PIC S9(11)V99.
181000		10     X837I-IP-NONPAY-PROF-CMPNT-AMT
181100		PIC S9(9)V99.
181200		10     FILLER
181300		PIC X(10).
181400
181500		CLAIM LEVEL ADJUSTMENTS ON SEPARATE RECORD
181600		LOOP-2330A OTHR SUBSCRIBER NAME
181700
181800		05     X837I-OTHR-SUBS-NAME-SEG.
181900
182000		10     X837I-OTHR-SUBS-TYPE-CODE
182100		PIC X(01).
182200		10     X837I-OTHR-SUBS-NAME-LAST
182300		PIC X(35).
182400		10     X837I-OTHR-SUBS-NAME-FIRST
182500		PIC X(25).
182600		10     X837I-OTHR-SUBS-NAME-MIDDLE
182700		PIC X(25).
182800		10     X837I-OTHR-SUBS-NAME-SFX
182900		PIC X(10).
183000		10     X837I-OTHR-SUBS-ID-CODE-TYPE
183100		PIC X(02).
183200		10     X837I-OTHR-SUBS-ID-CODE
183300		PIC X(80).
183400		10     FILLER
183500		PIC X(10).
183600

 

Page 170 of 326

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183700		05     X837I-OTHR-SUBS-ADDR-SEG.
183800
183900		10     X837I-OTHR-SUBS-ADDR1
184000		PIC X(55).
184100		10     X837I-OTHR-SUBS-ADDR2
184200		PIC X(55).
184300		10     FILLER
184400		PIC X(10).
184500
184600		05     X837I-OTHR-SUBS-CITY-STATE-SEG.
184700
184800		10     X837I-OTHR-SUBS-CITY
184900		PIC X(30).
185000		10     X837I-OTHR-SUBS-STATE-CODE
185100		PIC X(02).
185200		10     X837I-OTHR-SUBS-ZIP-CODE
185300		PIC X(15).
185400		10     X837I-OTHR-SUBS-COUNTRY-CODE
185500		PIC X(03).
185600		10     FILLER
185700		PIC X(10).
185800
185900		05     X837I-OTHR-SUBS-2ND-ID-SEG
186000		OCCURS 3 TIMES
186100		INDEXED BY X837I-OTHR-SUBS-2ND-ID-NDX.
186200
186300		10     X837I-OTHR-SUBS-2ND-ID-TYPE
186400		PIC X(03).
186500		10     X837I-OTHR-SUBS-2ND-ID
186600		PIC X(30).
186700		10     FILLER
186800		PIC X(10).
186900
187000		LOOP-2330B OTHR PAYER NAME
187100
187200		05     X837I-OTHR-PAYER-NAME-SEG.
187300
187400		10     X837I-OTHR-PAYER-NAME
187500		PIC X(35).
187600		10     X837I-OTHR-PAYER-ID-CODE-TYPE
187700		PIC X(02).
187800		10     X837I-OTHR-PAYER-ID-CODE
187900		PIC X(80).
188000		10     FILLER
188100		PIC X(10).
188200
188300		05     X837I-OTHR-PAYER-ADDR-SEG.
188400
188500		10     X837I-OTHR-PAYER-ADDR1
188600		PIC X(55).
188700		10     X837I-OTHR-PAYER-ADDR2

 

Page 171 of 326

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188800		PIC X(55).
188900		10     FILLER
189000		PIC X(10).
189100
189200		05     X837I -OTHR-PAYER-CITY-ST-SEG.
189300
189400		10     X837I-OTHR-PAYER-CITY
189500		PIC X(30).
189600		10     X837I-OTHR-PAYER-STATE-CODE
189700		PIC X(02).
189800		10     X837I-OTHR-PAYER-ZIP-CODE
189900		PIC X(15).
190000		10     X837I-OTHR-PAYER-COUNTRY-CODE
190100		PIC X(03).
190200		10     FILLER
190300		PIC X(10).
190400
190500		05     X837I -CLAIM-ADJUD-DATE-SEG.
190600		10     X837I-CLAIM-ADJUD-DATE
190700		PIC X(08).
190800
190900		05     X837I -OTHR-PAYER-2ND-IDENT-SEG
191000		OCCURS 2 TIMES
191100		INDEXED BY X837I-OTHR-PAYER-2ND-IDENT-NDX.
191200
191300		10     X837I-OTHR-PAYER-2ND-ID-TYPE
191400		PIC X(03).
191500		10     X837I-OTHR-PAYER-2ND-ID
191600		PIC X(30).
191700		10     FILLER
191800		PIC X(10).
191900
192000		05     X837I -OTHR-PAYER-PA-REF-SEG.
192100
192200		10     X837I-OTHR-PAYER-PA-REF-IND
192300		PIC X(03).
192400		10     X837I-OTHR-PAYER-PA-REF-NUMBER
192500		PIC X(30).
192600		10     FILLER
192700		PIC X(10).
192800
192900		LOOP-2330C OTHR PAYER PATIENT
193000
193100		05     X837I -OTHR-PAYER-▇▇▇-INFO-SEG.
193200
193300		10     X837I-OTHR-PAYER-▇▇▇-ID-QUAL
193400		PIC X(02).
193500		10     X837I-OTHR-PAYER-▇▇▇-ID-NBR
193600		PIC X(80).
193700		10     FILLER
193800		PIC X(10).

 

Page 172 of 326

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193900
194000		05     X837I-OTHR-PAYER-▇▇▇-ID-SEG.
194100
194200		10     X837I-OTHR-PAYER-▇▇▇-ID2-QUAL
194300		PIC X(02).
194400		10     X837I-OTHR-PAYER-▇▇▇-ID3-NBR
194500		PIC X(30).
194600		10     FILLER
194700		PIC X(10).
194800
194900		LOOP-2330D OTHR PAYER ATTENDING PROVIDER
195000
195100		05     X837I-OTHR-PYR-ATND-PROV-SEG.
195200
195300		10     X837I-OTHR-PYR-ATND-PROV-QUAL
195400		PIC X(01).
195500		10     FILLER
195600		PIC X(10).
195700
195800		05     X837I-OTHR-PYR-ATND-PRV-ID-SEG
195900		OCCURS 3 TIMES
196000		INDEXED BY X837I-OTHR-PYR-ATND-PRV-ID-NDX.
196100
196200		10     X837I-OTHR-PYR-ATND-PRV-ID-QL
196300		PIC X(03).
196400		10     X837I-OTHR-PYR-ATND-PRV-ID
196500		PIC X(30).
196600		10     FILLER
196700		PIC X(10).
196800
196900		LOOP-2330E OTHR PAYER OPERATING PROVIDER
197000
197100		05     X837I-OTHR-PYR-OPER-PROV-SEG.
197200
197300		10     X837I-OTHR-PYR-OPER-PROV-QUAL
197400		PIC X(01).
197500		10     FILLER
197600		PIC X(10).
197700
197800		05     X837I-OTHR-PYR-OPER-PRV-ID-SEG
197900		OCCURS 3 TIMES
198000		INDEXED BY X837I-OTHR-PYR-OPER-PRV-ID-NDX.
198100
198200		10     X837I-OTHR-PYR-OPER-PRV-ID-QL
198300		PIC X(03).
198400		10     X837I-OTHR-PYR-OPER-PRV-ID
198500		PIC X(30).
198600		10     FILLER
198700		PIC X(10).
198800
198900		LOOP-2330E OTHR PAYER OTHER PROVIDER

 

Page 173 of 326

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199000
199100		05     X837I-OTHR-PYR-OTHR-PROV-SEG.
199200
199300		10     X837I-OTHR-PYR-OTHR-PROV-QUAL
199400		PIC X(01).
199500		10     FILLER
199600		PIC X(10).
199700
199800		05     X837I-OTHR-PYR-OTHR-PRV-ID-SEG
199900		OCCURS 3 TIMES
200000		INDEXED BY X837I-OTHR-PYR-OTHR-PRV-ID-NDX.
200100
200200		10     X837I-OTHR-PYR-OTHR-PRV-ID-QL
200300		PIC X(03).
200400		10     X837I-OTHR-PYR-QTHR-PRV-ID
200500		PIC X(30).
200600		10     FILLER
200700		PIC X(10).
200800
200900		LOOP-2330H OTHR PAYER SERVICE FACILITY PROVIDER
201000
201100		05     X837I-OTHR-PYR-FAC-PROV-SEG.
201200
201300		10     X837I-OTHR-PYR-FAC-PROV-QUAL
201400		PIC X(01).
201500		10     FILLER
201600		PIC X(10).
201700
201800		05     X837I-OTHR-PYR-FAC-PRV-ID-SEG
201900		OCCURS 3 TIMES
202000		INDEXED BY X837I-OTHR-PYR-FAC-PRV-ID-NDX.
202100
202200		10     X837I-OTHR-PYR-FAC-PRV-ID-QL
202300		PIC X(03).
202400		10     X837I-OTHR-PYR-FAC-PRV-ID
202500		PIC X(30).
202600		10     FILLER
202700		PIC X(10).
202800
202900
203000
203100
203200		8371 - CLAIM LEVEL-ADJUSTMENT (99)
203300
203400
203500
203600		8371 CLAIM LEVEL ADJUSTMENT
203700
203800		01     X837I-CLAIM-LVL-ADJUSTMENT.
203900
204000		05     X837I-RECORD-CODE

 

Page 174 of 326

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204100		PIC X(02).
204200
204300		05     X837I-SORT-KEY.
204400
204500		10     X837I-PROV-SEQ-NUM
204600		VALUE ZEROES
204700		PIC 9(11).
204800
204900		10     X837I-SUBSCRIBER-SEQ-NUM
205000		VALUE ZEROES
205100		PIC 9(11).
205200
205300		10     X837I-PATIENT-SEQ
205400		VALUE ZEROES
205500		PIC 9(11).
205600
205700		10     X837I-CLAIM-SEQ
205800		VALUE ZEROES
205900		PIC 9(11).
206000
206100		10     X837I-SVC-LINE-SEQ
206200		VALUE ZEROES
206300		PIC 9(11).
206400
206500
206600		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
206700		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORD.
206800
206900
207000		10     X837I-SUB-SEQ
207100		VALUE ZEROES
207200		PIC 9(11).
207300
207400		10     X837I-TX-CODE
207500		VALUE ‘06’
207600		PIC X(02).
207700
207800		10     X837I-TX-CODE-SEQ-NUM
207900		VALUE ZEROES
208000		PIC 9(07).
208100
208200		END OF HDR SORT-KEY
208300
208400
208500
208600		05     X837I-CLAIM-ADJ-SEG
208700		OCCURS 05 TIMES
208800		INDEXED BY X837I-CLAIM-ADJ-NDX.
208900
209000		10     X837I-CLAIM-ADJ-GROUP-CODE
209100		PIC X(02).

 

Page 175 of 326

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209200		10     X837I-CLAIM-ADJ
209300		OCCURS 6 TIMES
209400		INDEXED BY X837I-CLAIM-ADJ-NDX.
209500		15     X837I-CLAIM-ADJ-REASON-CD
209600		PIC X(05).
209700		15     X837I-CLAIM-ADJ-AMOUNT
209800		PIC S9(11)V99.
209900		15     X837I-CLAIM-ADJ-UNITS
210000		PIC S9(7)V9(4).
210100
210200
210300
210400
210500		837I - CLAIM-SERVICE-LINE (MAX 50)
210600
210700
210800
210900		837I CLAIM SERVICE LINE
211000
211100		01     X837I-CLAIM-SVC-LINE.
211200
211300		05     X837I-RECORD-CODE
211400		PIC X(02).
211500
211600		05     X837I-SORT-KEY.
211700
211800		10     X837I-PROV-SEQ-NUM
211900		VALUE ZEROES
212000		PIC 9(11).
212100
212200		10     X837I-SUBSCRIBER-SEQ-NUM
212300		VALUE ZEROES
212400		PIC 9(11).
212500
212600		10     X837I-PATIENT-SEQ
212700		VALUE ZEROES
212800		PIC 9(11).
212900
213000		10     X837I-CLAIM-SEQ
213100		VALUE ZEROES
213200		PIC 9(11).
213300
213400		10     X837I-SVC-LINE-SEQ
213500		VALUE ZEROES
213600		PIC 9(11).
213700
213800
213900		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’WHEN USED ON A
214000		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
214100
214200

 

Page 176 of 326

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214300		10     X837I-SUB-SEQ
214400		VALUE ZEROES
214500		PIC 9(11).
214600
214700		10     X837I-TX-CODE
214800		VALUE ‘07’
214900		PIC X(02).
215000
215100		10     X837I-TX-CODE-SEQ-NUM
215200		VALUE ZEROES
215300		PIC 9(07).
215400
215500		END OF HDR SORT-KEY
215600
215700
215800
215900		LOOP-ID-2400
216000
216100		05     X837I-LN-ASSIGNED-NBR-SEG.
216200
216300		10     X837I-LN-ASSIGNED-NBR
216400		PIC S9(9).
216500
216600		05     X837I-LN-INSTITUTIONAL-SVC-SEG.
216700
216800		10     X837I-LN-REV-CODE
216900		PIC X(48).
217000		10     X837I-LN-SVC-ID-QUAL
217100		PIC X(02).
217200		10     X837I-LN-PROC-CODE
217300		PIC X(48).
217400		10     X837I-LN-PROC-MOD-1
217500		PIC X(02).
217600		10     X837I-LN-PROC-MOD-2
217700		PIC X(02).
217800		10     X837I-LN-PROC-MOD-3
217900		PIC X(02).
218000		10     X837I-LN-PROC-MOD-4
218100		PIC X(02).
218200		10     X837I-LN-SUBMITTED-CHRG
218300		PIC S9(11)V99.
218400		10     X837I-LN-SVC-CD-MEAS-TYPE
218500		PIC X(02).
218600		10     X837I-LN-SVC-CD-UNITS
218700		PIC S9(7)V9(4).
218800		10     X837I-LN-SVC-RATE
218900		PIC S9(7)V9(4).
219000		10     X837I-LN-NON-CVRD-CHARG-AMT
219100		PIC S9(11)V9(2).
219200		10     FILLER
219300		PIC X(10).

 

Page 177 of 326

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219400
219500		05     X837I-LN-SUPPLMENT-INFO-SEG
219600		OCCURS 5 TIMES
219700		INDEXED BY X837I-LN-SUPPLMENT-INFO-NDX.
219800
219900		10     X837I-LN-ATTACHMENT-TYPE
220000		PIC X(02).
220100		10     X837I-LN-ATTCH-TRANSMIT-CODE
220200		PIC X(02).
220300		10     X837I-LN-ATTACHMENT-CNTL-NBR
220400		PIC X(80).
220500		10     FILLER
220600		PIC X(10).
220700
220800		05     X837I-LN-SVC-DATE-SEG
220900		PIC X(08).
221000
221100		05     X837I-LN-ASSESMENT-DATE-SEG
221200		PIC X(08).
221300
221400		05     X837I-LN-SVC-TAX-AMT-SEG
221500		PIC S9(11)V99.
221600
221700		05     X837I-LN-FACILITY-TAX-AMT-SEG
221800		PIC S9(11)V99.
221900
222000		05     X837I-LN-PRICE-REPRICE-SEG.
222100
222200		10     X837I-LN-PRICE-METHOD
222300		PIC X(02).
222400		10     X837I-LN-PRICE-ALLOWED
222500		PIC S9(11)V99.
222600		10     X837I-LN-PRICE-SAVINGS
222700		PIC S9(11)V99.
222800		10     X837I-LN-REPRICE-ORG-ID
222900		PIC X(30).
223000		10     X837I-LN-PRICE-RATE
223100		PIC S9(11)V9(4).
223200		10     X837I-LN-PRICE-APG-CODE
223300		PIC X(30).
223400		10     X837I-LN-PRICE-APG-AMT
223500		PIC S9(11)V99.
223600		10     X837I-LN-PRICE-APPRV-REV-CD
223700		PIC X(48).
223800		10     X837I-LN-PRICE-SVC-QUAL
223900		PIC X(02).
224000		10     X837I-LN-PRICE-APPRV-PROC-CD
224100		PIC X(48).
224200		10     X837I-LN-PRICE-UNIT-MEAS-CD
224300		PIC X(02).
224400		10     X837I-LN-PRICE-APPROVED-UNITS

 

 

Page 178 of 326

---

224500		PIC S9(7)V9(4).
224600		10     X837I-LN-PRICE-REJECT-REA
224700		PIC X(02).
224800		10     X837I-LN-PRICE-COMPLIANCE-CD
224900		PIC X(02).
225000		10     X837I-LN-PRICE-EXCEPTION-CD
225100		PIC X(02).
225200		10     FILLER
225300		PIC X(10).
225400
225500		LOOP-ID-2420A
225600
225700		05     X837I-LN-ATND-PHY-NAME-SEG.
225800
225900		10     X837I-LN-ATND-PHY-NME-TP
226000		PIC X(01).
226100		10     X837I-LN-ATND-PHY-NM-LAST
226200		PIC X(35).
226300		10     X837I-LN-ATND-PHY-NM-FIRST
226400		PIC X(25).
226500		10     X837I-LN-ATND-PHY-NM-MIDDLE
226600		PIC X(25).
226700		10     X837I-LN-ATND-PHY-NM-SFX
226800		PIC X(10).
226900		10     X837I-LN-ATND-PHY-ID-CODE
227000		PIC X(02).
227100		10     X837I-LN-ATND-PHY-ID-NBR
227200		PIC X(80).
227300		10     FILLER
227400		PIC X(10).
227500
227600		05     X837I-LN-ATND-PHY-SPEC-SEG.
227700
227800		10     X837I-LN-ATND-PHY-TYPE-CODE
227900		PIC X(03).
228000		10     X837I-LN-ATND-PHY-SPEC-CODE
228100		PIC X(30).
228200		10     FILLER
228300		PIC X(10).
228400
228500		05     X837I-LN-ATND-PHY-2ND-ID-SEG.
228600
228700		10     X837I-LN-ATND-PHY-2ND-ID-CD
228800		PIC X(03).
228900		10     X837I-LN-ATND-PHY-2ND-ID
229000		PIC X(30).
229100		10     FILLER
229200		PIC X(10).
229300
229400		LOOP-ID-2420B
229500

 

Page 179 of 326

---

229600		05     X837I-LN-OPER-PHY-NAME-SEG.
229700
229800		10     X837I-LN-OPER-PHY-NME-TP
229900		PIC X(01).
230000		10     X837I-LN-OPER-PHY-NM-LAST
230100		PIC X(35).
230200		10     X837I-LN-OPER-PHY-NM-FIRST
230300		PIC X(25).
230400		10     X837I-LN-OPER-PHY-NM-MIDDLE
230500		PIC X(25).
230600		10     X837I-LN-OPER-PHY-NM-SFX
230700		PIC X(10).
230800		10     X837I-LN-OPER-PHY-ID-CODE
230900		PIC X(02).
231000		10     X837I-LN-OPER-PHY-ID-NBR
231100		PIC X(80).
231200		10     FILLER
231300		PIC X(10).
231400
231500		05     X837I-LN-OPER-PHY-SPEC-SEG.
231600
231700		10     X837I-LN-OPER-PHY-TYPE-CODE
231800		PIC X(03).
231900		10     X837I-LN-OPER-PHY-SPEC-CODE
232000		PIC X(30).
232100		10     FILLER
232200		PIC X(10)
232300
232400		05     X837I-LN-OPER-PHY-2ND-ID-SEG.
232500
232600		10     X837I-LN-OPER-PHY-2ND-ID-CD
232700		PIC X(03).
232800		10     X837I-LN-OPER-PHY-2ND-ID
232900		PIC X(30).
233000		10     FILLER
233100		PIC X(10).
233200
233300		LOOP-ID-2420C
233400
233500		05     X837I-LN-OTHR-PROV-NAME-SEG.
233600
233700		10     X837I-LN-OTHR-PROV-NME-TP
233800		PIC X(01).
233900		10     X837I-LN-OTHR-PROV-NM-LAST
234000		PIC X(35).
234100		10     X837I-LN-OTHR-PROV-NM-FIRST
234200		PIC X(25).
234300		10     X837I-LN-OTHR-PROV-NM-MIDDLE
234400		PIC X(25).
234500		10     X837I-LN-OTHR-PROV-NM-SFX
234600		PIC X(10).

 

Page 180 of 326

---

234700		10     X837I-LN-OTHR-PROV-ID-CODE
234800		PIC X(02).
234900		10     X837I-LN-OTHR-PROV-ID-NBR
235000		PIC X(80).
235100		10     FILLER
235200		PIC X(10).
235300
235400		05     X837I-LN-OTHR-PROV-SPEC-SEG.
235500
235600		10     X837I-LN-OTHR-PROV-TYPE-CODE
235700		PIC X(03).
235800		10     X837I-LN-OTHR-PROV-SPEC-CODE
235900		PIC X(30).
236000		10     FILLER
236100		PIC X(10).
236200
236300		05     X837I-LN-OTHR-PROV-2ND-ID-SEG.
236400
236500		10     X837I-LN-OTHR-PROV-2ND-ID-CD
236600		PIC X(03).
236700		10     X837I-LN-OTHR-PROV-2ND-ID
236800		PIC X(30).
236900		10     FILLER
237000		PIC X(10).
237100
237200
237300
237400
237500		837I - LINE-DRUG-ID (MAX 25)
237600
237700
237800
237900		837I LINE DRUG IDENTIFICATION
238000
238100		01     X837I-LINE-DRUG-ID.
238200
238300		05     X837I-RECORD-CODE
238400		PIC X(02).
238500
238600		05     X837I-SORT-KEY.
238700
238800		10     X837I-PROV-SEQ-NUM
238900		VALUE ZEROES
239000		PIC 9(11).
239100
239200		10     X837I-SUBSCRIBER-SEQ-NUM
239300		VALUE ZEROES
239400		PIC 9(11).
239500
239600		10     X837I-PATIENT-SEQ
239700		VALUE ZEROES

 

Page 181 of 326

---

239800		PIC 9(11).
239900
240000		10     X837I-CLAIM-SEQ
240100		VALUE ZEROES
240200		PIC 9(11).
240300
240400		10     X837I-SVC-LINE-SEQ
240500		VALUE ZEROES
240600		PIC 9(11).
240700
240800
240900		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
241000		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
241100
241200
241300		10     X837I-SUB-SEQ
241400		VALUE ZEROES
241500		PIC 9(11).
241600
241700		10     X837I-TX-CODE
241800		VALUE ‘08’
241900		PIC X(02).
242000
242100		10     X837I-TX-CODE-SEQ-NUM
242200		VALUE ZEROES
242300		PIC 9(07).
242400
242500		END OF HDR SORT-KEY
242600
242700
242800
242900		LOOP-ID-2410
243000
243100		05     X837I-LN-DRUG-ID-SEG.
243200
243300		10     X837I-LN-DRUG-CODE
243400		PIC X(48).
243500		10     FILLER
243600		PIC X(10).
243700
243800		05     X837I-LN-DRUG-PRICING-SEG.
243900
244000		10     X837I-LN-DRUG-UNIT-PRICE
244100		PIC S9(11)V99.
244200		10     X837I-LN-DRUG-NBR-UNITS
244300		PIC S9(7)V9(4).
244400		10     X837I-LN-DRUG-MEAS-CODE
244500		PIC X(02).
244600		10     FILLER
244700		PIC X(10).
244800

 

Page 182 of 326

---

244900		05     X837I-LN-DRUG-PERSCIP-SEG.
245000
245100		10     X837I-LN-DRUG-PERSCIP-NBR
245200		PIC X(30).
245300		10     FILLER
245400		PIC X(10).
245500
245600
245700
245800
245900		837I - LINE-LVL-ADJUSTMENT (MAX 99)
246000
246100
246200
246300		837I LINE LEVEL ADJUSTMENTS
246400
246500		01     X837I-LINE-LVL-ADJUSTMENTS.
246600
246700		05     X837I-RECORD-CODE
246800		PIC X(02).
246900
247000		05     X837I-SORT-KEY.
247100
247200		10     X837I-PROV-SEQ-NUM
247300		VALUE ZEROES
247400		PIC 9(11).
247500
247600		10     X837I-SUBSCRIBER-SEQ-NUM
247700		VALUE ZEROES
247800		PIC 9(11).
247900
248000		10     X837I-PATIENT-SEQ
248100		VALUE ZEROES
248200		PIC 9(11).
248300
248400		10     X837I-CLAIM-SEQ
248500		VALUE ZEROES
248600		PIC 9(11).
248700
248800		10     X837I-SVC-LINE-SEQ
248900		VALUE ZEROES
249000		PIC 9(11).
249100
249200
249300		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
249400		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
249500
249600
249700		10     X837I-SUB-SEQ
249800		VALUE ZEROES
249900		PIC 9(11).

 

Page 183 of 326

---

250000
250100		10     X837I-TX-CODE
250200		VALUE ‘09’
250300		PIC X(02).
250400
250500		10     X837I-TX-CODE-SEQ-NUM
250600		VALUE ZEROES
250700		PIC 9(07).
250800
250900		END OF HDR SORT-KEY
251000
251100
251200
251300		LOOP-ID-2430
251400
251500		05     X837I-LINE-LVL-ADJ-SEG.
251600
251700		10     X837I-LINE-ADJ-PYR-ID
251800		PIC X(80).
251900		10     X837I-LINE-ADJ-AMOUNT-PAID
252000		PIC S9(11)V99.
252100		10     X837I-LINE-ADJ-SVC-ID-QUAL
252200		PIC X(02).
252300		10     X837I-LINE-ADJ-SVC-ID
252400		PIC X(48).
252500		10     X837I-LINE-ADJ-SVC-MOD-1
252600		PIC X(02).
252700		10     X837I-LINE-ADJ-SVC-MOD-2
252800		PIC X(02).
252900		10     X837I-LINE-ADJ-SVC-MOD-3
253000		PIC X(02).
253100		10     X837I-LINE-ADJ-SVC-MOD-4
253200		PIC X(02).
253300		10     X837I-LINE-ADJ-SVC-CD-DESC
253400		PIC X(80).
253500		10     X837I-LINE-ADJ-SVC-REV-CD
253600		PIC X(48).
253700		10     X837I-LINE-ADJ-UNITS-OF-SVC
253800		PIC S9(7)V9(4).
253900		10     X837I-LINE-ADJ-BUNDLE-LINE-NBR
254000		PIC S9(4).
254100		10     FILLER
254200		PIC X(10).
254300
254400		05     X837I-LINE-ADJ-SEG
254500		OCCURS 99 TIMES
254600		INDEXED BY X837I-LINE-ADJ-NDX.
254700
254800		10     X837I-LINE-ADJ-GROUP-CODE
254900		PIC X(02).
255000		10     X837I-LINE-ADJ

 

Page 184 of 326

---

255100		OCCURS 6 TIMES
255200		INDEXED BY X837I-LINE-ADJ-NDX.
255300		15     X837I-LINE-ADJ-REASON-CD
255400		PIC X(05).
255500		15     X837I-LINE-ADJ-AMOUNT
255600		PIC S9(11)V99.
255700		15     X837I-LINE-ADJ-UNITS
255800		PIC S9(7)V9(4).
255900
256000		05     X837I-LINE-ADJ-DATE-SEG.
256100
256200		10     X837I-LINE-DATE-CLAIM-PAID
256300		PIC X(08).
256400
256500
256600
256700
256800		8371 - TRANSACTION TRAILER RECORD
256900
257000
257100		01     X837I-TX-TRAILER.
257200
257300		05     X837I-RECORD-CODE
257400		PIC X(02).
257500
257600		05     X837I-SORT-KEY.
257700
257800		10     X837I-PROV-SEQ-NUM
257900		VALUE ZEROES
258000		PIC 9(11).
258100
258200		10     X837I-SUBSCRIBER-SEQ-NUM
258300		VALUE ZEROES
258400		PIC 9(11).
258500
258600		10     X837I-PATIENT-SEQ
258700		VALUE ZEROES
258800		PIC 9(11).
258900
259000		10     X837I-CLAIM-SEQ
259100		VALUE ZEROES
259200		PIC 9(11).
259300
259400		10     X837I-SVC-LINE-SEQ
259500		VALUE ZEROES
259600		PIC 9(11).
259700
259800
259900		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
260000		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
260100

 

Page 185 of 326

---

260200
260300		10     X837I-SUB-SEQ
260400		VALUE ZEROES
260500		PIC 9(11).
260600
260700		10     X837I-TX-CODE
260800		VALUE ‘99’
260900		PIC X(02).
261000
261100		10     X837I-TX-CODE-SEQ-NUM
261200		VALUE ZEROES
261300		PIC 9(07).
261400
261500		END OF HDR SORT-KEY
261600
261700
261800
261900		05     X837I-TX-TRAILER-SEG.
262000
262100		10     X837I-TRAILER-NUM-OF-SEG
262200		PIC 9(10).
262300		10     X837I-TRAILER-CTL-NUM
262400		PIC X(09).
262500		10     FILLER
262600		PIC X(10).

 

Page 186 of 326

---

000010
000020
000030		PROFESSIONAL CLAIM EDI INTERFACE FILE
000040		COPYBOOK X837PV01
000050
000060
000070		THE HEALTH CARE PROFESSIONAL CLAIM EDI INTERFACE
000080		HAS THE SAME DATA CONTENT AS THE
000090		837 HEALTH CARE PROFESSIONAL CLAIM TRANSACTION
000100
000110		THE HEALTH CARE PROFESSIONAL CLAIM INTERFACE
000120		COPYBOOK CONTAINS 12 RECORDS:
000130
000140		RECORD		DESCRIPTION
000150
000160
000170		X837P-TX-HEADER		CONTAINS TRANSACTION HEADER
000180
000190		X837P-PROVIDER		CONTAINS LOOP 2000A, 2010AA
000200				AND 2010AB SEGMENTS
000210
000220		X837P-SUBSCRIBER		CONTAINS LOOP 2000B. 2010BA, 2010BB
000230				2010BC AND 2010BD SEGMENTS.
000240
000250		X837P-PATIENT		CONTAINS LOOP 2000C AND 2010CA
000260		.		SEGMENTS.
000270
000280		X837P-CLAIM		CONTAINS LOOP 2300, 2305, 2310A,
000290				2310B, 2310C, 2310D AND 2310E
000300				SEGMENTS.
000310
000320		X837P-OTHER-SUBSCRIBER		CONTAINS LOOP
000330				2320 (MINUS CLAIM-LVL-ADJ),
000340				2330A, 2330B, 2330C, 2330D,
000350				2330E, 2330F, 2330G
000360				AND 2330H SEGMENTS.
000370
000380		X837P-CLAIM-LVL-ADJ		CONTAINS CLAIM-LVL-ADJ ONLY
000390				SEGMENTS FROM LOOP 2320.
000400
000410		X837P-SVC-LINE		CONTAINS LOOP 2400, 2410, 2420A,
000420				2420B, 2420C, 2420D, 2420E
000430				AND 2420F SEGMENTS.
000440
000450		X837P-LINE-DRUG-ID		CONTAINS LOOP 2410 SEGMENTS.
000460
000470		X837P-LINE-LVL-ADJ		CONTAINS LOOP 2430 SEGMENTS.
000480
000490		X837P-FORM-IDENT-CODE		CONTAINS LOOP 2440 SEGMENTS.
000500
000510		X837P-TX-TRAILER		CONTAINS TRANSACTION TRAILER

 

Page 187 of 326

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000520		SEGMENTS
000530
000540		EACH RECORD BEGINS WITH THE SAME 8 FIELDS, THE SORT-KEY.
000550
000560		FIELD		DESCRIPTION
000570
000580
000590		X837P-PROV-SEQ-NUM		PURPOSE IS TO UNIQUELY IDENTIFY
000600				EACH PROVIDER’S DATA.
000610				ZERO FOR HEADER AND 9’S FOR
000620				TRAILER.
000630
000640		X837P-SUBSCRIBER-SEQ-NUM		PURPOSE IS TO UNIQUELY IDENTIFY
000650				EACH SUBSCRIBER’S DATA FOR A
000660				PROVIDER
000670
000680		X837P-PATIENT-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
000690				EACH PATIENT’S DATA FOR A
000700				PROVIDER
000710
000720		X837P-CLAIM-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
000730				EACH CLAIM’S DATA FOR A PATIENT
000740
000750		X837P-SUB-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
000760				EACH OTHER-SUBSCRIBER’S DATA
000770				FOR A CLAIM -OR-
000780				TO UNIQUELY IDENTIFY
000790				EACH FORM-IDENT-CODE RECORDS’S
000800				DATA FOR A CLAIM
000810
000820		X837P-CLAIM-LVL-ADJ-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
000830				EACH SET OF CLAIM LVL ADJUSTMENTS
000840				FOR A CLAIM
000850
000860		X837P-SVC-LINE-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
000870				EACH SVC-LINE’S DATA FOR A CLAIM
000880
000890		X837P-LINE-LVL-ADJ-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
000900				EACH SET OF LINE LVL ADJUSTMENTS
000910				FOR A CLAIM
000920
000930		X837P-FORM-IDENT-CODE-SEQ		PURPOSE IS TO UNIQUELY IDENTIFY
000940				EACH SET OF FORM IDENTIFICATIONS.
000950
000960		X837P-TX-CODE		IDENTIFIES EACH TYPE OF RECORD
000970				00 FOR X837P-TX-HEADER
000980				01 FOR X837P-PROVIDER
000990				02 FOR X837P-SUBSCRIBER
001000				03 FOR X837P-PATIENT
001010				04 FOR X837P-CLAIM
001020				08 FOR X837P-OTHER-SUBS-INFO

 

 

Page 188 of 326

---

001030				06 FOR X837P-CLAIM-LVL-ADJ
001040				07 FOR X837P-SVC-LINE
001050				08 FOR X837P-LINE-DRUG-ID
001060				09 FOR X837P-LINE-LVL-ADJ
001070				10 FOR X837P-FORM-IDENT-CODE
001080				99 FOR X837P-TX-TRAILER
001090
001100
001110		X837P-TX-CODE-SEQ-NUM		TO SEQUENCE RECORDS WITHIN A
001120				RECORD TYPE. THE SEQUENCE NUMBER
001130				FOR THE FIRST RECORD IF ‘0001’,
001140				FOR THE SECOND ‘002’, ETC.

001150

001160

001170

001180

THE FOLLOWING EXAMPLE SHOWS HOW THIS WORKS, WHERE

001190

PPPPP

=

PROVIDER-SEQ

CCCCC

=

CLAIM-SEQ

001200

SSSSS

=

SUBSCRIBER-SEQ

LLLLL

=

LINE-SEQ

001210

TTTTT

=

PATIENT-SEQ

HHHHHH

=

SUB-SEQ

001220

 

001230

PROV

SUBS

▇▇▇

CLM

SVC

SUB

TX

TX

001240

RECORD

SEQ

SEQ

SEQ

SEQ

SEQ

SEQ

CDE

SEQ

001250

001260

TX-HEADER

ZERO

ZERO

ZERO

ZERO

ZERO

ZERO

00

ZERO

001270

PROVIDER

PPPPP

ZERO

ZERO

ZERO

ZERO

ZERO

01

ZERO

001280

SUBSCRIBER

PPPPP

SSSSS

ZERO

ZERO

ZERO

ZERO

02

ZERO

001290

PATIENT

PPPPP

SSSSS

TTTTT

ZERO

ZERO

ZERO

03

ZERO

001300

CLAIM

PPPPP

SSSSS

TTTTT

CCCCC

ZERO

ZERO

04

ZERO

001310

OTHER-SUBS-INFO

PPPPP

SSSSS

TTTTT

CCCCC

ZERO

HHHHH

05

ZERO

001320

CLAIM-LVL-ADJ

PPPPP

SSSSS

TTTTT

CCCCC

ZERO

HHHHH

06

1-999

001330

SVC-LINE

PPPPP

SSSSS

TTTTT

CCCCC

LLLLL

ZERO

07

ZERO

001340

LINE-DRUG-ID

PPPPP

SSSSS

TTTTT

CCCCC

LLLLL

ZERO

09

1-25

001350

LINE-LVL-ADJ

PPPPP

SSSSS

TTTTT

CCCCC

LLLLL

ZERO

08

1-999

001360

FORM-IDENT-CODE

PPPPP

SSSSS

TTTTT

CCCCC

LLLLL

FFFFF

10

ZERO

001370

TX-TRAILER

99999

SSSSS

TTTTT

CCCCC

ZERO

ZERO

99

99999

 

001380
001390
001400
001410
001420		837P - TRANSACTION HEADER RECORD
001430
001440
001450		01     X837P-TX-HEADER.
001460
001470		05     X837P-RECORD-CODE
001480		PIC X(02).
001490
001500		05     X837P-SORT-KEY.
001510
001520		10     X837P-PROV-SEQ-NUM
001530		VALUE ZEROES

 

Page 189 of 326

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001540		PIC 9(11).
001550
001560		10     X837P-SUBSCRIBER-SEQ-NUM
001570		VALUE ZEROES
001580		PIC 9(11).
001590
001600		10     X837P-PATIENT-SEQ
001610		VALUE ZEROES
001620		PIC 9(11).
001630
001640		10     X837P-CLAIM-SEQ
001650		VALUE ZEROES
001660		PIC 9(11).
001670
001680		10     X837P-SVC-LINE-SEQ
001690		VALUE ZEROES
001700		PIC 9(11).
001710
001720
001730		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
001740		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
001750
001760		SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A
001770		‘FORM-IDENT-CODE’ RECORD.
001780
001790		10     X837P-SUB-SEQ
001800		VALUE ZEROES
001810		PIC 9(11).
001820
001830		10     X837P-TX-CODE
001840		VALUE ‘00’
001850		PIC X(02).
001860
001870		10     X837P-TX-CODE-SEQ-NUM
001880		VALUE ZEROES
001890		PIC 9(07).
001900
001910		END OF HDR SORT-KEY
001920
001930
001940
001950		05     X837P-TX-HEADER-SEG.
001960
001970		10     X837P-TX-ID
001980		VALUE ‘837’
001990		PIC X(03).
002000		10     X837P-TX-CTL-NUM
002010		PIC X(09).
002020		10     FILLER
002030		PIC X(10).
002040

 

Page 190 of 326

---

002050		05     X837P-BEG-SEGMENT.
002060
002070		10     X837P-TX-HIERACH-STRUCT-CODE
002080		PIC X(04).
002090		10     X837P-TX-PURPOSE-CODE
002100		PIC X(02).
002110		10     X837P-TX-ID-CODE
002120		PIC X(30).
002130		10     X837P-TX-CREATION-DATE
002140		PIC X(08).
002150		10     X837P-TX-CREATION-TIME
002160		PIC X(08).
002170		10     X837P-TX-TYPE-CODE
002180		PIC X(02).
002190		10     FILLER
002200		PIC X(10).
002210
002220		05     X837P-XMIT-TYPE-ID-SEG.
002230		10     X837P-XMIT-REF-ID-CODE
002240		PIC X(02).
002250		10     X837P-XMIT-REF-ID
002260		PIC X(30).
002270		10     FILLER
002280		PIC X(10).
002290
002300		05     X837P-SUBMITTER-NAME-SEG.
002310
002320		10     X837P-SUBMITTER-ENTITY-CODE
002330		PIC X(02).
002340		10     X837P-SUBMITTER-NAME-LAST
002350		PIC X(35).
002360		10     X837P-SUBMITTER-NAME-FIRST
002370		PIC X(25).
002380		10     X837P-SUBMITTER-NAME-MIDDLE
002390		PIC X(25).
002400		10     X837P-SUBMITTER-ID-CODE
002410		PIC X(80).
002420		10     FILLER
002430		PIC X(10).
002440
002450		05     X837P-SUBMITTER-CONTACT-SEG
002460		OCCURS 2 TIMES
002470		INDEXED BY X837P-SUBMITTER-CONTACT-NDX.
002480
002490		10     X837P-CONTACT-NAME
002500		PIC X(60).
002510		10     X837P-COMMUNICATION-TYPE-CODE
002520		PIC X(02).
002530		10     X837P-COMMUNICATION-NUMBER
002540		PIC X(80).
002550		10     FILLER

 

Page 191 of 326

---

002560		PIC X(10).
002570
002580		05     X837P-RECEIVER-NAME-SEG.
002590
002600		10     X837P-RECEIVER-NAME-LAST
002610		PIC X(35).
002620		10     X837P-RECEIVER-ID-CODE
002630		PIC X(80).
002640		10     FILLER
002650		PIC X(10).
002660
002670
002680
002690
002700		837P - DETAIL, BILLING/PAY-TO PROVIDER
002710
002720
002730		837P LOOP 2000A DETAIL, BILLING/PAY-TO PROVIDER
002740
002750		01     X837P-PROVIDER.
002760
002770		05     X837P-RECORD-CODE
002780		PIC X(02).
002790
002800		05     X837P-SORT-KEY.
002810
002820		10     X837P-PROV-SEQ-NUM
002830		VALUE ZEROES
002840		PIC 9(11).
002850
002860		10     X837P-SUBSCRIBER-SEQ-NUM
002870		VALUE ZEROES
002880		PIC 9(11).
002890
002900		10     X837P-PATIENT-SEQ
002910		VALUE ZEROES
002920		PIC 9(11).
002930
002940		10     X837P-CLAIM-SEQ
002950		VALUE ZEROES
002960		PIC 9(11).
002970
002980		10     X837P-SVC-LINE-SEQ
002990		VALUE ZEROES
003000		PIC 9(11).
003010
003020
003030		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
003040		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
003050
003060		SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A

 

Page 192 of 326

---

003070		‘FORM-IDENT-CODE’ RECORD.
003080
003090		10     X837P-SUB-SEQ
003100		VALUE ZEROES
003110		PIC 9(11).
003120
003130		10     X837P-TX-CODE
003140		VALUE ‘01’
003150		PIC X(02).
003160
003170		10     X837P-TX-CODE-SEQ-NUM
003180		VALUE ZEROES
003190		PIC 9(07).
003200
003210		END OF HDR SORT-KEY
003220
003230
003240
003250		LOOP-ID-2000A
003260
003270		05     X837P-PROV-HIERACHICAL-LVL-SEG.
003280
003290		10     X837P-PROV-HIER-NBR
003300		PIC X(12).
003310		10     X837P-PROV-HIER-LVL-CODE
003320		PIC X(02).
003330		10     X837P-PROV-HIER-CHILD-CODE
003340		PIC X(01).
003350		10     FILLER
003360		PIC X(10).
003370
003380
003390		05     X837P-PROV-SPECIALTY-INFO-SEG.
003400
003410		10     X837P-PROV-TYPE-CODE
003420		PIC X(03).
003430		10     X837P-PROV-SPECIALTY-CODE
003440		PIC X(30).
003450		10     FILLER
003460		PIC X(10).
003470
003480		05     X837P-CURRENCY-INFO-SEG.
003490
003500		10     X837P-CURRENCY-CODE
003510		PIC X(03).
003520		10     FILLER
003530		PIC X(10).
003540
003550		LOOP-ID-2010AA
003560
003570		05     X837P-BILLING-PROV-NAME-SEG.

 

Page 193 of 326

---

003580
003590		10     X837P-▇▇▇▇-PROV-ENTITY-CODE
003600		PIC X(01).
003610		10     X837P-▇▇▇▇-PROV-NAME-LAST
003620		PIC X(35).
003630		10     X837P-▇▇▇▇-PROV-NAME-FIRST
003640		PIC X(25).
003650		10     X837P-▇▇▇▇-PROV-NAME-MIDDLE
003660		PIC X(25).
003670		10     X837P-▇▇▇▇-PROV-NAME-SFX
003680		PIC X(10).
003690		10     X837P-▇▇▇▇-PROV-ID-CODE
003700		PIC X(02).
003710		10     X837P-▇▇▇▇-PROV-ID-NBR
003720		PIC X(80).
003730		10     FILLER
003740		PIC X(10).
003750
003760		05     X837P-▇▇▇▇-PROV-ADDR-SEG.
003770
003780		10     X837P-▇▇▇▇-PROV-ADDR1
003790		PIC X(55).
003800		10     X837P-▇▇▇▇-PROV-ADDR2
003810		PIC X(55).
003820		10     FILLER
003830		PIC X(10).
003840
003850		05     X837P-▇▇▇▇-PROV-LOC-SEG.
003860
003870		10     X837P-▇▇▇▇-PROV-CITY
003880		PIC X(30).
003890		10     X837P-▇▇▇▇-PROV-STATE
003900		PIC X(02).
003910		10     X837P-▇▇▇▇-PROV-ZIP
003920		PIC X(15).
003930		10     X837P-▇▇▇▇-PROV-COUNTRY
003940		PIC X(03).
003950		10     FILLER
003960		PIC X(10).
003970
003980		05     X837P-▇▇▇▇-PROV-2ND-IDENT-SEG.
003990		OCCURS 8 TIMES
004000		INDEXED BY X837P-▇▇▇▇-PROV-2ND-IDENT-NDX.
004010
004020		10     X837P-▇▇▇▇-PROV-2ND-ID-CODE
004030		PIC X(03).
004040		10     X837P-▇▇▇▇-PROV-2ND-ID
004050		PIC X(30).
004060		10     FILLER
004070		PIC X(10).
004080

 

Page 194 of 326

---

004090		05     X837P-▇▇▇▇-PROV-BANK-CARD-SEG
004100		OCCURS 8 TIMES
004110		INDEXED BY X837P-▇▇▇▇-PROV-BANK-CARD-NDX.
004120
004130		10     X837P-▇▇▇▇-PROV-CRDT-CRD-ID-TP
004140		PIC X(03).
004150		10     X837P-▇▇▇▇-PROV-CRDT-CRD-ID
004160		PIC X(30).
004170		10     FILLER
004180		PIC X(10).
004190
004200		05     X837P-▇▇▇▇-PROV-CONTACT-SEG
004210		OCCURS 2 TIMES
004220		INDEXED BY X837P-▇▇▇▇-PROV-CONTACT-NDX.
004230
004240		10     X837P-▇▇▇▇-PRV-CONTACT-NAME
004250		PIC X(60).
004260		10     X837P-▇▇▇▇-PRV-CONTACT-NB-TP-1
004270		PIC X(02).
004280		10     X837P-▇▇▇▇-PRV-CONTACT-NB-1
004290		PIC X(80).
004300		10     X837P-▇▇▇▇-PRV-CONTACT-NB-TP-2
004310		PIC X(02).
004320		10     X837P-▇▇▇▇-PRV-CONTACT-NB-2
004330		PIC X(80).
004340		10     X837P-▇▇▇▇-PRV-CONTACT-NB-TP-3
004350		PIC X(02).
004360		10     X837P-▇▇▇▇-PRV-CONTACT-NB-3
004370		PIC X(80).
004380		10     FILLER
004390		PIC X(10).
004400
004410		LOOP-ID-2010AB
004420
004430		05     X837P-PAY-TO-PROV-NAME-SEG.
004440
004450		10     X837P-PAYTO-PROV-ENTITY-CODE
004460		PIC X(01).
004470		10     X837P-PAYTO-PROV-NAME-LAST
004480		PIC X(35).
004490		10     X837P-PAYTO-PROV-NAME-FIRST
004500		PIC X(25).
004510		10     X837P-PAYTO-PROV-NAME-MIDDLE
004520		PIC X(25).
004530		10     X837P-PAYTO-PROV-NAME-SFX
004540		PIC X(10).
004550		10     X837P-PAYTO-PROV-ID-CODE
004560		PIC X(02).
004570		10     X837P-PAYTO-PROV-ID-NBR
004580		PIC X(80).
004590		10     FILLER

 

Page 195 of 326

---

004600		PIC X(10).
004610
004620		05     X837P-PAY-TO-PROV-ADDR-SEG.
004630
004640		10     X837P-PAYTO-PROV-ADDR1
004650		PIC X(55).
004660		10     X837P-PAYTO-PROV-ADDR2
004670		PIC X(55).
004680		10     FILLER
004690		PIC X(10).
004700
004710		05     X837P-PAYTO-PROV-LOC-SEG.
004720
004730		10     X837P-PAYTO-PROV-CITY
004740		PIC X(30).
004750		10     X837P-PAYTO-PROV-STATE
004760		PIC X(02).
004770		10     X837P-PAYTO-PROV-ZIP
004780		PIC X(15).
004790		10     X837P-PAYTO-PROV-COUNTRY
004800		PIC X(03).
004810
004820		05     X837P-PAYTO-PROV-2ND-ID-SEG.
004830		OCCURS 5 TIMES
004840		INDEXED BY X837P-PAYTO-PROV-2ND-ID-NDX.
004850
004860		10     X837P-PAYTO-PROV-2ND-ID-CODE
004870		PIC X(03).
004880		10     X837P-PAYTO-PROV-2ND-ID
004890		PIC X(30).
004900		10     FILLER
004910		PIC X(10).
004920
004930
004940
004950		837P - SUBSCRIBER
004960
004970
004980
004990		837P DETAIL, SUBSCRIBER HIERARCHAL LEVEL
005000
005010		01     X837P-SUBSCRIBER.
005020
005030		05     X837P-RECORD-CODE
005040		PIC X(02).
005050
005060		05     X837P-SORT-KEY.
005070
005080		10     X837P-PROV-SEQ-NUM
005090		VALUE ZEROES
005100		PIC 9(11).

 

Page 196 of 326

---

005110
005120		10     X837P-SUBSCRIBER-SEQ-NUM
005130		VALUE ZEROES
005140		PIC 9(11).
005150
005160		10     X837P-PATIENT-SEQ
005170		VALUE ZEROES
005180		PIC 9(11).
005190
005200		10     X837P-CLAIM-SEQ
005210		VALUE ZEROES
005220		PIC 9(11).
005230
005240		10     X837P-SVC-LINE-SEQ
005250		VALUE ZEROES
005260		PIC 9(11).
005270
005280
005290		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
005300		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORD.
005310
005320		SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A
005330		‘FORM-IDENT-CODE’ RECORD.
005340
005350		10     X837P-SUB-SEQ
005360		VALUE ZEROES
005370		PIC 9(11).
005380
005390		10     X837P-TX-CODE
005400		VALUE ‘02’
005410		PIC X(02).
005420
005430		10     X837P-TX-CODE-SEQ-NUM
005440		VALUE ZEROES
005450		PIC 9(07).
005460
005470		END OF HDR SORT-KEY
005480
005500
005510		LOOP-ID-2000B
005520
005530		05     X837P-SUBS-HIERACHICAL-LVL-SEG.
005540
005550		10     X837P-SUBS-HIER-NBR
005560		PIC X(12).
005570		10     X837P-SUBS-HIER-PARENT-NBR
005580		PIC X(12).
005590		10     X837F-SUBS-HIER-LVL-CODE
005600		PIC X(02).
005610		10     X837P-SUBS-HIER-CHILD-CODE

 

Page 197 of 326

---

005620		PIC X(01).
005630		10     FILLER
005640		PIC X(10).
005650
005660		05     X837P-SUBSCRIBER-INFO-SEG.
005670
005680		10     X837P-SUBS-PYR-RESPONS-SEQ-CD
005690		PIC X(01).
005700		10     X837P-SUBS-RELATIONSHIP-CODE
005710		PIC X(02).
005720		10     X837P-SUBS-POLICY-NBR
005730		PIC X(30).
005740		10     X837P-SUBS-PLAN-NAME
005750		PIC X(60).
005760		10     X837P-SUBS-INSURANCE-TYPE-CODE
005770		PIC X(03).
005780		10     X837P-SUBS-CLAIM-FILING-IND-CD
005790		PIC X(02).
005800		10     FILLER
005810		PIC X(10).
005820
005830		05     X837P-SUBS-PATIENT-INFO-SEG.
005840
005850		10     X837P-SUBS-DATE-OF-DEATH
005860		PIC X(08).
005870		10     X837P-SUBS-WEIGHT-CODE
005880		PIC X(02).
005890		10     X837P-SUBS-WEIGHT
005900		PIC 9(5).
005910		10     X837P-SUBS-PREGNANCY-INDICATOR
005920		PIC X(01).
005930		10     FILLER
005940		PIC X(10).
005950
005960		LOOP-ID-2010BA
005970
005980		05     X837P-SUBS-NAME-SEG.
005990
006000		10     X837P-SUBS-TYPE-CODE
006010		PIC X(01).
006020		10     X837P-SUBS-NAME-LAST
006030		PIC X(35).
006040		10     X837P-SUBS-NAME-FIRST
006050		PIC X(25).
006060		10     X837P-SUBS-NAME-MIDDLE
006070		PIC X(25).
006080		10     X837P-SUBS-NAME-SFX
006090		PIC X(10).
006100		10     X837P-SUBS-ID-CODE-TYPE
006110		PIC X(02).
006120		10     X837P-SUBS-ID-CODE

 

Page 198 of 326

---

006130		PIC X(80).
006140		10     FILLER
006150		PIC X(10).
006160
006170		05     X837P-SUBS-ADDR-SEG.
006180
006190		10     X837P-SUBS-ADDR1
006200		PIC X(55).
006210		10     X837P-SUBS-ADDR2
006220		PIC X(55).
006230		10     FILLER
006240		PIC X(10).
006250
006260		05     X837P-SUBS-CITY-STATE-SEG.
006270
006280		10     X837P-SUBS-CITY
006290		PIC X(30).
006300		10     X837P-SUBS-STATE-CODE
006310		PIC X(02).
006320		10     X837P-SUBS-ZIP-CODE
006330		PIC X(15).
006340		10     X837P-SUBS-COUNTRY-CODE
006350		PIC X(03).
006360		10     FILLER
006370		PIC X(10).
006380
006390		05     X837P-SUBS-DEMOGRAPHIC-SEG.
006400
006410		10     X837P-OTHR-INSURED-DOB
006420		PIC X(08).
006430		10     X837P-OTHR-GENDER-CODE
006440		PIC X(01).
006450		10     FILLER
006460		PIC X(10).
006470
006480		05     X837P-SUBS-2ND-ID-SEG.
006490		OCCURS 4 TIMES
006500		INDEXED BY X837P-SUBS-2ND-ID-NDX.
006510
006520		10     X837P-SUBS-2ND-ID-TYPE
006530		PIC X(03).
006540		10     X837P-SUBS-2ND-ID
006550		PIC X(30).
006560		10     FILLER
006570		PIC X(10).
006580
006590		05     X837P-SUBS-PROP-CLAIM-NBR-SEG.
006600
006610		10     X837P-SUBS-PROP-CLAIM-NBR
006620		PIC X(30).
006630		10     FILLER

 

Page 199 of 326

---

006640		PIC X(10).
006650
006660		LOOP-ID-2010BB
006670
006680		05     X837P-PAYER-NAME-SEG.
006690
006700		10     X837P-PAYER-NAME
006710		PIC X(35).
006720		10     X837P-PAYER-ID-CODE-TYPE
006730		PIC X(02).
006740		10     X837P-PAYER-ID-CODE
006750		PIC X(80).
006760		10     FILLER
006770		PIC X(10).
006780
006790		05     X837P-PAYER-ADDR-SEG.
006800
006810		10     X837P-PAYER-ADDR1
006820		PIC X(55).
006830		10     X837P-PAYER-ADDR2
006840		PIC X(55).
006850		10     FILLER
006860		PIC X(10).
006870
006880		05     X837P-PAYER-CITY-STATE-SEG.
006890
006900		10     X837P-PAYER-CITY
006910		PIC X(30).
006920		10     X837P-PAYER-STATE-CODE
006930		PIC X(02).
006940		10     X837P-PAYER-ZIP-CODE
006950		PIC X(15).
006960		10     X837P-PAYER-COUNTRY-CODE
006970		PIC X(03).
006980		10     FILLER
006990		PIC X(10).
007000
007010		05     X837P-PAYER-2ND-ID-SEG
007020		OCCURS 3 TIMES
007030		INDEXED BY X837P-PAYER-2ND-ID-NDX.
007040
007050		10     X837P-PAYER-2ND-ID-TYPE
007060		PIC X(03).
007070		10     X837P-PAYER-2ND-ID
007080		PIC X(30).
007090		10     FILLER
007100		PIC X(10).
007110
007120		05     X837P-PAYER-PROP-CLAIM-NBR-SEG.
007130
007140		10     X837P-PAYER-PROP-CLAIM-NBR

 

Page 200 of 326

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007150		PIC X(30).
007160		10     FILLER
007170		PIC X(10).
007180
007190		LOOP-ID-2010BC
007200
007210		05     X837P-RESPON-PARTY-NAME-SEG.
007220
007230		10     X837P-RESP-PARTY-ENTITY-CODE
007240		PIC X(01).
007250		10     X837P-RESP-PARTY-NAME-LAST
007260		PIC X(35).
007270		10     X837P-RESP-PARTY-NAME-FIRST
007280		PIC X(25).
007290		10     X837P-RESP-PARTY-NAME-MIDDLE
007300		PIC X(25).
007310		10     X837P-RESP-PARTY-NAME-SFX
007320		PIC X(10).
007330		10     FILLER
007340		PIC X(10).
007350
007360		05     X837P-RESPON-PARTY-ADDR-SEG.
007370
007380		10     X837P-RESP-PARTY-ADDR1
007390		PIC X(55).
007400		10     X837P-RESP-PARTY-ADDR2
007410		PIC X(55).
007420		10     FILLER
007430		PIC X(10).
007440
007450		05     X837P-RESPON-PARTY-LOC-SEG.
007460
007470		10     X837P-RESP-PARTY-CITY
007480		PIC X(30).
007490		10     X837P-RESP-PARTY-STATE
007500		PIC X(02).
007510		10     X837P-RESP-PARTY-ZIP
007520		PIC X(15).
007530		10     X837P-RESP-PARTY-COUNTRY
007540		PIC X(03).
007550		10     FILLER
007560		PIC X(10).
007570
007580		LOOP-ID-2010BD
007590
007600		05     X837P-CARD-HOLDER-NAME-SEG.
007610
007620		10     X837P-CARD-HLDR-TYPE-CODE
007630		PIC X(01).
007640		10     X837P-CARD-HLDR-NAME-LAST
007650		PIC X(35).

 

Page 201 of 326

---

007660		10     X837P-CARD-HLDR-NAME-FIRST
007670		PIC X(25).
007680		10     X837P-CARD-HLDR-NAME-MIDDLE
007690		PIC X(25).
007700		10     X837P-CARD-HLDR-NAME-SFX
007710		PIC X(10).
007720		10     X837P-CARD-HLDR-ID-CODE-TYPE
007730		PIC X(02).
007740		10     X837P-CARD-HLDR-ID-CODE
007750		PIC X(80).
007760		10     FILLER
007770		PIC X(10).
007780
007790		05     X837P-CRDT-DBT-CARD-INFO-SEG.
007800		OCCURS 2 TIMES
007810		INDEXED BY X837P-CRDT-DBT-CARD-INFO-NDX.
007820
007830		10     X837P-CRDT-DBT-CARD-AUTH-NBR
007840		PIC X(30).
007850		10     FILLER
007860		PIC X(10).
007870
007880
007890
007900		837P - PATIENT
007910
007920
007930
007940		837P DETAIL, PATIENT HIERARCHAL LEVEL
007950
007960		01     X837P-PATIENT.
007970
007980		05     X837P-RECORD-CODE
007990		PIC X(02).
008000
008010		05     X837P-SORT-KEY.
008020
008030		10     X837P-PROV-SEQ-NUM
008040		VALUE ZEROES
008050		PIC 9(11).
008060
008070		10     X837P-SUBSCRIBER-SEQ-NUM
008080		VALUE ZEROES
008090		PIC 9(11).
008100
008110		10     X837P-PATIENT-SEQ
008120		VALUE ZEROES
008130		PIC 9(11).
008140
008150		10     X837P-CLAIM-SEQ
008160		VALUE ZEROES

 

Page 202 of 326

---

008170		PIC 9(11).
008180
008190		10     X837P-SVC-LINE-SEQ
008200		VALUE ZEROES
008210		PIC 9(11).
008220
008230
008240		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
008250		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
008260
008270		SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A
008280		‘FORM-IDENT-CODE’ RECORD.
008290
008300		10     X837P-SUB-SEQ
008310		VALUE ZEROES
008320		PIC 9(11).
008330
008340		10     X837P-TX-CODE
008350		VALUE ‘03’
008360		PIC X(02).
008370
008380		10     X837P-TX-CODE-SEQ-NUM
008390		VALUE ZEROES
008400		PIC 9(07).
008410
008420		END OF HDR SORT-KEY
008430
008440
008450
008460		LOOP-ID-2000C
008470
008480		05     X837P-▇▇▇-HIERACHICAL-LVL-SEG.
008490
008500		10     X837P-▇▇▇-HIER-NBR
008510		PIC X(12).
008520		10     X837P-▇▇▇-HIER-PARENT-NBR
008530		PIC X(12).
008540		10     X837P-▇▇▇-HIER-LVL-CODE
008550		PIC X(02).
008560		10     X837P-▇▇▇-HIER-CHILD-CODE
008570		PIC X(01).
008580		10     FILLER
008590		PIC X(10).
008600
008610		05     X837P-PATIENT-INFO-SEG.
008620
008630		10     X837P-▇▇▇-RELATIONSHIP-CODE
008640		PIC X(02).
008650		10     X837P-▇▇▇-DATE-OF-DEATH
008660		PIC X(08).
008670		10     X837P-▇▇▇-WEIGHT-CODE

 

Page 203 of 326

---

008680		PIC X(02).
008690		10     X837P-▇▇▇-WEIGHT
008700		PIC 9(5).
008710		10     X837P-▇▇▇-PREGNANCY-INDICATOR
008720		PIC X(01).
008730		10     FILLER
008740		PIC X(10).
008750
008760		LOOP-ID-2010CA
008770
008780		05     X837P-▇▇▇-NAME-SEG.
008790
008800		10     X837P-▇▇▇-TYPE-CODE
008810		PIC X(01).
008820		10     X837P-▇▇▇-NAME-LAST
008830		PIC X(35).
008840		10     X837P-▇▇▇-NAME-FIRST
008850		PIC X(25).
008860		10     X837P-▇▇▇-NAME-MIDDLE
008870		PIC X(25).
008880		10     X837P-▇▇▇-NAME-SFX
008890		PIC X(10).
008900		10     X837P-▇▇▇-ID-CODE-TYPE
008910		PIC X(02).
008920		10     X837P-▇▇▇-ID-CODE
008930		PIC X(80).
008940		10     FILLER
008950		PIC X(10).
008960
008970		05     X837P-▇▇▇-ADDR-SEG.
008980
008990		10     X837P-▇▇▇-ADDR1
009000		PIC X(55).
009010		10     X837P-▇▇▇-ADDR2
009020		PIC X(55).
009030		10     FILLER
009040		PIC X (10).
009050
009060		05     X837P-▇▇▇-CITY-STATE-SEG.
009070
009080		10     X837P-▇▇▇-CITY
009090		PIC X(30).
009100		10     X837P-▇▇▇-STATE-CODE
009110		PIC X(02).
009120		10     X837P-▇▇▇-ZIP-CODE
009130		PIC X(15).
009140		10     X837P-▇▇▇-COUNTRY-CODE
009150		PIC X(03).
009160		10     FILLER
009170		PIC X(10).
009180

 

Page 204 of 326

---

009190		05     X837P-▇▇▇-DEMOGRAPHIC-SEG.
009200
009210		10     X837P-▇▇▇-DOB
009220		PIC X(08).
009230		10     X837P-▇▇▇-▇▇▇▇▇-CODE
009240		PIC X(01).
009250		10     FILLER
009260		PIC X(10).
009270
009280		05     X837P-▇▇▇-2ND-ID-SEG
009290		OCCURS 5 TIMES
009300		INDEXED BY X837P-▇▇▇-2ND-ID-NDX.
009310
009320		10     X837P-▇▇▇-2ND-ID-TYPE
009330		PIC X(03).
009340		10     X837P-▇▇▇-2ND-ID
009350		PIC X(30).
009360		10     FILLER
009370		PIC X(10).
009380
009390		05     X837P-▇▇▇-PROP-CLAIM-NBR-SEG.
009400		10     X837P-▇▇▇-PROP-CLAIM-NBR
009410		PIC X(30).
009420		10     FILLER
009430		PIC X(10).
009440
009450
009460
009470		837P - CLAIM-INFO
009480
009490
009500
009510		837P CLAIM INFORMATION
009520
009530		01     X837P-CLAIM-INFO.
009540
009550		05     X837P-RECORD-CODE
009560		PIC X(02).
009570
009580		05     X837P-SORT-KEY.
009590
009600		10     X837P-PROV-SEQ-NUM
009610		VALUE ZEROES
009620		PIC 9(11).
009630
009640		10     X837P-SUBSCRIBER-SEQ-NUM
009650		VALUE ZEROES
009660		PIC 9(11).
009670
009680		10     X837P-PATIENT-SEQ
009690		VALUE ZEROES

 

Page 205 of 326

---

009700		PIC 9(11).
009710
009720		10     X837P-CLAIM-SEQ
009730		VALUE ZEROES
009740		PIC 9(11).
009750
009760		10     X837P-SVC-LINE-SEQ
009770		VALUE ZEROES
009780		PIC 9(11).
009790
009800
009810		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
009820		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORD.
009830
009840		SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A
009850		‘FORM-IDENT-CODE’ RECORD.
009860
009870		10     X837P-SUB-SEQ
009880		VALUE ZEROES
009890		PIC 9(11).
009900
009910		10     X837P-TX-CODE
009920		VALUE ‘04’
009930		PIC X(02).
009940
009950		10     X837P-TX-CODE-SEQ-NUM
009960		VALUE ZEROES
009970		PIC 9(07).
009980
009990		END OF HDR SORT-KEY
010000
010010
010020
010030		LOOP-ID-2300
010040
010050		05     X837P-CLM-INFO-SEG.
010060
010070		10     X837P-CLM-PATIENT-CTL-NUM
010080		PIC X(38).
010090		10     X837P-CLM-TOT-CHARGE-AMOUNT
010100		PIC S9(11)V99.
010110		10     X837P-CLM-PLACE-OF-SVC-CODE
010120		PIC X(02).
010130		10     X837P-CLM-FREQ-TYPE-CODE
010140		PIC X(01).
010150		10     X837P-CLM-PROV-SIG-ON-FILE
010160		PIC X(01).
010170		10     X837P-CLM-MCARE-ASSIGNMENT-IND
010180		PIC X(01).
010190		10     X837P-CLM-ASSIGN-BENE-IND
010200		PIC X(01).

 

Page 206 of 326

---

010210		10     X837P-CLM-RELEASE-OF-INFO-IND
010220		PIC X(01).
010230		10     X837P-CLM-▇▇▇-SIG-SOURCE-CODE
010240		PIC X(01).
010250		10     X837P-CLM-RELATED-CAUSES
010260		OCCURS 3 TIMES
010270		INDEXED BY X837P-CLM-RELATED-CAUSES-NDX.
010280		15     X837P-CLM-RELATED-CAUSE-CD
010290		PIC X(02).
010300		10     X837P-CLM-ACCIDENT-STATE-CD
010310		PIC X(02).
010320		10     X837P-CLM-COUNTRY-CD
010330		PIC X(03).
010340		10     X837P-CLM-SPECIAL-PROG-CD
010350		PIC X(03).
010360		10     X837P-CLM-PARTIC-PROV-CD
010370		PIC X(01).
010380		10     X837P-CLM-DELAY-REASON-CD
010390		PIC X(02).
010400		10     FILLER
010410		PIC X(10).
010420
010430		05     X837P-CLM-INIT-TREAT-DATE-SEG
010440		PIC X(08).
010450
010460		05     X837P-CLM-LAST-SEEN-DATE-SEG
010470		PIC X(08).
010480
010490		05     X837P-CLM-ONSET-ILL-DATE-SEG
010500		PIC X(08).
010510
010520		05     X837P-CLM-ACUTE-DATE-SEG
010530		OCCURS 5 TIMES
010540		INDEXED BY X837P-CLM-ACUTE-DATE-NDX
010550		PIC X(08).
010560
010570		05     X837P-CLM-ONSET-SIM-DATE-SEG
010580		OCCURS 10 TIMES
010590		INDEXED BY X837P-CLM-ONSET-SIM-DATE-NDX
010600		PIC X(08).
010610
010620		05     X837P-CLM-ACCIDENT-DATE-SEG
010630		OCCURS 10 TIMES
010640		INDEXED BY X837P-CLM-ACCIDENT-DATE-NDX
010650		PIC X(08).
010660
010670		05     X837P-CLM-LST-MENSTR-DATE-SEG
010680		PIC X(08).
010690
010700		05     X837P-CLM-LST-XRAY-DATE-SEG
010710		PIC X(08).

 

Page 207 of 326

---

010720
010730		05     X837P-CLM-VIS-HEAR-PERS-DT-SEG
010740		PIC X(08).
010750
010760		05     X837P-CLM-DISAB-BEGIN-DATE-SEG
010770		OCCURS 5 TIMES
010780		INDEXED BY X837P-CLM-DISAB-BEGIN-DATE-NDX
010790		PIC X(08).
010800
010810		05     X837P-CLM-DISAB-END-DATE-SEG
010820		OCCURS 5 TIMES
010830		INDEXED BY CLM-DISAB-END-DATE-NDX
010840		PIC X(08).
010850
010860		05     X837P-CLM-LAST-WRKD-DATE-SEG
010870		PIC X(08).
010880
010890		05     X837P-CLM-AUTH-WRK-RTN-DT-SEG
010900		PIC X(08).
010910
010920		05     X837P-CLM-ADMISSION-DATE-SEG
010930		PIC X(08).
010940
010950		05     X837P-CLM-DISCHARGE-DATE-SEG
010960		PIC X(08).
010970
010980		05     X837P-CLM-CARE-DATE-SEG
010990
011000		OCCURS 2 TIMES
011010		INDEXED BY X837P-CLM-CARE-DATE-NDX.
011020		10     X837P-CLM-CARE-DATE-QUAL
011030		PIC X(03).
011040		10     X837P-CLM-CARE-DATE
011050		PIC X(08).
011060		10     FILLER
011070		PIC X(10).
011080
011090		05     X837P-CLM-SUPPLMENT-INFO-SEG
011100		OCCURS 10 TIMES
011110		INDEXED BY X837P-CLM-SUPPLEMENT-INFO-NDX.
011120
011130		10     X837P-CLM-ATTACHMENT-TYPE
011140		PIC X(02).
011150		10     X837P-CLM-ATTCH-TRANSMAIT-CODE
011160		PIC X(02).
011170		10     X837P-CLM-ATTACHMENT-CNTL-NBR
011180		PIC X(80).
011190		10     X837P-CLM-ATTACHMENT-CNTL-NBR
011200		PIC X(80).
011210		10     FILLER
011220		PIC X(10).

 

Page 446 of 326

---

011230
011240		05     X837P-CLM-CONTRACT-INFO-SEG.
011250
011260		10     X837P-CLM-CONTRACT-TYPE
011270		PIC X(02).
011280		10     X837P-CLM-CONTRACT-AMOUNT
011290		PIC S9(11)V99.
011300		10     X837P-CLM-CONTRACT-PERCENT
011310		PIC S9(4)V9(4).
011320		10     X837P-CLM-CONTRACT-CODE
011330		PIC X(30).
011340		10     X837P-CLM-CONTRACT-DISC-PCT
011350		PIC S9(4)V9(4).
011360		10     X837P-CLM-CONTRACT-VERSION
011370		PIC X(30).
011380		10     FILLER
011390		PIC X(10).
011400
011410		05     X837P-CLM-CARD-MAX-AMT-SEG.
011420		10     X837P-CLM-CARD-MAX-AMT
011430		PIC S9(11)V99.
011440
011450		05     X837P-CLM-▇▇▇-PAID-AMT-SEG.
011460		10     X837P-CLM-▇▇▇-PAID-AMT
011470		PIC S9(11)V99.
011480
011490		05     X837P-CLM-TOT-PUR-SVC-AMT-SEG.
011500		10     X837P-CLM-TOT-PUR-SVC-AMT
011510		PIC S9(11)V99.
011520
011530		05     X837P-CLM-SVC-AUTH-EXCEP-SEG.
011540		10     X837P-CLM-SVC-AUTH-EXCEP-CD
011550		PIC X(30).
011560
011570		05     X837P-CLM-MCARE-4081-IND-SEG.
011580		10     X837P-CLM-MCARE-4081-IND
011590		PIC X(30).
011600
011610		05     X837P-CLM-MAMOGRAM-CERT-SEG.
011620		10     X837P-CLM-MAMMOGRAM-CERT-NBR
011630		PIC X(30).
011640
011650		05     X837P-CLM-PA-REF-NBR-SEG.
011660		OCCURS 2 TIMES
011670		INDEXED BY X837P-CLM-PA-REF-NBR-NDX
011680
011690		10     X837P-CLM-PA-REF-QUAL
011700		PIC X(03).
011710		10     X837P-CLM-PA-REF-NBR
011720		PIC X(30).
011730		10     FILLER

 

 

Page 209 of 326

---

011740		PIC X(10).
011750
011760		05     X837P-CLM-ORIG-REF-NBR-SEG.
011770		10     X837P-CLM-ORIG-REF-NBR
011780		PIC X(30).
011790
011800		05     X837P-CLM-CLIA-NBR-SEG.
011810		OCCURS 3 TIMES
011820		INDEXED BY X837P-CLM-CLIA-NBR-NDX.
011830		10     X837P-CLM-CLIA-NBR
011840		PIC X(30).
011850
011860		05     X837P-CLM-REPRICED-CLM-SEG.
011870		10     X837P-CLM-REPRICED-CLM-NBR
011880		PIC X(30).
011890
011900		05     X837P-CLM-ADJ-REPRICED-CLM-SEG.
011910		10     X837P-CLM-ADJ-REPRICED-CLM-NBR
011920		PIC X(30).
011930
011940		05     X837P-CLM-INVEST-DEV-SEG.
011950		10     X837P-CLM-INVEST-DEV-EXEMPTN
011960		PIC X(30).
011970
011980		05     X837P-CLM-CLRHSE-TRACE-SEG.
011990		10     X837P-CLM-CLRHSE-TRACE-NBR
012000		PIC X(30).
012010
012020		05     X837P-CLM-APG-SEG.
012030		OCCURS 4 TIMES
012040		INDEXED BY X837P-CLM-APG-NDX.
012050		10     X837P-CLM-APG-NBR
012060		PIC X(30).
012070
012080		05     X837P-CLM-DEMO-PROJ-SEG.
012090		10     X837P-CLM-DEMO-PROJ-ID
012100		PIC X(30).
012110
012120		05     X837P-CLM-FILE-INFO-SEG.
012130		OCCURS 10 TIMES
012140		INDEXED BY X837P-CLM-FILE-INFO-NDX.
012150		10     X837P-CLM-FUTURE-REQUITEMENT
012160		PIC X(80).
012170
012180		05     X837P-CLM-NOTE-SEG.
012190
012200		10     X837P-CLM-NOTE-REF-CODE
012210		PIC X(03).
012220		10     X837P-CLM-NOTE-TEXT
012230		PIC X(80).
012240		10     FILLER

 

Page 210 of 326

---

012250		PIC X(10).
012260
012270		05     X837P-CLM-AMBULANCE-SEG.
012280
012290		10     X837P-CLM-AMB-▇▇▇-WEIGHT
012300		PIC S9(4).
012310		10     X837P-CLM-AMB-TRANS-CD
012320		PIC X(01).
012330		10     X837P-CLM-AMB-TRANS-REA-CD
012340		PIC X(01).
012350		10     X837P-CLM-AMB-DISTANCE
012360		PIC S9(5).
012370		10     X837P-CLM-AMB-RND-TRIP-DESC
012380		PIC X(80).
012390		10     X837P-CLM-AMB-STRETCHER-DESC
012400		PIC X(80).
012410		10     FILLER
012420		PIC X(10).
012430
012440		05     X837P-CLM-SPINAL-MANIP-SEG.
012450
012460		10     X837P-CLM-SPINAL-COND-DESC
012470		OCCURS 2 TIMES
012480		INDEXED BY X837P-CLM-SPINAL-COND-DESC-NDX
012490		PIC X(80).
012500		10     X837P-CLM-SPINAL-XRAY-AVAIL
012510		PIC X(01).
012520		10     FILLER
012530		PIC X(10).
012540
012550		05     X837P-CLM-AMB-CERT-SEG
012560		OCCURS 3 TIMES
012570		INDEXED BY X837P-CLM-AMB-CERT-NDX.
012580
012590		10     X837P-CLM-AMB-CERT-CD-APPLIES
012600		PIC X(01).
012610		10     X837P-CLM-AMB-COND-IND
012620		OCCURS 5 TIMES
012630		INDEXED BY X837P-CLM-AMB-COND-IND-NDX
012640		PIC X(02).
012650		10     FILLER
012660		PIC X(10).
012670
012680		05     X837P-CLM-▇▇▇-INFO-VISION-SEG
012690		OCCURS 3 TIMES
012700		INDEXED BY X837P-CLM-▇▇▇-INFO-VISION-NDX.
012710
012720		10     X837P-CLM-VISION-COND-CATEGORY
012730		PIC X(02).
012740		10     X837P-CLM-VISION-CERT-APPLIES
012750		PIC X(01).

 

Page 211 of 326

---

012760		10     X837P-CLM-VISION-COND-IND
012770		OCCURS 5 TIMES
012780		INDEXED BY X837P-CLM-VISION-COND-IND-NDX
012790		PIC X(02).
012800
012810		05     X837P-CLM-HOMEBOUND-IND-SEG.
012820
012830		10     X837P-CLM-HOMEBOUND-CERT-IND
012840		PIC X(01).
012850		10     X837P-CLM-HOMEBOUND-COND-IND
012860		PIC X(02).
012870		10     FILLER
012880		PIC X(10).
012890
012900		05     X837P-CLM-EPSDT-REF-SEG.
012910
012920		10     X837P-CLM-EPSDT-CERT-CD-APPLS
012930		PIC X(01).
012940		10     X837P-CLM-EPSDT-COND-IND
012950		OCCURS 3 TIMES
012960		INDEXED BY X837P-CLM-EPSDT-COND-IND-NDX
012970		PIC X(02).
012980		10     FILLER
012990		PIC X(10).
013000
013010		05     X837P-CLM-DIAGNOSIS-SEG
013020		OCCURS 8 TIMES
013030		INDEXED BY X837P-CLM-DIAGNOSIS-NDX.
013040
013050		10     X837P-CLM-DIAG-LIST-QUAL
013060		PIC X(03).
013070		10     X837P-CLM-DIAG-CODE
013080		PIC X(30).
013090		10     FILLER
013100		PIC X(10).
013110
013120		05     X837P-CLM-PRICE-REPRICE-SEG.
013130
013140		10     X837P-CLM-PRICE-METHOD
013150		PIC X(02).
013160		10     X837P-CLM-PRICE-ALLOWED
013170		PIC S9(11)V99.
013180		10     X837P-CLM-PRICE-SAVINGS
013190		PIC S9(11)V99.
013200		10     X837P-CLM-REPRICE-ORG-ID
013210		PIC X(30).
013220		10     X837P-CLM-PRICE-RATE
013230		PIC S9(11)V99.
013240		10     X837P-CLM-PRICE-APG-CODE
013250		PIC X(30).
013260		10     X837P-CLM-PRICE-APG-AMT

 

Page 212 of 326

---

013270		PIC S9(11)V99.
013280		10     X837P-CLM-PRICE-REJECT-REA
013290		PIC X(02).
013300		10     X837P-CLM-PRICE-COMPLIANCE-CD
013310		PIC X(02).
013320		10     X837P-CLM-PRICE-EXCEPTION-CD
013330		PIC X(02).
013340		10     FILLER
013350		PIC X(10).
013360		LOOP-ID-2305
013370
013380		05     X837P-CLM-HOME-HEALTH-INFO
013390		OCCURS 6 TIMES
013400		INDEXED BY X837P-CLM-HOME-HEALTH-INFO-NDX.
013410
013420		10     X837P-CLM-HOME-HEALTH-INFO-SEG.
013430
013440		15     X837P-CLM-HH-DISCIPLINE-CODE
013450		PIC X(02).
013460		15     X837P-CLM-HH-TOT-VISITS
013470		PIC S9(5).
013480		15     X837P-CLM-HH-TOT-VISITS-PROJ
013490		PIC S9(5).
013500
013510		10     X837P-CLM-HOME-HEALTH-DELV-SEG
013520		OCCURS 3 TIMES
013530		INDEXED BY X837P-CLM-HOME-HEALTH-DELV-NDX.
013540
013550		15     X837P-CLM-HH-NBR-VISITS
013560		PIC S9(05).
013570		15     X837P-CLM-HH-VISIT-FREQ
013580		PIC X(02).
013590		15     X837P-CLM-HH-FREQ-COUNT
013600		PIC S9(5).
013610		15     X837P-CLM-HH-VISIT-UNITS
013620		PIC X(02).
013630		15     X837P-CLM-HH-NBR-OF-UNITS
013640		PIC S9(5).
013650		15     X837P-CLM-HH-VISIT-PATTERN
013660		PIC X(02).
013670		15     X837P-CLM-HH-TIME-CODE
013680		PIC X(01).
013690
013700		10     FILLER
013710		PIC X(10).
013720
013730
013740		LOOP-ID-2310A
013750		05     X837P-CLM-REF-PROV-NAME-LOOP
013760		OCCURS 2 TIMES
013770		INDEXED BY X837P-CLM-REF-PROV-NAME-NDX.

 

Page 213 of 326

---

013780
013790		10     X837P-CLM-REF-PROV-NAME-SEG.
013800
013810		15     X837P-CLM-REF-PROV-TYPE
013820		PIC X(03).
013830		15     X837P-CLM-REF-PROV-NME-TP
013840		PIC X(01).
013850		15     X837P-CLM-REF-PROV-NM-LAST
013860		PIC X(35).
013870		15     X837P-CLM-REF-PROV-NM-FIRST
013880		PIC X(25).
013890		15     X837P-CLM-REF-PROV-NM-MIDDLE
013900		PIC X(25).
013910		15     X837P-CLM-REF-PROV-NM-SFX
013920		PIC X(10).
013930		15     X837P-CLM-REF-PROV-ID-CODE
013940		PIC X(02).
013950		15     X837P-CLM-REF-PROV-ID-NBR
013960		PIC X(80).
013970		15     FILLER
013980		PIC X(10).
013990
014000		10     X837P-CLM-REF-PROV-SPEC-SEG.
014010
014020		15     X837P-CLM-REF-PROV-TYPE-CODE
014030		PIC X(03).
014040		15     X837P-CLM-REF-PROV-SPEC-CODE
014050		PIC X(30).
014060		15     FILLER
014070		PIC X(10).
014080
014090		10     X837P-CLM-REF-PROV-2ND-ID-SEG
014100		OCCURS 5 TIMES
014110		INDEXED BY X837P-CLM-REF-PROV-2ND-ID-NDX.
014120
014130		15     X837P-CLM-REF-PROV-2ND-ID-CODE
014140		PIC X(03).
014150		15     X837P-CLM-REF-PROV-2ND-ID
014160		PIC X(30).
014170		15     FILLER
014180		PIC X(10).
014190
014200		LOOP-ID-2310B
014210
014220		05     X837P-CLM-REND-PROV-NAME-SEG.
014230
014240		10     X837P-CLM-REND-PROV-TYPE
014250		PIC X(03).
014260		10     X837P-CLM-REND-PROV-NME-TP
014270		PIC X(01).
014280		10     X837P-CLM-REND-PROV-NM-LAST

 

Page 214 of 326

---

014290		PIC X(35).
014300		10     X837P-CLM-REND-PROV-NM-FIRST
014310		PIC X(25).
014320		10     X837P-CLM-REND-PROV-NM-MIDDLE
014330		PIC X(25).
014340		10     X837P-CLM-REND-PROV-NM-SFX
014350		PIC X(10).
014360		10     X837P-CLM-REND-PROV-ID-CODE
014370		PIC X(02).
014380		10     X837P-CLM-REND-PROV-ID-NBR
014390		PIC X(80).
014400		10     FILLER
014410		PIC X(10).
014420
014430		05     X837P-CLM-REND-PROV-SPEC-SEG.
014440
014450		10     X837P-CLM-REND-PROV-TYPE-CODE
014460		PIC X(03).
014470		10     X837P-CLM-REND-PROV-SPEC-CODE
014480		PIC X(30).
014490		10     FILLER
014500		PIC X(10).
014510
014520		05     X837P-CLM-REND-PROV-2ND-ID-SEG
014530		OCCURS 5 TIMES
014540		INDEXED BY X837P-CLM-REND-PROV-2ND-ID-NDX.
014550
014560		10     X837P-CLM-REND-PROV-2ND-ID-CD
014570		PIC X(03).
014580		10     X837P-CLM-REND-PROV-2ND-ID
014590		PIC X(30).
014600		10     FILLER
014610		PIC X(10).
014620
014630		LOOP-ID-2310C
014640
014650		05     X837P-CLM-PUR-PROV-NAME-SEG.
014660
014670		10     X837P-CLM-PUR-PROV-NME-TP
014680		PIC X(01).
014690		10     X837P-CLM-PUR-PROV-NAME
014700		PIC X(35).
014710		10     X837P-CLM-PUR-PROV-ID-CODE
014720		PIC X(02).
014730		10     X837P-CLM-PUR-PROV-ID-NBR
014740		PIC X(80).
014750		10     FILLER
014760		PIC X(10).
014770
014780		05     X837P-CLM-PUR-PROV-2ND-ID-SEG
014790		OCCURS 5 TIMES

 

Page 215 of 326

---

014800		INDEXED BY X837P-CLM-PUR-PROV-2ND-ID-NDX.
014810
014820		10     X837P-CLM-PUR-PROV-2ND-ID-CODE
014830		PIC X(03).
014840		10     X837P-CLM-PUR-PROV-2ND-ID
014850		PIC X(30).
014860		10     FILLER
014870		PIC X(10).
014880
014890		LOOP-ID-2310D
014900		05     X837P-CLM-SVC-FAC-LOC-SEG.
014910
014920		10     X837P-CLM-SVC-FAC-TYPE
014930		PIC X(03).
014940		10     X837P-CLM-SVC-FAC-NAME
014950		PIC X(35).
014960		10     X837P-CLM-SVC-FAC-ID-QUAL
014970		PIC X(02).
014980		10     X837P-CLM-SVC-FAC-ID
014990		PIC X(80).
015000		10     FILLER
015010		PIC X(10).
015020
015030		05     X837P-CLM-SVC-FAC-LOC-ADDR-SEG.
015040
015050		10     X837P-CLM-SVC-FAC-ADDR1
015060		PIC X(55).
015070		10     X837P-CLM-SVC-FAC-ADDR2
015080		PIC X(55).
015090		10     FILLER
015100		PIC X(10).
015110
015120		05     X837P-CLM-SVC-FAC-CTY-ST-SEG.
015130
015140		10     X837P-CLM-SVC-FAC-CITY
015150		PIC X(30).
015160		10     X837P-CLM-SVC-FAC-STATE-CODE
015170		PIC X(02).
015180		10     X837P-CLM-SVC-FAC-ZIP-CODE
015190		PIC X(15).
015200		10     X837P-CLM-SVC-FAC-COUNTRY-CODE
015210		PIC X(03).
015220		10     FILLER
015230		PIC X(10).
015240
015250		05     X837P-CLM-SVC-FAC-2ND-ID-SEG
015260		OCCURS 5 TIMES
015270		INDEXED BY X837P-CLM-SVC-FAC-2ND-ID-NDX.
015280
015290		10     X837P-CLM-SVC-FAC-2ND-ID-TYPE
015300		PIC X(03).

 

Page 216 of 326

---

015310		10     X837P-CLM-SVC-FAC-2ND-ID
015320		PIC X(30).
015330		10     FILLER
015340		PIC X(10).
015350
015360		LOOP-ID-2310E
015370
015380		05     X837P-CLM-SUPR-PRV-NAME-SEG.
015390
015400		10     X837P-CLM-SUPR-PRV-NAME-LAST
015410		PIC X(35).
015420		10     X837P-CLM-SUPR-PRV-NAME-FIRST
015430		PIC X(25).
015440		10     X837P-CLM-SUPR-PRV-NAME-MIDDLE
015450		PIC X(25).
015460		10     X837P-CLM-SUPR-PRV-SFX
015470		PIC X(10).
015480		10     X837P-CLM-SUPR-PRV-ID-QUAL
015490		PIC X(02).
015500		10     X837P-CLM-SUPR-PRV-ID-CODE
015510		PIC X(80).
015520		10     FILLER
015530		PIC X(10).
015540
015550		05     X837P-CLM-SUPR-PROV-2ND-ID-SEG
015560		OCCURS 5 TIMES
015570		INDEXED BY X837P-CLM-SUPR-PROV-2ND-ID-NDX.
015580
015590		10     X837P-CLM-SUPR-PROV-2ND-ID-CD
015600		PIC X(03).
015610		10     X837P-CLM-SUPR-PROV-2ND-ID
015620		PIC X(30).
015630		10     FILLER
015640		PIC X(10).
015650
015660		OTHER SUBSCRIBER INFORMATION IN SEPARATE RECORD
015670		CLAIM LEVEL ADJUSTMENTS IN SEPARATE RECORD
015680
015690
015700
015710		837P – OTHER SUBSCRIBER INFORMATION
015720
015730
015740
015750		837P OTHER SUBSCRIBER INFORMATION
015760
015770		01     X837P-OTHER-SUBSCRIBER-INFO.
015780
015790		05     X837P-RECORD-CODE
015800		PIC X(02).
015810

 

Page 217 of 326

---

015820		05     X837P-SORT-KEY.
015830
015840		10     X837P-PROV-SEQ-NUM
015850		VALUE ZEROES
015860		PIC 9(11).
015870
015880		10     X837P-SUBSCRIBER-SEQ-NUM
015890		VALUE ZEROES
015900		PIC 9(11).
015910
015920		10     X837P-PATIENT-SEQ
015930		VALUE ZEROES
015940		PIC 9(11).
015950
015960		10     X837P-CLAIM-SEQ
015970		VALUE ZEROES
015980		PIC 9(11).
015990
016000		10     X837P-SVC-LINE-SEQ
016010		VALUE ZEROES
016020		PIC 9(11).
016030
016040
016050		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
016060		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
016070
016080		SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A
016090		‘FORM-IDENT-CODE’ RECORD.
016100
016110		10     X837P-SUB-SEQ
016120		VALUE ZEROES
016130		PIC 9(11).
016140
016150		10     X837P-TX-CODE
016160		VALUE ‘05’
016170		PIC X(02).
016180
016190		10     X837P-TX-CODE-SEQ-NUM
016200		VALUE ZEROES
016210		PIC 9(07).
016220
016230		END OF HDR SORT-KEY
016240
016250
016260
016270		LOOP-2320 OTHER SUBSCRIBER INFORMATION - START
016280
016290		05     X837P-OTHR-SUBS-INFO-SEG.
016300
016310		10     X837P-PAYER-RESPONS-CODE
016320		PIC 9 (01).

 

Page 218 of 326

---

016330		10     X837P-INDIVIDUAL-RELAT-CODE
016340		PIC 9(02).
016350		10     X837P-OTHR-SUBS-POLICY-NBR
016360		PIC X(30).
016370		10     X837P-OTHR-SUBS-PLAN-NAMER
016380		PIC X(60).
016390		10     X837P-OTHR-SOBS-INSUR-TYPE-CD
016400		PIC 9(03).
016410		10     X837P-OTHR-SUBS-FILING-IND-CD
016420		PIC 9(01).
016430		10     X837P-OTHR-SUBS-FILING-IND-CD
016440		PIC 9(01).
016450		10     FILLER
016460		PIC X(10).
016470
016480		05     X837P-COB-PAYER-AMOUNT
016490		PIC S9(11)V99.
016500
016510		05     X837P-COB-APPROVED-AMOUNT
016520		PIC S9(11)V99.
016530
016540		05     X837P-COB-ALLOWED-AMOUNT
016550		PIC S9(11)V99.
016560
016570		05     X837P-COB-▇▇▇-RESPONS-AMOUNT
016580		PIC S9(11)V99.
016590
016600		05     X837P-COB-COVERED-AMOUNT
016610		PIC S9(11)V99.
016620
016630		05     X837P-COB-DISCOUNT-AMOUNT
016640		PIC S9(11)V99.
016650
016660		05     X837P-COB-PER-DAY-LIMIT-AMOUNT
016670		PIC S9(11)V99.
016680
016690		05     X837P-COB-PATIENT-PAID-AMOUNT
016700		PIC S9(11)V99.
016710
016720		05     X837P-COB-TAX-AMOUNT
016730		PIC S9(11)V99.
016740
016750		05     X837P-COB-TOT-CLM-B4-TAXES-AMT
016760		PIC S9(11)V99.
016770
016780		05     X837P-OTHR-SUBS-DEMO-SEG.
016790
016800		10     X837P-OTHR-INSURED-DOB
016810		PIC X(08).
016820		10     X837P-OTHR-GENDER-CODE
016830		PIC X(01).

 

Page 219 of 326

---

016840		10     FILLER
016850		PIC X(10).
016860
016870		05     X837P-OTHR-INS-COVRG-INFO-SEG.
016880
016890		10     X837P-ASSIGNMENT-OF-BENE-IND
016900		PIC X(01).
016910		10     X837P-▇▇▇-SIG-SOURCE-CODE
016920		PIC X(01).
016930		10     FILLER
016940		PIC X(10).
016950
016960		05     X837P-MCARE-OP-AJUDICATION-SEG.
016970
016980		10     X837P-OP-REIMBURSEMENT-RATE
016990		PIC S9V99.
017000		10     X837P-HCPCS-APYABLE-AMOUNT
017010		PIC S9(11)V99.
017020		10     X837P-MCARE-OP-REMARKS
017030		OCCURS 5 TIMES
017040		INDEXED BY X837P-MCARE-OP-REMARKS-NDX.
017050		15     X837P-MCARE-OP-REMARKS-CODE
017060		PIC X(30).
017070		10     X837P-ESDR-PAID-AMOUNT
017080		PIC S9(11)V99.
017090		10     X837P-PROFESSIONAL-COMPONENT
017100		PIC S9(9)V99.
017110		10     FILLER
017120		PIC X(10).
017130
017140		CLAIM LEVEL ADJUSTMENTS ON SEPARATE RECORD
017150		LOOP-2330A OTHR SUBSCRIBER NAME
017160
017170		05     X837P-OTHR-SUBS-NAME-SEG.
017180
017190		10     X837P-OTHR-SUBS-TYPE-CODE
017200		PIC X(01).
017210		10     X837P-OTHR-SUBS-NAME-LAST
017220		PIC X(35).
017230		10     X837P-OTHR-SUBS-NAME-FIRST
017240		PIC X(25).
017250		10     X837P-OTHR-SUBS-NAME-MIDDLE
017260		PIC X(25).
017270		10     X837P-OTHR-SUBS-NAME-SFX
017280		PIC X(10).
017290		10     X837P-OTHR-SUBS-ID-CODE-TYPE
017300		PIC X(02).
017310		10     X837P-OTHR-SUBS-ID-CODE
017320		PIC X(80).
017330		10     FILLER
017340		PIC X(10).

 

Page 220 of 326

---

017350
017360		05     X837P-OTHR-SUBS-ADDR-SEG.
017370
017380		10     X837P-OTHR-SUBS-ADDR1
017390		PIC X(55).
017400		10     X837P-OTHR-SUBS-ADDR2
017410		PIC X(55).
017420		10     FILLER
017430		PIC X(10).
017440
017450		05     X837P-OTHR-SUBS-CITY-STATE-SEG.
017460
017470		10     X837P-OTHR-SUBS-CITY
017480		PIC X(30).
017490		10     X837P-OTHR-SUBS-STATE-CODE
017500		PIC X(02).
017510		10     X837P-OTHR-SUBS-ZIP-CODE
017520		PIC X(15).
017530		10     X837P-OTHR-SUBS-COUNTRY-CODE
017540		PIC X(03).
017550		10     FILLER
017560		PIC X(10).
017570
017580		05     X837P-OTHR-SUBS-2ND-ID-SEG
017590		OCCURS 3 TIMES
017600		INDEXED BY X837P-OTHR-SUBS-2ND-ID-NDX.
017610
017620		10     X837P-OTHR-SUBS-2ND-ID-TYPE
017630		PIC X(03).
017640		10     X837P-OTHR-SUBS-2ND-ID
017650		PIC X(30).
017660		10     FILLER
017670		PIC X(10).
017680
017690		LOOP-2330B OTHR PAYER NAME
017700
017710		05     X837P-OTHR-PAYER-NAME-SEG.
017720
017730		10     X837P-OTHR-PAYER-NAME
017740		PIC X(35).
017750		10     X837P-OTHR-PAYER-ID-CODE-TYPE
017760		PIC X(02).
017770		10     X837P-OTHR-PAYER-ID-CODE
017780		PIC X(80).
017790		10     FILLER
017800		PIC X(10).
017810
017820		05     X837P-OTHR-PAYER-CONTACT-SEG
017830		OCCURS 2 TIMES
017840		INDEXED BY X837P-OTHR-PAYER-CONTACT-NDX.
017850

 

Page 221 of 326

---

017860		10     X837P-OTHR-PAYER-CONTACT-NAME
017870		PIC X(60).
017880		10     X837P-OTHR-PYR-CONTACT-NBR
017890		OCCURS 3 TIMES
017900		INDEXED BY X837P-OTHR-PYR-CONTACT-NBR-NDX.
017910		15     X837P-OTHR-PAYER-CONTACT-TYPE
017920		PIC X(02).
017930		15     X837P-OTHR-PAYER-CONTACT-NBR
017940		PIC X(80).
017950		10     FILLER
017960		PIC X(10).
017970
017980		05     X837P-CLAIM-ADJUD-DATE-SEG.
017990		10     X837P-CLAIM-ADJUD-DATE
018000		PIC X(08).
018010
018020		05     X837P-OTHR-PAYER-2ND-IDENT-SEG
018030		OCCURS 2 TIMES
018040		INDEXED BY X837P-OTHR-PAYER-2ND-IDENT-NDX.
018050
018060		10     X837P-OTHR-PAYER-2ND-ID-TYPE
018070		PIC X(03).
018080		10     X837P-OTHR-PAYER-2ND-ID
018090		PIC X(30).
018100		10     FILLER
018110		PIC X(10).
018120
018130		05     X837P-OTHR-PAYER-PA-REF-SEG
018140		OCCURS 2 TIMES
018150		INDEXED BY X837P-OTHR-PAYER-PA-REF-NDX.
018160
018170		10     X837P-OTHR-PAYER-PA-REF-IND
018180		PIC X(03).
018190		10     X837P-OTHR-PAYER-PA-REF-NUMBER
018200		PIC X(30).
018210		10     FILLER
018220		PIC X(10).
018230
018240		05     X837P-OTHR-PAYER-ADJ-IND-SEG
018250		OCCURS 2 TIMES
018260		INDEXED BY X837P-OTHR-PAYER-ADJ-IND-NDX.
018270
018280		10     X837P-OTHR-PAYER-ADJ-IND
018290		PIC X(03).
018300		10     FILLER
018310		PIC X(10).
018320
018330		LOOP-2330C OTHR PAYER PATIENT
018340
018350		05     X837P-OTHR-PAYER-▇▇▇-INFO-SEG.
018360

 

Page 222 of 326

---

018370		10     X837P-OTHR-PAYER-▇▇▇-ID-TYPE
018380		PIC X(02).
018390		10     X837P-OTHR-PAYER-▇▇▇-ID-NBR
018400		PIC X(80).
018410		10     FILLER
018420		PIC X(10).
018430
018440		05     X837P-OTHR-PYR-▇▇▇-2ND-ID-SEG
018450		OCCURS 3 TIMES
018460		INDEXED BY X837P-OTHR-PYR-▇▇▇-2ND-ID-NDX.
018470
018480		10     X837P-OTHR-PYR-▇▇▇-2ND-ID-TYP
018490		PIC X(03).
018500		10     X837P-OTHR-PYR-▇▇▇-2ND-ID-NBR
018510		PIC X(30).
018520		10     FILLER
018530		PIC X(10).
018540
018550		LOOP-2330D OTHR PAYER REFERRING PROV
018560
018570		05     X837P-OTHR-PAYER-REF-PROV-LOOP
018580		OCCURS 2 TIMES
018590		INDEXED BY X837P-OTHR-PAYER-REF-PROV-NDX.
018600
018610		10     X8 37P-OTHR-PAYER-REF-PROV-SEG.
018620
018630		15     X837P-OTHR-PYR-REF-PROV-TYPE
018640		PIC X(03).
018650		15     X837P-OTHR-PYR-REF-PROV-NME-TP
018660		PIC X(01).
018670		15     FILLER
018680		PIC X(10).
018690
018700		10     X837P-OTHR-PYR-REF-PROV-ID-SEG
018710		OCCURS 3 TIMES
018720		INDEXED BY X837P-OTHR-PYR-REF-PROV-ID-NDX.
018730
018740		15     X837P-OTHR-PYR-REF-PROV-ID-TYP
018750		PIC X(03).
018760		15     X837P-OTHR-PYR-REF-PROV-ID
018770		PIC X(30).
018780		15     FILLER
018790		PIC X(10).
018800		LOOP-2330E OTHR PAYER RENDERING PROV
018810
018820		05     X837P-OTHR-PAYER-REND-PROV-SEG.
018830
018840		10     X837P-OTHR-PYR-REND-PROV-NM-TP
018850		PIC X(01).
018860		10     FILLER
018870		PIC X(10).

 

Page 223 of 326

---

018880
018890		05     X837P-OTHR-PYR-REND-PRV-ID-SEG
018900		OCCURS 3 TIMES
018910		INDEXED BY X837P-OTHR-PYR-REND-PRV-ID-NDX.
018920
018930		10     X837P-OTHR-PYR-REND-PRV-ID-TYP
018940		PIC X(03).
018950		10     X837P-OTHR-PYR-REND-PRV-ID
018960		PIC X(30).
018970		10     FILLER
018980		PIC X(10).
018990
019000		LOOP-2330F OTHR PAYER PURCHASED SVC PROV
019010
019020		05     X837P-OTHR-PYR-PUR-PROV-SEG.
019030
019040		10     X837P-OTHR-PYR-PUR-PROV-NME-TP
019050		PIC X(01).
019060		10     FILLER
019070		PIC X(10).
019080
019090		05     X837P-OTHR-PYR-PUR-PROV-ID-SEG
019100		OCCURS 3 TIMES
019110		INDEXED BY X837P-OTHR-PYR-PUR-PROV-ID-NDX.
019120
019130		10     X837P-OTHR-PYR-PUR-PROV-ID-TYP
019140		PIC X(03).
019150		10     X837P-OTHR-PYR-PUR-PROV-ID
019160		PIC X(30).
019170		10     FILLER
019180		PIC X(10).
019190
019200		LOOP-2330G OTHR PAYER SVC FACILIT LOC
019210
019220		05     X837P-OTHR-PAYER-FAC-LOC-SEG.
019230
019240		10     X837P-OTHR-PYR-FAC-LOC-TYPE
019250		PIC X(03).
019260		10     FILLER
019270		PIC X(10).
019280
019290		05     X837P-OTHR-PYR-FAC-LOC-ID-SEG
019300		OCCURS 3 TIMES
019310		INDEXED BY X837P-OTHR-PYR-FAC-LOC-ID-NDX.
019320
019330		10     X837P-OTHR-PYR-FAC-LOC-ID-TYP
019340		PIC X(03).
019350		10     X837P-OTHR-PYR-FAC-LOC-ID
019360		PIC X(30).
019370		10     FILLER
019380		PIC X(10).

 

Page 224 of 326

---

019390
019400		LOOP-2330H OTHR PAYER SUPRV PROV
019410
019420		05     X837P-OTHR-PAYER-SUPR-PRV-SEG.
019430
019440		10     X837P-OTHR-PYR-SUPR-PRV-ID-TYP
019450		PIC X(01).
019460		10     FILLER
019470		PIC X(10).
019480
019490
019500
019510		837P - CLAIM LEVEL-ADJUSTMENT (99)
019520
019530
019540
019550		837P CLAIM LEVEL ADJUSTMENT
019560
019570		01     X837P-CLAIM-LVL-ADJUSTMENT.
019580
019590		05     X837P-RECORD-CODE
019600		PIC X(02).
019610
019620		05     X837P-SORT-KEY.
019630
019640		10     X837P-PROV-SEQ-NUM
019650		VALUE ZEROES
019660		PIC 9(11).
019670
019680		10     X837P-SUBSCRIBER-SEQ-NUM
019690		VALUE ZEROES
019700		PIC 9(11).
019710
019720		10     X837P-PATIENT-SEQ
019730		VALUE ZEROES
019740		PIC 9(11).
019750
019760		10     X837P-CLAIM-SEQ
019770		VALUE ZEROES
019780		PIC 9(11).
019790
019800		10     X837P-SVC-LINE-SEQ
019810		VALUE ZEROES
019820		PIC 9(11).
019830
019840
019850		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
019860		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
019870
019880		SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A
019890		‘FORM-IDENT-CODE, RECORD.

 

Page 225 of 326

---

019900
019910		10     X837P-SUB-SEQ
019920		VALUE ZEROES
019930		PIC 9(11).
019940
019950		10     X837P-TX-CODE
019960		VALUE ‘06’
019970		PIC X(02).
019980
019990		10     X837P-TX-CODE-SEQ-NUM
020000		VALUE ZEROES
020010		PIC 9(07).
020020
020030		END OF HDR SORT-KEY
020040
020050
020060
020070		05     X837P-CLAIM-ADJ-SEG
020080		OCCURS 99 TIMES
020090		INDEXED BY X837P-CLAIM-ADJ-NDX.
020100
020110		10     X837P-CLAIM-ADJ-GROUP-CODE
020120		PIC X(02).
020130		10     X837P-CLAIM-ADJ
020140		OCCURS 6 TIMES
020150		INDEXED BY X837P-CLAIM-ADJ-NDX.
020160		15     X837P-CLAIM-ADJ-REASON-CD
020170		PIC X(05).
020180		15     X837P-CLAIM-ADJ-AMOUNT
020190		PIC S9(11)V99.
020200		15     X837P-CLAIM-ADJ-UNITS
020210		PIC S9(7)V9(4).
020220
020230
020240
020250
020260		837P - CLAIM-SERVICE-LINE (MAX 50)
020270
020280
020290
020300		837P CLAIM SERVICE LINE
020310
020320		01     X837P-CLAIM-SVC-LINE.
020330
020340		05     X837P-RECORD-CODE
020350		PIC X(02).
020360
020370		05     X837P-SORT-KEY.
020380
020390		10     X837P-PROV-SEQ-NUM
020400		VALUE ZEROES

 

Page 226 of 326

---

020410		PIC 9(11).
020420
020430		10     X837P-SUBSCRIBER-SEQ-NUM
020440		VALUE ZEROES
020450		PIC 9(11).
020460
020470		10     X837P-PATIENT-SEQ
020480		VALUE ZEROES
020490		PIC 9(11).
020500
020510		10     X837P-CLAIM-SEQ
020520		VALUE ZEROES
020530		PIC 9(11).
020540
020550		10     X837P-SVC-LINE-SEQ
020560		VALUE ZEROES
020570		PIC 9(11).
020580
020590
020600		SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
020610		‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
020620
020630		SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A
020640		‘FORM-IDENT-CODE’ RECORD.
020650
020660		10     X837P-SUB-SEQ
020670		VALUE ZEROES
020680		PIC 9(11).
020690
020700		10     X837P-TX-CODE
020710		VALUE ‘07’
020720		PIC X(02).
020730
020740		10     X837P-TX-CODE-SEQ-NUM
020750		VALUE ZEROES
020760		PIC 9(07).
020770
020780		END OF HDR SORT-KEY
020790
020800
020810
020820		LOOP-ID-2400
020830
020840		05     X837P-LN-ASSIGNED-NBR-SEG.
020850
020860		10     X837P-LN-ASSIGNED-NBR
020870		PIC S9(9).
020880
020890		05     X837P-LN-PROF-SVC-SEG.
020900
020910		10     X837P-LN-SVC-ID-QUAL

 

Page 227 of 326

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020920		PIC X(02).
020930		10     X837P-LN-SVC-ID
020940		PIC X(48).
020950		10     X837P-LN-SVC-MOD-1
020960		PIC X(02).
020970		10     X837P-LN-SVC-MOD-2
020980		PIC X(02).
020990		10     X837P-LN-SVC-MOD-3
021000		PIC X(02).
021010		10     X837P-LN-SVC-MOD-4
021020		PIC X(02).
021030		10     X837P-LN-SUBMITTED-CHRG
021040		PIC S9(11)V99.
021050		10     X837P-LN-SVC-CD-MEAS-TYPE
021060		PIC X(02).
021070		10     X837P-LN-SVC-CD-UNITS
021080		PIC S9(7)V9(4).
021090		10     X837P-LN-POS-CODE
021100		PIC X(02).
021110		10     X837P-LN-DIAG-PTR-1
021120		PIC X(02).
021130		10     X837P-LN-DIAG-PTR-2
021140		PIC X(02).
021150		10     X837P-LN-DIAG-PTR-3
021160		PIC X(02).
021170		10     X837P-LN-DIAG-PTR-4
021180		PIC X(02).
021190		10     X837P-LN-EMERG-IND
021200		PIC X(01).
021210		10     X837P-LN-EPSDT-IND
021220		PIC X(01).
021230		10     X837P-LN-FAM-PLANNING-IND
021240		PIC X(01).
021250		10     X837P-LN-COPAY-WAIVER-CD
021260		PIC X(01).
021270		10     FILLER
021280		PIC X(10).
021290
021300		05     X837P-LN-DME-SVC-SEG.
021310
021320		10     X837P-LN-DME-SVC-ID-QUAL
021330		PIC X(02).
021340		10     X837P-LN-DME-SVC-ID
021350		PIC X(48).
021360		10     X837P-LN-DME-SVC-CD-MEAS-TYPE
021370		PIC X(02).
021380		10     X837P-LN-DME-SVC-CD-UNITS
021390		PIC S9(7)V9(4).
021400		10     X837P-LN-DME-SVC-RET-PRICE
021410		PIC S9(11)V9 (2).
021420		10     X837P-LN