Contract



 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 







 CONFIDENTIAL – NOT FOR CIRCULATION 
  
 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

  










 CONFIDENTIAL – NOT FOR CIRCULATION 
  


							
				
	 	 	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	  	 Foster 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

  










 CONFIDENTIAL – NOT FOR CIRCULATION 
  


							
	 	 	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

  










 CONFIDENTIAL – NOT FOR CIRCULATION 
  


							
	 	 	 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

  










 CONFIDENTIAL – NOT FOR CIRCULATION 
  

 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
41900-001-0000000027 (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 foster care or other out-of-home placement; 

  

	 	1.2.3.1.5	Children less than nineteen (19) years of age who are receiving foster 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 (GAPP); 

  

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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
bill for services, a line item of services, or all services for one recipient within a bill. 
  
 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 Atlanta Service Region, DCH 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 (Georgia.gov) 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	McLaughlin SMOG Index; 

  

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	 	4.3.2.4.5	The Flesch-Kincaid 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 (www.ghp.georgia.gov). 

  

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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 
  

			
	 SERVICE

	  	 COVERAGE LIMITATIONS


	Ambulatory Surgical Services	  	 
		
	Audiology Services	  	Not covered for Members age 21 and older. Available under EPSDT as part of a written service plan.


  

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	 SERVICE

	  	 COVERAGE LIMITATIONS


	Childbirth Education Services	  	 
	Dental Services	  	Preventive, diagnostic and treatment services provided to Members under age 21. Emergency Services only for Members age 21 and older.
		
	Durable Medical Equipment	  	 
		
	Early and Periodic Screening, Diagnostic, and Treatment Services	  	 
		
	Emergency Transportation Services	  	 
		
	Emergency Services	  	 
		
	Family Planning Services and Supplies	  	 
		
	Federally Qualified Health Center Services	  	Ambulatory services such as dental services are subject to any limitations applicable to the specific ambulatory service.
		
	Home Health Services	  	Not covered: social services, chore services, meals on wheels, audiology services.
		
	Hospice Services	  	Available to Members certified as being terminally ill and having a medical prognosis of life expectancy of six (6) months or less.
	Inpatient Hospital Services	  	 
		
	Laboratory and Radiological Services	  	Not covered: portable X-ray services; services provided in facilities not meeting the definition of an independent laboratory or X-ray facility; services or procedures referred to another
testing facility; services furnished by a State or public laboratory; services or procedures performed by a facility not certified to perform them.
		
	Mental Health Services	  	Community Mental Health Rehabilitation services are only available as part of a written service plan.


  

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	 SERVICE

	  	 COVERAGE LIMITATIONS


	Nurse Midwife Services	  	 
		
	Nurse Practitioner Services	  	 
		
	Nursing Facility Services	  	Not covered: Long-term nursing facility stays (over 30 Days)
		
	Obstetrical Services	  	 
		
	Occupational Therapy Services	  	Not covered for Members age 21 and older. Available under EPSDT as part of a written service plan.
		
	Optometric Services	  	Not covered for Members age 21 and older: routine refractive services and optical devices.
		
	Orthotic and Prosthetic Services	  	Not covered for Members age 21 and older: orthopedic shoes and supportive devices for the feet which are not an integral part of a leg brace; hearing aids and accessories.
		
	Oral Surgery	  	 
		
	Outpatient Hospital Services	  	 
		
	Pharmacy Services	  	Not covered: certain outpatient drugs pursuant to Section 1927(d) of the Social Security Act. Additionally, certain over the counter (OTC) drugs must be included, pursuant to the Georgia
State Policies and Procedures Manual.
		
	Physical Therapy Services	  	Not covered for Members age 21 and older. Available under EPSDT as part of a written service plan.
		
	Physician Services	  	 
		
	Podiatric Services	  	Not covered: services for flatfoot; subluxation; routine foot care, supportive devices; vitamin B-12 injections.
		
	Pregnancy-Related Services	  	 
		
	Private Duty Nursing Services	  	 
		
	Rural Health Clinic Services	  	 


  

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	 SERVICE

	  	 COVERAGE LIMITATIONS


	Speech Therapy Services	  	Not covered for Members age 21 and older; available under EPSDT as part of a written service plan.
		
	Substance Abuse Treatment Services (Inpatient)	  	Substance abuse treatment, inpatient and rehabilitative, are covered as part of a written service plan.
		
	Swing Bed Services	  	 
		
	Targeted Case Management	  	Covered for pregnant women under age 21 and other pregnant women at risk for adverse outcomes; infants and toddlers with established risk for developmental delay.
		
	Transplants	  	Not covered for Members age 21 and older: heart, lung and heart/lung transplants.


  

	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	Foster 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, (www.ghp.georgia.gov). 

  

	 	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	  	 
	 	  	Two Peachtree Street, NW-40th Floor	  	 
	 	  	Atlanta, Georgia 30303-3159	  	 

  

	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: 

  

	 	    	http://gta.georgia.gov/00/channel_modifieddate/0,2096,1070969_6947051,00. 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
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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 Davis Bacon Act (40 U.S.C. § 276a et seq.), the Copeland 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 Byrd
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: 
  
 Kathy Driggers 
 Georgia Department of
Community Health 
 2 Peachtree Street, NW - 35th Floor 
 Atlanta, GA 30303-3159 
 (404) 657-7793 – Phone 
 (404) 656-5537
– Fax 
 e-mail address: kdriggers@dch.state.ga.us 
  
 Project Leader: 
  
 Kathy Driggers 
 Georgia Department of
Community Health 
 2 Peachtree Street, NW - 37th Floor 
 Atlanta, GA 30303-3159 
 (404) 657-7793 – Phone 
  

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 (404) 656-5537 – Fax 
 e-mail address: kdriggers@dch.state.ga.us 
  
 For Contractor: 
 Peach State
Health Plan, Inc. 
 Daniel R Paquin 
 2484 Briarciff Suite 24 
 Atlanta GA 30329 
 (404) 812-0386 
 (404) - Fax 812-0391 
 e-mail address dpaquin@centene.com 
  

	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 Fulton 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. 

  

 Page 175 of 214 









 CONFIDENTIAL – NOT FOR CIRCULATION 
  


	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 



  

 Page 176 of 214 









 CONFIDENTIAL – NOT FOR CIRCULATION 
  


	 	 
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. 

  

 Page 177 of 214 









 CONFIDENTIAL – NOT FOR CIRCULATION 
  


	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 








 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, Daniel R Paquin, 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 13th day of July, 2005. 
  

	
	
	/s/    DANIEL R. PAQUIN        
	Daniel R. Paquin
	Vice President
	
	/s/    KAREY L. WITTY        
	Karey L. Witty
	Treasurer
	
	/S/    GWELDA
SWILLEY-BURKE        
	Gwelda Swilley-Burke
	Secretary


  










 CONFIDENTIAL – NOT FOR CIRCULATION 
  

 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/    TIM
BURGESS        	 	 	 	7/18/05
	Tim Burgess, Commissioner	 	 	 	Date
			
	DOAS STATE PURCHASING REPRESENTATIVE	 	 	 	 
			
	/S/    ANNE
MAIZE        	 	 	 	7/18/05
	Anne Maize	 	 	 	Date
			
	  	 	 	 	 
	CONTRACTOR NAME	 	 	 	 


							
				
	 By:
	 	/S/    DANIEL R
PAQUIN        	 	 	 	7/15/2005
	 	 	 Signature
	 	 	 	Date


					
			
	Daniel R Paquin	 	 	 	  
	 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




	*	Must be President, Vice President, CEO or other authorized officer 

  

	**	Must be Corporate Secretary 

  

 Page 179 of 214 









							
	 Secretary of State
 Corporations Division
 315 West Tower
 #2 Martin Luther King, Jr. Dr.
 Atlanta, Georgia 30334-1530
	  	 CONTROL NUMBER
 EFFECTIVE DATE
 JURISDICTION
 REFERENCE
 PRINT DATE
 FORM NUMBER
	 	 :   0547424
 :   06/15/2005
 :   FULTON
 :   0077
 :   07/13/2005
 :   302
	  	 
	 TROUTMAN SANDERS LLP
 MARTIN M. WILSON
 STE 5200, 600 PEACHTREE ST., NE
 ATLANTA, GA 303082216
	  	 	 	 	  	 

  
 CERTIFICATE OF
INCORPORATION 
  
 I, Cathy Cox, 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. 
  
 

 
  

	
	
	/S/    CATHY
COX        
	Cathy Cox
	Secretary of State


  









 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.	Dan Paquin 


	 	    	7711 Carondelet, Suite 800 


	 	    	St. Louis, MO 63105 

  

	 	2.	Brent Layton 


	 	    	4230 Lovingwood Trail 


	 	    	Powder Springs, GA 30127 

  

	 	3.	Brenda Williams 


	 	    	934 Carlisle Road 


	 	    	Stone Mountain, GA 30083 

  

	 	4.	Gwelda Swilley Burke 


	 	    	4729 Outlook Way 


	 	    	Marietta, GA 30066 

  

	 	5.	Scott Garrett 


	 	    	2230 Eagle Nest Bluff 


	 	    	Lawrenceville, GA 30044 

  
 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. 
  









 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: 
  

			
	 Dan Paquin
 7711 Carondelet, Suite 800
 St. Louis, MO 63105
	  	 Karey L. Witty
 7711 Carondelet, Suite 800
 St. Louis, MO 63105


  
 Gwelda Swilley Burke 
 4729 Outlook Way 
 Marietta, GA 30066 
  

 -2- 








 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.	  	 Michael F. Neidorff
 7711 Carondelet, Suite
800
 St. Louis, MO 63105
	  	President
			
	2.	  	 Dan Paquin
 7711 Carondelet, Suite 800
 St. Louis, MO 63105
	  	Vice President
			
	3.	  	 Gwelda Swilley Burke
 4729 Outlook Way
 Marietta, GA 30066
	  	Secretary
			
	4.	  	 Karey L. Witty
 7711 Carondelet, Suite 800
 St. Louis, MO 63105
	  	Treasurer

  

 -3- 








 14. 
  
 The initial home office and principal place of business of the Corporation shall be located at 2581 Piedmont Road, Suite A 400, Atlanta, Fulton County,
Georgia 30324, 
  
 The initial registered office of the
Corporation shall be: 600 Peachtree St., Suite 5200, Atlanta, Fulton County, Georgia 30308-2216. The initial registered agent of the Corporation at such address is Martin M. Wilson. 
  
 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 27th
day of February 2004. 
  
 [SIGNATURES ON NEXT PAGE] 
  

 -4- 









	
	
	/S/    DAN
PAQUIN        
	Dan Paquin
	
	/S/    BRENT
LAYTON        
	Brent Layton
	
	/S/    BRENDA
WILLIAMS        
	Brenda Williams
	
	/S/    GWELDA SWILLEY
BURKE        
	Gwelda Swilley Burke
	
	/S/    SCOTT
GARRETT        
	Scott Garrett


  

 -5- 








 IN THE PROBATE COURT FOR FULTON COUNTY 
 STATE OF GEORGIA 
  

									
	In Re: Certification of Publication	 	)	 	 	 	 	 	 
	of Charter for Peach State Health	 	)	 	 	 	 	 	 
	Plan, Inc.	 	)	 	 	 	 	 	 

  
 CERTIFICATE OF
PUBLICATION 
  
 I, Pinkie Toomer, Probate Judge of Fulton
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 Fulton County, Georgia wherein are published the legal advertisements of said County, to wit: the Fulton 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 5th day of November, 2004. 
  

	
	
	/S/    PINKIE
TOOMER        
	Honorable Pinkie Toomer
	Judge of the Probate Court
	Fulton County, Georgia


  
 Prepared by: 
 Martin M. Wilson 
 Georgia Bar No. 768862 
 Troutman Sanders LLP 
 600 Peachtree Street, N.E., Suite 5200 
 Atlanta, GA 30308-2216 
 404-885-3338 
  









 

 
  
 OFFICE OF 
 INSURANCE AND SAFETY FIRE COMMISSIONER 
  

			
	 JOHN W. OXENDINE
 COMMISSIONER OF INSURANCE
 SAFETY FIRE COMMISSIONER
 INDUSTRIAL LOAN COMMISSIONER
 COMPTROLLER GENERAL
	 	 SEVENTH FLOOR, WEST TO
 FLOYD BUILDING
 2 MARTIN LUTHER KING, JR.,
 ATLANTA, GEORGIA 3033
 (404) 656-2056 TDD# (404) 65
 www.gainsurance.org


  
 June 15, 2005

  
 Honorable Cathy Cox 
 Secretary of State 
 214 State Capitol 
 Atlanta, Georgia 30334 
  

	Re:	Peach State Health Plan, Inc. 

 Fulton 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 
  

	
	Sincerely,
	
	/S/    JOHN W.
OXENDINE        
	John W. Oxendine
	Commissioner of Insurance


  
 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 
  









 

 
  
 OFFICE OF 
 INSURANCE AND SAFETY FIRE COMMISSIONER 
  

					
	 JOHN W. OXENDINE
 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
 FLOYD BUILDING
 2 MARTIN LUTHER KING, JR.,
 ATLANTA, GEORGIA 3033
 (404) 656-2056 TDD# (404) 65
 www.gainsurance.org


  
 I, John W. Oxendine, 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 Pinkie T. Toomer of the Probate Court of Fulton, 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 15th day of June, 2005. 
  

	
	
	/S/    JOHN W.
OXENDINE        
	John W. Oxendine
	Insurance and Safety Fire Commissioner
	State of Georgia


  
 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 
  









 Publication Date: 10/29/04 Invoice # : 900 Account #: 070195-00035 
  
 PUBLISHER’S AFFIDAVIT 
  
 STATE OF GEORGIA 
 COUNTY OF FULTON 

Re: Peach State Health Plan 
  
 Before me, the undersigned, a Notary Public, this day personally came Julia Jackson 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/    JULIA
JACKSON        
	Julia Jackson

  
 Subscribed and sworn to before me this
10/29/04. 
  

	
	
	/S/    KAWEEMAH
NELSON        
	 Notary Public


  
 

 
  










 CONFIDENTIAL – NOT FOR CIRCULATION 
  

 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. 
  

 Page 180 of 214 









 CONFIDENTIAL – NOT FOR CIRCULATION 
  

 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; 

  

 Page 181 of 214 









 CONFIDENTIAL – NOT FOR CIRCULATION 
  


	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

  

 Page 182 of 214 









 CONFIDENTIAL – NOT FOR CIRCULATION 
  

 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/    DANIEL R.
PAQUIN        	 	 	 	 	 	7/15/2005
	 	 	 Signature
	 	 	 	 	 	Date
					
	 	 	 Daniel R. Paquin, 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: Elvina Calland, Director, Contract and Procurement Administration, Georgia Department of Community Health, 35th Floor, 2 Peachtree Street, N.W., Atlanta, Georgia 30303-3159. 
  
 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: 2484 Briarcliff Road Suite 24 
          Atlanta, GA 30329 
  
 PHONE: 404-812-0386            FAX: 404-812-0391 
  
 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 
 2 PEACHTREE STREET, N.W. 
 ATLANTA, GEORGIA 30303-3159 
  
 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): Daniel R Paquin

					
	Signature:	 	/s/    Illegible        	 	 	 	Date:	 	 7/15/2005

				
	 Telephone No.: 404-812-0386
	 	 	 	 	 	 

  

									
		
	 Company or Agency Name and Address:
	 	 Peach State Health Plan, Inc.
 2484
Briarcliff Road Suite 24
 Atlanta, GA 30329


  

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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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 CONFIDENTIAL – NOT FOR CIRCULATION 
  


	 	 
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): Daniel R Paquin

				
	* Signature:	 	/S/    DANIEL R
PAQUIN        	 	 	 	Date: 7/15/2005
					
	 Title:
	 	Executive Administrator	 	 	 	 	 	 
				
	 Telephone No.: 404-812-0386
	 	 	 	 Fax No.
	 	 414-812-0391

		
	 Company or Agency Name and Address:
	 	 Peach State Health Plan, Inc.
 2484 Briarcliff Road, Suite 24
 Atlanta, GA 30329




	*	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 Sonny Perdue 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:


  
 Jay Morgan 
  
 Brenda A. Williams 
  
 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/    DANIEL R
PAQUIN        	 	 	 	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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 CONFIDENTIAL – NOT FOR CIRCULATION 
  

 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

  










 CONFIDENTIAL – NOT FOR CIRCULATION 
  

 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 
 Two Peachtree Street, NW-40th Floor 
 Atlanta, Georgia 30303-3159 
  
 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 (Cobb County)
 404-524-5811 (Fulton County)
 404-669-0233 (So. Fulton/Clayton County)
	  	 4.      State Ombudsman Office
 1-888-454-5826
 (Nursing Home or
Personal Care Home)


  
 You may also ask for free mediation
services by calling 404-657-2806. 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

	  	 SW


	 Barrow
 Bartow
 Butts
 Carroll
 Cherokee
 Clayton
 Cobb
 Coweta
 DeKalb
 Douglas
 Fayette
 Forsyth
 Fulton
 Gwinnett
 Haralson
 Henry
 Jasper
 Newton
 Paulding
 Pickens
 Rockdale
 Spalding
 Walton
	  	 Baldwin
 Bibb
 Bleckley
 Chattahoochee
 Crawford
 Crisp
 Dodge
 Dooly
 Harris

Heard
 Houston
 Jones
 Lamar
 Laurens

Macon
 Marion
 Meriwether
 Monroe
 Muscogee
 Peach
 Pike
 Pulaski
 Talbot
 Taylor
 Telfair
 Treutlen
 Troup
 Twiggs
 Upson
 Wheeler
 Wilcox
 Wilkinson
 Johnson
	  	 Burke
 Columbia
 Emanuel
 Glascock
 Greene
 Hancock
 Jefferson
 Jenkins
 Lincoln
 McDuffie
 Putnam
 Richmond
 Screven
 Taliaferro
 Warren
 Washington
 Wilkes
	  	 Banks
 Catoosa
 Chattooga
 Clarke
 Dade
 Dawson
 Elbert

Fannin
 Floyd
 Franklin
 Gilmer
 Gordon
 Habersham
 Hall
 Hart
 Jackson
 Lumpkin
 Madison
 Morgan
 Murray
 Oconee
 Oglethorpe
 Polk
 Rabun
 Stephens
 Towns

Union
 Walker
 White
 Whitfield
	  	 Appling
 Bacon
 Brantley
 Bryan
 Bulloch
 Camden
 Candler
 Charlton
 Chatham
 Effingham
 Evans
 Glynn
 Jeff Davis
 Liberty
 Long
 Mclntosh
 Montgomery
 Pierce
 Tattnall
 Toombs
 Ware
 Wayne
	  	 Atkinson
 Baker
 Ben Hill
 Berrien
 Brooks
 Calhoun
 Clay

Clinch
 Coffee
 Colquitt
 Cook
 Decatur
 Dougherty
 Early
 Echols
 Grady
 Irwin
 Lanier
 Lee
 Lowndes
 Miller
 Mitchell
 Quitman
 Randolph
 Seminole
 Schley
 Stewart
 Sumter
 Terrell
 Thomas
 Tift

Turner
 Webster
 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


  

 Page 200 of 214 









 CONFIDENTIAL – NOT FOR CIRCULATION 
  

 ATTACHMENT L 
  
 INFORMATION MANAGEMENT AND SYSTEMS 
  

 Page 201 of 214 








 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. 
  

 Page 1 of 13 








 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

  

 Page 2 of 13 








 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: FEINs/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.

  

 Page 3 of 13 








 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.

  

 Page 4 of 13 








 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

  

 Page 5 of 13 








 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

  

 Page 6 of 13 








 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. 
  

 Page 7 of 13 









	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

  

 Page 8 of 13 









	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. 
  

 Page 9 of 13 









	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.

  

 Page 10 of 13 








 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. 

  

 Page 11 of 13 








 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 








 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 








 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 









							
	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	  	05	  	001-999
	000850	  	SVC DETAIL	  	06	  	001-999

  

 Page 2 of 326 









			
	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 









			
	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 









			
	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 









			
	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 









			
	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 









			
	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 









			
	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 









			
	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 









			
	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 









			
	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 









			
	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 SUMMARY) OR
	000220	  	 	  	LOOPS 2000B AND 2100B (FOR
	000230	  	 	  	INDIVIDUAL)
	000240	  	 	  	 
	000250	  	X820-ORG-OR-INDIV-DTL	  	CONTAINS LOOP 2300A (FOR
	000260	  	 	  	ORGANIZATIONAL SUMMARY) OR
	000270	  	 	  	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 SUMMARY) OR
	000340	  	 	  	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	  	ZEROS	  	ZEROS	  	00	  	ZEROS
	000760	  	ORG/INDIV IDENT	  	IIIII	  	ZEROS	  	01	  	ZEROS
	000770	  	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 









							
	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 









									
	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	  	ZEROS	  	00	  	ZEROS
	000780	  	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 









			
	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	  	 834 LOOP 1000A SPONSOR 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 









			
	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	  	 834 LOOP 1000C TPA/BROKER 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	  	 834 LOOP 1100C TPA/BROKER 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 









			
	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	  	 

  

 Page 59 of 326 









			
	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 









					
	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 









					
	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 









													
	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	  	ZEROS	  	ZEROS	  	00	  	ZEROS
	001170	  	 PAYER IDENT
	  	ZEROS	  	ZEROS	  	ZEROS	  	01	  	ZEROS
	001180	  	 PAYEE IDENT
	  	ZEROS	  	ZEROS	  	ZEROS	  	02	  	ZEROS
	001190	  	 PROV SUMMARY
	  	PPPPP	  	ZEROS	  	ZEROS	  	03	  	ZEROS
	001200	  	 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 









			
	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 









			
	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 









			
	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	  	 835 PAYER IDENTIFICATION RECORD (LOOP 1000A)

	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 









			
	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 









			
	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	  	 835 PAYEE IDENTIFICATION RECORD (LOOP 1000B)

	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 









			
	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 









			
	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-GRAMM-RUDD-AMT


  

 Page 71 of 326 









			
	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-PAT-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	  	 835 PROVIDER ADJUSTMENT RECORD - PLB SEGMENT,

	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	  	 835 TRANSACTION TRAILER RECORD - SE SEGMENT,

	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	  	PAT	  	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-BILL-PROV-TYPE-CODE

	003420	  	 PIC X(01).

	003430	  	 10     X83ZD-BILL-PROV-NAME-LAST

	003440	  	 PIC X(35).

	003450	  	 10     X83ZD-BILL-PROV-NAME-FIRST

	003460	  	 PIC X(25).

	003470	  	 10     X83ZD-BILL-PROV-NAME-MIDDLE

	003480	  	 PIC X(25).

	003490	  	 10     X83ZD-BILL-PROV-NAME-SFX

	003500	  	 PIC X(10).

	003510	  	 10     X83ZD-BILL-PROV-ID-CODE-TYPE

	003520	  	 PIC X(02).

	003530	  	 10     X83ZD-BILL-PROV-ID-CODE

	003540	  	 PIC X(80).

	003550	  	 10     FILLER

	003560	  	 PIC X(10).


  

 Page 100 of 326 









			
	003570	  	 
	003580	  	 05     X837D-BILL-PROV- ADDR-SEG.

	003590	  	 
	003600	  	 10     X837D-BILL-PROV-ADDR1

	003610	  	 PIC X(55).

	003620	  	 10     X837D-BILL-PROV-ADDR2

	003630	  	 PIC X(55).

	003640	  	 10     FILLER

	003650	  	 PIC X(10).

	003660	  	 
	003670	  	 05     X837D-BILL-PROV- LOC-SEG.

	003680	  	 
	003690	  	 10     X837D-BILL-PROV- CITY

	003700	  	 PIC X(30).

	003710	  	 10     X837D-BILL-PROV-STATE

	003720	  	 PIC X(02).

	003730	  	 10     X837D-BILL-PROV-ZIP

	003740	  	 PIC X(15).

	003750	  	 10     X837D-BILL-PROV-COUNTRY

	003760	  	 PIC X(03).

	003770	  	 10     FILLER

	003780	  	 PIC X(10).

	003790	  	 
	003800	  	 05     X837D-BILL-PROV-2ND-IDENT-SEG

	003810	  	 OCCURS 5 TIMES

	003820	  	 INDEXED BY X837D-BILL-PROV-2ND-IDENT-NDX.

	003830	  	 
	003840	  	 10     X837D-BILL-PROV-2ND-ID-CODE

	003850	  	 PIC X(03).

	003860	  	 10     X837D-BILL-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-PAT-HIERACHICAL-LVL-SEG.

	007500	  	 
	007510	  	 10     X837D-PAT-HIER-NBR

	007520	  	 PIC X(12).

	007530	  	 10     X837D-PAT-HIER-PARENT-NBR

	007540	  	 PIC X(12).

	007550	  	 10     X837D-PAT-HIER-LVL-CODE

	007560	  	 PIC X(02).

	007570	  	 10     X837D-PAT-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-PAT-RELATIONSHIP-CODE


  

 Page 108 of 326 









			
	007650	  	 PIC X(02).

	007660	  	 10     X837D-PAT-STUDENT-STATUS-CD

	007670	  	 PIC X(01).

	007680	  	 10     FILLER

	007690	  	 PIC X(10).

	007700	  	 
	007710	  	LOOP-ID-2010CA
	007720	  	 
	007730	  	 05     X837D-PAT-NAME-SEG.

	007740	  	 
	007750	  	 10     X837D-PAT-TYPE-CODE

	007760	  	 PIC X(01).

	007770	  	 10     X837D-PAT-NAME-LAST

	007780	  	 PIC X(35).

	007790	  	 10     X837D-PAT-NAME-FIRST

	007800	  	 PIC X(25).

	007810	  	 10     X837D-PAT-NAME-MIDDLE

	007820	  	 PIC X(25).

	007830	  	 10     X837D-PAT-NAME-SFX

	007840	  	 PIC X(10).

	007850	  	 10     X837D-PAT-ID-CODE-TYPE

	007860	  	 PIC X(02).

	007870	  	 10     X837D-PAT-ID-CODE

	007880	  	 PIC X(80).

	007890	  	 10     FILLER

	007900	  	 PIC X(10).

	007910	  	 
	007920	  	 05     X837D-PAT-ADDR-SEG.

	007930	  	 
	007940	  	 10     X837D-PAT-ADDR1

	007950	  	 PIC X(55).

	007960	  	 10     X837D-PAT-ADDR2

	007970	  	 PIC X(55).

	007980	  	 10     FILLER

	007990	  	 PIC X(10).

	008000	  	 
	008010	  	 05     X837D-PAT-CITY-STATE-SEG.

	008020	  	 
	008030	  	 10     X837D-PAT-CITY

	008040	  	 PIC X(30).

	008050	  	 10     X837D-PAT-STATE-CODE

	008060	  	 PIC X(02).

	008070	  	 10     X837D-PAT-ZIP-CODE

	008080	  	 PIC X(15).

	008090	  	 10     X837D-PAT-COUNTRY-CODE

	008100	  	 PIC X(03).

	008110	  	 10     FILLER

	008120	  	 PIC X(10).

	008130	  	 
	008140	  	 05     X837D-PAT-DEMOGRAPHIC-SEG.

	008150	  	 

  

 Page 109 of 326 









			
	008160	  	 10     X837D-PAT-DOB

	008170	  	 PIC X(08).

	008180	  	 10     X837D-PAT-GENDER-CODE

	008190	  	 PIC X(01).

	008200	  	 10     FILLER

	008210	  	 PIC X(10).

	008220	  	 
	008230	  	 05     X837D-PAT-2ND-ID-SEG

	008240	  	 OCCURS 5 TIMES

	008250	  	 INDEXED BY X837D-PAT-2ND-ID-NDX.

	008260	  	 
	008270	  	 10     X837D-PAT-2ND-ID-TYPE

	008280	  	 PIC X(03).

	008290	  	 10     X837D-PAT-2ND-ID

	008300	  	 PIC X(30).

	008310	  	 10     FILLER

	008320	  	 PIC X(10).

	008330	  	 
	008340	  	 05     X837D-PAT-PROP-CLAIM-NBR-SEG.

	008350	  	 10     X837D-PAT-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-DELAY-REAS-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-PAT-PAID-AMT-SEG.

	010100	  	 
	010110	  	 10     X837D-CLM-PAT-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-PAT-RESPON-SEG.

	013200	  	 
	013210	  	 10     X837D-COB-PAT-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-PAT-INFO-SEG.

	014870	  	 
	014880	  	 10     X837D-OTHR-PYR-PAT-NAME

	014890	  	 PIC X(35).

	014900	  	 10     X837D-OTHR-PYR-PAT-PRIME-QUAL

	014910	  	 PIC X(02).

	014920	  	 10     X837D-OTHR-PYR-PAT-PRIME-ID

	014930	  	 PIC X(30).

	014940	  	 10     FILLER

	014950	  	 PIC X(10).

	014960	  	 
	014970	  	 05     X837D-OTHR-PAYER-PAT-ID-SEG

	014980	  	 OCCURS 3 TIMES

	014990	  	 INDEXED BY X837D-OTHR-PAYER-PAT-ID-NDX.

	015000	  	 
	015010	  	 10     X837D-OTHR-PAYER-PAT-ID-QUAL

	015020	  	 PIC X(03).

	015030	  	 10     X837D-OTHR-PAYER-PAT-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).


  

 Page 131 of 326 









			
	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	  	 837D - TRANSACTION TRAILER RECORD

	020010	  	 
	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	  	PAT	  	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-BILL-PROV-ENTITY-CODE

	035000	  	 PIC X(01).

	035100	  	 10     X837I-BILL-PROV-NAME-LAST

	035200	  	 PIC X(35).

	035300	  	 10     X837I-BILL-PROV-ID-CODE

	035400	  	 PIC X(02).

	035500	  	 10     X837I-BILL-PROV-ID-NBR

	035600	  	 PIC X(80).

	035700	  	 10     FILLER


  

 Page 141 of 326 









			
	035800	  	 PIC X(10).

	035900	  	 
	036000	  	 05     X837I-BILL-PROV-ADDR-SEG.

	036100	  	 
	036200	  	 10     X837I-BILL-PROV-ADDR1

	036300	  	 PIC X(55).

	036400	  	 10     X837I-BILL-PROV-ADDR2

	036500	  	 PIC X(55).

	036600	  	 10     FILLER

	036700	  	 PIC X(10).

	036800	  	 
	036900	  	 05     X837I-BILL-PROV-LOC-SEG.

	037000	  	 
	037100	  	 10     X837I-BILL-PROV-CITY

	037200	  	 PIC X(30).

	037300	  	 10     X837I-BILL-PROV-STATE

	037400	  	 PIC X(02).

	037500	  	 10     X837I-BILL-PROV-ZIP

	037600	  	 PIC X(15).

	037700	  	 10     X837I-BILL-PROV-COUNTRY

	037800	  	 PIC X(03).

	037900	  	 10     FILLER

	038000	  	 PIC X(10).

	038100	  	 
	038200	  	 05     X837I-BILL-PROV-2ND-IDENT-SEG

	038300	  	 OCCURS 8 TIMES

	038400	  	 INDEXED BY X837I-BILL-PROV-2ND-IDENT-NDX.

	038500	  	 
	038600	  	 10     X837I-BILL-PROV-2ND-ID-CODE

	038700	  	 PIC X(03).

	038800	  	 10     X837I-BILL-PROV-2ND-ID

	038900	  	 PIC X(30).

	039000	  	 10     FILLER

	039100	  	 PIC X(10).

	039200	  	 
	039300	  	 05     X837I-BILL-PROV-BANK-CARD-SEG

	039400	  	 OCCURS 8 TIMES

	039500	  	 INDEXED BY X837I-BILL-PROV-BANK-CARD-NDX.

	039600	  	 
	039700	  	 10     X837I-BILL-PROV-CRDT-CRD-ID-TP

	039800	  	 PIC X(03).

	039900	  	 10     X837I-BILL-PROV-CRDT-CRD-ID

	040000	  	 PIC X(30).

	040100	  	 10     FILLER

	040200	  	 PIC X(10).

	040300	  	 
	040400	  	 05     X837I-BILL-PROV-CONTACT-SEG

	040500	  	 OCCURS 2 TIMES

	040600	  	 INDEXED BY X837I-BILL-PROV-CONTACT-NDX.

	040700	  	 
	040800	  	 10     X837I-BILL-PRV-CONTACT-NAME


  

 Page 142 of 326 









			
	040900	  	 PIC X(60).

	041000	  	 10     X837I-BILL-PROV-COMM-INFO

	041100	  	 OCCURS 3 TIMES

	041200	  	 INDEXED BY X837I-BILL-PROV-COMM-INFO-NDX.

	041300	  	 15     X837I-BILL-PROV-COMM-QUAL

	041400	  	 PIC X(02).

	041500	  	 15     X837I-BILL-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 









			
	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 









			
	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-PAT-HIERACHICAL-LVL-SEG.

	081200	  	 
	081300	  	 10     X837I-PAT-HIER-NBR

	081400	  	 PIC X(12).

	081500	  	 10     X837I-PAT-HIER-PARENT-NBR

	081600	  	 PIC X(12).


  

 Page 150 of 326 









			
	081700	  	 10     X837I-PAT-HIER-LVL-CODE

	081800	  	 PIC X(02).

	081900	  	 10     X837I-PAT-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-PAT-RELATIONSHIP-CODE

	082700	  	 PIC X(02).

	082800	  	 10     FILLER

	082900	  	 PIC X(10).

	083000	  	 
	083100	  	LOOP-ID-2010CA
	083200	  	 
	083300	  	 05     X837I-PAT-NAME-SEG.

	083400	  	 
	083500	  	 10     X837I-PAT-TYPE-CODE

	083600	  	 PIC X(01).

	083700	  	 10     X837I-PAT-NAME-LAST

	083800	  	 PIC X(35).

	083900	  	 10     X837I-PAT-NAME-FIRST

	084000	  	 PIC X(25).

	084100	  	 10     X837I-PAT-NAME-MIDDLE

	084200	  	 PIC X(25).

	084300	  	 10     X837I-PAT-NAME-SFX

	084400	  	 PIC X(10).

	084500	  	 10     X837I-PAT-ID-CODE-TYPE

	084600	  	 PIC X(02).

	084700	  	 10     X837I-PAT-ID-CODE

	084800	  	 PIC X(80).

	084900	  	 10     FILLER

	085000	  	 PIC X(10).

	085100	  	 
	085200	  	 05     X837I-PAT-ADDR-SEG.

	085300	  	 
	085400	  	 10     X837I-PAT-ADDR1

	085500	  	 PIC X(55).

	085600	  	 10     X837I-PAT-ADDR2

	085700	  	 PIC X(55).

	085800	  	 10     FILLER

	085900	  	 PIC X(10).

	086000	  	 
	086100	  	 05     X837I-PAT-CITY-STATE-SEG.

	086200	  	 
	086300	  	 10     X837I-PAT-CITY

	086400	  	 PIC X(30).

	086500	  	 10     X837I-PAT-STATE-CODE

	086600	  	 PIC X(02).

	086700	  	 10     X837I-PAT-ZIP-CODE


  

 Page 151 of 326 









			
	086800	  	 PIC X(15).

	086900	  	 10     X837I-PAT-COUNTRY-CODE

	087000	  	 PIC X(03).

	087100	  	 10     FILLER

	087200	  	 PIC X(10).

	087300	  	 
	087400	  	 05     X837I-PAT-DEMOGRAPHIC-SEG.

	087500	  	 
	087600	  	 10     X837I-PAT-DOB

	087700	  	 PIC X(08).

	087800	  	 10     X837I-PAT-GENDER-CODE

	087900	  	 PIC X(01).

	088000	  	 10     FILLER

	088100	  	 PIC X(10).

	088200	  	 
	088300	  	 05     X837I-PAT-2ND-ID-SEG

	088400	  	 OCCURS 5 TIMES

	088500	  	 INDEXED BY X837I-PAT-2ND-ID-NDX.

	088600	  	 
	088700	  	 10     X837I-PAT-2ND-ID-TYPE

	088800	  	 PIC X(03).

	088900	  	 10     X837I-PAT-2ND-ID

	089000	  	 PIC X(30).

	089100	  	 10     FILLER

	089200	  	 PIC X(10).

	089300	  	 
	089400	  	 05     X837I-PAT-PROP-CLAIM-NBR-SEG.

	089500	  	 10     X837I-PAT-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 









			
	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 









			
	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-DELAY-REAS-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-PAT-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 









			
	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-PAT-PAID-AMT-SEG.

	105700	  	 
	105800	  	 10     X837I-CLM-PAT-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 









			
	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 









			
	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 









			
	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 









			
	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 









			
	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 









			
	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 









			
	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 









			
	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-PAT-INFO-SEG.

	193200	  	 
	193300	  	 10     X837I-OTHR-PAYER-PAT-ID-QUAL

	193400	  	 PIC X(02).

	193500	  	 10     X837I-OTHR-PAYER-PAT-ID-NBR

	193600	  	 PIC X(80).

	193700	  	 10     FILLER

	193800	  	 PIC X(10).


  

 Page 172 of 326 









			
	193900	  	 
	194000	  	 05     X837I-OTHR-PAYER-PAT-ID-SEG.

	194100	  	 
	194200	  	 10     X837I-OTHR-PAYER-PAT-ID2-QUAL

	194300	  	 PIC X(02).

	194400	  	 10     X837I-OTHR-PAYER-PAT-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 









			
	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 









			
	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 









			
	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 









			
	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 









			
	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 









					
	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	  	PAT	  	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 









			
	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-BILL-PROV-ENTITY-CODE

	003600	  	 PIC X(01).

	003610	  	 10     X837P-BILL-PROV-NAME-LAST

	003620	  	 PIC X(35).

	003630	  	 10     X837P-BILL-PROV-NAME-FIRST

	003640	  	 PIC X(25).

	003650	  	 10     X837P-BILL-PROV-NAME-MIDDLE

	003660	  	 PIC X(25).

	003670	  	 10     X837P-BILL-PROV-NAME-SFX

	003680	  	 PIC X(10).

	003690	  	 10     X837P-BILL-PROV-ID-CODE

	003700	  	 PIC X(02).

	003710	  	 10     X837P-BILL-PROV-ID-NBR

	003720	  	 PIC X(80).

	003730	  	 10     FILLER

	003740	  	 PIC X(10).

	003750	  	 
	003760	  	 05     X837P-BILL-PROV-ADDR-SEG.

	003770	  	 
	003780	  	 10     X837P-BILL-PROV-ADDR1

	003790	  	 PIC X(55).

	003800	  	 10     X837P-BILL-PROV-ADDR2

	003810	  	 PIC X(55).

	003820	  	 10     FILLER

	003830	  	 PIC X(10).

	003840	  	 
	003850	  	 05     X837P-BILL-PROV-LOC-SEG.

	003860	  	 
	003870	  	 10     X837P-BILL-PROV-CITY

	003880	  	 PIC X(30).

	003890	  	 10     X837P-BILL-PROV-STATE

	003900	  	 PIC X(02).

	003910	  	 10     X837P-BILL-PROV-ZIP

	003920	  	 PIC X(15).

	003930	  	 10     X837P-BILL-PROV-COUNTRY

	003940	  	 PIC X(03).

	003950	  	 10     FILLER

	003960	  	 PIC X(10).

	003970	  	 
	003980	  	 05     X837P-BILL-PROV-2ND-IDENT-SEG.

	003990	  	 OCCURS 8 TIMES

	004000	  	 INDEXED BY X837P-BILL-PROV-2ND-IDENT-NDX.

	004010	  	 
	004020	  	 10     X837P-BILL-PROV-2ND-ID-CODE

	004030	  	 PIC X(03).

	004040	  	 10     X837P-BILL-PROV-2ND-ID

	004050	  	 PIC X(30).

	004060	  	 10     FILLER

	004070	  	 PIC X(10).

	004080	  	 

  

 Page 194 of 326 









			
	004090	  	 05     X837P-BILL-PROV-BANK-CARD-SEG

	004100	  	 OCCURS 8 TIMES

	004110	  	 INDEXED BY X837P-BILL-PROV-BANK-CARD-NDX.

	004120	  	 
	004130	  	 10     X837P-BILL-PROV-CRDT-CRD-ID-TP

	004140	  	 PIC X(03).

	004150	  	 10     X837P-BILL-PROV-CRDT-CRD-ID

	004160	  	 PIC X(30).

	004170	  	 10     FILLER

	004180	  	 PIC X(10).

	004190	  	 
	004200	  	 05     X837P-BILL-PROV-CONTACT-SEG

	004210	  	 OCCURS 2 TIMES

	004220	  	 INDEXED BY X837P-BILL-PROV-CONTACT-NDX.

	004230	  	 
	004240	  	 10     X837P-BILL-PRV-CONTACT-NAME

	004250	  	 PIC X(60).

	004260	  	 10     X837P-BILL-PRV-CONTACT-NB-TP-1

	004270	  	 PIC X(02).

	004280	  	 10     X837P-BILL-PRV-CONTACT-NB-1

	004290	  	 PIC X(80).

	004300	  	 10     X837P-BILL-PRV-CONTACT-NB-TP-2

	004310	  	 PIC X(02).

	004320	  	 10     X837P-BILL-PRV-CONTACT-NB-2

	004330	  	 PIC X(80).

	004340	  	 10     X837P-BILL-PRV-CONTACT-NB-TP-3

	004350	  	 PIC X(02).

	004360	  	 10     X837P-BILL-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 









			
	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-PAT-HIERACHICAL-LVL-SEG.

	008490	  	 
	008500	  	 10     X837P-PAT-HIER-NBR

	008510	  	 PIC X(12).

	008520	  	 10     X837P-PAT-HIER-PARENT-NBR

	008530	  	 PIC X(12).

	008540	  	 10     X837P-PAT-HIER-LVL-CODE

	008550	  	 PIC X(02).

	008560	  	 10     X837P-PAT-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-PAT-RELATIONSHIP-CODE

	008640	  	 PIC X(02).

	008650	  	 10     X837P-PAT-DATE-OF-DEATH

	008660	  	 PIC X(08).

	008670	  	 10     X837P-PAT-WEIGHT-CODE


  

 Page 203 of 326 









			
	008680	  	 PIC X(02).

	008690	  	 10     X837P-PAT-WEIGHT

	008700	  	 PIC 9(5).

	008710	  	 10     X837P-PAT-PREGNANCY-INDICATOR

	008720	  	 PIC X(01).

	008730	  	 10     FILLER

	008740	  	 PIC X(10).

	008750	  	 
	008760	  	LOOP-ID-2010CA
	008770	  	 
	008780	  	 05     X837P-PAT-NAME-SEG.

	008790	  	 
	008800	  	 10     X837P-PAT-TYPE-CODE

	008810	  	 PIC X(01).

	008820	  	 10     X837P-PAT-NAME-LAST

	008830	  	 PIC X(35).

	008840	  	 10     X837P-PAT-NAME-FIRST

	008850	  	 PIC X(25).

	008860	  	 10     X837P-PAT-NAME-MIDDLE

	008870	  	 PIC X(25).

	008880	  	 10     X837P-PAT-NAME-SFX

	008890	  	 PIC X(10).

	008900	  	 10     X837P-PAT-ID-CODE-TYPE

	008910	  	 PIC X(02).

	008920	  	 10     X837P-PAT-ID-CODE

	008930	  	 PIC X(80).

	008940	  	 10     FILLER

	008950	  	 PIC X(10).

	008960	  	 
	008970	  	 05     X837P-PAT-ADDR-SEG.

	008980	  	 
	008990	  	 10     X837P-PAT-ADDR1

	009000	  	 PIC X(55).

	009010	  	 10     X837P-PAT-ADDR2

	009020	  	 PIC X(55).

	009030	  	 10     FILLER

	009040	  	 PIC X (10).

	009050	  	 
	009060	  	 05     X837P-PAT-CITY-STATE-SEG.

	009070	  	 
	009080	  	 10     X837P-PAT-CITY

	009090	  	 PIC X(30).

	009100	  	 10     X837P-PAT-STATE-CODE

	009110	  	 PIC X(02).

	009120	  	 10     X837P-PAT-ZIP-CODE

	009130	  	 PIC X(15).

	009140	  	 10     X837P-PAT-COUNTRY-CODE

	009150	  	 PIC X(03).

	009160	  	 10     FILLER

	009170	  	 PIC X(10).

	009180	  	 

  

 Page 204 of 326 









			
	009190	  	 05     X837P-PAT-DEMOGRAPHIC-SEG.

	009200	  	 
	009210	  	 10     X837P-PAT-DOB

	009220	  	 PIC X(08).

	009230	  	 10     X837P-PAT-ENDER-CODE

	009240	  	 PIC X(01).

	009250	  	 10     FILLER

	009260	  	 PIC X(10).

	009270	  	 
	009280	  	 05     X837P-PAT-2ND-ID-SEG

	009290	  	 OCCURS 5 TIMES

	009300	  	 INDEXED BY X837P-PAT-2ND-ID-NDX.

	009310	  	 
	009320	  	 10     X837P-PAT-2ND-ID-TYPE

	009330	  	 PIC X(03).

	009340	  	 10     X837P-PAT-2ND-ID

	009350	  	 PIC X(30).

	009360	  	 10     FILLER

	009370	  	 PIC X(10).

	009380	  	 
	009390	  	 05     X837P-PAT-PROP-CLAIM-NBR-SEG.

	009400	  	 10     X837P-PAT-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-PAT-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-PAT-PAID-AMT-SEG.

	011460	  	 10     X837P-CLM-PAT-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-PAT-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-PAT-INFO-VISION-SEG

	 012690
	  	 OCCURS 3 TIMES

	 012700
	  	 INDEXED BY X837P-CLM-PAT-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-PAT-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-PAT-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-PAT-INFO-SEG.

	018360	 	 

  

 Page 222 of 326 









			
	018370	 	 10     X837P-OTHR-PAYER-PAT-ID-TYPE

	018380	 	 PIC X(02).

	018390	 	 10     X837P-OTHR-PAYER-PAT-ID-NBR

	018400	 	 PIC X(80).

	018410	 	 10     FILLER

	018420	 	 PIC X(10).

	018430	 	 
	018440	 	 05     X837P-OTHR-PYR-PAT-2ND-ID-SEG

	018450	 	 OCCURS 3 TIMES

	018460	 	 INDEXED BY X837P-OTHR-PYR-PAT-2ND-ID-NDX.

	018470	 	 
	018480	 	 10     X837P-OTHR-PYR-PAT-2ND-ID-TYP

	018490	 	 PIC X(03).

	018500	 	 10     X837P-OTHR-PYR-PAT-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 









			
	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-DME-SVC-PUR-PRICE


  

 Page 228 of 326 









			
	 021430
	  	 PIC S9(11)V9(2).

	 021440
	  	 10     X837P-LN-DME-SVC-FREQ

	 021450
	  	 PIC X(01).

	 021460
	  	 10     FILLER

	 021470
	  	 PIC X(10).

	 021480
	  	 
	 021490
	  	 
	 021500
	  	 05     X837P-LN-DMERC-CMN-IND-SEG.

	 021510
	  	 
	 021520
	  	 10     X837P-LN-ATTCH-TRANSMIT-CD

	 021530
	  	 PIC X(02).

	 021540
	  	 
	 021550
	  	 05     X837P-LN-AMBULANCE-SEG.

	 021560
	  	 
	 021570
	  	 10     X837P-LN-AMB-PAT-WEIGHT

	 021580
	  	 PIC S9(4).

	 021590
	  	 10     X837P-LN-AMB-TRANS-CD

	 021600
	  	 PIC X(01).

	 021610
	  	 10     X837P-LN-AMB-TRANS-REA-CD

	 021620
	  	 PIC X(01).

	 021630
	  	 10     X837P-LN-AMB-DISTANCE

	 021640
	  	 PIC S9(5).

	 021650
	  	 10     X837P-LN-AMB-RND-TRIP-DESC

	 021660
	  	 PIC X(80).

	 021670
	  	 10     X837P-LN-AMB-STRETCHER-DESC

	 021680
	  	 PIC X(80).

	 021690
	  	 10     FILLER

	 021700
	  	 PIC X(10).

	 021710
	  	 
	 021720
	  	 05     X837P-LN-SPINAL-MANIP-SEG

	 021730
	  	 OCCURS 5 TIMES

	 021740
	  	 INDEXED BY X837P-LN-SPINAL-MANIP-NDX.

	 021750
	  	 
	 021760
	  	 10     X837P-LN-SPINAL-COND-CD

	 021770
	  	 PIC X(01).

	 021780
	  	 10     X837P-LN-SPINAL-COND-DESC

	 021790
	  	 OCCURS 2 TIMES

	 021800
	  	 INDEXED BY X837P-LN-SPINAL-COND-DESC-NDX

	 021810
	  	 PIC X(80).

	 021820
	  	 10     X837P-LN-SPINAL-XRAY-AVAIL

	 021830
	  	 PIC X(01).

	 021840
	  	 10     FILLER

	 021850
	  	 PIC X(10).

	 021860
	  	 
	 021870
	  	 05     X837P-LN-DUR-MED-EQIP-SEG.

	 021880
	  	 
	 021890
	  	 10     X837P-LN-DUR-MED-CERT-CD

	 021900
	  	 PIC X(01).

	 021910
	  	 10     X837P-LN-DUR-MED-TIME-REQ

	 021920
	  	 PIC S9(9)V99.

	 021930
	  	 10     FILLER


  

 Page 229 of 326 









			
	 021940
	  	 PIC X(10).

	 021950
	  	 
	 021960
	  	 05     X837P-LN-HOME-OXYGEN-SEG.

	 021970
	  	 
	 021980
	  	 10     X837P-LN-HOME-OXY-CERT-TYPE

	 021990
	  	 PIC X(01).

	 022000
	  	 10     X837P-LN-HOME-OXY-CERT-PER

	 022010
	  	 PIC S9(9)V99.

	 022020
	  	 10     X837P-LN-HOME-OXY-BLOOD-GAS

	 022030
	  	 PIC S9(9)V99.

	 022040
	  	 10     X837P-LN-HOME-OXY-SATURATION

	 022050
	  	 PIC S9(9)V99.

	 022060
	  	 10     X837P-LN-HOME-OXY-TEST-COND

	 022070
	  	 PIC X(01).

	 022080
	  	 10     X837P-LN-HOME-OXY-TEST-FIND-1

	 022090
	  	 PIC X(01).

	 022100
	  	 10     X837P-LN-HOME-OXY-TEST-FIND-2

	 022110
	  	 PIC X(01).

	 022120
	  	 10     X837P-LN-HOME-OXY-TEST-FIND-3

	 022130
	  	 PIC X(01).

	 022140
	  	 10     FILLER

	 022150
	  	 PIC X(10).

	 022160
	  	 
	 022170
	  	 05     X837P-LN-AMB-CERT-SEG

	 022180
	  	 OCCURS 3 TIMES

	 022190
	  	 INDEXED BY X837P-LN-AMB-CERT-NDX.

	 022200
	  	 
	 022210
	  	 10     X837P-LN-AMB-CERT-CD-APPLIES

	 022220
	  	 PIC X(01).

	 022230
	  	 10     X837P-LN-AMB-COND-IND

	 022240
	  	 OCCURS 5 TIMES

	 022250
	  	 INDEXED BY X837P-LN-AMB-COND-IND-NDX

	 022260
	  	 PIC X(02).

	 022270
	  	 10     FILLER

	 022280
	  	 PIC X(10).

	 022290
	  	 
	 022300
	  	 05     X837P-LN-HOSPICE-EMP-SEG.

	 022310
	  	 
	 022320
	  	 10     X837P-LN-HOSPICE-EMP-IND

	 022330
	  	 PIC X(01).

	 022340
	  	 10     X837P-LN-HOSPICE-EMP-COND

	 022350
	  	 PIC X(02).

	 022360
	  	 10     FILLER

	 022370
	  	 PIC X(10).

	 022380
	  	 
	 022390
	  	 05     X837P-LN-DMERC-COND-SEG

	 022400
	  	 OCCURS 2 TIMES

	 022410
	  	 INDEXED BY X837P-LN-DMERC-COND-NDX.

	 022420
	  	 
	 022430
	  	 10     X837P-LN-DMREC-CATEGORY

	 022440
	  	 PIC X(02).


  

 Page 230 of 326 









			
	 022450
	  	 10     X837P-LN-DMREC-CERT-CD-APPLIES

	 022460
	  	 PIC X(01).

	 022470
	  	 10     X837P-LN-DMREC-COND-IND

	 022480
	  	 OCCURS 5 TIMES

	 022490
	  	 INDEXED BY X837P-LN-DMREC-COND-IND-NDX

	 022500
	  	 PIC X(02).

	 022510
	  	 10     FILLER

	 022520
	  	 PIC X(10).

	 022530
	  	 
	 022540
	  	 05     X837P-LN-DATE-OF-SVC-SEG

	 022550
	  	 PIC X(08).

	 022560
	  	 
	 022570
	  	 05     X837P-LN-CERT-REVISION-SEG

	 022580
	  	 PIC X(08).

	 022590
	  	 
	 022600
	  	 05     X837P-LN-DATE-BEGIN-THER-SEG

	 022610
	  	 PIC X(08).

	 022620
	  	 
	 022630
	  	 05     X837P-LN-DATE-LAST-CERT-SEG

	 022640
	  	 PIC X(08).

	 022650
	  	 
	 022660
	  	 05     X837P-LN-DATE-LAST-SEEN-SEG

	 022670
	  	 PIC X(08).

	 022680
	  	 
	 022690
	  	 05     X837P-LN-DATE-OF-TEST-SEG

	 022700
	  	 PIC X(08).

	 022710
	  	 
	 022720
	  	 05     X837P-LN-DATE-OXY-GAS-TEST-SEG

	 022730
	  	 PIC X(08).

	 022740
	  	 
	 022750
	  	 05     X837P-LN-DATE-SHIPPED-SEG

	 022760
	  	 PIC X(08).

	 022770
	  	 
	 022780
	  	 05     X837P-LN-DATE-ONSET-CUR-SEG

	 022790
	  	 PIC X(08).

	 022800
	  	 
	 022810
	  	 05     X837P-LN-DATE-LAST-XRAY-SEG

	 022820
	  	 PIC X(08).

	 022830
	  	 
	 022840
	  	 05     X837P-LN-DATE-ACUTE-START-SEG

	 022850
	  	 PIC X(08).

	 022860
	  	 
	 022870
	  	 05     X837P-LN-DATE-INIT-TREAT-SEG

	 022880
	  	 PIC X(08).

	 022890
	  	 
	 022900
	  	 05     X837P-LN-DATE-ONSET-SIM-SEG

	 022910
	  	 PIC X(08).

	 022920
	  	 
	 022930
	  	 05     X837P-LN-TEST-RESULT-SEG

	 022940
	  	 OCCURS 20 TIMES

	 022950
	  	 INDEXED BY X837P-LN-TEST-RESULT-NDX.


  

 Page 231 of 326 









			
	 022960
	  	 
	 022970
	  	 10     X837P-LN-TEST-MEAS-ID

	 022980
	  	 PIC X(02).

	 022990
	  	 10     X837P-LN-TEST-MEAS-QUAL

	 023000
	  	 PIC X(03).

	 023010
	  	 10     X837P-LN-TEST-RESULTS

	 023020
	  	 PIC X(20).

	 023030
	  	 10     FILLER

	 023040
	  	 PIC X(10).

	 023050
	  	 
	 023060
	  	 05     X837P-LN-CONTRACT-INFO-SEG.

	 023070
	  	 
	 023080
	  	 10     X837P-LN-CONTRACT-TYPE

	 023090
	  	 PIC X(02).

	 023100
	  	 10     X837P-LN-CONTRACT-AMOUNT

	 023110
	  	 PIC S9(11)V99.

	 023120
	  	 10     X837P-LN-CONTRACT-PERCENT

	 023130
	  	 PIC S9(4)V9(4).

	 023140
	  	 10     X837P-LN-CONTRACT-CODE

	 023150
	  	 PIC X(30).

	 023160
	  	 10     X837P-LN-CONTRACT-DISC-PCT

	 023170
	  	 PIC S9(4)V9(4).

	 023180
	  	 10     X837P-LN-CONTRACT-VERSION

	 023190
	  	 PIC X(30).

	 023200
	  	 10     FILLER

	 023210
	  	 PIC X(10).

	 023220
	  	 
	 023230
	  	 05     X837P-LN-REPRICED-REF-SEG.

	 023240
	  	 
	 023250
	  	 10     X837P-LN-REPRICED-REF-ID

	 023260
	  	 PIC X(30).

	 023270
	  	 
	 023280
	  	 05     X837P-LN-ADJ-REPRICED-REF-SEG.

	 023290
	  	 
	 023300
	  	 10     X837P-LN-ADJ-REPRICED-REF-ID

	 023310
	  	 PIC X(30).

	 023320
	  	 
	 023330
	  	 05     X837P-LN-PA-REF-NBR-SEG

	 023340
	  	 OCCURS 2 TIMES

	 023350
	  	 INDEXED BY X837P-LN-PA-REF-NBR-NDX.

	 023360
	  	 
	 023370
	  	 10     X837P-LN-PA-REF-NBR

	 023380
	  	 PIC X(30).

	 023390
	  	 
	 023400
	  	 05     X837P-LN-ITEM-CNTL-NBR-SEG.

	 023410
	  	 
	 023420
	  	 10     X837P-LN-ITEM-CNTL-NBR

	 023430
	  	 PIC X(30).

	 023440
	  	 
	 023450
	  	 05     X837P-LN-MAMMO-CERT-NBR-SEG.

	 023460
	  	 

  

 Page 232 of 326 









			
	 023470
	  	 10     X837P-LN-MAMMO-CERT-NBR

	 023480
	  	 PIC X(30).

	 023490
	  	 
	 023500
	  	 05     X837P-LN-CLIA-NBR-SEG.

	 023510
	  	 
	 023520
	  	 10     X837P-LN-CLIA-NBR

	 023530
	  	 PIC X(30).

	 023540
	  	 
	 023550
	  	 05     X837P-LN-REF-CLIA-NBR-SEG.

	 023560
	  	 
	 023570
	  	 10     X837P-LN-REF-CLIA-NBR

	 023580
	  	 PIC X(30).

	 023590
	  	 
	 023600
	  	 05     X837P-LN-IMMUN-BATCH-NBR-SEG.

	 023610
	  	 
	 023620
	  	 10     X837P-LN-IMMUN-BATCH-NBR

	 023630
	  	 PIC X(30).

	 023640
	  	 
	 023650
	  	 05     X837P-LN-APG-NBR-SEG.

	 023660
	  	 
	 023670
	  	 10     X837P-LN-APG-NBR

	 023680
	  	 PIC X(30).

	 023690
	  	 
	 023700
	  	 05     X837P-LN-OXY-FLOW-RATE-SEG.

	 023710
	  	 
	 023720
	  	 10     X837P-LN-OXY-FLOW-RATE

	 023730
	  	 PIC X(30).

	 023740
	  	 
	 023750
	  	 05     X837P-LN-UPN-NBR-SEG.

	 023760
	  	 
	 023770
	  	 10     X837P-LN-UNIVERSAL-PROD-QUAL

	 023780
	  	 PIC X(03).

	 023790
	  	 10     X837P-LN-UNIVERSAL-PROD-NBR

	 023800
	  	 PIC X(30).

	 023810
	  	 
	 023820
	  	 05     X837P-LN-SALES-TAX-SEG.

	 023830
	  	 
	 023840
	  	 10     X837P-LN-SALES-TAX-AMT

	 023850
	  	 PIC S9(11)V99.

	 023860
	  	 
	 023870
	  	 05     X837P-LN-APPROVED-AMT-SEG.

	 023880
	  	 
	 023890
	  	 10     X837P-LN-APPROVED-AMT

	 023900
	  	 PIC S9(11)V99.

	 023910
	  	 
	 023920
	  	 05     X837P-LN-POSTAGE-AMT-SEG.

	 023930
	  	 
	 023940
	  	 10     X837P-LN-POSTAGE-AMT

	 023950
	  	 PIC S9(11)V99.

	 023960
	  	 
	 023970
	  	 05     X837P-LN-FILE-INFO-SEG


  

 Page 233 of 326 









			
	023980	  	 OCCURS 10 TIMES

	023990	  	 INDEXED BY X837P-LN-FILE-INFO-NDX.

	024000	  	 
	024010	  	 10     X837P-LN-FILE-INFO

	024020	  	 PIC X(80).

	024030	  	 
	024040	  	 05     X837P-LN-NOTE-SEG.

	024050	  	 
	024060	  	 10     X837P-LN-NOTE-CODE

	024070	  	 PIC X(03).

	024080	  	 10     X837P-LN-NOTE-TEXT

	024090	  	 PIC X(80).

	024100	  	 
	024110	  	 05     X837P-LN-PUR-SVC-SEG.

	024120	  	 
	024130	  	 10     X837P-LN-PUR-SVC-ID

	024140	  	 PIC X(30).

	024150	  	 10     X837P-LN-PUR-SVC-AMT

	024160	  	 PIC S9(11)V99.

	024170	  	 
	024180	  	 05     X837P-LN-CARE-SVC-DELV-SEG.

	024190	  	 
	024200	  	 10     X837P-LN-SVC-NBR-VISITS

	024210	  	 PIC S9(05).

	024220	  	 10     X837P-LN-SVC-VISIT-FREQ

	024230	  	 PIC X(02).

	024240	  	 10     X837P-LN-SVC-FREQ-COUNT

	024250	  	 PIC S9(5).

	024260	  	 10     X837P-LN-SVC-VISIT-UNITS

	024270	  	 PIC X(02).

	024280	  	 10     X837P-LN-SVC-NBR-OF-UNITS

	024290	  	 PIC S9(7)V9(4).

	024300	  	 10     X837P-LN-SVC-VISIT-PATTERN

	024310	  	 PIC X(02).

	024320	  	 10     X837P-LN-SVC-TIME-CODE

	024330	  	 PIC X(01).

	024340	  	 10     FILLER

	024350	  	 PIC X(10).

	024360	  	 
	024370	  	 05     X837P-LN-PRICE-REPRICE-SEG.

	024380	  	 
	024390	  	 10     X837P-LN-PRICE-METHOD

	024400	  	 PIC X(02).

	024410	  	 10     X837P-LN-PRICE-ALLOWED

	024420	  	 PIC S9(11)V99.

	024430	  	 10     X837P-LN-PRICE-SAVINGS

	024440	  	 PIC S9(11)V99.

	024450	  	 10     X837P-LN-REPRICE-ORG-ID

	024460	  	 PIC X(30).

	024470	  	 10     X837P-LN-PRICE-RATE

	024480	  	 PIC S9(11)V99.


  

 Page 234 of 326 









			
	024490	  	 10     X837P-LN-PRICE-APG-CODE

	024500	  	 PIC X(30).

	024510	  	 10     X837P-LN-PRICE-APG-AMT

	024520	  	 PIC S9(11)V99.

	024530	  	 10     X837P-LN-PRICE-SVC-QUAL

	024540	  	 PIC X(02).

	024550	  	 10     X837P-LN-PRICE-UNIT-MEAS-CD

	024560	  	 PIC X(02).

	024570	  	 10     X837P-LN-PRICE-APPROVED-UNITS

	024580	  	 PIC S9(7)V9(4).

	024590	  	 10     X837P-LN-PRICE-REJECT-REA

	024600	  	 PIC X(02).

	024610	  	 10     X837P-LN-PRICE-COMPLIANCE-CD

	024620	  	 PIC X(02).

	024630	  	 10     X837P-LN-PRICE-EXCEPTION-CD

	024640	  	 PIC X(02).

	024650	  	 10     FILLER

	024660	  	 PIC X(10).

	024670	  	 
	024680	  	 
	024690	  	LOOP-ID-2410 HAS ITS OWN RECORD TYPE
	024700	  	 
	024710	  	LOOP-ID-2420A
	024720	  	 
	024730	  	 05     X837P-LN-REND-PROV-NAME-SEG.

	024740	  	 
	024750	  	 10     X837P-LN-REND-PROV-TYPE

	024760	  	 PIC X(03).

	024770	  	 10     X837P-LN-REND-PROV-NME-TP

	024780	  	 PIC X(01).

	024790	  	 10     X837P-LN-REND-PROV-NM-LAST

	024800	  	 PIC X(35).

	024810	  	 10     X837P-LN-REND-PROV-NM-FIRST

	024820	  	 PIC X(25).

	024830	  	 10     X837P-LN-REND-PROV-NM-MIDDLE

	024840	  	 PIC X(25).

	024850	  	 10     X837P-LN-REND-PROV-NM-SFX

	024860	  	 PIC X(10).

	024870	  	 10     X837P-LN-REND-PROV-ID-CODE

	024880	  	 PIC X(02).

	024890	  	 10     X837P-LN-REND-PROV-ID-NBR

	024900	  	 PIC X(80).

	024910	  	 10     FILLER

	024920	  	 PIC X(10).

	024930	  	 
	024940	  	 05     X837P-LN-REND-PROV-SPEC-SEG.

	024950	  	 
	024960	  	 10     X837P-LN-REND-PROV-TYPE-CODE

	024970	  	 PIC X(03).

	024980	  	 10     X837P-LN-REND-PROV-SPEC-CODE

	024990	  	 PIC X(30).


  
  

 Page 235 of 326 









			
	025000	  	 10     FILLER

	025010	  	 PIC X(10).

	025020	  	 
	025030	  	 05     X837P-LN-REND-PROV-2ND-ID-SEG

	025040	  	 OCCURS 5 TIMES

	025050	  	 INDEXED BY X837P-LN-REND-PROV-2ND-ID-NDX.

	025060	  	 
	025070	  	 10     X837P-LN-REND-PROV-2ND-ID-CD

	025080	  	 PIC X(03).

	025090	  	 10     X837P-LN-REND-PROV-2ND-ID

	025100	  	 PIC X(30).

	025110	  	 10     FILLER

	025120	  	 PIC X(10).

	025130	  	LOOP-ID-2420B
	025140	  	 
	025150	  	 05     X837P-LN-PUR-PROV-NAME-SEG.

	025160	  	 
	025170	  	 10     X837P-LN-PUR-PROV-NME-TP

	025180	  	 PIC X(01).

	025190	  	 10     X837P-LN-PUR-PROV-ID-CODE

	025200	  	 PIC X(02).

	025210	  	 10     X837P-LN-PUR-PROV-ID-NBR

	025220	  	 PIC X(80).

	025230	  	 10     FILLER

	025240	  	 PIC X(10).

	025250	  	 
	025260	  	 05     X837P-LN-PUR-PROV-2ND-ID-SEG

	025270	  	 OCCURS 5 TIMES

	025280	  	 INDEXED BY X837P-LN-PUR-PROV-2ND-ID-NDX.

	025290	  	 
	025300	  	 10     X837P-LN-PUR-PROV-2ND-ID-CODE

	025310	  	 PIC X(03).

	025320	  	 10     X837P-LN-PUR-PROV-2ND-ID

	025330	  	 PIC X(30).

	025340	  	 10     FILLER

	025350	  	 PIC X(10).

	025360	  	LOOP-ID-2420C
	025370	  	 
	025380	  	 05     X837P-LN-SVC-FAC-LOC-SEG.

	025390	  	 
	025400	  	 10     X837P-LN-SVC-FAC-TYPE

	025410	  	 PIC X(03).

	025420	  	 10     X837P-LN-SVC-FAC-NAME

	025430	  	 PIC X(35).

	025440	  	 10     X837P-LN-SVC-FAC-ID-QUAL

	025450	  	 PIC X(02).

	025460	  	 10     X837P-LN-SVC-FAC-ID

	025470	  	 PIC X(80).

	025480	  	 10     FILLER

	025490	  	 PIC X(10).

	025500	  	 

  

 Page 236 of 326 









			
	025510	  	 05     X837P-LN-SVC-FAC-LOC-ADDR-SEG.

	025520	  	 
	025530	  	 10     X837P-LN-SVC-FAC-ADDR1

	025540	  	 PIC X(55).

	025550	  	 10     X837P-LN-SVC-FAC-ADDR2

	025560	  	 PIC X(55).

	025570	  	 10     FILLER

	025580	  	 PIC X(10).

	025590	  	 
	025600	  	 05     X837P-LN-SVC-FAC-CTY-ST-SEG.

	025610	  	 
	025620	  	 10     X837P-LN-SVC-FAC-CITY

	025630	  	 PIC X(30).

	025640	  	 10     X837P-LN-SVC-FAC-STATE-CODE

	025650	  	 PIC X(02).

	025660	  	 10     X837P-LN-SVC-FAC-ZIP-CODE

	025670	  	 PIC X(15).

	025680	  	 10     X837P-LN-SVC-FAC-COUNTRY-CODE

	025690	  	 PIC X(03).

	025700	  	 10     FILLER

	025710	  	 PIC X(10).

	025720	  	 
	025730	  	 05     X837P-LN-SVC-FAC-2ND-ID-SEG

	025740	  	 OCCURS 5 TIMES

	025750	  	 INDEXED BY X837P-LN-SVC-FAC-2ND-ID-NDX.

	025760	  	 
	025770	  	 10     X837P-LN-SVC-FAC-2ND-ID-TYPE

	025780	  	 PIC X(03).

	025790	  	 10     X837P-LN-SVC-FAC-2ND-ID

	025800	  	 PIC X(30).

	025810	  	 10     FILLER

	025820	  	 PIC X(10).

	025830	  	 
	025840	  	LOOP-ID-2420D
	025850	  	 
	025860	  	 05     X837P-LN-SUPR-PRV-NAME-SEG.

	025870	  	 
	025880	  	 10     X837P-LN-SUPR-PRV-NAME-LAST

	025890	  	 PIC X(35).

	025900	  	 10     X837P-LN-SUPR-PRV-NAME-FIRST

	025910	  	 PIC X(25).

	025920	  	 10     X837P-LN-SUPR-PRV-NAME-MIDDLE

	025930	  	 PIC X(25).

	025940	  	 10     X837P-LN-SUPR-PRV-SFX

	025950	  	 PIC X(10).

	025960	  	 10     X837P-LN-SUPR-PRV-ID-QUAL

	025970	  	 PIC X(02).

	025980	  	 10     X837P-LN-SUPR-PRV-ID-CODE

	025990	  	 PIC X(80).

	026000	  	 10     FILLER

	026010	  	 PIC X(10).


  
  

 Page 237 of 326 









			
	026020	  	 
	026030	  	 05     X837P-LN-SUPR-PROV-2ND-ID-SEG

	026040	  	 OCCURS 5 TIMES

	026050	  	 INDEXED BY X837P-LN-SUPR-PROV-2ND-ID-NDX.

	026060	  	 
	026070	  	 10     X837P-LN-SUPR-PROV-2ND-ID-CD

	026080	  	 PIC X(03).

	026090	  	 10     X837P-LN-SUPR-PROV-2ND-ID

	026100	  	 PIC X(30).

	026110	  	 10     FILLER

	026120	  	 PIC X(10).

	026130	  	 
	026140	  	LOOP-ID-2420E
	026150	  	 
	026160	  	 05     X837P-LN-ORDR-PRV-NAME-SEG.

	026170	  	 
	026180	  	 10     X837P-LN-ORDR-PRV-ENTITY-CODE

	026190	  	 PIC X(01).

	026200	  	 10     X837P-LN-ORDR-PRV-NAME-LAST

	026210	  	 PIC X(35).

	026220	  	 10     X837P-LN-ORDR-PRV-NAME-FIRST

	026230	  	 PIC X(25).

	026240	  	 10     X837P-LN-ORDR-PRV-NAME-MID

	026250	  	 PIC X(25).

	026260	  	 10     X837P-LN-ORDR-PRV-NAME-SFX

	026270	  	 PIC X(10).

	026280	  	 10     X837P-LN-ORDR-PRV-ID-CODE

	026290	  	 PIC X(02).

	026300	  	 10     X837P-LN-ORDR-PRV-ID-NBR

	026310	  	 PIC X(80).

	026320	  	 10     FILLER

	026330	  	 PIC X(10).

	026340	  	 
	026350	  	 05     X837P-LN-ORDR-PRV-ADDR-SEG.

	026360	  	 
	026370	  	 10     X837P-LN-ORDR-PRV-ADDR1

	026380	  	 PIC X(55).

	026390	  	 10     X837P-LN-ORDR-PRV-ADDR2

	026400	  	 PIC X(55).

	026410	  	 10     FILLER

	026420	  	 PIC X(10).

	026430	  	 
	026440	  	 05     X837P-LN-ORDR-PRV-LOC-SEG.

	026450	  	 
	026460	  	 10     X837P-LN-ORDR-PRV-CITY

	026470	  	 PIC X(30).

	026480	  	 10     X837P-LN-ORDR-PRV-STATE

	026490	  	 PIC X(02).

	026500	  	 10     X837P-LN-ORDR-PRV-ZIP

	026510	  	 PIC X(15).

	026520	  	 10     X837P-LN-ORDR-PRV-COUNTRY


  

 Page 238 of 326 









			
	026530	  	 PIC X(03).

	026540	  	 10     FILLER

	026550	  	 PIC X(10).

	026560	  	 
	026570	  	 05     X837P-LN-ORDR-PRV-2ND-ID-SEG

	026580	  	 OCCURS 5 TIMES

	026590	  	 INDEXED BY X837P-LN-ORDR-PRV-2ND-IDT-NDX.

	026600	  	 
	026610	  	 10     X837P-LN-ORDR-PRV-2ND-ID-CODE

	026620	  	 PIC X(03).

	026630	  	 10     X837P-LN-ORDR-PRV-2ND-ID

	026640	  	 PIC X(30).

	026650	  	 10     FILLER

	026660	  	 PIC X(10).

	026670	  	 
	026680	  	 05     X837P-LN-ORDR-PRV-CTAC-SEG.

	026690	  	 
	026700	  	 10     X837P-LN-ORDR-PRV-CTAC-NAME

	026710	  	 PIC X(60).

	026720	  	 10     X837P-LN-ORDR-PRV-CTAC-NB-TP-1

	026730	  	 PIC X(02).

	026740	  	 10     X837P-LN-ORDR-PRV-CTAC-NB-1

	026750	  	 PIC X(80).

	026760	  	 10     X837P-LN-ORDR-PRV-CTAC-NB-TP-2

	026770	  	 PIC X(02).

	026780	  	 10     X837P-LN-ORDR-PRV-CTAC-NB-2

	026790	  	 PIC X(80).

	026800	  	 10     X837P-LN-ORDR-PRV-CTAC-NB-TP-3

	026810	  	 PIC X(02).

	026820	  	 10     X837P-LN-ORDR-PRV-CTAC-NB-3

	026830	  	 PIC X(80).

	026840	  	 10     FILLER

	026850	  	 PIC X(10).

	026860	  	LOOP-ID-2420F
	026870	  	 05     X837P-LN-REF-PROV-NAME-LOOP

	026880	  	 OCCURS 2 TIMES

	026890	  	 INDEXED BY X837P-LN-REF-PROV-NAME-NDX.

	026900	  	 
	026910	  	 10     X837P-LN-REF-PROV-NAME-SEG.

	026920	  	 
	026930	  	 15     X837P-LN-REF-PROV-TYPE

	026940	  	 PIC X(03).

	026950	  	 15     X837P-LN-REF-PROV-NME-TP

	026960	  	 PIC X(01).

	026970	  	 15     X837P-LN-REF-PROV-NM-LAST

	026980	  	 PIC X(35).

	026990	  	 15     X837P-LN-REF-PROV-NM-FIRST

	027000	  	 PIC X(25).

	027010	  	 15     X837P-LN-REF-PROV-NM-MIDDLE

	027020	  	 PIC X(25).

	027030	  	 15     X837P-LN-REF-PROV-NM-SFX


  

 Page 239 of 326 









			
	027040	  	 PIC X(10).

	027050	  	 15     X837P-LN-REF-PROV-ID-CODE

	027060	  	 PIC X(02).

	027070	  	 15     X837P-LN-REF-PROV-ID-NBR

	027080	  	 PIC X(80).

	027090	  	 15     FILLER

	027100	  	 PIC X(10).

	027110	  	 
	027120	  	 10     X837P-LN-REF-PROV-SPEC-SEG.

	027130	  	 
	027140	  	 15     X837P-LN-REF-PROV-TYPE-CODE

	027150	  	 PIC X(03).

	027160	  	 15     X837P-LN-REF-PROV-SPEC-CODE

	027170	  	 PIC X(30).

	027180	  	 15     FILLER

	027190	  	 PIC X(10).

	027200	  	 
	027210	  	 10     X837P-LN-REF-PROV-2ND-ID-SEG

	027220	  	 OCCURS 5 TIMES

	027230	  	 INDEXED BY X837P-LN-REF-PROV-2ND-ID-NDX.

	027240	  	 
	027250	  	 15     X837P-LN-REF-PROV-2ND-ID-CODE

	027260	  	 PIC X(03).

	027270	  	 15     X837P-LN-REF-PROV-2ND-ID

	027280	  	 PIC X(30).

	027290	  	 15     FILLER

	027300	  	 PIC X(10).

	027310	  	 
	027320	  	LOOP-ID-2420G
	027330	  	 
	027340	  	 05     X837P-LN-OTH-PYR-PA-NME-LOOP

	027350	  	 OCCURS 4 TIMES

	027360	  	 INDEXED BY X837P-LN-OTH-PYR-PA-NME-NDX.

	027370	  	 
	027380	  	 10     X837P-LN-OTH-PYR-PA-NME-SEG.

	027390	  	 
	027400	  	 15     X837P-LN-OTH-PYR-PA-NME-NAME

	027410	  	 PIC X(35).

	027420	  	 15     X837P-LN-OTH-PYR-PA-NME-QUAL

	027430	  	 PIC X(02).

	027440	  	 15     X837P-LN-OTH-PYR-PA-NME-ID

	027450	  	 PIC X(80).

	027460	  	 15     FILLER

	027470	  	 PIC X(10).

	027480	  	 
	027490	  	 10     X837P-LN-OTH-PYR-PA-NBR-SEG

	027500	  	 OCCURS 2 TIMES

	027510	  	 INDEXED BY X837P-LN-OTH-PYR-PA-NBR-NDX.

	027520	  	 
	027530	  	 15     X837P-LN-OTH-PYR-PA-NBR-QUAL

	027540	  	 PIC X(03).


  

 Page 240 of 326 









			
	027550	  	 15     X837P-LN-OTH-PYR-PA-NBR

	027560	  	 PIC X(80).

	027570	  	 
	027580	  	LOOP-ID-2430 HAS ITS OWN RECORD TYPE
	027590	  	LOOP-ID-2440 HAS ITS OWN RECORD TYPE
	027600	  	 
	027610	  	 
	027620	  	 
	027630	  	 837P - LINE-DRUG-ID (MAX 25)

	027640	  	 
	027650	  	 
	027660	  	 
	027670	  	 837P LINE DRUG IDENTIFCATIION

	027680	  	 
	027690	  	 01     X837P-LINE-DRUG-ID.

	027700	  	 
	027710	  	 05     X837P-RECORD-CODE

	027720	  	 PIC X(02).

	027730	  	 
	027740	  	 05     X837P-SORT-KEY.

	027750	  	 
	027760	  	 10     X837P-PROV-SEQ-NUM

	027770	  	 VALUE ZEROES

	027780	  	 PIC 9(11).

	027790	  	 
	027800	  	 10     X837P-SUBSCRIBER-SEQ-NUM

	027810	  	 VALUE ZEROES

	027820	  	 PIC 9 (11).

	027830	  	 
	027840	  	 10     X837P-PATIENT-SEQ

	027850	  	 VALUE ZEROES

	027860	  	 PIC 9(11).

	027870	  	 
	027880	  	 10     X837P-CLAIM-SEQ

	027890	  	 VALUE ZEROES

	027900	  	 PIC 9(11).

	027910	  	 
	027920	  	 10     X837P-SVC-LINE-SEQ

	027930	  	 VALUE ZEROES

	027940	  	 PIC 9(11).

	027950	  	 
	027960	  	 
	027970	  	SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A
	027980	  	‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.
	027990	  	 
	028000	  	SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A
	028010	  	‘FORM-IDENT-CODE’ RECORD.
	028020	  	 
	028030	  	 10     X837P-SUB-SEQ

	028040	  	 VALUE ZEROES

	028050	  	 PIC 9(11).


  

 Page 241 of 326 









			
	028060	  	 
	028070	  	 10     X837P-TX-CODE

	028080	  	 VALUE ‘08’

	028090	  	 PIC X(02).

	028100	  	 
	028110	  	 10     X837P-TX-CODE-SEQ-NUM

	028120	  	 VALUE ZEROES

	028130	  	 PIC 9(07).

	028140	  	 
	028150	  	END OF HDR SORT-KEY
	028160	  	 
	028170	  	 
	028180	  	 
	028190	  	LOOP-ID-2410
	028200	  	 
	028210	  	 05     X837P-LN-DRUG-ID-SEG.

	028220	  	 
	028230	  	 10     X837P-LN-DRUG-CODE

	028240	  	 PIC X(48).

	028250	  	 10     FILLER

	028260	  	 PIC X(10).

	028270	  	 
	028280	  	 05     X837P-LN-DRUG-PRICING-SEG.

	028290	  	 
	028300	  	 10     X837P-LN-DRUG-UNIT-PRICE

	028310	  	 PIC S9(11)V99.

	028320	  	 10     X837P-LN-DRUG-NBR-UNITS

	028330	  	 PIC S9(7)V9 (4).

	028340	  	 10     X837P-LN-DRUG-MEAS-CODE

	028350	  	 PIC X(02).

	028360	  	 10     FILLER

	028370	  	 PIC X(10).

	028380	  	 
	028390	  	 05     X837P-LN-DRUG-PERSCIP-SEG.

	028400	  	 
	028410	  	 10     X837P-LN-DRUG-PERSCIP-NBR

	028420	  	 PIC X(30).

	028430	  	 10     FILLER

	028440	  	 PIC X(10).

	028450	  	 
	028460	  	 
	028470	  	 
	028480	  	 
	028490	  	 837 P – LINE-LVL-ADJUSTMENT (MAX 99)

	028500	  	 
	028510	  	 
	028520	  	 
	028530	  	837P LINE LEVEL ADJUSTMENTS
	028540	  	 
	028550	  	 01     X837P-LINE-LVL-ADJUSTMENTS.

	028560	  	 

  

 Page 242 of 326 









			
	028570	  	 05     X837P-RECORD-CODE

	028580	  	 PIC X(02).

	028590	  	 
	028600	  	 05     X837P-SORT-KEY.

	028610	  	 
	028620	  	 10     X837P-PROV-SEQ-NUM

	028630	  	 VALUE ZEROES

	028640	  	 PIC 9(11).

	028650	  	 
	028660	  	 10     X837P-SUBSCRIBER-SEQ-NUM

	028670	  	 VALUE ZEROES

	028680	  	 PIC 9(11).

	028690	  	 
	028700	  	 10     X837P-PATIENT-SEQ

	028710	  	 VALUE ZEROES

	028720	  	 PIC 9(11).

	028730	  	 
	028740	  	 10     X837P-CLAIM-SEQ

	028750	  	 VALUE ZEROES

	028760	  	 PIC 9(11).

	028770	  	 
	028780	  	 10     X837P-SVC-LINE-SEQ

	028790	  	 VALUE ZEROES

	028800	  	 PIC 9(11).

	028810	  	 
	028820	  	 
	028830	  	 SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A

	028840	  	 ‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’RECORD.

	028850	  	 
	028860	  	 SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A

	028870	  	 ‘FORM-IDENT-CODE’ RECORD.

	028880	  	 
	028890	  	 10     X837P-SUB-SEQ

	028900	  	 VALUE ZEROES

	028910	  	 PIC 9(11).

	028920	  	 
	028930	  	 10     X837P-TX-CODE

	028940	  	 VALUE ‘09’

	028950	  	 PIC X(02).

	028960	  	 
	028970	  	 10     X837P-TX-CODE-SEQ-NUM

	028980	  	 VALUE ZEROES

	028990	  	 PIC 9(07).

	029000	  	 
	029010	  	END OF HDR SORT-KEY
	029020	  	 
	029030	  	 
	029040	  	 
	029050	  	LOOP-ID-2430
	029060	  	 
	029070	  	 05     X837P-LINE-LVL-ADJ-SEG.


  

 Page 243 of 326 









			
	029080	  	 
	029090	  	 10     X837P-LINE-ADJ-OTHR-PYR-ID

	029100	  	 PIC X(80).

	029110	  	 10     X837P-LINE-ADJ-AMOUNT

	029120	  	 PIC S9(11)V99.

	029130	  	 10     X837P-LINE-ADJ-SVC-ID-QUAL

	029140	  	 PIC X(02).

	029150	  	 10     X837P-LINE-ADJ-SVC-ID

	029160	  	 PIC X(48).

	029170	  	 10     X837P-LINE-ADJ-SVC-MOD-1

	029180	  	 PIC X(02).

	029190	  	 10     X837P-LINE-ADJ-SVC-MOD-2

	029200	  	 PIC X(02).

	029210	  	 10     X837P-LINE-ADJ-SVC-MOD-3

	029220	  	 PIC X(02).

	029230	  	 10     X837P-LINE-ADJ-SVC-MOD-4

	029240	  	 PIC X(02).

	029250	  	 10     X837P-LINE-ADJ-SVC-CD-DESC

	029260	  	 PIC X(80).

	029270	  	 10     X837P-LINE-ADJ-UNITS-OF-SVC

	029280	  	 PIC S9(7)V9(4).

	029290	  	 10     X837P-LINE-ADJ-BUNDLE-LINE-NBR

	029300	  	 PIC S9(4).

	029310	  	 10     FILLER

	029320	  	 PIC X(10).

	029330	  	 
	029340	  	 05     X837P-LINE-ADJ-SEG

	029350	  	 OCCURS 99 TIMES

	029360	  	 INDEXED BY X837P-LINE-ADJ-NDX.

	029370	  	 
	029380	  	 10     X837P-LINE-ADJ-GROUP-CODE

	029390	  	 PIC X(02).

	029400	  	 10     X837P-LINE-ADJ

	029410	  	 OCCURS 6 TIMES

	029420	  	 INDEXED BY X837P-LINE-ADJ-NDX.

	029430	  	 15     X837P-LINE-ADJ-REASON-CD

	029440	  	 PIC X(05).

	029450	  	 15     X837P-LINE-ADJ-AMOUNT

	029460	  	 PIC S9(11)V99.

	029470	  	 15     X837P-LINE-ADJ-UNITS

	029480	  	 PIC S9(7)V9(4).

	029490	  	 
	029500	  	 05     X837P-LINE-ADJ-DATE-SEG.

	029510	  	 
	029520	  	 10     X837P-LINE-DATE-CLAIM-PAID

	029530	  	 PIC X(08).

	029540	  	 
	029550	  	 
	029560	  	 
	029570	  	 
	029580	  	 837P - FORM IDENTIFICATION CODE (MAX 99)


  

 Page 244 of 326 









			
	 029590
	  	 
	 029600
	  	 
	 029610
	  	 837P  FOR IDENTIFICATION CODE

	 029620
	  	 
	 029630
	  	 01     X837P-FORM-IDENTIFICATION-CODE.

	 029640
	  	 
	 029650
	  	 05     X837P-RECORD-CODE

	 029660
	  	 PIC X(02).

	 029670
	  	 
	 029680
	  	 05     X837P-SORT-KEY.

	 029690
	  	 
	 029700
	  	 10     X837P-PROV-SEQ-NUM

	 029710
	  	 VALUE ZEROES

	 029720
	  	 PIC 9(11).

	 029730
	  	 
	 029740
	  	 10     X837P-SUBSCRIBER-SEQ-NUM

	 029750
	  	 VALUE ZEROES

	 029760
	  	 PIC 9(11).

	 029770
	  	 
	 029780
	  	 10     X837P-PATIENT-SEQ

	 029790
	  	 VALUE ZEROES

	 029800
	  	 PIC 9(11).

	 029810
	  	 
	 029820
	  	 10     X837P-CLAIM-SEQ

	 029830
	  	 VALUE ZEROES

	 029840
	  	 PIC 9(11).

	 029850
	  	 
	 029860
	  	 10     X837P-SVC-LINE-SEQ

	 029870
	  	 VALUE ZEROES

	 029880
	  	 PIC 9(11).

	 029890
	  	 
	 029900
	  	 
	 029910
	  	 SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A

	 029920
	  	 ‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.

	 029930
	  	 
	 029940
	  	 SUB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A

	 029950
	  	 ‘FORM-IDENT-CODE’ RECORD.

	 029960
	  	 
	 029970
	  	 10     X837P-SUB-SEQ

	 029980
	  	 VALUE ZEROES

	 029990
	  	 PIC 9(11).

	 030000
	  	 
	 030010
	  	 10     X837P-TX-CODE

	 030020
	  	 VALUE ‘10’

	 030030
	  	 PIC X(02).

	 030040
	  	 
	 030050
	  	 10     X837P-TX-CODE-SEQ-NUM

	 030060
	  	 VALUE ZEROES

	 030070
	  	 PIC 9(07).

	 030080
	  	 
	 030090
	  	END OF HDR SORT-KEY

  
  

 Page 245 of 326 









			
	030100	  	 
	030110	  	 
	030120	  	 
	030130	  	 LOOP-ID-2440

	030140	  	 
	030150	  	 05     X837P-FORM-ID-CODE-SEG.

	030160	  	 
	030170	  	 10     X837P-FORM-ID-CODE

	030180	  	 PIC X(03).

	030190	  	 10     X837P-FORM-ID

	030200	  	 PIC X(30).

	030210	  	 
	030220	  	 05     X837P-FORM-SUPPORT-DOC-SEG

	030230	  	 OCCURS 99 TIMES

	030240	  	 INDEXED BY X837P-FORM-SUPPORT-DOC-NDX.

	030250	  	 
	030260	  	 10     X837P-FORM-QUES-NBR

	030270	  	 PIC X(20).

	030280	  	 10     X837P-FORM-QUES-RESPONSE-Y-N

	030290	  	 PIC X(01).

	030300	  	 10     X837P-FORM-QUES-RESPONSE-TXT

	030310	  	 PIC X(30).

	030320	  	 10     X837P-FORM-QUES-RESPONSE-DATE

	030330	  	 PIC X(08).

	030340	  	 10     X837P-FORM-QUES-RESPONSE-PCT

	030350	  	 PIC S9 (4)V9 (4).

	030360	  	 
	030370	  	 
	030380	  	 
	030390	  	 
	030400	  	 837P - TRANSACTION TRAILER RECORD

	030410	  	 
	030420	  	 
	030430	  	 01     X837P-TX-TRAILER.

	030440	  	 
	030450	  	 05     X837P-RECORD-CODE

	030460	  	 PIC X(02).

	030470	  	 
	030480	  	 05     X837P-SORT-KEY.

	030490	  	 
	030500	  	 10     X837P-PROV-SEQ-NUM

	030510	  	 VALUE ZEROES

	030520	  	 PIC 9(11).

	030530	  	 
	030540	  	 10     X837P-SUBSCRIBER-SEQ-NUM

	030550	  	 VALUE ZEROES

	030560	  	 PIC 9(11).

	030570	  	 
	030580	  	 10     X837P-PATIENT-SEQ

	030590	  	 VALUE ZEROES

	030600	  	 PIC 9(11).


  

 Page 246 of 326 









			
	030610	  	 
	030620	  	 10     X837P-CLAIM-SEQ

	030630	  	 VALUE ZEROES

	030640	  	 PIC 9(11).

	030650	  	 
	030660	  	 10     X837P-SVC-LINE-SEQ

	030670	  	 VALUE ZEROES

	030680	  	 PIC 9(11).

	030690	  	 
	030700	  	 
	030710	  	 SUB-SEQ IS THE ‘OTHER-SUBSCRIBER-SEQ’ WHEN USED ON A

	030720	  	 ‘OTHER-SUBSCRIBER-INFO’ RECORD OR A ‘CLAIM-LVL-ADJ’ RECORD.

	030730	  	 
	030740	  	 SOB-SEQ IS THE ‘FORM-IDENT-SEQ’ WHEN USED ON A

	030750	  	 ‘FORM-IDENT-CODE’ RECORD.

	030760	  	 
	030770	  	 10     X837P-SUB-SEQ

	030780	  	 VALUE ZEROES

	030790	  	 PIC 9(11).

	030800	  	 
	030810	  	 10     X837P-TX-CODE

	030820	  	 VALUE ‘99’

	030830	  	 PIC X(02).

	030840	  	 
	030850	  	 10     X837P-TX-CODE-SEQ-NUM

	030860	  	 VALUE ZEROES

	030870	  	 PIC 9(07).

	030880	  	 
	030890	  	END OF HDR SORT-KEY
	030900	  	 
	030910	  	 
	030920	  	 
	030930	  	 05     X837P-TX-TRAILER-SEG.

	030940	  	 
	030950	  	 10     X837P-TRAILER-NUM-OF-SEG

	030960	  	 PIC 9(10).

	030970	  	 10     X837P-TRAILER-CTL-NUM

	030980	  	 PIC X(09).

	030990	  	 10     FILLER

	031000	  	 PIC X(10).


  

 Page 247 of 326 








 Attachment L.5.2 
  
 GEORGIA MHN CLAIMS SUBSYSTEM 
 WINDOW
LAYOUT 
  
 EXAM ENTRY/CORRECTION – HCFA1500 FUNCTIONAL GROUP

  
 HCFA1500 MAIN PAGE WINDOW 
 

 
  
  

 Page 248 of 326 








 GEORGIA MHN CLAIMS SUBSYSTEM 
 WINDOW EXHIBIT 
  
 EXAM ENTRY/CORRECTION — HCFA1500 FUNCTIONAL GROUP 
  
 HCFA1500 MAIN PAGE WINDOW 
  

																	
	 Field Name

	 	 Table Column Name

	 	 Table Name

	 	 Format

	 	 Prot

 (A,C,N)

	 	 Req

 (A,C,N)

	 	 Std Edits

	 	 Specifications

	 	Note
Ref


	Doc	 	C_HDR_DOC_NUM	 	C_HDR_TB	 	X(6)	 	C	 	A	 	S	 	 	 	1
									
	ID	 	B_ALT_ID	 	C_HDR_TB	 	X(13)	 	N	 	N	 	N/A	 	 	 	 
									
	St	 	C_HDR_STAT_CD	 	C_HDR_TB	 	X(l)	 	A	 	N/A	 	N/A	 	 	 	 
									
	DTy	 	C_BAT_DOC_TY_CD	 	C HDR TB	 	X(l)	 	A	 	N/A	 	N/A	 	 	 	 
									
	CTy	 	C_HDR_TY_CD	 	C HDR TB	 	X(l)	 	A	 	N/A	 	N/A	 	 	 	 
									
	TTy	 	C_HDR_TXN_TY_CD	 	C_HDR_TB	 	X(l)	 	A	 	N/A	 	N/A	 	 	 	 
									
	PTy	 	C_BAT_PYMT_TY_CD	 	C_HDR_TB	 	X(l)	 	A	 	N/A	 	N/A	 	 	 	 
									
	Locn	 	C_EXC_LOCN_CD	 	C_HDR_TB	 	X(3)	 	A	 	N/A	 	N/A	 	 	 	 
									
	Last Cycl	 	C_HDR_LST_CYCL_DT	 	C_HDR_TB	 	DATE	 	A	 	N/A	 	N/A	 	Format: MM/DD/CCYY	 	 
									
	Diagnosis Code	 	R_DIAG_CD	 	C_HDR_DIAG_TB	 	X(10)	 	N	 	N	 	S	 	 	 	 
									
	L/F/Mi (1)	 	B_LAST_NAM	 	C_HDR_TB	 	X(21)	 	N	 	N	 	N/A	 	 	 	 
									
	L/F/Mi (2)	 	B_FST_NAM	 	C_HDR_TB	 	X(15)	 	N	 	N	 	N/A	 	 	 	 
									
	L/F/Mi (3)	 	B_MI_NAM	 	C_HDR_TB	 	X(l)	 	N	 	N	 	N/A	 	 	 	 
									
	DOB	 	C_SUBM_CLNT_DOB_DT	 	C_HDR_TB	 	DATE	 	N	 	N	 	D	 	Format: MM/DD/CCYY	 	 
									
	Sex	 	B_GENDER_CD	 	C_HDR_TB	 	X(1)	 	A	 	N/A	 	N/A	 	 	 	 
									
	Age (Y/M) (Y)	 	C_HDR_CLNT_AGE_YR	 	C_HDR_TB	 	9(3)	 	A	 	N/A	 	N/A	 	 	 	 

  

 Page 249 of 326 









																	
	 Field Name

	 	 Table Column Name

	 	 Table Name

	 	 Format

	 	 Prot
 (A,C,N)

	 	 Req
 (A,C,N)

	 	 Std Edits

	 	 Specifications

	 	Note
Ref


	Age (Y/M) (M)	 	C_HDR_CLNT_AGE_ MO	 	C_HDR_TB	 	9(3)	 	A	 	N/A	 	N/A	 	 	 	 
									
	Employment	 	C_OCCUP_RLTD_IND	 	C_HDR_HCFA1500_TB	 	X(1)	 	N	 	N	 	N/A	 	Checkbox. Checked if value is “Y”	 	 
									
	Auto	 	C_AUTO_RLTD_IND	 	C_HDR_HCFA1500_TB	 	X(1)	 	N	 	N	 	N/A	 	Checkbox. Checked if value is “Y”	 	 
									
	Other	 	C_OTHR RLTD IND	 	C_HDR_HCFA1500_TB	 	X(I)	 	N	 	N	 	N/A	 	Checkbox. Checked if value is “Y”	 	 
									
	III	 	C_ILLNESS_DT	 	C_HDR_HCFA1500_TB	 	DATE	 	N	 	N	 	D	 	 	 	 
									
	Other Ins	 	C_HDR_INSR_CD	 	C_HDR_TB	 	X(1)	 	N	 	N	 	N/A	 	Checkbox. Checked if value is “Y”	 	 
									
	Major Program	 	B_MAJ_PROG_CD	 	C_HDR_TB	 	X(1)	 	A	 	N/A	 	N/A	 	 	 	 
									
	Aid Cat	 	B_AID_CAT_CD	 	C_HDR_COE_TB	 	X(3)	 	A	 	N/A	 	N/A	 	 	 	 
									
	Referring Prov	 	C_REF_PROV_ID	 	C_HDR_TB	 	X(12)	 	N	 	N	 	N/A	 	 	 	 
									
	Hosp Fr/To (1)	 	C_ADMIT_DATE	 	C_HDR_HCFA1500_TB	 	DATE	 	N	 	N	 	D	 	Format: MM/DD/YY	 	 
									
	Hosp Fr/To (2)	 	C_DISCH_DT	 	C_HDR_HCFA1500_TB	 	DATE	 	N	 	N	 	D	 	Format: MM/DD/YY	 	 
									
	PA	 	A_ID	 	C_HDR_TB	 	X(12)	 	N	 	N	 	N/A	 	 	 	 
									
	LI	 	C_LI_NUM	 	C_LI_TB	 	9(3)	 	A	 	N/A	 	N/A	 	Multi-column list box.	 	 
									
	S	 	C_REIMB_STAT_CD	 	C_LI_TB	 	X(1)	 	A	 	N/A	 	N/A	 	 	 	 
									
	FDOS	 	C_LI_FST_DOS_DT	 	C_LI_TB	 	DATE	 	N	 	N	 	D	 	Format: MM/DD/YY	 	 
									
	LDOS	 	C_LI_LAST_DOS_DT	 	C_LI_TB	 	DATE	 	N	 	N	 	D	 	Format: MM/DD/YY	 	 
									
	PS	 	R_PL_OF_SVC_CD	 	C_LI_TB	 	X(2)	 	N	 	N	 	N/A	 	 	 	 
									
	Proc	 	R_PROC_CD	 	C_LI_TB	 	X(7)	 	N	 	N	 	N/A	 	 	 	 
									
	Ml	 	C_PROC_MOD_1ST_CD	 	C_LI_TB	 	X(2)	 	N	 	N	 	N/A	 	 	 	 
									
	M2	 	C_PROC_MOD_2ND_CD	 	C_LI_TB	 	X(2)	 	N	 	N	 	N/A	 	 	 	 
									
	M3	 	C_PROC_MOD_3RD_CD	 	C_LI_TB	 	X(2)	 	N	 	N	 	N/A	 	 	 	 

  

 Page 250 of 326 









																	
	 Field Name

	 	 Table Column Name

	 	 Table Name

	 	 Format

	 	 Prot
 (A,C,N)

	 	 Req
 (A,C,N)

	 	 Std Edits

	 	 Specifications

	 	Note
Ref


									
	M4	 	C_PROC_MOD_4TH_CD	 	C_LI_TB	 	X(2)	 	N	 	N	 	N/A	 	 	 	 
									
	Dx Related	 	C_1500_1ST_RLTD_ID	 	C_LI_HCFA1500_TB	 	X(1)	 	N	 	N	 	N/A	 	 	 	2
									
	 	 	C_1500_2ND_RLTD_ID	 	 	 	X(1)	 	 	 	 	 	 	 	 	 	 
									
	 	 	C_1500_3RD_RLTD_ID	 	 	 	X(1)	 	 	 	 	 	 	 	 	 	 
									
	 	 	C_1500_4TH_RLTD_ID	 	 	 	X(1)	 	 	 	 	 	 	 	 	 	 
									
	 	 	C_1500_5TH_RLTD_ID	 	 	 	X(1)	 	 	 	 	 	 	 	 	 	 
									
	 	 	C_1500_6TH_RLTD_ID	 	 	 	X(1)	 	 	 	 	 	 	 	 	 	 
									
	 	 	C_l 500_7TH_RLTD_ID	 	 	 	X(1)	 	 	 	 	 	 	 	 	 	 
									
	 	 	C_1500_8TH_RLTD_ID	 	 	 	X(1)	 	 	 	 	 	 	 	 	 	 
									
	Submit Chrg	 	C_LI_SUBM_CHRG_AMT	 	C_LI_TB	 	S9(7)V99	 	N	 	N	 	N	 	 	 	 
									
	S Unit	 	C_LI_SUBM_UNT_NUM	 	C_LI_TB	 	S9(7)V99	 	N	 	N	 	N	 	Entered/displayed as whole units.	 	 
									
	FamPlan	 	C_FAM_PLAN_CD	 	C_LI_HCFA1500_TB	 	X(1)	 	N	 	N	 	N/A	 	 	 	 
									
	Health Ck	 	C_EPSDT_CD	 	C_LI_HCFA1500_TB	 	X(1)	 	N	 	N	 	N/A	 	 	 	 
									
	Allow Chrg	 	C_LI_ALLW_CHRG_AMT	 	C_LI_TB	 	S9(7)V99	 	A	 	N/A	 	N/A	 	 	 	 
									
	A Unit	 	C_LI_ALLOW_UNT_NUM	 	C_LI_TB	 	S9(7)V99	 	A	 	N/A	 	N/A	 	Displayed as whole units.	 	 
									
	BR	 	C_BSE_AMT_SRC_CD	 	C_LI_TB	 	X(2)	 	A	 	N/A	 	N/A	 	 	 	 
									
	Patient #	 	C_HDR_PAT_ACCT_DAT	 	C_HDR_TB	 	X(20)	 	N	 	N	 	N/A	 	 	 	 
									
	Reimb	 	C_TOT_REIMB_AMT	 	C_HDR_TB	 	S9(9)V99	 	A	 	N/A	 	N/A	 	 	 	 
									
	Tot Chrg	 	C_TOT_CHRG_AMT	 	C_HDR_TB	 	S9(9)V99	 	N	 	N	 	N	 	 	 	 
									
	COB	 	C_TOT_TPL_AMT	 	C_HDR_TB	 	S9(9)V99	 	N	 	N	 	N	 	 	 	 
									
	Net	 	C_TOT_NET_CHRG_AMT	 	C_HDR_TB	 	S9(9)V99	 	N	 	N	 	N	 	 	 	 
									
	Discount	 	C_DISCOUNT_AMT	 	C_HDR_TB	 	S9(9)V99	 	N	 	N	 	N	 	 	 	 

  

 Page 251 of 326 









																	
	 Field Name

	 	 Table Column Name

	 	Table Name

	 	Format

	 	 Prot
 (A,C,N)

	 	 Req
 (A,C,N)

	 	Std
Edits

	 	 Specifications

	  	Note
Ref


	Sign/Date (1)	 	C_PROV_SIGN_IND	 	C_HDR_TB	 	X(l)	 	N	 	N	 	N/A	 	Checkbox. Checked if value is “Y”	  	 
	Sign/Date (2)	 	C_BILLED_DT	 	C_HDR_TB	 	DATE	 	N	 	N	 	D	 	Format: MM/DD/CCYY	  	 
	Prov ID	 	C_BLNG_PROV_ID	 	C_HDR_TB	 	X(12)	 	N	 	N	 	N/A	 	 	  	 
	Type	 	C-BLNG-PROV-TY-CD	 	C_HDR_TB	 	X(3)	 	A	 	N/A	 	N/A	 	 	  	 
	Spec	 	C-BLNG-SPEC-CD	 	C_HDR_TB	 	X(3)	 	A	 	N/A	 	N/A	 	 	  	 
	Override Loc	 	C_OVRRD_EXC_ LOC_CD	 	C_HDR_TB	 	X(3)	 	N	 	N	 	N/A	 	 	  	 
	COS	 	C_COS_CD	 	C_HDR_TB	 	X(3)	 	A	 	N/A	 	N/A	 	 	  	 
	Notes	 	C-HDR-RMK-IND	 	C_HDR_TB	 	X(l)	 	A	 	N/A	 	N/A	 	 	  	 
	Attachments (1)	 	C_1ST_ATTACH_CD	 	C_HDR_TB	 	X(2)	 	N	 	N	 	N/A	 	 	  	 
	Attachments (2)	 	C_2ND_ATTACH_CD	 	C_HDR_TB	 	X(2)	 	N	 	N	 	N/A	 	 	  	 
	Attachments (3)	 	C_3RD_ATTACH_CD	 	C_HDR_TB	 	X(2)	 	N	 	N	 	N/A	 	 	  	 
	Attachments (4)	 	C_4TH_ATTACH_CD	 	C_HDR_TB	 	X(2)	 	N	 	N	 	N/A	 	 	  	 
	Attachments (5)	 	C_5TH_ATTACH_CD	 	C_HDR_TB	 	X(2)	 	N	 	N	 	N/A	 	 	  	 
	Attachments (6)	 	C_6TH_ATTACH_CD	 	C_HDR_TB	 	X(2)	 	N	 	N	 	N/A	 	 	  	 
	Man Adj Rsn	 	C_OVRRD_EXC_CD	 	C_HDR_OVRRD_EXC_TB	 	X(4)	 	N	 	N	 	V	 	Where Line Number on the table = 0, and Sequence Number = 1	  	 
	Remark Code	 	C_OVRRD_EOB_CD	 	C_HDR_OVRRD_EOB_TB	 	X(4)	 	N	 	N	 	V	 	Where Line Number on the table = 0, and Sequence Number = 1	  	 
	Replcd/Rsn/ (1)	 	C_KEYED_REPLCD_NUM	 	C_HDR_ADJ_VD_TB	 	9(17)	 	A	 	N/A	 	N/A	 	 	  	 
	Replcd/Rsn/ (2)	 	C_HDR_ADJ_RSN_CD	 	C_HDR_ADJ_VD_TB	 	X(3)	 	A	 	N/A	 	N/A	 	 	  	 
	(Medicare)	 	N/A	 	N/A	 	N/A	 	N/A	 	N/A	 	N/A	 	Grouping	  	 
	MIC	 	C_HD_MCARE_CARR_ID	 	C_HDR_MCARE_TB	 	X(6)	 	N	 	N/A	 	N/A	 	 	  	 
	EOMB Dt	 	C_HD_MCARE_EOMB_DT	 	C_HDR_MCARE_TB	 	DATE	 	N	 	N/A	 	N/A	 	Format: MM/DD/CCYY	  	 

  

 Page 252 of 326 









																	
	 Field Name

	 	 Table Column Name

	 	 Table Name

	 	 Format

	 	 Prot
(A,C,N)

	 	 Req
 (A,C,N)

	 	 Std
Edits

	 	 Specifications

	  	Note
Ref


	Allow Amt	 	C_MCARE_ALLOW_AMT	 	C_HDR_MCARE_TB	 	S9(7)V99	 	N	 	N/A	 	N/A	 	 	  	 
	Coins Amt	 	C_MCARE_COINS_AMT	 	C_HDR_MCARE_TB	 	S9(7)V99	 	N	 	N/A	 	N/A	 	 	  	 
	Ded Amt	 	C_MCARE_DED_AMT	 	C_HDR_MCARE_TB	 	S9(7)V99	 	N	 	N/A	 	N/A	 	 	  	 
	Paid Amt	 	C_MCARE_PD_AMT	 	C_HDR_MCARE_TB	 	S9(7)V99	 	N	 	N/A	 	N/A	 	 	  	 
	LI	 	C_LI_NUM	 	C_LI_EXC_TB	 	9(3)	 	A	 	N/A	 	N/A	 	 	  	 
	Exc	 	R_CLM_EXC_CD	 	C_LI_EXC_TB	 	X(4)	 	A	 	N/A	 	N/A	 	 	  	 
	St	 	R_CLM_EXC_DISP_CD	 	C_LI_EXC_TB	 	X(l)	 	N	 	A	 	N/A	 	 	  	3
	User ID	 	C_LI_EXC_CLRK_ID	 	C_LI_EXC_TB	 	X(7)	 	A	 	N/A	 	N/A	 	 	  	 

  
 Notes: 
  
 1 - Protected for Claims corrections. For exam entry, sequentially assigned by system if the
document number is available. 
  
 2 - Up to four characters containing a 1, 2, 3
and/or 4 may be entered in the field. Characters are placed in first through fourth related code fields, respectively. 
  
 3 - If changed, only “C=Clear Force”, “F = Force Pay”, or “D = Forced Deny” are valid. Force Pay and Force Deny are valid if allowed on
Claims Exception Disposition table. If code change is allowed, the User ID field will be populated with the current User ID who made the change. If code change is not allowed, a window error message will appear indicating either “Force
Pay” or “Force Deny” is not allowed with the exception and the Exception Disposition code will revert back to its original value. 
  

											
	LEGEND:	 	For Prot and Req:	 	A = Always	 	For Std Edits:	 	D = Date Edit	 	V = Valid Value Edit
	 	 	 	 	C = Conditionally	 	 	 	N = Numeric Edits	 	S = System Generated
						
	 	 	 	 	N= Never	 	 	 	 	 	 

  

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 GEORGIA MHN CLAIMS SUBSYSTEM WINDOW LAYOUT 
  
 EXAM ENTRY/CORRECTION – UB92 FUNCTIONAL GROUP 
  
 UB92 MAIN PAGE WINDOW 
  
 

 
  

 Page 254 of 326 








 GEORGIA MHN CLAIMS SUBSYSTEM 
 WINDOW EXHIBIT 
  
 EXAM ENTRY/CORRECTION – UB92 FUNCTIONAL GROUP 
  
 UB92 MAIN PAGE WINDOW 
  

																	
	 Field Name

	 	 Table Column Name

	  	 Table Name

	  	Format

	  	 Prot
 (A,C,N)

	  	 Req
 (A,C,N)

	  	Std Edits

	 	 Specifications

	  	Note Ref


	 Doc
	 	C_HDR _DOC_NUM	  	C_HDR_TB	  	X(6)	  	C	  	A	  	S	 	 	  	1
	 ID
	 	B_ALT_ID	  	C_HDR_TB	  	X(13)	  	A	  	N/A	  	N/A	 	 	  	 
	 Prov
	 	C_BLNG_PROV_ID	  	C_HDR_TB	  	X(12)	  	A	  	N/A	  	N/A	 	 	  	 
	 Stat
	 	C_HDR_STAT_CD	  	C_HDR_TB	  	X(1)	  	A	  	N/A	  	N/A	 	 	  	 
	 Doc Ty
	 	C_BAT_DOC_TY_CD	  	C_HDR_TB	  	X(1)	  	A	  	N/A	  	N/A	 	 	  	 
	 Clm Ty
	 	C_HDR_TY_CD	  	C_HDR_TB	  	X(1)	  	A	  	N/A	  	N/A	 	 	  	 
	 Txn Ty
	 	C_HDR_TXN_TY_CD	  	C_HDR_TB	  	X(1)	  	A	  	N/A	  	N/A	 	 	  	 
	 Pay Type
	 	C_BAT_PYMT_TY_CD	  	C_HDR_TB	  	X(1)	  	A	  	N/A	  	N/A	 	 	  	 
	 Locn
	 	C_EXC_LOCN_CD	  	C_HDR_TB	  	X(3)	  	A	  	N/A	  	N/A	 	 	  	 
	 Last Cycl
	 	C_HDR_LST_CYCL_ DT	  	C_HDR_TB	  	DATE	  	A	  	N/A	  	N/A	 	Format: MM/DD/CCYY	  	 
	 Pat#
	 	C_HDR_PAT_ACCT_DAT	  	C_HDR_TB	  	X(20)	  	N	  	N	  	N/A	 	 	  	 
	 Type of Bill
	 	 C_TY_OF_BILL_1_2_CD
 C_TY_OF_BILL_3_CD
	  	C_HDR_UB92_TB	  	X(2)
X(1)	  	N	  	N	  	N/A	 	Entry field is a 3 character working storage field.	  	 
	 Fr/Thru Dt(1)
	 	C_HDR_SVC_FST_DT	  	C_HDR_TB	  	DATE	  	N	  	N	  	D	 	Format: MM/DD/YY	  	 
	 Fr/Thru Dt (2)
	 	C_HDR_SVC_LST_DT	  	C_HDR_TB	  	DATE	  	N	  	N	  	D	 	Format: MM/DD/YY	  	 
	 CovDays
	 	C_CVRD_DAYS_NUM	  	C_HDR_UB92_TB	  	9(4)	  	N	  	N	  	N	 	 	  	 
	 NCD
	 	C_NCVRD_DAYS_NUM	  	C_HDR_UB92_TB	  	9(4)	  	N	  	N	  	N	 	 	  	 

  

 Page 255 of 326 









																	
	 Field Name

	  	 Table Column Name

	  	 Table Name

	  	Format

	 	 Prot
 (A,C,N)

	  	Req
(A,C,N)

	  	Std
Edits

	  	 Specifications

	  	Note
Ref


	 COS
	  	C_COS_CD	  	C_HDR_TB	  	X(3)	 	A	  	N/A	  	N/A	  	 	  	 
	 F/Mi/L (l)
	  	B_LAST_NAM	  	C_HDR_TB	  	X(21)	 	N	  	N	  	N/A	  	 	  	 
	 F/Mi/L (2)
	  	B_FST_NAM	  	C_HDR_TB	  	X(15)	 	N	  	N	  	N/A	  	 	  	 
	 F/Mi/L (3)
	  	B_MI_NAM	  	C_HDR_TB	  	X(l)	 	N	  	N	  	N/A	  	 	  	 
	 DOB
	  	C_SUBM_CLNT_DOB_DT	  	C_HDR_TB	  	DATE	 	N	  	N	  	D	  	Format: MM/DD/CCYY	  	 
	 Sex
	  	B_GENDER_CD	  	C_HDR_TB	  	X(l)	 	A	  	N/A	  	N/A	  	 	  	 
	 Age (Y/M) (Y)
	  	C_HDR_CLNT_AGE_YR	  	C_HDR_TB	  	9(3)	 	A	  	N/A	  	N/A	  	 	  	 
	 Age (Y/M) (M)
	  	C_HDR_CLNT_AGE_YR_MO	  	C_HDR_TB	  	9(3)	 	A	  	N/A	  	N/A	  	 	  	 
	 MP
	  	B_MAJ_PROG_CD	  	C_HDR_TB	  	X(l)	 	A	  	N/A	  	N/A	  	 	  	 
	 Aid Cat
	  	B_AID_CAT_CD	  	C_HDR_COE_TB	  	X(3)	 	A	  	N/A	  	N/A	  	 	  	 
	 Adm Date
	  	C_HDR_UB92_ADM_DT	  	C_HDR_UB92_TB	  	DATE	 	N	  	N	  	D	  	Format: MM/DD/YY	  	 
	 Hour
	  	C_UB92_ADM_HR_CD	  	C_HDR_UB92_TB	  	X(2)	 	N	  	N	  	N/A	  	 	  	 
	 Adm Type
	  	C_TY_OF_ADM_CD	  	C_HDR_UB92_TB	  	X(l)	 	N	  	N	  	N/A	  	Look up	  	 
	 Src
	  	C_ADM_SRC_CD	  	C_HDR_UB92_TB	  	X(l)	 	N	  	N	  	N/A	  	 	  	 
	 Dis Hr
	  	C_UB92_DISCH_HR_CD	  	C_HDR_UB92_TB	  	X(2)	 	N	  	N	  	N/A	  	 	  	 
	 Status
	  	C_PAT_STAT_CD	  	C_HDR_UB92_TB	  	X(2)	 	N	  	N	  	N/A	  	 	  	 
	 Medical Record Num
	  	C_UB92_MED_REC_NUM	  	C_HDR_UB92_TB	  	X(17)	 	N	  	N	  	N/A	  	 	  	 
	 Cond Cd
	  	C_COND_CD	  	C_HDR_COND_CD_TB	  	X(2)	 	N	  	N	  	N/A	  	Where Sequence number on the table = “01”	  	 
	 Occ Code
	  	C_OCC_CD	  	C_HDR_OCC_CD_TB	  	X(2)	 	N	  	N	  	N/A	  	Where Sequence number on the table = “01”	  	 
	 Occ Date
	  	C_UB92_OCC_CD_DT	  	C_HDR_OCC_CD_TB	  	DATE	 	N	  	N	  	D	  	Format: MM/DD/YY Where Sequence number on the table = “01”	  	 

  

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	 Field Name

	  	 Table Column Name

	  	 Table Name

	  	Format

	 	 Prot
 (A,C,N)

	  	 Req
 (A,C,N)

	  	Std
Edits

	  	 Specifications

	  	Note
Ref


	 LI
	  	C_LI_NUM	  	C_LI_TB	  	9(3)	 	A	  	N/A	  	N/A	  	Multi-column list box.	  	 
	 S
	  	C_REIMB_STAT_CD	  	C_LI_TB	  	X(l)	 	A	  	N/A	  	N/A	  	 	  	 
	 Rev
	  	R_REV_CD	  	C_LI_UB92_TB	  	X(7)	 	N	  	N	  	N/A	  	 	  	 
	 Proc
	  	R_PROC_CD	  	C_LI_TB	  	X(7)	 	N	  	N	  	N/A	  	 	  	 
	 Rate
	  	C_LI_UB92_RATE_NUM	  	C_LI_UB92_TB	  	S9(7)V99	 	N	  	N	  	N	  	 	  	 
	 FDOS
	  	C_LI_FST_DOS_DT	  	C_LI_TB	  	DATE	 	N	  	N	  	D	  	Format: MM/DD/YY	  	 
	 S Unit
	  	C_LI_SUBM_UNT_NUM	  	C_LI_TB	  	S9(7)V99	 	N	  	N	  	N	  	Entered/displayed as whole units.	  	 
	 Submit Chrg
	  	C_LI_SUBM_CHRG AMT	  	C_LI_TB	  	S9(7)V99	 	N	  	N	  	N	  	 	  	 
	 A Unit
	  	C_LI_ALLOW_UNT_NUM	  	C_LI_TB	  	S9(7)V99	 	A	  	N/A	  	N/A	  	Displayed as whole units.	  	 
	 Allow Chrg
	  	C_LI_ALLW_CHRG_AMT	  	C_LI_TB	  	S9(7)V99	 	A	  	N/A	  	N/A	  	 	  	 
	 BR
	  	C_BSE_AMT_SRC_CD	  	C_LI_TB	  	X(2)	 	A	  	N/A	  	N/A	  	 	  	 
	 LI
	  	C_LI_NUM	  	C_LI_EXC_TB	  	9(3)	 	A	  	N/A	  	N/A	  	 	  	 
	 Exc
	  	R_CLM_EXC_CD	  	C_LI_EXC_TB	  	X(4)	 	A	  	N/A	  	N/A	  	 	  	 
	 St
	  	R_CLM_EXC_DISP_CD	  	C_LI_EXC_TB	  	X(l)	 	N	  	A	  	N/A	  	 	  	2
	 User ID
	  	C_LI_EXC_CLRK_ID	  	C_LI_EXC_TB	  	X(7)	 	A	  	N/A	  	N/A	  	 	  	 
	 Spn
	  	C_OCC_SPN_CD	  	C_HDR_OCC_SPN_TB	  	X(2)	 	N	  	N	  	N/A	  	Multi-column list box.	  	 
	 From Date
	  	C_OCC_SPN_FR_DT	  	C_HDR_OCC_SPN_TB	  	DATE	 	N	  	N	  	D	  	Format: MM/DD/YY	  	 
	 Thru Date
	  	C_OCC_SPN_THRU_DT	  	C_HDR_OCC_SPN_TB	  	DATE	 	N	  	N	  	D	  	Format: MM/DD/YY	  	 
	 Valu
	  	C_VALU_CD	  	C_HDR_VALU_CD_TB	  	X(2)	 	N	  	N	  	N/A	  	 	  	 
	 Amount
	  	C_UB92_VALU_CD_AMT	  	C_H DR_VALU_CD_TB	  	S9(7)V99	 	N	  	N	  	N	  	 	  	 
	 PyCd
	  	C_HDR_UB92_PYR_CD	  	C_HDR_PYR_TB	  	X(l)	 	N	  	N	  	N/A	  	 	  	 

  

 Page 257 of 326 









																	
	 Field Name

	  	 Table Column Name

	  	 Table Name

	  	Format

	 	 Prot
 (A,C,N)

	  	 Req
 (A,C,N)

	  	Std
Edits

	  	 Specifications

	  	Note
Ref


	 Provider Number
	  	C_PYR_PROV_ID	  	C_HDR_PYR_TB	  	X(12)	 	N	  	N	  	N/A	  	When Py Cd = “D”, provider number is mapped to Provider number on the Title Bar for the main window in this group.	  	 
	 Prior Payment
	  	C_PYR_PR_PYMT_AMT	  	C_HDR_PYR_TB	  	S9(9)V99	 	N	  	N	  	N	  	 	  	 
	 Est Amt Due
	  	C_UB92_EST_DUE_AMT	  	C_HDR_PYR_TB	  	S9(9)V99	 	N	  	N	  	N	  	 	  	 
	 Cert – SSN – HIC - ID
	  	C_CERT_SSN_HIC_ID	  	C_HDR_PYR_TB	  	X(19)	 	N	  	N	  	N/A	  	When Py Cd = “D”, ID number is mapped to Member ID on the Title Bar for the main window in this group.	  	 
	 Treatment Auth Code
	  	C_UB92_PYR_AUTH_CD	  	C_HDR_PYR_TB	  	X(18)	 	N	  	N	  	N/A	  	 	  	 
	 Diagnosis Code
	  	C_UB92_A_DIAG_CD	  	C_HDR_DIAG_TB	  	X(10)	 	N	  	N	  	N/A	  	 	  	 
	 D RC
	  	C_UB92-DRG_DIAG_CD	  	C_HDR_DIAG_TB	  	X(l)	 	A	  	N/A	  	N/A	  	Where Sequence number on the table = “01”	  	 
	 Surgical Proc
	  	R_ICD9_CD	  	C_HDR_ICD_TB	  	X(7)	 	N	  	N	  	N/A	  	Where Sequence number on the table = “01”	  	 
	 Date
	  	C_HDR_UB92_ICD9_DT	  	C_HDR_ICD_TB	  	DATE	 	N	  	N	  	D	  	Format: MM/DD/YY Where Sequence number on the table = “01”	  	 
	 D RC
	  	C_UB92-DRG_SURG_CD	  	C_HDR_ICD_TB	  	X(7)	 	N	  	N	  	N/A	  	Where Sequence number on the table = “02”	  	 
	 Replcd/Reason (1)
	  	C_KEYED_REPLCD_NUM	  	C_HDR_ADJ_VD_TB	  	9(17)	 	A	  	N/A	  	N/A	  	 	  	 
	 Replcd/Reason (2)
	  	C_HDR_ADJ_RSN_CD	  	C_HDR_ADJ_VD_TB	  	X(3)	 	A	  	N/A	  	N/A	  	 	  	 
	 Other Insurance
	  	C_HDR_INSR_CD	  	C_HDR_TB	  	X(l)	 	N	  	N	  	N/A	  	Checkbox. Checked if value is “Y”	  	 
	 Patient Paid
	  	C_PAT_PD_AMT	  	C_HDR_TB	  	S9(9)V99	 	N	  	N	  	N	  	 	  	 
	 Admit Dx
	  	C_UB92_A_DIAG_CD	  	C_HDR_UB92_TB	  	X(l)	 	N	  	N	  	N/A	  	 	  	 
	 E Dx
	  	C_UB92_E_DIAG_CD	  	C_HDR_UB92_TB	  	X(l)	 	N	  	N	  	N/A	  	 	  	 
	 Attending Prov
	  	C_ATNDG_PROV_ID	  	C_HDR_UB92_TB	  	X(12)	 	N	  	N	  	N/A	  	 	  	 
	 Other Prov 1/2 (1)
	  	C_OTHR_PROV_1_ID	  	C_HDR_UB92_TB	  	X(12)	 	N	  	N	  	N/A	  	 	  	 
	 Other Prov 1/2 (2)
	  	C_OTHR_PROV_2_ID	  	C_HDR_UB92_TB	  	X(12)	 	N	  	N	  	N/A	  	 	  	 

  

 Page 258 of 326 









																	
	 Field Name

	  	 Table Column Name

	  	 Table Name

	  	 Format

	  	 Prot
(A,C,N)

	  	 Req
 (A,C,N)

	  	 Std
Edits

	  	 Specifications

	  	Note
Ref


	Signature/Date (1)	  	C_PROV_SIGN_IND	  	C_ HDR_TB	  	X(l)	  	N	  	N	  	N/A	  	Checkbox. Checked if value is “Y”	  	 
									
	Signature Date (2)	  	C_BILLED_DT	  	C_HDR_TB	  	DATE	  	N	  	N	  	D	  	Format: MM/DD/CCYY	  	 
									
	Attachments (1)	  	C_IST_ATTACH_CD	  	C_HDR_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	 
									
	Attachments (2)	  	C_2ND_ATTACH_CD	  	C_HDR_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	 
									
	Attachments (3)	  	C_3RD_ATTACH_CD	  	C_HDR_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	 
									
	Attachments (4)	  	C_4TH_ATTACH_CD	  	C_HDR_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	 
									
	Attachments (5)	  	C_5TH_ATTACH_CD	  	C_HDR_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	 
									
	Attachments (6)	  	C_6TH_ATTACH_CD	  	C_HDR_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	 
									
	Discount Amt	  	C_DICSOUNT_AMT	  	C_HDR_TB	  	S9(9)V99	  	A	  	N/A	  	N/A	  	 	  	 
									
	Reimb Amt	  	C_TOT_REIMB_AMT	  	C_HDR_TB	  	S9(9)V99	  	A	  	N/A	  	N/A	  	 	  	 
									
	Override Locn	  	C_OVRRD_EXC_LOC_CD	  	C_HDR_TB	  	X(3)	  	N	  	N/A	  	N/A	  	 	  	 
									
	Notes	  	C_HDR RMK_IND	  	C_HDR_TB	  	X(l)	  	N	  	N	  	N/A	  	Checkbox.Checked if value is “Y”	  	 
									
	(Medicare)	  	N/A	  	N/A	  	N/A	  	N/A	  	N/A	  	N/A	  	Grouping	  	 
									
	MIC	  	C_HD_MCARE_CARR_ID	  	C_HDR_MCARE _TB	  	X(6)	  	N	  	N/A	  	N/A	  	 	  	 
									
	EOMB Date	  	C_HD_MCARE_EOMB_DT	  	C_HDR_MCARE_TB	  	DATE	  	N	  	N/A	  	N/A	  	Format: MM/DD/CCYY	  	 
									
	Allow Amt	  	C_MCARE_ALLOW _AMT	  	C_HDR_MCARE_TB	  	S9(7)V99	  	N	  	N/A	  	N/A	  	 	  	 
									
	Coins Amt	  	C_MCARE_COINS_AMT	  	C_HDR_MCARE _TB	  	S9(7)V99	  	N	  	N/A	  	N/A	  	 	  	 
									
	Ded Amt	  	C_MCARE_DED_AMT	  	C_HDR_MCARE_TB	  	S9(7)V99	  	N	  	N/A	  	N/A	  	 	  	 
									
	Paid Amt	  	C_MCARE_PD_AMT	  	C_HDR_MCARE _TB	  	S9(7)V99	  	N	  	N/A	  	N/A	  	 	  	 
									
	Override Exc	  	C_OVRRD_EXC_CD	  	C_HDR_OVRRD_ EXC _TB	  	X(4)	  	N	  	N	  	N/A	  	Where Sequence number on the table = “01”	  	 
									
	Man Adj Rsn	  	C_OVRRD_EOB_CD	  	C_HDR_OVRRD_EOB_TB	  	X(4)	  	N	  	N	  	N/A	  	Where Sequence number on the table = “01”	  	 

  

 Page 259 of 326 








 Notes: 
  
 1 - For Exam Entry, populated with incremented document number, if available. For Corrections, field is protected. 
  
 2 - If changed, only “C=Clear Force”, “F = Force Pay”, or “D = Force
Deny” are valid. Force Pay and Force Deny are valid if allowed on Claims Exception Disposition table. If code change is allowed, the User ID field will be populated with the current User ID who made the change. If code change is not
allowed, a window error message will appear indicating either “Force Pay” or “Force Deny” is not allowed with the exception and the Exception Disposition code will revert back to its original value. 
  

											
	LEGEND:	  	For Prot and Req:	  	A = Always	  	For Std Edits:	  	D = Date Edit	  	V = Valid Value Edit
	 	  	 	  	C = Conditionally	  	 	  	N= Numeric Edits	  	S = System Generated
	 	  	 	  	N = Never	  	 	  	 	  	 

  

 Page 260 of 326 








 GEORGIA MHN CLAIMS SUBSYSTEM WINDOW LAYOUT 
  
 EXAM ENTRY / CORRECTION - DENTAL FUNCTIONAL GROUP 
  
 DENTAL MAIN PAGE WINDOW 
  
 

 
  

 Page 261 of 326 








 GEORGIA MHN CLAIMS SUBSYSTEM 
 WINDOW EXHIBIT 
  
 EXAM ENTRY/ CORRECTION - DENTAL FUNCTIONAL GROUP 
  
 DENTAL MAIN PAGE WINDOW 
  

																	
	 Field Name

	  	 Table Column Name

	  	Table Name

	  	Format

	 	Prot
(A,C,N)

	  	 Req
 (A,C,N)

	  	Std Edits

	  	 Specifications

	  	Note
Ref


	Doc	  	C_HDR_DOC_NUM	  	C_HDR_TB	  	X(6)	 	C	  	A	  	S	  	 	  	1
									
	PA	  	A_ID	  	C_HDR_TB	  	X(11)	 	N	  	N	  	N/A	  	 	  	 
									
	Stat	  	C_HDR_STAT_CD	  	C_HDR_TB	  	X(1)	 	A	  	N/A	  	N/A	  	 	  	 
									
	Doc Ty	  	C_BAT_DOC_TY_CD	  	C_HDR_TB	  	X(1)	 	A	  	N/A	  	N/A	  	 	  	 
									
	Clm Type	  	C_HDR_TY_CD	  	C_HDR_TB	  	X(1)	 	A	  	N/A	  	N/A	  	 	  	 
									
	Txn Type	  	C_HDR_TXN_TY_CD	  	C_HDR_TB	  	X(1)	 	A	  	N/A	  	N/A	  	 	  	 
									
	Pay Type	  	C _BAT_ PYMT_TY_CD	  	C_HDR_TB	  	X(1)	 	A	  	N/A	  	N/A	  	 	  	 
									
	Location	  	C _EXC_LOCN_CD	  	C_HDR_TB	  	X(3)	 	A	  	N/A	  	N/A	  	 	  	 
									
	Lcycl Dt	  	C _HDR_LST_CYCL_DT	  	C_HDR_TB	  	DATE	 	A	  	N/A	  	N/A	  	Format: MM/DD/CCYY	  	 
									
	F/Mi/L (3)	  	B_LAST_NAM	  	C_HDR_TB	  	X(21)	 	N	  	N	  	N/A	  	 	  	 
									
	F/Mi/L (l)	  	B_FST_NAM	  	C_HDR_TB	  	X(15)	 	N	  	N	  	N/A	  	 	  	 
									
	F/Mi/L (2)	  	B_MI_NAM	  	C_HDR_TB	  	X(l)	 	N	  	N	  	N/A	  	 	  	 
									
	DOB	  	C_ SUBM_CLNT_ DOB_DT	  	C_HDR_TB	  	DATE	 	N	  	N	  	D	  	Format: MM/DD/CCYY	  	 
									
	Sex	  	B_GENDER_CD	  	C_HDR_TB	  	X(1)	 	A	  	N/A	  	N/A	  	 	  	 
									
	Age(Y/M) (l)	  	C_HDR_CLNT_AGE_YR	  	C_HDR_TB	  	9(3)	 	A	  	N/A	  	N/A	  	 	  	 
									
	Age (Y/M) (2)	  	C_HDR_CLNT_AGE_MO	  	C_HDR_TB	  	9(2)	 	A	  	N/A	  	N/A	  	 	  	 

  

 Page 262 of 326 









																	
	 Field Name

	  	 Table
Column Name

	  	 Table Name

	  	Format

	  	 Prot
 (A,C,N)

	  	 Req
 (A,C,N)

	  	Std
Edits

	  	 Specifications

	  	Note
Ref


	 Maj Prog
	  	B_MAJ_PROG_CD	  	C_HDR_TB	  	X(1)	  	A	  	N/A	  	N/A	  	 	  	 
	 ID
	  	B_ALT_ID	  	C_HDR_TB	  	X(13)	  	N	  	N	  	N/A	  	 	  	 
	 Other Ins
	  	C_HDR_INSR_CD	  	C_HDR_TB	  	X(1)	  	N	  	N	  	N/A	  	Checkbox. Checked if value is “Y”	  	 
	 Prov ID
	  	C_BLNG_PROV_ID	  	C_HDR_TB	  	X(12)	  	N	  	N	  	N/A	  	 	  	 
	 Type
	  	C_BLNG_PROV_TY_CD	  	C_HDR_TB	  	X(3)	  	A	  	N/A	  	N/A	  	 	  	 
	 COS
	  	C_COS_CD	  	C_HDR_TB	  	 	  	 	  	 	  	 	  	 	  	 
	 Aid Cat
	  	B_AID_CAT_CD	  	C_HDR_COE_TB	  	X(3)	  	A	  	N/A	  	N/A	  	 	  	 
	 Place of Service
	  	N/A	  	N/A	  	N/A	  	N/A	  	N/A	  	N/A	  	Grouping	  	 
	 Office
	  	R_PL_OF_SVC_CD	  	C_LI_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	2
	 Hospital
	  	R_PL_OF_SVC_CD	  	C_LI_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	2
	 ECF
	  	R_PL_OF_SVC_CD	  	C_LI_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	2
	 Other
	  	R_PL_OF_SVC_CD	  	C_LI_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	2
	 Accident
	  	N/A	  	N/A	  	N/A	  	N/A	  	N/A	  	N/A	  	Grouping	  	 
	 Employment
	  	C_DENT_OCCP_IND	  	C_HDR_DENT_TB	  	X(1)	  	N	  	N	  	N/A	  	Checkbox. Checked if value is “Y”	  	 
	 Auto
	  	C_DENT_AUTO_IND	  	C_HDR_DENT_TB	  	X(1)	  	N	  	N	  	N/A	  	Checkbox. Checked if value is “Y”	  	 
	 Other
	  	C_DENT_OTHR_IND	  	C_HDR_DENT_TB	  	X(1)	  	N	  	N	  	N/A	  	Checkbox. Checked if value is “Y”	  	 
	 Li
	  	C_LI_NUM	  	C_LI_TB	  	9(3)	  	A	  	N/A
N/A	  	N/A	  	 	  	 
	 S
	  	C_REIMB_STAT_CD	  	C_LI_TB	  	X(1)	  	A	  	N/A	  	N/A	  	 	  	 
	 Svc Date
	  	C_LI_FST_DOS_DT	  	C_LI_TB	  	DATE	  	N	  	N	  	D	  	Format: MM/DD/YY	  	 
	 Tooth
	  	R_PROC_TOOTH_CD	  	C_LI_DENT_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	 

  

 Page 263 of 326 









																	
	 Field Name

	  	 Table
Column Name

	  	 Table Name

	  	Format

	  	 Prot
 (A,C,N)

	  	 Req
 (A,C,N)

	  	Std
Edits

	  	 Specifications

	  	Note
Ref


	 Surface
	  	C_DENT_1ST_SURF_CD	  	C_LI_DENT_TB	  	X(1)	  	N	  	N	  	N/A	  	 	  	3
	 	  	C_DENT_2ND_SURF_CD	  	 	  	X(1)	  	 	  	 	  	 	  	 	  	 
	 	  	C_DENT_3RD_SURF_CD	  	 	  	X(1)	  	 	  	 	  	 	  	 	  	 
	 	  	C_DENT_4TH_SURF_CD	  	 	  	X(1)	  	 	  	 	  	 	  	 	  	 
	 	  	C_DENT_5TH_SURF_CD	  	 	  	X(1)	  	 	  	 	  	 	  	 	  	 
	 	  	C_DENT_6TH_SURF_CD	  	 	  	X(1)	  	 	  	 	  	 	  	 	  	 
	 PS
	  	R_PL_OF_SVC_CD	  	C_LI_TB	  	X(2)	  	A	  	N/A	  	N/A	  	 	  	 
	 Proc
	  	R_PROC_CD	  	C_LI_TB	  	X(7)	  	N	  	N	  	N/A	  	 	  	 
	 S Unit
	  	C_LI_SUBM_UNT_NUM	  	C_LI_TB	  	S9(7)V99	  	N	  	N	  	N	  	Entered/displayed in whole units.	  	 
	 Submit Chrg
	  	C_LI_SUBM_CHRG_AMT	  	C_LI_TB	  	S9(7)V99	  	N	  	N	  	N	  	 	  	 
	 Allow Chrg
	  	C_LI_ALLW_CHRG_AMT	  	C_LI_TB	  	S9(7)V99	  	A	  	N/A	  	N/A	  	 	  	 
	 AUnit
	  	C_LI_ALLOW_UNT_NUM	  	C_LI_TB	  	S9(7)V99	  	A	  	N/A	  	N/A	  	Displayed in whole units.	  	 
	 BR
	  	C_BSE_AMT_SRC_CD	  	C_LI_TB	  	X(2)	  	A	  	N/A	  	N/A	  	 	  	 
	 LI
	  	C_LI_NUM	  	C_LI_EXC_TB	  	9(3)	  	A	  	N/A	  	N/A	  	 	  	 
	 Exc
	  	R_CLM_EXC_CD	  	C_LI_EXC_TB	  	X(4)	  	A	  	N/A	  	N/A	  	 	  	 
	 St
	  	R_CLM_EXC_DISP_CD	  	C_LI_EXC_TB	  	X(1)	  	N	  	A	  	N/A	  	 	  	4
	 Clerk ID
	  	C_LI_EXC_CLRK_ID	  	C_LI_EXC_TB	  	X(7)	  	A	  	N/A	  	N/A	  	 	  	 
	 Tot Chrg
	  	C_TOT_CHRG_AMT	  	C_HDR_TB	  	S9(9)V99	  	N	  	N	  	N	  	 	  	 
	 COB
	  	C_TOT_TPL_AMT	  	C_HDR_TB	  	S9(9)V99	  	N	  	N	  	N	  	 	  	 
	 Net
	  	C_TOT_NET_CHRG_AMT	  	C_HDR_TB	  	S9(9)V99	  	N	  	N	  	N	  	 	  	 
	 Reimb
	  	C_TOT_REIMB_AMT	  	C_HDR_TB	  	S9(9)V99	  	A	  	N/A	  	N/A	  	 	  	 
	 Sign/Date (1)
	  	C_PROV_SIGN_IND	  	C_HDR_TB	  	X(1)	  	N	  	N	  	N/A	  	Checkbox. Checked if value is “Y”	  	 

  

 Page 264 of 326 









																	
	 Field Name

	  	Table
Column Name

	  	Table Name

	  	Format

	  	 Prot
 (A,C,N)

	  	 Req
 (A,C,N)

	  	Std
Edits

	  	 Specifications

	  	Note
Ref


	 Sign/Date (2)
	  	C_BILLED_DT	  	C_HDR_TB	  	DATE	  	N	  	N	  	D	  	Format: MM/DD/CCYY	  	 
	 Notes
	  	C_HDR_RMK_IND	  	C_HDR_TB	  	X(1)	  	N	  	N	  	N/A	  	Checkbox. Checked if value is “Y”	  	 
	 Override Exe
	  	C_OVRRD_EXC_CD	  	C_HDR_OVRRD_EXC_TB	  	X(4)	  	N	  	N	  	N/A	  	Where Line Number on the table = 0, and Sequence Number = 1	  	 
	 Man Adj Rsn
	  	C_OVRRD_EOB_CD	  	C_HDR_OVRRD_EOB_TB	  	X(4)	  	N	  	N	  	N/A	  	Where Line Number on the table = 0, and Sequence Number = 1	  	 
	 Attachments (1)
	  	C_1ST_ATTACH_CD	  	C_HDR_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	 
	 Attachments (2)
	  	C_2ND_ATTACH_CD	  	C_HDR_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	 
	 Attachments (3)
	  	C_3RD_ATTACH_CD	  	C_HDR_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	 
	 Attachments (4)
	  	C_4TH_ATTACH_CD	  	C_HDR_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	 
	 Attachments (5)
	  	C_5TH_ATTACH_CD	  	C_HDR_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	 
	 Attachments (6)
	  	C_6TH_ATTACH_CD	  	C_HDR_TB	  	X(2)	  	N	  	N	  	N/A	  	 	  	 
	 Override Location
	  	C_OVRRD_EXC_LCN_CD	  	C_HDR_TB	  	X(3)	  	N	  	N	  	N/A	  	 	  	 
	 Replcd/Rsn/Repl cmt (1)
	  	C_ADJ_REPLCD_TCN	  	C_HDR_ADJ_VD_TB	  	X(17)	  	A	  	N/A	  	N/A	  	 	  	 
	 Replcd/Rsn/Repl cmt (2)
	  	C_HDR_ADJ_RSN_CD	  	C_HDR_ADJ_VD_TB	  	X(3)	  	A	  	N/A	  	N/A	  	 	  	 

  

 Page 265 of 326 








 Notes: 
  
 1 - For Exam Entry, populated with incremented document number, if available. For Corrections, protected. 
  
 2 - The P_ of Svc code (choice) will appear in each protected field of the PS column where line data is present. If more than 1 choice is
selected (checked), the left most choice will only appear in the PS column. 
  
 3
- Window field contains seven individual fields. First through seventh characters are mapped to the first through seventh surface codes, respectively. 
  
 4 - If changed, only “C=Clear Force”, “F = Force Pay”, or “D = Forced Deny” are valid Force Pay and Force Deny are valid if allowed on
Claims Exception Disposition table. If code change is allowed, the Clerk ID field will be populated with the current User ID who made the change. If code change is not allowed, a window error message will appear indicating either “Force
Pay” or “Force Deny” is not allowed with the exception and the Exception Disposition code will revert back to its original value. 
  

											
	LEGEND:	  	For Prot and Req:	  	A = Always	  	For Std Edits:	  	D = Date Edit	  	V = Valid Value Edit
	 	  	 	  	C = Conditionally	  	 	  	N = Numeric Edits	  	S = System Generated
						
	 	  	 	  	N = Never	  	 	  	 	  	 

  

 Page 266 of 326 








 Attachment L.5.3 
  

	*	ACS Capitation Claim File 

  

	
	 01     FIN00262IN.

	 05     C-TCN-NUM

	 PIC S9(17).

	 05     C-REPLCMT-TCN-NUM

	 PIC S9(17).

	 05     C-LI-NUM

	 PIC S9(3).

	 05     C-HDR-TXN-TY-CD

	 PIC X(1).

	 05     C-HDR-TY-CD

	 PIC X(1).

	 05     C-HDR-STAT-CD

	 PIC X(1).

	 05     C-COS-CD

	 PIC X(3).

	 05     C-RNDR-PROV-ID

	 PIC X(12).

	 05     P-TY-CD

	 PIC X(3).

	 05     P-SPECL-CD

	 PIC X(3).

	 05     G-CNTY-CD

	 PIC X(3).

	 05     R-PROC-CD

	 PIC X(7).

	 05     C-HDR-SVC-FST-DT

	 PIC X(10).

	 05     C-HDR-PD-DT

	 PIC X(10).

	 05     C-LI-REIMB-AMT

	 PIC S9(11)V9(2).

	 05     C-LI-REIMB-UNIT-AMT

	 PIC S9(7)V9(2).

	 05     B-MHN-ALT-ID

	 PIC X(13).

	 05     B-ALT-ID

	 PIC X(13).

	 05     B-LAST-NAM

	 PIC X(21).

	 05     B-FST-NAM

	 PIC X(15).

	 05     B-RES-CNTY-CD

	 PIC X(3).

	 05     C-HDR-CLNT-AGE

	 PIC S9(4).

	 05     B-RACE-CD

	 PIC X(1).

	 05     B-COE-CD

	 PIC X(3).


  

 Page 267 of 326 








 Attachment L.5.4 
  

			
	MEMBER:	  	N1X44141
	NAME:	  	X-MSTAT-FACILITY-CLMS
	SUBSYSTEM:	  	X Claims History
	VERSION:	  	1
	GENERATED:	  	2004-03-17 14:01:03 REQUESTED BY ACS0924
	
	Medstat Facility (INST)

  

			
	 01     W1X44141-X-MSTAT-FACILITY-CLMS.
	  	S4414
	 05     W1X44141-C-TCN-NUM
	  	 
	 PIC S9(00017).
	  	F1024
	 05     W1X44141-C-REPLCMT-TCN-NUM
	  	 
	 PIC S9(00017).
	  	F0702
	 05     W1X44141-C-LI-NUM
	  	 
	 PIC S9(00003).
	  	F1073
	 05     W1X44141-C-HDR-STAT-CD
	  	 
	 PIC X(00001).
	  	F1020
	 05     W1X44141-C-REIMB-STAT-CD
	  	 
	 PIC X(00001).
	  	F0162
	 05     W1X44141-C-HDR-TXN-TY-CD
	  	 
	 PIC X(00001).
	  	F1030
	 05     W1X44141-C-HDR-TY-CD
	  	 
	 PIC X(00001).
	  	F1031
	 05     W1X44141-C-HDR-UB92-ADM-DT
	  	 
	 PIC X(00010).
	  	F1033
	 05     W1X44141-C-ADM-SRC-CD
	  	 
	 PIC X(00001).
	  	F0138
	 05     W1X44141-C-TY-OF-ADM-CD
	  	 
	 PIC X(00001).
	  	F0137
	 05     W1X44141-C-PAT-STAT-CD
	  	 
	 PIC X(00002).
	  	F0168
	 05     W1X44141-B-DISCH-DSTN-CD
	  	 
	 PIC X(00001).
	  	F6367
	 05     W1X44141-C-RNDR-PROV-ID
	  	 
	 PIC X(00012).
	  	F1089
	 05     W1X44141-C-TY-OF-BLL-1-2-CD
	  	 
	 PIC X(00002).
	  	F1180
	 05     W1X44141-C-TY-OF-BILL-3-CD
	  	 
	 PIC X(00001).
	  	F1179

  

 Page 268 of 326 









			
	 05     W1X44141-C-HDR-SVC-FST-DT
	  	 
	 PIC X(00010).
	  	F1022
	 05     W1X44141-C-HDR-SVC-LST-DT
	  	 
	 PIC X(00010).
	  	F1023
	 05     W1X44141-C-HDR-PD-DT
	  	 
	 PIC X(00010).
	  	F1017
	 05     W1X44141-C-HDR-WARR-AMT
	  	 
	 PIC S9(00013)V9(00002).
	  	F1038
	 05     W1X44141-C-TOT-REIMB-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1028
	 05     W1X44141-C-LINE-TPL-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1029
	 05     W1X44141-C-LINE-SPDWN-AMT
	  	 
	 PIC S9(00007)V9(00002).
	  	F7166
	 05     W1X44141-C-COPAY-EXEMPT-CD
	  	 
	 PIC X(00001).
	  	F4468
	 05     W1X44141-C-LINE-COPAY-AMT
	  	 
	 PIC S9(00007)V9(00002).
	  	F5439
	 05     W1X44141-C-COS-CD
	  	 
	 PIC X(00003).
	  	F0175
	 05     W1X44141-P-TY-CD
	  	 
	 PIC X(00003).
	  	F0204
	 05     W1X44141-P-SPECL-CD
	  	 
	 PIC X(00003).
	  	F2653
	 05     W1X44141-B-LCKN-TY-CD
	  	 
	 PIC X(00004).
	  	F0036
	 05     W1X44141-C-LI-REF-PROV- ID
	  	 
	 PIC X(00012).
	  	F8294
	 05     W1X44141-G-ZIP5-CD
	  	 
	 PIC X(00005).
	  	F1511
	 05     W1X44141-G-ZIP4-CD
	  	 
	 PIC X(00004).
	  	F1510
	 05     W1X44141-G-CNTY-CD
	  	 
	 PIC X(00003).
	  	F2639
	 05     W1X44141-C-LI-SUBM-CHRG-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1091
	 05     W1X44141-C-LI-ALLW-CHRG-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1071
	 05     W1X44141-C-LI-REIMB-UNT-NUM
	  	 
	 PIC S9(00007)V9(00002).
	  	F1088
	 05     W1X44141-C-LI-FST-DOS-DT
	  	 
	 PIC X(00010).
	  	F1080
	 05     W1X44141-C-CVRD-DAYS-NUM
	  	 
	 PIC S9(00004).
	  	F1184
	 05     W1X44141-R-REV-CD
	  	 
	 PIC X(00007).
	  	F2112
	 05     W1X44141-R-PROC-CD
	  	 
	 PIC X(00007).
	  	F2042
	 05     W1X44141-R-DIAG-CD
	  	F1756
	 OCCURS 0010 TIMES
 INDEXED BY W1X44141-R-DIAG-CD-X
	  	 
	 PIC X(00010).
	  	 

  

 Page 269 of 326 









			
	 05     W1X44141-R-ICD9-CD
	  	F1931
	 OCCURS 0006 TIMES
	  	 
	 INDEXED BY W1X44141-R-ICD9-CD-X
	  	 
	 PIC X(00007).
	  	 
	 05     W1X44141-R-PL-OF-SVC-CD
	  	 
	 PIC X(00002).
	  	F2017
	 05     W1X44141-R-DRG-CD
	  	 
	 PIC X(00005).
	  	F1783
	 05     W1X44141-R-EMER-TRMT-IND
	  	 
	 PIC X(00001).
	  	F1888
	 05     W1X44141-A-TY-CD
	  	 
	 PIC X(00002).
	  	F0150
	 05     W1X44141-C-LI-FAM-PLNG-IND
	  	 
	 PIC X(00001).
	  	F1078
	 05     W1X44141-C-UB92-DISCH-DT
	  	 
	 PIC X(00010).
	  	F1185
	 05     W1X44141-C-UB92-ADM-HR-CD
	  	 
	 PIC X(00002).
	  	F1182
	 05     W1X44141-C-UB92-DISCH-HR-CD
	  	 
	 PIC X(00002).
	  	F1186
	 05     W1X44141-C-OCC-CD
	  	F0159
	 OCCURS 0010 TIMES
	  	 
	 INDEXED BY W1X44141-C-OCC-CD-X
	  	 
	 PIC X(00002).
	  	 
	 05     W1X44141-C-UB92-OCC-CD-DT
	  	F1194
	 OCCURS 0010 TIMES
	  	 
	 INDEXED BY W1X44141-C-UB92-OCC-CD-DT-X
	  	 
	 PIC X(00010).
	  	 
	 05     W1X44141-C-VALU-CD
	  	F0157
	 OCCURS 0008 TIMES
	  	 
	 INDEXED BY W1X44141-C-VALU-CD-X
	  	 
	 PIC X(00002).
	  	 
	 05     W1X44141-C-UB92-VALU-CD-AMT
	  	F1199
	 OCCURS 0008 TIMES
	  	 
	 INDEXED BY W1X44141-C-UB92-VALU-CD-AMT-X
	  	 
	 PIC S9(00007)V9(00002).
	  	 
	 05     W1X44141-B-ALT-ID
	  	 
	 PIC X(00013).
	  	F0535
	 05     W1X44141-B-MHN-ALT-ID
	  	 
	 PIC X(00013).
	  	F2542
	 05     W1X44141-B-LAST-NAM
	  	 
	 PIC X(00021).
	  	F0639
	 05     W1X44141-B-FST-NAM
	  	 
	 PIC X(00015).
	  	F0637
	 05     W1X44141-B-GENDER-CD
	  	 
	 PIC X(00001).
	  	F0229
	 05     W1X44141-B-DOB-DT
	  	 
	 PIC X (00010).
	  	F0601
	 05     W1X44141-B-RES-CNTY-CD
	  	 
	 PIC X(00003).
	  	F1394

  

 Page 270 of 326 









			
	 05     W1X44141-C-HDR-CLNT-AGE
	  	 
	 PIC S9(00004).
	  	F0971
	 05     W1X44141-B-RACE-CD
	  	 
	 PIC X(00001).
	  	F0230
	 05     W1X44141-B-COE-CD
	  	 
	 PIC X(00003).
	  	F2678
	 05     W1X44141-C-MCARE-PD-AMT
	  	 
	 PIC S9 (00011)V9 (00002).
	  	F1110
	 05     W1X44141-C-LI-MCARE-PD-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1085
	 05     W1X44141-C-MCARE-COINS-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1013
	 05     W1X44141-C-LI-MCARE-COI-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1107
	 05     W1X44141-C-MCARE-DED-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1108
	 05     W1X44141-C-LI-MCARE-DED-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1084
	 05     W1X44141-C-REMARK-CD
	  	F5651
	 OCCURS 0010 TIMES
	  	 
	 INDEXED BY W1X44141-C-REMARK-CD-X
	  	 
	 PIC X(00005).
	  	 
	 05     W1X44141-C-DRG-PYMT-AMT
	  	 
	 PIC S9(00009)V9(00002).
	  	F7041
	 05     W1X44141-C-REPLCD-TCN-NUM
	  	 
	 PIC S9(00017).
	  	F0701
	 05     W1X44141-R-CLM-EXC-CD
	  	F1737
	 OCCURS 0010 TIMES
	  	 
	 INDEXED BY W1X44141-R-CLM-EXC-CD-X
	  	 
	 PIC X(00004).
	  	 
	 05     W1X44141-C-HDR-COPAY-AMT
	  	 
	 PIC S9(00007)V9(00002).
	  	 
	 05     W1X44141-C-HDR-SPDWN-AMT
	  	 
	 PIC S9(00007)V9(00002).
	  	 
	 05     W1X44141-C-HDR-TPL-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	 
	 05     W1X44141-C-LI-REIMB-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	 
	 05     W1X44141-C-HDR-FAM-PLNG-IND
	  	 
	 PIC X(00001).
	  	 

  

 Page 271 of 326 








 Attachment L.5.5 
  

			
	MEMBER:	  	W1X43921
	NAME:	  	X-MSTAT-PROF-CLMS
	SUBSYSTEM:	  	X Claims History
	VERSION:	  	1
	GENERATED:	  	2004-03-17 14:01:03 REQUESTED BY ACS0924

  
 Medstat Professional (MED) 

 

			
	 01.    W1X43921-X-MSTAT-PROF-CLMS.
	 	S4392
	 05     W1X43921-C-TCN-NUM
	 	 
	 PIC S9(00017).
	 	F1024
	 05     W1X43921-C-REPLCMT-TCN-NUM
	 	 
	 PIC S9(00017).
	 	F0702
	 05     W1X43921-C-LI-NUM
	 	 
	 PIC S9(00003).
	 	F1073
	 05     W1X43921-A-TY-CD
	 	 
	 PIC X(00002).
	 	F0150
	 05     W1X43921-C-HDR-STAT-CD
	 	 
	 PIC X(00001).
	 	F1020
	 05     W1X43921-C-REIMB-STAT-CD
	 	 
	 PIC X(00001).
	 	F0162
	 05     W1X43921-C-HDR-TXN-TY-CD
	 	 
	 PIC X(00001).
	 	F1030
	 05     W1X43921-C-HDR-TY-CD
	 	 
	 PIC X(00001).
	 	F1031
	 05     W1X43921-C-HDR-PD-DT
	 	 
	 PIC X(00010).
	 	F1017
	 05     W1X43921-C-HDR-WARR-AMT
	 	 
	 PIC S9(00013)V9(00002).
	 	F1038
	 05     W1X43921-C-TOT-REIMB-AMT
	 	 
	 PIC S9(00011)V9(00002).
	 	F1028
	 05     W1X43921-C-LINE-TPL-AMT
	 	 
	 PIC S9(00011)V9(00002).
	 	F1029
	 05     W1X43921-C-COPAY-EXEMPT-CD
	 	 
	 PIC X(00001).
	 	F4468
	 05     W1X43921-C-LINE-COPAY-AMT
	 	 
	 PIC S9(00007)V9(00002).
	 	F5439
	 05     W1X43921-C-LINE-SPDWN-AMT
	 	 
	 PIC S9(00007)V9(00002).
	 	F7166

  

 Page 272 of 326 









			
	 05     W1X43921-C-LI-ALLW-CHRG-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1071
	 05     W1X43921-C-LI-SUBM-CHRG-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1091
	 05     W1X43921-C-LI-REIMB-UNT-NUM
	  	 
	 PIC S9(00007)V9(00002).
	  	F1088
	 05     W1X43921-C-LI-FST-DOS-DT
	  	 
	 PIC X(00010).
	  	F1080
	 05     W1X43921-C-LI-LAST-DOS-DT
	  	 
	 PIC X(00010).
	  	F1083
	 05     W1X43921-C-COS-CD
	  	 
	 PIC X(00003).
	  	F0175
	 05     W1X43921-R-DIAG-CD
	  	F1756
	 OCCURS 0004 TIMES
	  	 
	 INDEXED BY W1X43921-R-DIAG-CD-X
	  	 
	 PIC X(00010).
	  	 
	 05     W1X43 921-R-PROC-CD
	  	 
	 PIC X(00007).
	  	F2042
	 05     W1X43921-C-PROC-MOD-1ST-CD
	  	 
	 PIC X(00002).
	  	F0489
	 05     W1X43921-C-PROC-MOD-2ND-CD
	  	 
	 PIC X(00002).
	  	F0490
	 05     W1X43921-C-PROC-MOD-3RD-CD
	  	 
	 PIC X(00002).
	  	F6083
	 05     W1X43921-C-PROC-MOD-4TH-CD
	  	 
	 PIC X(00002).
	  	F9773
	 05     W1X43921-C-LI-REF-PROV-ID
	  	 
	 PIC X(00012).
	  	F8294
	 05     W1X43921-C-REFERRAL-ID
	  	 
	 PIC X(00012).
	  	F7033
	 05     W1X43921-B-LCKN-TY-CD
	  	 
	 PIC X(00004).
	  	F0036
	 05     W1X43921-C-RNDR-PROV-ID
	  	 
	 PIC X(00012).
	  	F1089
	 05     W1X43921-P-TY-CD
	  	 
	 PIC X(00003).
	  	F0204
	 05     W1X43921-P-SPECL-CD
	  	 
	 PIC X(00003).
	  	F2653
	 05     W1X43921-G-CNTY-CD
	  	 
	 PIC X(00003).
	  	F2639
	 05     W1X43921-G-ZIP5-CD
	  	 
	 PIC X(00005).
	  	F1511
	 05     W1X43921-G-ZIP4-CD
	  	 
	 PIC X(00004).
	  	F1510
	 05     W1X43921-R-PL-OF-SVC-CD
	  	 
	 PIC X(00002).
	  	F2017
	 05     W1X43921-C-LI-FAM-PLNG-IND
	  	 
	 PIC X(00001) .
	  	F1078
	 05     W1X43921-B-MHN-ALT-ID
	  	 
	 PIC X(00013) .
	  	F2542
	 05     W1X43921-B-ALT-ID
	  	 
	 PIC X(00013).
	  	F0535

  

 Page 273 of 326 









			
	 05     W1X43921-B-DOB-DT
	  	 
	 PIC X(00010).
	  	F0601
	 05     W1X43921-B-GENDER-CD
	  	 
	 PIC X(00001).
	  	F0229
	 05     W1X43921-B-LAST-NAM
	  	 
	 PIC X(00021).
	  	F0639
	 05     W1X43921-B-FST-NAM
	  	 
	 PIC X(00015).
	  	F0637
	 05     W1X43921-B-RES-CNTY-CD
	  	 
	 PIC X(00003).
	  	F1394
	 05     W1X43921-C-HDR-CLNT-AGE
	  	 
	 PIC S9(00004).
	  	F0971
	 05     W1X43921-B-RACE-CD
	  	 
	 PIC X(00001).
	  	F0230
	 05     W1X43921-B-COE-CD
	  	 
	 PIC X(00003).
	  	F2678
	 05     W1X43921-C-MCARE-PD-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1110
	 05     W1X43921-C-LI-MCARE-PD-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1085
	 05     W1X43921-C-MCARE-COINS-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1013
	 05     W1X43921-C-LI-MCARE-COI-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1107
	 05     W1X43921-C-MCARE-DED-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1108
	 05     W1X43921-C-LI-MCARE-DED-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1084
	 05     W1X43921-C-REMARK-CD
	  	F5651
	 OCCURS 0010 TIMES
	  	 
	 INDEXED BY W1X43921-C-REMARK-CD-X
	  	 
	 PIC X(00005).
	  	 
	 05     W1X43921-C-REPLCD-TCN-NUM
	  	 
	 PIC S9(00017).
	  	F0701
	 05     W1X43921-R-CLM-EXC-CD
	  	F1737
	 OCCURS 0010 TIMES
	  	 
	 INDEXED BY W1X43921-R-CLM-EXC-CD-X
	  	 
	 PIC X(00004).
	  	 
	 05     W1X43921-C-HDR-COPAY-AMT
	  	 
	 PIC S9(00007)V9(00002).
	  	F5439
	 05     W1X43921-C-HDR-SPDWN-AMT
	  	 
	 PIC S9(00007)V9(00002).
	  	F7166
	 05     W1X43921-C-HDR-TPL-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1029
	 O5    W1X43921-C-LI-REIMB-AMT
	  	 
	 PIC S9(00011)V9(00002).
	  	F1028

  

 Page 274 of 326 








 Attachment L.5.6 
  
 ACS Provider File 
  

			
	 01     PRV00262IN.
	  	 
	 05     PROVID
	  	 
	 PIC X(12).
	  	 
	 05     PROVNAME
	  	 
	 PIC X(50).
	  	 
	 05     P-LOC-ADDR-G-LINE1-AD
	  	 
	 PIC X(50).
	  	 
	 05     P-LOC-ADDR-G-LINE2-AD
	  	 
	 PIC X(50).
	  	 
	 05     P-LOC-ADDR-G-CITY-NAM
	  	 
	 PIC X(20).
	  	 
	 05     P-LOC-ADDR-G-ST-CD
	  	 
	 PIC X(2).
	  	 
	 05     PROVZIP
	  	 
	 PIC X(5).
	  	 
	 05     P-LOC-ADDR-G-ZIP4-CD
	  	 
	 PIC X(4).
	  	 
	 05     P-LOC-ADDR-G-CNTY-CD
	  	 
	 PIC X(3).
	  	 
	 05     P-LOC-ADDR-G-PHON-NUM
	  	 
	 PIC X(10).
	  	 
	 05     P-SSN-NUM
	  	 
	 PIC X(9).
	  	 
	 05     P-COHORT-l-Gender-1
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-1-LO-AGE-l
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-1-HI-AGE-l
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-l-Gender-2
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-1-LO-AGE-2
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-1-HI-AGE-2
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-l-Gender-3
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-1-LO-AGE-3
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-1-HI-AGE-3
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-2-Gender-l
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-2-LO-AGE-l
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-2-HI-AGE-l
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-2-Gender-2
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-2-LO-AGE-2
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-2-HI-AGE-2
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-2-Gender-3
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-2-LO-AGE-3
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-2-HI-AGE-3
	  	 
	 PIC X(4).
	  	 

  

 Page 275 of 326 









			
	 05     P-COHORT-3-Gender-1
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-3-LO-AGE-1
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-3-HI-AGE-1
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-3-Gender-2
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-3-LO-AGE-2
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-3-HI-AGE-2
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-3-Gender-3
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-3-LO-AGE-3
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-3-HI-AGE-3
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-4-Gender-1
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-4-LO-AGE-1
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-4-HI-AGE-1
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-4-Gender-2
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-4-LO-AGE-2
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-4-HI-AGE-2
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-4-Gender-3
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-4-LO-AGE-3
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-4-HI-AGE-3
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-5-Gender-1
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-5-LO-AGE-1
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-5-HI-AGE-1
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-5-Gender-2
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-5-LO-AGE-2
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-5-HI-AGE-2
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-5-Gender-3
	  	 
	 PIC X(1).
	  	 
	 05     P-COHORT-5-LO-AGE-3
	  	 
	 PIC X(4).
	  	 
	 05     P-COHORT-5-HI-AGE-3
	  	 
	 PIC X(4).
	  	 
	 05     P-DEA-NUM
	  	 
	 PIC X(11).
	  	 
	 05     P-FED-TAX-ID
	  	 
	 PIC X(9).
	  	 
	 05     P-FED-TAXID-BEG-DT
	  	 
	 PIC X(10).
	  	 
	 05     P-FED-TAXID-END-DT
	  	 
	 PIC X(10).
	  	 
	 05     P-LIC-NUM
	  	 
	 PIC X(10).
	  	 
	 05     P-LOCN-CD
	  	 
	 PIC X(1).
	  	 

  

 Page 276 of 326 









	
	 05     P-NCPDP-NUM

	 PIC X(9).

	 05     P-NPI-NUM

	 PIC X(12).

	 05     P-TY-CD

	 PIC X(3).

	 05     P-INDIV-GRP-CD

	 PIC X(1).

	 05     P-AFFIL-GROUP-P-ID-1

	 PIC X(12).

	 05     P-AFFIL-PCP-IND-1

	 PIC X(1).

	 05     P-AFFIL-GROUP-P-ID-2

	 PIC X(12).

	 05     P-AFFIL-PCP-IND-2

	 PIC X(1).

	 05     P-AFFIL-GROUP-P-ID-3

	 PIC X(12).

	 05     P-AFFIL-PCP-IND-3

	 PIC X(1).

	 05     P-AFFIL-GROUP-P-ID-4

	 PIC X(12).

	 05     P-AFFIL-PCP-IND-4

	 PIC X(1).

	 05     P-AFFIL-GROUP-P-ID-5

	 PIC X(12).

	 05     P-AFFIL-PCP-IND-5

	 PIC X(1).

	 05     P-COS-Cd-1

	 PIC X(3).

	 05     P-COS-STAT-CD-1

	 PIC X(2).

	 05     P-COS-STAT-EFF-DT-1

	 PIC X(10).

	 05     P-COS-STAT-END-DT-1

	 PIC X(10).

	 05     P-COS-Cd-2

	 PIC X(3).

	 05     P-COS-STAT-CD-2

	 PIC X(2).

	 05     P-COS-STAT-EFF-DT-2

	 PIC X(10).

	 05     P-COS-STAT-END-DT-2

	 PIC X(10).

	 05     P-COS-Cd-3

	 PIC X(3).

	 05     P-COS-STAT-CD-3

	 PIC X(2).

	 05     P-COS-STAT-EFF-DT-3

	 PIC X(10).

	 05     P-COS-STAT-END-DT-3

	 PIC X(10).

	 05     P-COS-Cd-4

	 PIC X(3).

	 05     P-COS-STAT-CD-4

	 PIC X(2).

	 05     P-COS-STAT-EFF-DT-4

	 PIC X(10).

	 05     P-COS-STAT-END-DT-4

	 PIC X(10).

	 05     P-COS-Cd-5

	 PIC X(3).

	 05     P-COS-STAT-CD-5

	 PIC X(2).

	 05     P-COS-STAT-EFF-DT-5

	 PIC X(10).


  

 Page 277 of 326 









	
	 05     P-COS-STAT-END-DT-5

	 PIC X(10).

	 05     P-CURR-MBR-NUM

	 PIC X(7).

	 05     P-NTRPRS-ID

	 PIC X(9).

	 05     P-ID-GROUP-ID

	 PIC X(12).

	 05     FILLER

	 PIC X(10).

	 05     P-PAYEE-ADR-G-LINE1

	 PIC X(50).

	 05     P-PAYEE-ADR-G-LINE2

	 PIC X(50).

	 05     P-PAYEE-ADR-G-CITY

	 PIC X(20).

	 05     P-PAYEE-ADR-G-ST-CD

	 PIC X(2).

	 05     P-PAYEE-ADR-G-ZIP5-CD

	 PIC X(5).

	 05     P-PAYEE-ADR-G-ZIP4-CD

	 PIC X(4).

	 05     P-MAIL-ADR-G-LINE1-AD

	 PIC X(50).

	 05     P-MAIL-ADR-G-LINE2-AD

	 PIC X(50).

	 05     P-MAIL-ADR-G-CITY-NAM

	 PIC X(20).

	 05     P-MAIL-ADR-G-ST-CD

	 PIC X(2).

	 05     P-MAIL-ADR-G-ZIP5-CD

	 PIC X(5).

	 05     P-MAIL-ADR-G-ZIP4-CD

	 PIC X(4).


  

 Page 278 of 326 








 Attachment L.5.7 
  

			
	MEMBER:	  	W1B44071
	NAME:	  	B-STD-MBR-EXT2

  
 This is the unpacked copybook layout
of the standardized member extract. 
  

			
	 01     W1B44071-B-STD-MBR-EXT2.
	  	 
	 05     W1B44071-B-STD-MBR-MISC2.
	  	S2479
	 10     W1B44071-B-SYS-ID
	  	 
	 PIC 9(9).
	  	F0694
	 10     W1B44071-B-SSN-NUM
	  	 
	 PIC X(9).
	  	F0686
	 10     W1B44071-B-CAL-DOB-DT
	  	 
	 PIC X(8).
	  	F0302
	 10     W1B44071-B-MCARE-ID
	  	 
	 PIC X(12).
	  	F0623
	 10     W1B44071-B-MHN-ALT-ID
	  	 
	 PIC X(13).
	  	F2542
	 10     W1B44071-B-LAST-NAM
	  	 
	 PIC X(21).
	  	F0639
	 10     W1B44071-B-FST-NAM
	  	 
	 PIC X(15).
	  	F0637
	 10     W1B44071-B-MI-NAM
	  	 
	 PIC X(1).
	  	F0640
	 10     W1B44071-B-SFX-NAM
	  	 
	 PIC X(3).
	  	F3599
	 10     W1B44071-B-GENDER-CD
	  	 
	 PIC X(1).
	  	F0229
	 10     W1B44071-B-CAL-DOD-DT
	  	 
	 PIC X(8).
	  	F2903
	 10     W1B44071-B-RACE-CD
	  	 
	 PIC X(1).
	  	F0230
	 10     W1B44071-B-ETH-CD
	  	 
	 PIC X(1).
	  	F8717
	 10     W1B44071-B-RES-CNTY-CD
	  	 
	 PIC X(3).
	  	F1394
	 10     W1B44071-B-LIV-ARRANGE-CD
	  	 
	 PIC X(2).
	  	F8539

  

 Page 279 of 326 









			
	 10     W1B44071-B-CONFID-CD
	  	 
	 PIC X(1).
	  	F5609
	 10     W1B44071-B-MRTL-STAT-CD
	  	 
	 PIC X(1).
	  	F2715
	 10     W1B44071-B-RPT-APPL-DT
	  	 
	 PIC X(8).
	  	F8986
	 10     W1B44071-B-AP-LAST-NAM
	  	 
	 PIC X(21).
	  	F9579
	 10     W1B44071-B-AP-FST-NAM
	  	 
	 PIC X(15).
	  	F7281
	 10     W1B44071-B-AP-MI-NAM
	  	 
	 PIC X(1).
	  	F9641
	 10     W1B44071-B-AP-SFX-NAM
	  	 
	 PIC X(3).
	  	F7750
	 10     W1B44071-B-AP-SSN-NUM
	  	 
	 PIC X(9).
	  	F4099
	 10     W1B44071-B-AP-RPT-DOB-DT
	  	 
	 PIC X(8).
	  	F8643
	 10     W1B44071-B-AP-GENDER-CD
	  	 
	 PIC X(1).
	  	F9217
	 10     W1B44071-B-AP-EMPLR-NAM
	  	 
	 PIC X(40).
	  	F7691
	 10     W1B44071-B-CUSTD-LAST-NAM
	  	 
	 PIC X(21).
	  	F6138
	 10     Wl B44071-B-CUSTD-FST-NAM
	  	 
	 PIC X(15).
	  	F5079
	 10     W1B44071-B-CUSTD-MI-NAM
	  	 
	 PIC X(1).
	  	F4731
	 10     W1B44071-B-CUSTD-SFX-NAM
	  	 
	 PIC X(3).
	  	F9121
	 10     W1B44071-B-CUSTD-SSN-NUM
	  	 
	 PIC X(9).
	  	F7346

  

 Page 280 of 326 









					
	 	  	 10     W1B44071-B-AP-CRT-ORD-IND
	  	 
	 	  	 PIC X(1).
	  	F5692
	 	  	 10     W1B44071-B-RPT-PREG-DUE-DT
	  	 
	 	  	 PIC X(8).
	  	F9596
	 	  	 10     W1B44071-B-RPT-PREG-TRM-DT
	  	 
	 	  	 PIC X(8).
	  	F7032
	 	  	 10     W1B44071-G-EMAIL-AD
	  	 
	 	  	 PIC X(50).
	  	F4329
	 	  	 05     W1B44071-B-STD-MBR-CASE2.
	  	S3132
	 	  	 10     W1B44071-B-CASE-NUM
	  	 
	 	  	 PIC X(12).
	  	F0586
	 	  	 10     W1B44071-B-MAJ-PROG-CD
	  	 
	 	  	 PIC X(1).
	  	F4429
	 	  	 10     W1B44071-B-CASE-HH-SYS-ID
	  	 
	 	  	 PIC 9(9).
	  	F9515
	 	  	 10     W1B44071-B-CASE-HH-SSN-NUM
	  	 
	 	  	 PIC X(9).
	  	F1134
	 	  	 10     W1B44071-B-CASE-HH-LAST-NAM
	  	 
	 	  	 PIC X(21).
	  	F8118
	 	  	 10     W1B44071-B-CASE-HH-FST-NAM
	  	 
	 	  	 PIC X(15).
	  	F7420
	 	  	 10     W1B44071-B-CASE-HH-MI-NAM
	  	 
	 	  	 PIC X(1).
	  	F3388
	 	  	 10     W1B44071-B-CASE-HH-SFX-NAM
	  	 
	 	  	 PIC X(3).
	  	F2700
	 	  	 10     W1B44071-B-CASE-ADLT-SZ-NUM
	  	 
	 	  	 PIC 9(2).
	  	F7791
	 	  	 10     W1B44071-B-CASE-CHLD-SZ-NUM
	  	 
	 	  	 PIC 9(2).
	  	F7413
	 	  	 10     W1B44071-B-CASE-TOT-GRS-AMT
	  	 
	 	  	 PIC 9(7)v9(2).
	  	F8509
	 	  	 10     W1B44071-B-CASE-TOT-NET-AMT
	  	 
	 	  	 PIC 9(7)v9(2).
	  	F5189
	 	  	 10     W1B44071-B-CASE-GRS-ERN-AMT
	  	 
	 	  	 PIC 9(7)v9(2).
	  	F7056

  

 Page 281 of 326 









					
	 	 	 10     W1B44071-B-CASE-NET-ERN-AMT
	  	 
	 	 	 PIC 9(7)v9(2).
	  	F7499
	 	 	 10     W1B44071-B-CASE-GRS-UEA-AMT
	  	 
	 	 	 PIC 9(7)v9(2).
	  	F4983
	 	 	 10     W1B44071-B-CASE-NET-UEA-AMT
	  	 
	 	 	 PIC 9(7)v9(2).
	  	F5781
	 	 	 10     W1B44071-B-CASE-TOT-RES-AMT
	  	 
	 	 	 PIC 9(7)v9(2).
	  	F9666
	 	 	 10     W1B44071-B-REP-LAST-NAM
	  	 
	 	 	 PIC X(21).
	  	F9311
	 	 	 10     W1B44071-B-REP-FST-NAM
	  	 
	 	 	 PIC X(15).
	  	F8349
	 	 	 10     W1B44071-B-REP-MI-NAM
	  	 
	 	 	 PIC X(1).
	  	F7356
	 	 	 10     W1B44071-B-REP-SFX-NAM
	  	 
	 	 	 PIC X(3).
	  	F9867
	 	 	 10     W1B44071-B-REP-TYPE-CD
	  	 
	 	 	 PIC X(2).
	  	F7430
	 	 	 10     W1B44071-G-PHON-NUM
	  	 
	 	 	 PIC X(10).
	  	F1610
	 	 	 10     W1B44071-G-PHON-EXT-NUM
	  	 
	 	 	 PIC X(5).
	  	F7175
	 	 	 05     W1B44072-B-STD-MBR-RES-ADR.
	  	S4962
	 	 	 10     W1B44072-G-LINE1-AD
	  	 
	 	 	 PIC X(50).
	  	F1507
	 	 	 10     W1B44072-G-LINE2-AD
	  	 
	 	 	 PIC X(50).
	  	F1508
	 	 	 10     W1B44072-G-CITY-NAM
	  	 
	 	 	 PIC X(20).
	  	F1506
	 	 	 10     W1B44072-G-ST-CD
	  	 
	 	 	 PIC X(2).
	  	F2638
	 	 	 10     W1B44072-G-ZIP5-CD
	  	 
	 	 	 PIC X(5).
	  	F1511
	 	 	 10     W1B44072-G-ZIP4-CD
	  	 
	 	 	 PIC X(4).
	  	F1510
	 	 	 10     W1B44072-B-RES-CNTY-CD
	  	 
	 	 	 PIC X(3).
	  	F1394
	 	 	 05     W1B44073-B-STD-MBR-MLG-ADR.
	  	S6382
	 	 	 10     W1B44073-G-LINE1-AD
	  	 
	 	 	 PIC X(50).
	  	F1507
	 	 	 10     W1B44073-G-LINE2-AD
	  	 
	 	 	 PIC X(50).
	  	F1508

  

 Page 282 of 326 









					
	 	 	 10     W1B44073-G-CITY-NAM
	  	 
	 	 	 PIC X(20).
	  	F1506
	 	 	 10     W1B44073-G-ST-CD
	  	 
	 	 	 PIC X(2).
	  	F2638
	 	 	 10     W1B44073-G-ZIP5-CD
	  	 
	 	 	 PIC X(5).
	  	F1511
	 	 	 10     W1B44073-G-ZIP4-CD
	  	 
	 	 	 PIC X(4).
	  	F1510
	 	 	 10     W1B44073-B-RES-CNTY-CD
	  	 
	 	 	 PIC X(3).
	  	F1394
	 	 	 05     W1B44074-B-STD-MBR-COE2
	  	 
	 	 	 OCCURS 36 TIMES
	  	 
	 	 	 INDEXED BY W1B44074-B-STD-MBR-COE2-X.
	  	S3372
	 	 	 10     W1B44074-B-MAJ-PROG-CD
	  	 
	 	 	 PIC X(1).
	  	F4429
	 	 	 10     W1B44074-B-COE-CD
	  	 
	 	 	 PIC X(3).
	  	F2678
	 	 	 10     W1B44074-B-RPT-ELIG-BEG-DAT
	  	 
	 	 	 PIC X(8).
	  	F9337
	 	 	 10     W1B44074-B-RPT-ELIG-END-DAT
	  	 
	 	 	 PIC X(8).
	  	F4784
	 	 	 10     W1B44074-B-ELIG-TERM-RSN-CD
	  	 
	 	 	 PIC X(3).
	  	F8848
	 	 	 10     W1B44074-B-ALT-ID
	  	 
	 	 	 PIC X(13).
	  	F0535
	 	 	 10     W1B44074-B-RES-CNTY-CD
	  	 
	 	 	 PIC X(3).
	  	F1394
	 	 	 10     W1B44074-B-CASE-NUM
	  	 
	 	 	 PIC X(12).
	  	F0586
	 	 	 10     W1B44074-B-REL-HEAD-HH-CD
	  	 
	 	 	 PIC X(2).
	  	F2676
	 	 	 10     W1B44074-B-EMA-IND
	  	 
	 	 	 PIC X(1).
	  	F4348
	 	 	 10     W1B44074-B-CRSPD-PROG-CD
	  	 
	 	 	 PIC X(1).
	  	F9412
	 	 	 10     W1B44074-B-RPT-FDAY-LIAB-DT
	  	 
	 	 	 PIC X(8).
	  	F7343
	 	 	 10     W1B44074-B-FST-DAY-LIAB-AMT
	  	 
	 	 	 PIC 9(7)v9(2).
	  	F4457
	 	 	 10     W1B44074-B-FST-DAY-LIAB-CD
	  	 
	 	 	 PIC X(1).
	  	F4469

  

 Page 283 of 326 









					
	 	 	 05     W1B44071-B-STD-MBR-RETRO
	  	 
	 	 	 OCCURS 6 TIMES
	  	 
	 	 	 INDEXED BY W1B44071-B-STD-MBR-RETRO-X.
	  	S9506
	 	 	 10     W1B44071-B-RETRO8-EFF-DT
	  	 
	 	 	 PIC X(8).
	  	F8899
	 	 	 10     W1B44071-B-RETRO8-BEG-DT
	  	 
	 	 	 PIC X(8).
	  	F5121
	 	 	 10     W1B44071-B-RETRO8-END-DT
	  	 
	 	 	 PIC X(8).
	  	F3478
	 	 	 05     W1B44071-B-STD-MBR-LCKN
	  	 
	 	 	 OCCURS 18 TIMES
	  	 
	 	 	 INDEXED BY W1B44071-B-STD-MBR-LCKN-X.
	  	S3707
	 	 	 10     W1B44071-B-LCKN-TY-CD
	  	 
	 	 	 PIC X(4).
	  	F0036
	 	 	 10     W1B44071-B-RPT-LCKN-BEG-DT
	  	 
	 	 	 PIC X(8).
	  	F9316
	 	 	 10     W1B44071-B-RPT-LCKN-END-DT
	  	 
	 	 	 PIC X(8).
	  	F4580
	 	 	 10     W1B44071-H-PLN-ID
	  	 
	 	 	 PIC X(4).
	  	F1402
	 	 	 10     W1B44071-P-ID
	  	 
	 	 	 PIC X(12).
	  	F1563
	 	 	 10     W1B44071-B-LCKN-ASGN-RSN-CD
	  	 
	 	 	 PIC X(4).
	  	F1440
	 	 	 10     W1B44071-B-LCKN-CHG-RSN-CD
	  	 
	 	 	 PIC X(3).
	  	F0207
	 	 	 05     W1B44072-B-STD-MBR-MCARE
	  	 
	 	 	 OCCURS 36 TIMES
	  	 
	 	 	 INDEXED BY W1B44072-B-STD-MBR-MCARE-X.
	  	S8826
	 	 	 10     W1B44072-B-MCARE-ID
	  	 
	 	 	 PIC X(12).
	  	F0623
	 	 	 10     W1B44072-B-MCARE-CD
	  	 
	 	 	 PIC X(1).
	  	F7924
	 	 	 10     W1B44072-B-RPT-MCARE-BEG-DT
	  	 
	 	 	 PIC X(8).
	  	F3642
	 	 	 10     W1B44072-B-RPT-MCARE-END-DT
	  	 
	 	 	 PIC X(8).
	  	F4019

  

 Page 284 of 326 









			
	 10     W1B44072-B-MCARE-HMO-C-NUM
	  	 
	 PIC X(5).
	  	F9534
	 10     W1B44072-B-MCARE-ELIG-CD
	  	 
	 PIC X(2).
	  	F8576
	 05     W1B44071-B-STD-MBR-LTC
	  	 
	 OCCURS 24 TIMES
	  	 
	 INDEXED BY W1B44071-B-STD-MBR-LTC-X.
	  	S4238
	 10     WlB44071-B-RPT-LTC-BEG-DT
	  	 
	 PIC X(8).
	  	F8706
	 10     WlB44071-B-RPT-LTC-END-DT
	  	 
	 PIC X(8).
	  	F4044
	 10     W1B44071-B-LVL-OF-CARE-CD
	  	 
	 PIC X(3).
	  	F5075
	 10     W1B44071-P-ID
	  	 
	 PIC X(12).
	  	F1563
	 10     W1B44071-B-NH-STAT-CD
	  	 
	 PIC X(1).
	  	F8018
	 05     W1B44071-B-STD-MBR-LTC-PAT-LI2
	  	 
	 OCCURS 24 TIMES
	  	 
	 INDEXED BY W1B44071-B-STD-MBR-LTC-PAT-LI2-X.
	  	S2852
	 10     W1B44071-B-RPT-LIAB-BEG-DT
	  	 
	 PIC X(8).
	  	F5127
	 10     W1B44071-B-PAT-LIAB-TY-CD
	  	 
	 PIC X(1).
	  	F5944
	 10     W1B44071-B-LTC-LIAB-AMT
	  	 
	 PIC 9(5)v9(2).
	  	F8951
	 10     W1B44071-B-RPT-LIAB-END-DT
	  	 
	 PIC X(8).
	  	F5649
	 05     W1B44071-B-STD-MBR-ALT-ID
	  	 
	 OCCURS 6 TIMES
	  	 
	 INDEXED BY W1B44071-B-STD-MBR-ALT-ID-X.
	  	S5423
	 10     W1B44071-B-ALT-ID
	  	 
	 PIC X(13).
	  	F0535
	 10     W1B44071-B-ALT-ID-TY-CD
	  	 
	 PIC X(3).
	  	F8995

  

 Page 285 of 326 









					
	05     W1B44071-G-AUD-ADD-DT	  	 
	PIC X(10).	  	F2628
	05     FILLER	  	 
	PIC X(14).	  	F0000

  

 Page 286 of 326 








 Attachment L.5.8 Attached document titled L.5.8 and L.5.9. 
  
 Attachment L.5.9 Attached document titled L.5.8 and L.5.9. 
  

 Page 287 of 326 








 Attachment L.5.10 
  
 Georgia Registry of Immunization Transactions and Services – 
 Flat File Specification Version 5.0 (Revised 09/30/2004) 
  
 Immunization data is passed to the central registry using three flat files containing client, immunization, and comment information (optional) respectively. The files will be linked via a 24-character Record
Identifier supplied by the provider of the file. This identifier will uniquely identify each client and will appear in each immunization and comment (optional) record to link the immunization and comment (optional) to the client. Character fields
need to be left justified and blank-filled, number fields right justified and blank-filled, and date fields in format MMDDYYYY with leading zeroes. If a site is unable to supply any information for a specified field, the entire field needs be filled
with blanks. 
  
 Below are the fields to include in each of the files. Files need
to be generated using the ASCII character set. Records will be fixed length and need to be terminated with a carriage return/line feed. 
  
 Client Data 
  

											
	 Column

	  	Data type

	 	Pos #

	  	Required

	  	Default

	  	 Notes


	 Record Identifier
	  	Char (24)	 	1	  	Y	  	 	  	Supplied by sender, used to link a Client to Immunization records.
	 Client Status
	  	Char (1)	 	25	  	 	  	A	  	Use the IR code set for Client Status.
	 First Name
	  	Char (25)	 	26	  	Y	  	 	  	If client does not have a first name, “NO FIRST NAME” must be entered in this field.
	 Middle Name
	  	Char (25)	 	51	  	 	  	 	  	 
	 Last Name
	  	Char (35)	 	76	  	Y	  	 	  	 
	 Name Suffix
	  	Char (10)	 	111	  	 	  	 	  	JR, III, etc.
	 Birth Date
	  	Date (8)	 	121	  	Y	  	 	  	MMDDYYYY
	 Death Date
	  	Date (8)	 	129	  	 	  	 	  	MMDDYYYY
	 Mothers First Name
	  	Char (25)	 	137	  	 	  	 	  	These are mandatory fields in IR. However, if the information is unavailable for historical records, fill these fields with blanks.
	 Mothers Maiden Last Name
	  	Char (35)	 	162	  	 	  	 	  

  

 Page 288 of 326 









											
	 Column

	 	 Data type

	  	 Pos #

	 	 Required

	 	 Default

	 	 Notes


	Sex (Gender)	 	Char (1)	  	197	 	 	 	 	 	Use the IR code set for Sex (Gender).
	Race	 	Char (1)	  	198	 	 	 	 	 	Use the IR code set for Race.
	Ethnicity	 	Char (2)	  	199	 	 	 	 	 	Use the IR code set for Ethnicity.
	SSN	 	Char (9)	  	201	 	 	 	 	 	 
	Contact Allowed	 	Char (2)	  	210	 	 	 	02	 	Controls whether notices are sent. Use the IR code set for Contact. If <null> default to 02 ‘Yes’.
	Consent to Share	 	Char (1)	  	212	 	 	 	<null>	 	Controls visibility of records to other organizations. Use Y, N, or <null> (unknown).
	Chart Number	 	Char (20)	  	213	 	 	 	 	 	Identifier within the sending organization’s system. Mandatory for organizations exchanging data for HEDIS reporting.
	Responsible Party First Name	 	Char (25)	  	233	 	 	 	 	 	 
	Responsible Party Middle Name	 	Char (25)	  	258	 	 	 	 	 	 
	Responsible Party Last Name	 	Char (35)	  	283	 	 	 	 	 	 
	Responsible Party Relationship	 	Char (2)	  	318	 	 	 	 	 	Use the IR code set for Relationship. If Responsible Party name is entered and Relationship = “” or null, relationship defaults to 21 - Unknown.
	Street Address	 	Char (55)	  	320	 	 	 	 	 	Residential address of responsible person. If the mailing address line is NOT populated, the street address will appear on mailing labels, client reports and online display
screens.
	Mailing Address Line	 	Char (55)	  	375	 	 	 	 	 	Mailing address of responsible person. Use if mailing address is different from street address. If the mailing address is populated, it is the address that will appear on mailing labels, client
reports and online display screens.
	Other Address Line	 	Char (55)	  	430	 	 	 	 	 	 
	City	 	Char (52)	  	485	 	 	 	 	 	 
	State	 	Char (2)	  	537	 	 	 	 	 	 
	Zip	 	Char (9)	  	539	 	 	 	 	 	If +4 zip is used, the first 5 characters and second 4 characters are concatenated into a single value, without separators.
	County	 	Char (5)	  	548	 	 	 	 	 	Use the IR code set for County.

  

 Page 289 of 326 









											
	 Column

	 	 Data type

	  	 Pos #

	 	 Required

	 	 Default

	 	 Notes


	Phone	 	Char (17)	  	553	 	 	 	 	 	Format as digits only starting with the area code, ex. 4041234567.
	Sending Organization	 	Char (5)	  	570	 	 	 	 	 	 This is ID of the provider organization that owns this client and corresponding immunization records. Contact the Help Desk for the
appropriate organization ID.
 * This field is optional if an organization is sending all of its own records. This field is required if an organization
other than the organization that owns the record(s) is transmitting this file.

	Eligibility Code	 	Char (3)	  	575	 	*either on client or imm record for new imms.	 	V00 – on new clients with historical imms.	 	Indicates the eligibility of the client. If a valid eligibility code is not received on the client or on the immunization record for a new immunization, the immunization will be rejected.
Use the IR code set for Eligibility.
	Eligibility Effective date	 	Date (8)	  	578	 	 	 	 	 	MMDDYYYY This is the effective date of the client’s eligibility code. For existing clients, the effective date on the incoming client record is compared to the effective date on the
database. If the eligibility date on the incoming record is more recent, the client eligibility is updated with the incoming eligibility code and effective date. The client eligibility may be different from the immunization eligibility
code.

  

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 Immunization Data 
  

											
	 Column

	 	 Data type

	  	 Pos #

	 	 Required

	 	 Default

	 	 Notes


	Client Record Identifier	 	Char (24)	  	1	 	Y	 	 	 	Supplied by sender, used to link Immunizations to a Clients record.
	Vaccine Group	 	Char (16)	  	25	 	*	 	 	 	 Use the IR code set for Vaccine Codes.
 *Either Vaccine Group or CPT Code or Trade Name is required.
 Order of preference: Trade Name, CPT, Vaccine Group

	CPT Code	 	Char (5)	  	41	 	*	 	 	 
	Trade Name	 	Char (24)	  	46	 	*	 	 	 
	Vaccination Date	 	Date (8)	  	70	 	Y	 	 	 	MMDDYYYY
	Administration Route Code	 	Char (2)	  	78	 	 	 	 	 	Use the IR code set for Administration Route.
	Body Site Code	 	Char (4)	  	80	 	 	 	 	 	Use the IR code set for Body Site.
	Reaction Code	 	Char (8)	  	84	 	 	 	 	 	Use the IR code set for Reaction.
	Manufacturer Code	 	Char (4)	  	92	 	 	 	 	 	Use the IR code set for Manufacturers.
	Immunization Information Source	 	Char (2)	  	96	 	*	 	01	 	Indicates whether this immunization was administered by your organization (from inventory entered in GRITS) or the immunization information is historical from client record. Use the IR code set
for Immunization Information Source. Note: For organizations set up to decrement new immunizations from GRITS inventory via data exchange, this field is mandatory.
	Lot Number	 	Char (30)	  	98	 	 	 	 	 	Immunizations stored in GRITS as historical records will not correspond to GRITS inventory; however, the Lot Number will be stored as historical information. Note: For organizations set up to
decrement new immunizations from GRITS inventory via data exchange, this field is mandatory.
	Provider Name	 	Char (50)	  	128	 	 	 	 	 	The historical provider name.
	Administered By Name	 	Char (50)	  	178	 	 	 	 	 	The name of the person who administered the vaccination.
	Site Name	 	Char (30)	  	228	 	 	 	 	 	The Site Name or Site ID of the clinic site where the vaccination occurred. Note: For organizations set up to decrement new immunizations from GRITS inventory via data exchange, this field is
mandatory if the organization has multiple sites to ensure inventory is deducted from the appropriate site.
	Sending Organization	 	Char (5)	  	258	 	 	 	 	 	This is ID of the provider organization that owns this client and

  

 Page 291 of 326 









											
	 Column

	 	Data type

	 	Pos #

	 	Required

	 	Default

	 	 Notes


	 	 	 	 	 	 	 	 	 	 	 corresponding immunization records. Contact the Help Desk for the appropriate organization ID.
 * This field is optional if an organization is sending all of its own records. This field is required if an organization other than the organization that owns the
record(s) is transmitting this file.

	 Eligibility Code
	 	Char (3)	 	263	 	*either on
client or
imm record
for new
imms.	 	V00 on
historic.	 	Indicates the eligibility of the client at the time the vaccine was administered. If a valid eligibility is not received on the client or on the immunization record for a new immunization,
the immunization will be rejected. Use the IR code set for Eligibility.

  

 Page 292 of 326 








 Comment Code (Optional File - But Recommended) 
  

											
	 Column

	 	Data type

	 	Pos #

	 	Required

	 	Default

	 	 Notes


	 Client Record Identifier
	 	Char (24)	 	1	 	Y	 	 	 	Supplied by sender, used to link Comments to a Clients record. This field is required if a comment code is being sent.
	 Comment Code
	 	Char (2)	 	25	 	Y	 	 	 	Use the IR code set for Comments.
	 Applies to Date
	 	Date (8)	 	27	 	Y	 	 	 	The date to which the comment applies. MMDDYYYY
	 Observation Method
	 	Char (4)	 	35	 	 	 	 	 	For Varicella use only – Use IR code set for OBMETHOD

  
 Example 
  
 Records need to be blank filled. In the following example, blanks are represented
with the ‘*’ character for illustrative purposes. 
  
 Client Record

  
 *****************12345ALAUREN*****************RAE*******************MAERZ*************************** 
 ********08141985********GAIL*********************CARPENTER******************FWNH*******02Y************** 
 ***33THOMAS*****************RAPHAEL****************MAERZ**************************33125*WEST*STRE 
 ET*********************************************************************************** 
 ****************FULTON**************************GA535291234GA121*******4049876543*** 
 *V0110091985 
  
 Immunization Record 
  
 *******************12345DTAP***************TETRAMUNE************10091985**************00******************** 
 ***************************************************************************************************** 
 *****************************V01 
  
 Comment
Code Record 
  
 *********************123453310091985SERO

  

 Page 293 of 326 









					
	 Table Item

	  	Code

	  	 Description


	Administration Route	  	ID	  	Intradermal
	 	  	IM	  	Intramuscular
	 	  	IN	  	Intranasal
	 	  	IV	  	Intravenous
	 	  	PO	  	Oral
	 	  	SC	  	Subcutaneous
	 	  	TD	  	Transdermal
			
	Body Site	  	LA	  	Left Ann
	 	  	LG	  	Left Gluteous Medius
	 	  	LT	  	Left Thigh
	 	  	LD	  	Left Deltoid
	 	  	LVL	  	Left Vastus Lateralis
	 	  	LLFA	  	Left Lower Forearm
	 	  	RA	  	Right Arm
	 	  	RG	  	Right Gluteous Medius
	 	  	RT	  	Right Thigh
	 	  	RD	  	Right Deltoid
	 	  	RVL	  	Right Vastus Lateralis
	 	  	RLFA	  	Right Lower Forearm
			
	Client Status	  	A	  	Active
	 	  	N	  	Inactive
	 	  	P	  	Permanently Inactive – Deceased Clients
			
	Comments	  	03	  	Allergy to baker’s yeast (anaphylactic)
	 	  	04	  	Allergy to egg ingestion (anaphylactic)
	 	  	05	  	Allergy to gelatin (anaphylactic)
	 	  	06	  	Allergy to neomycin (anaphylactic) MMR & IPV
	 	  	07	  	Allergy to Streptomycin (anaphylactic)
	 	  	08	  	Allergy to Thimerosal (anaphylactic)
	 	  	15	  	Encephalopathy within 7 days of previous dose of DTP

  

 Page 294 of 326 









					
	 Table Item

	  	Code

	  	 Description


	 	  	18	  	Guillain-Barre Syndrome (GBS) within 6 weeks after DTP/DTaP
	 	  	21	  	Current acute illness, moderate to severe (with or without fever)(e.g. diarrhea, otitis media, vomiting)
	 	  	22	  	Chronic illness (e.g., chronic gastrointestinal disease)
	 	  	23	  	Immune globulin(IG) administration, recent or simultaneous
	 	  	26	  	Serologic immunity: hepatitis B
	 	  	27	  	Serologic immunity: measles
	 	  	28	  	Serologic immunity: mumps
	 	  	31	  	Serologic immunity: rubella
	 	  	33	  	Immunity: Varicella (chicken pox)
	 	  	34	  	Immunodeficiency (family history)
	 	  	35	  	Immunodeficiency (household contact)
	 	  	36	  	Immunodeficiency (in recipient) OPV & MMR & VZV
	 	  	37	  	Neurologic disorders, underlying (seizure disorder)
	 	  	39	  	Pregnancy (in recipient)
	 	  	40	  	Thrombocytopenia
	 	  	41	  	Thrombocytopenia purpura (history)
			
	 Contact
	  	01	  	No contact allowed – Notices are not to be sent.
	 	  	02	  	Contact Allowed – Notices will be sent.
			
	 County
	  	GA001	  	APPLING
	 	  	GA003	  	ATKINSON
	 	  	GA005	  	BACON
	 	  	GA007	  	BAKER
	 	  	GA009	  	BALDWIN
	 	  	GA011	  	BANKS
	 	  	GA013	  	BARROW
	 	  	GA015	  	BARTOW
	 	  	GA017	  	BEN HILL
	 	  	GA019	  	BERRIEN
	 	  	GA021	  	BIBB
	 	  	GA023	  	BLECKLEY
	 	  	GA025	  	BRANTLEY

  

 Page 295 of 326 









					
	 Table Item

	  	Code

	  	 Description


	 	  	GA027	  	BROOKS
	 	  	GA029	  	BRYAN
	 	  	GA031	  	BULLOCH
	 	  	GA033	  	BURKE
	 	  	GA035	  	BUTTS
	 	  	GA037	  	CALHOUN
	 	  	GA039	  	CAMDEN
	 	  	GA043	  	CANDLER
	 	  	GA045	  	CARROLL
	 	  	GA047	  	CATOOSA
	 	  	GA049	  	CHARLTON
	 	  	GA051	  	CHATHAM
	 	  	GA053	  	CHATTAHOOCHEE
	 	  	GA055	  	CHATTOOGA
	 	  	GA057	  	CHEROKEE
	 	  	GA059	  	CLARKE
	 	  	GA061	  	CLAY
	 	  	GA063	  	CLAYTON
	 	  	GA065	  	CLINCH
	 	  	GA067	  	COBB
	 	  	GA069	  	COFFEE
	 	  	GA071	  	COLQUITT
	 	  	GA073	  	COLUMBIA
	 	  	GA075	  	COOK
	 	  	GA077	  	COWETA
	 	  	GA079	  	CRAWFORD
	 	  	GA081	  	CRISP
	 	  	GA083	  	DADE
	 	  	GA085	  	DAWSON
	 	  	GA087	  	DECATUR
	 	  	GA089	  	DEKALB
	 	  	GA091	  	DODGE
	 	  	GA093	  	DOOLY
	 	  	GA095	  	DOUGHERTY

  

 Page 296 of 326 









					
	 Table Item

	  	Code

	  	 Description


	 	  	GA097	  	DOUGLAS
	 	  	GA099	  	EARLY
	 	  	GA101	  	ECHOLS
	 	  	GA103	  	EFFINGHAM
	 	  	GA105	  	ELBERT
	 	  	GA107	  	EMANUEL
	 	  	GA109	  	EVANS
	 	  	GA111	  	FANNIN
	 	  	GA113	  	FAYETTE
	 	  	GA115	  	FLOYD
	 	  	GA117	  	FORSYTH
	 	  	GA119	  	FRANKLIN
	 	  	GA121	  	FULTON
	 	  	GA123	  	GILMER
	 	  	GA125	  	GLASCOCK
	 	  	GA127	  	GLYNN
	 	  	GA129	  	GORDON
	 	  	GA131	  	GRADY
	 	  	GA133	  	GREENE
	 	  	GA135	  	GWINNETT
	 	  	GA137	  	HABERSHAM
	 	  	GA139	  	HALL
	 	  	GA141	  	HANCOCK
	 	  	GA143	  	HARALSON
	 	  	GA145	  	HARRIS
	 	  	GA147	  	HART
	 	  	GA149	  	HEARD
	 	  	GA151	  	HENRY
	 	  	GA153	  	HOUSTON
	 	  	GA155	  	IRWIN
	 	  	GA157	  	JACKSON
	 	  	GA159	  	JASPER
	 	  	GA161	  	JEFF DAVIS
	 	  	GA163	  	JEFFERSON

  

 Page 297 of 326 









					
	 Table Item

	  	Code

	    	 Description


	 	  	GA165	    	JENKINS
	 	  	GA167	    	JOHNSON
	 	  	GA169	    	JONES
	 	  	GA171	    	LAMAR
	 	  	GA173	    	LANIER
	 	  	GA175	    	LAURENS
	 	  	GA177	    	LEE
	 	  	GA179	    	LIBERTY
	 	  	GA181	    	LINCOLN
	 	  	GA183	    	LONG
	 	  	GA185	    	LOWNDES
	 	  	GA187	    	LUMPKIN
	 	  	GA189	    	MCDUFFIE
	 	  	GA191	    	MCINTOSH
	 	  	GA193	    	MACON
	 	  	GA195	    	MADISON
	 	  	GA197	    	MARION
	 	  	GA199	    	MERIWETHER
	 	  	GA201	    	MILLER
	 	  	GA205	    	MITCHELL
	 	  	GA207	    	MONROE
	 	  	GA209	    	MONTGOMERY
	 	  	GA211	    	MORGAN
	 	  	GA213	    	MURRAY
	 	  	GA215	    	MUSCOGEE
	 	  	GA217	    	NEWTON
	 	  	GA219	    	OCONEE
	 	  	GA221	    	OGLETHORPE
	 	  	GA223	    	PAULDING
	 	  	GA225	    	PEACH
	 	  	GA227	    	PICKENS
	 	  	GA229	    	PIERCE
	 	  	GA231	    	PIKE
	 	  	GA233	    	POLK

  

 Page 298 of 326 









					
	 Table Item

	  	Code

	    	 Description


	 	  	GA235	    	PULASKI
	 	  	GA237	    	PUTNAM
	 	  	GA239	    	QUITMAN
	 	  	GA241	    	RABUN
	 	  	GA243	    	RANDOLPH
	 	  	GA245	    	RICHMOND
	 	  	GA247	    	ROCKDALE
	 	  	GA249	    	SCHLEY
	 	  	GA251	    	SCREVEN
	 	  	GA253	    	SEMINOLE
	 	  	GA255	    	SPALDING
	 	  	GA257	    	STEPHENS
	 	  	GA259	    	STEWART
	 	  	GA261	    	SUMTER
	 	  	GA263	    	TALBOT
	 	  	GA265	    	TALIAFERRO
	 	  	GA267	    	TATTNALL
	 	  	GA269	    	TAYLOR
	 	  	GA271	    	TELFAIR
	 	  	GA273	    	TERRELL
	 	  	GA275	    	THOMAS
	 	  	GA277	    	TIFT
	 	  	GA279	    	TOOMBS
	 	  	GA281	    	TOWNS
	 	  	GA283	    	TREUTLEN
	 	  	GA285	    	TROUP
	 	  	GA287	    	TURNER
	 	  	GA289	    	TWIGGS
	 	  	GA291	    	UNION
	 	  	GA293	    	UPSON
	 	  	GA295	    	WALKER
	 	  	GA297	    	WALTON
	 	  	GA299	    	WARE
	 	  	GA301	    	WARREN

  

 Page 299 of 326 









					
	 Table Item

	  	Code

	    	 Description


	 	  	GA303	    	WASHINGTON
	 	  	GA305	    	WAYNE
	 	  	GA307	    	WEBSTER
	 	  	GA309	    	WHEELER
	 	  	GA311	    	WHITE
	 	  	GA313	    	WHITFIELD
	 	  	GA315	    	WILCOX
	 	  	GA317	    	WILKES
	 	  	GA319	    	WILKINSON
	 	  	GA321	    	WORTH
			
	 	  	V01	    	Insured – Vaccines Covered
			
	 Eligibility
	  	 	    	 
			
	 	  	V02	    	Medicaid
			
	 	  	V03	    	No Insurance
			
	 	  	V04	    	American Indian/Alaska Native
			
	 	  	V05	    	Insured – No Vaccine/Underinsured
			
	 	  	V06	    	PeachCare
			
	 	  	V00	    	Elig Not Determined/Unknown *allowed on historical immunizations only
			
	 Ethnicity
	  	NH	    	Non-Hispanic
	 	  	H	    	Hispanic
			
	 Immunization
 Information Source
	  	00	    	New shot, vaccine administered by providing organization. Organization becomes owner of the shot, so other organizations cannot edit/delete the shot. For organizations set up to decrement new
immunizations from GRITS inventory via data exchange, ‘00’ will cause inventory for the providing organization to be affected.
	 	  	01	    	Historical shot, recorded from client record. No affect on inventory.

  

 Page 300 of 326 









					
	 Table Item

	 	Code

	  	 Description


	Manufacturers	 	AB	  	Abbott Laboratories
	 	 	AD	  	Adams Laboratories
	 	 	ALP	  	Alpha Therapeutic Corporation
	 	 	AR	  	Armour (Inactive- use AVB)
	 	 	AVB	  	Aventis Behring L.L.C. (formerly Centeon L.L.C.; includes Armour Pharmaceutical Company)
	 	 	AVI	  	Aviron
	 	 	BA	  	Baxter Healthcare Corporation (Inactive- use BAH)
	 	 	BAH	  	Baxter Healthcare Corporation (includes Hyland Immuno, Immuno International AG, and North American Vaccine, Inc.)
	 	 	BAY	  	Bayer (Including Miles And Cutter)
	 	 	BP	  	Berna Products (Including Swiss Serum And Vib) (Inactive- use BPC)
	 	 	BPC	  	Berna Products Corporation (Including Swiss Serum And Vib)
	 	 	CEN	  	Centeon (Including Armour Pharm) (Inactive- use AVB)
	 	 	CHI	  	Chiron Corporation
	 	 	CMP	  	Celltech Medeva Pharmaceuticals (Inactive- use PWJ)
	 	 	CON	  	Connaught (Inactive- use PMC)
	 	 	EVN	  	Evans Medical Limited (Inactive-use PWJ)
	 	 	GRE	  	Greer Laboratories Inc.
	 	 	IAG	  	Immuno International Ag (Inactive- use BAH)
	 	 	IM	  	Merieux (Inactive-use PMC)
	 	 	IUS	  	Immuno-U.S., Inc.
	 	 	JPN	  	Osaka University (Biken)
	 	 	KGC	  	Korea Green Cross Corporation
	 	 	LED	  	Lederle (Inactive-use WAL)
	 	 	MA	  	Massachusetts Public Health Biologic Lab (Inactive-use MBL)
	 	 	MBL	  	Massachusetts Biologic Laboratories (formerly Massachusetts Public Health Biologic Laboratories)
	 	 	MED	  	Medimmune, Inc.
	 	 	MIL	  	Miles (Inactive-use BAY)
	 	 	MIP	  	Michigan Biologic Prod Inst.
	 	 	MSD	  	Merck & Co., Inc.
	 	 	NAV	  	North American Vaccine, Inc. (Inactive-use BAH)
	 	 	NAB	  	NABI (formerly North American Biologicals, Inc)

  

 Page 301 of 326 









					
	Table Item

	 	Code

	  	 Description


	 	 	NOV	  	Novartis Pharmaceutical Corp.
	 	 	NYB	  	New York Blood Center
	 	 	OTC	  	Organon Teknika Corporation
	 	 	ORT	  	Ortho Diagnostic Systems, Inc.
	 	 	PD	  	Parke-Davis
	 	 	PMC	  	Aventis Pasteur (formerly Pasteur Merieux Connaught)
	 	 	PRX	  	Praxis Biologics (Inactive-use WAL)
	 	 	PWJ
SCL	  	Powerject Pharmaceuticals (Includes Celltech Medeva Vaccines and Evans Medical Limited) Sclavo, Inc.
	 	 	SI	  	Swiss Serum and Vaccine Inst. (Inactive-use BPC)
	 	 	SKB	  	GlaxoSmithKline (formerly SmithKline Beecham; includes SmithKline Beecham and Glaxo Wellcome)
	 	 	USA	  	Us Army Med Research
	 	 	WA
WAL	  	 Wyeth-Ayerst (Inactive-use WAL)
 Wyeth-Ayerst-Lederle-Praxis

	 	 	OTH	  	Other manufacturer
	 	 	UNK	  	Unknown manufacturer
			
	Observation method
(For varicella immunity)	 	SERO	  	Serologic
	 	 	DIAG	  	Diagnosed
	 	 	HIST	  	Historical
			
	Race	 	I
A	  	 American Indian or Alaska Native
 Asian or Pacific
Islander

	 	 	B
W	  	 Black or African-American
 White

	 	 	H	  	Hispanic
	 	 	O	  	Other
	 	 	U	  	Unknown
			
	Relationship	 	18	  	Self
	 	 	61	  	Aunt
	 	 	62	  	Brother

  

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	 Table Item

	 	Code

	  	 Description


	 	 	33	  	Father
	 	 	87	  	Foster Father
	 	 	88	  	Foster Mother
	 	 	97	  	Grandfather
	 	 	98	  	Grandmother
	 	 	26	  	Guardian
	 	 	32	  	Mother
	 	 	B7	  	Sister
	 	 	64	  	Spouse
	 	 	48	  	Stepfather
	 	 	49	  	Stepmother
	 	 	D3	  	Uncle
	 	 	G8	  	Other Relationship
	 	 	G9	  	Other Relative
			
	Reaction Codes	 	10	  	Anaphylaxis within 24 hours
	 	 	11	  	Hypotonic-hyporesponsive collapse within 48 hours of immunization
	 	 	12	  	Seizure occurring within 3 days
	 	 	13	  	Persistent crying lasting >= 3 hours within 48 hours of immunization
	 	 	17	  	Temperature >= 105 (40.5 C) within 48 hours of immunization
			
	Sex (Gender)	 	F	  	Female
	 	 	M	  	Male
	 	 	U	  	Unknown
			
	VAERS reactions	 	D	  	Patient Died
	 	 	L	  	Life threatening illness
	 	 	E	  	Required emergency room/doctor visit
	 	 	H	  	Required hospitalization
	 	 	P	  	Resulted in prolongation of hospitalization
	 	 	J	  	Resulted in permanent disability

  

 Page 303 of 326 








 VACCINE CODES 
  

													
	CPT

	  	CVX

	  	 Group

	  	 Vaccine

	  	 Trade Name

	  	 Description

	  	MFG


	90476	  	54	  	Adeno	  	Adeno T4	  	Adeno T4	  	Adenovirus type 4, live oral	  	 
	90477	  	55	  	 	  	Adeno T7	  	Adeno T7	  	Adenovirus type 7, live oral	  	 
	90581	  	24	  	Anthrax	  	Anthrax	  	Anthrax	  	Anthrax	  	 
	90585	  	19	  	BCG	  	BCG-TB	  	BCG-TB	  	Bacillus Calmette-Guerin TB	  	 
	90586	  	 	  	 	  	BCG-Cancer	  	BCG-Cancer	  	Bacillus Calmette-Guerin bladder cancer	  	 
	90728	  	19	  	 	  	 	  	 	  	 	  	 
	 	  	 	  	 	  	 	  	 	  	Deleted BCG code	  	 
							
	90725	  	26	  	Cholera	  	Cholera-Injectable	  	Cholera-I	  	Cholera injectable	  	 
	90592	  	 	  	 	  	Cholera-Oral	  	Cholera-O	  	Cholera Oral	  	 
	90719	  	 	  	Diphtheria	  	Diphtheria	  	Diphtheria	  	Diphtheria	  	 
	90702	  	28	  	DTP/aP	  	DT	  	DT	  	Diphtheria tetanus pediatric	  	 
	90701	  	01	  	 	  	DTP	  	DTP	  	Diphtheria, tetanus, whole cell pertussis	  	 
	90700	  	20	  	 	  	DTaP	  	Tripedia	  	Diphtheria, tetanus, acellular pertussis	  	PMC
	 	  	 	  	 	  	 	  	Infanrix	  	 	  	SKB
	 	  	 	  	 	  	 	  	Acel-Imune	  	 	  	 
	 	  	 	  	 	  	 	  	 	  	 	  	WAL
	 	  	 	  	 	  	 	  	Certiva	  	 	  	BAH
	 	  	106	  	 	  	DTaP, 5 pertussis antigens	  	DAPTACEL	  	Diphtheria, tetanus, acellular pertussis, 5 antigens	  	PMC
	 	  	107	  	 	  	DTaP-Unspecified	  	 	  	DTaP-Unspecified	  	 
							
	90720	  	22	  	 	  	DTP-Hib	  	Tetramune	  	DTP – Hib combination	  	 
	 	  	 	  	 	  	 	  	 	  	 	  	WAL
	90721	  	50	  	 	  	DTaP-Hib	  	TriHIBit	  	DTaP-Hib combination	  	PMC
	90723	  	110	  	 	  	DTaP-Hep B-IPV	  	Pediarix	  	DTaP-Hep B-IPV combination	  	SKB
	90735	  	39	  	Encephalitis	  	Japanese encephalitis	  	JE-Vax	  	Japanese encephalitis	  	 
	 	  	 	  	 	  	 	  	 	  	 	  	PMC
	90632	  	52	  	HepA	  	HepA adult	  	VAQTA Adult	  	Hepatitis A adult	  	MSD
	 	  	 	  	 	  	 	  	Havrix Adult	  	 	  	SKB
	90633	  	83	  	 	  	HepA peds 2 dose	  	VAQTA Peds 2 dose	  	Hepatitis A pediatric/adolescent 2 dose	  	MSD

  

 Page 304 of 326 









													
	 CPT

	  	CVX

	  	 Group

	  	 Vaccine

	  	 Trade Name

	  	 Description

	  	MFC


	 	  	 	  	 	  	 	  	 	  	 	  	SKB
	 	  	 	  	 	  	 	  	Havrix Peds 2 dose	  	 	  	 
							
	90634	  	84	  	 	  	HepA peds 3 dose	  	VAQTA Peds 3 dose	  	Hepatitis A pediatric/adolescent 3 dose	  	MSD
	 	  	 	  	 	  	 	  	 	  	 	  	SKB
	 	  	 	  	 	  	 	  	Havrix Peds 3 dose	  	 	  	 
	90636	  	104	  	 	  	HepA-HepB	  	 	  	Hepatitus A & Hepatitus B adult	  	SKB
	 	  	 	  	 	  	 	  	Twinrix	  	 	  	 
	90730	  	85	  	 	  	 	  	 	  	 	  	 
	 	  	 	  	 	  	 	  	 	  	Deleted HepA code	  	 
							
	90744	  	08	  	HepB	  	HepB pediatric	  	 	  	Hepatitis B pediatric/adolescent .5 ml	  	MSD
	 	  	 	  	 	  	 	  	Recombivax Peds	  	 	  	 
	 	  	 	  	 	  	 	  	Engerix-B Peds	  	 	  	SKB
	90743	  	43	  	HepB	  	HepB adult	  	Recombivax Adult	  	Hepatitis B adolescent 2 dose (adult form)	  	MSD
	90746	  	 	  	 	  	 	  	 	  	Hepatitis B adult dose 1ml	  	MSD
	 	  	 	  	 	  	 	  	Engerix-B Adult	  	Hepatitis B adult dose 1ml	  	SKB
	90740	  	44	  	 	  	HepB dialysis 3 dose	  	 	  	Hepatitis B Dialysis 3	  	MSD
	 	  	 	  	 	  	 	  	Recombivax Dialysis	  	dose/immunosuppressed	  	 
	90747	  	 	  	 	  	HepB dialysis 4 dose	  	Engerix-B Dialysis	  	Hepatitis B Dialysis 4 dose	  	SKB
	90748	  	51	  	 	  	HepB-Hib	  	Comvax	  	HepB-Hib Combination	  	MSD
	90636	  	104	  	 	  	HepA-HepB	  	 	  	Hepatitus A & Hepatitus B adult	  	 
	 	  	 	  	 	  	 	  	Twinrix	  	 	  	SKB
	90723	  	110	  	 	  	 	  	 	  	 	  	 
	 	  	 	  	 	  	DTaP-Hep B-IPV	  	Pediarix	  	DTaP-Hep B-IPV combination	  	SKB
	90745	  	42	  	 	  	 	  	 	  	 	  	 
	 	  	 	  	 	  	 	  	 	  	Deleted HepB code	  	 
	90731	  	45	  	 	  	 	  	 	  	 	  	 
							
	90645	  	47	  	Hib	  	Hib-HbOC	  	HibTITER	  	Hemophilus influenza b HbOC 4 dose	  	 
	 	  	 	  	 	  	 	  	 	  	 	  	WAL
	90646	  	46	  	 	  	Hib-PRP-D	  	ProHIBit	  	Hemophilus influenza b PRP-D booster	  	PMC
	90647	  	49	  	 	  	Hib-OMP	  	PedvaxHIB	  	Hemophilus influenza b OMP 3 dose	  	MSD
	90648	  	48	  	 	  	Hib-PRP-T	  	OmniHib	  	Hemophilus influenza b PRP-T 4 dose	  	SKB
	 	  	 	  	 	  	 	  	ActHib	  	 	  	PMC

  

 Page 305 of 326 









													
	 CPT

	  	CVX

	  	Group

	  	 Vaccine

	  	 Trade Name

	  	 Description

	  	MFG


	 90720
	  	22	  	 	  	DTP-Hib	  	Tetramune	  	DTP – Hib combination	  	 
	 	  	 	  	 	  	 	  	 	  	 	  	WAL
							
	 90721
	  	50	  	 	  	DTaP-Hib	  	TriHIBit	  	DTaP-Hib combination	  	PMC
							
	 	  	 	  	 	  	 	  	 	  	 	  	 
	 90748
	  	51	  	 	  	HepB-Hib	  	Comvax	  	HepB-Hib Combination	  	MSD
	 90737
	  	17	  	 	  	 	  	 	  	 	  	 
							
	 	  	 	  	 	  	 	  	 	  	Deleted Hib Code	  	 
							
	 90281
	  	86	  	Ig	  	Ig	  	Ig	  	Ig human	  	 
	 90283
	  	87	  	 	  	IgIV	  	IgIV	  	Ig IV human	  	 
	 90291
	  	29	  	 	  	CMV-IgIV	  	CMV-IgIV	  	Cytomegalovirus Ig IV human	  	 
	 90371
	  	30	  	 	  	HBIg	  	HBIg	  	Hepatitis B Ig human	  	 
	 90375
	  	34	  	 	  	RIg	  	RIg	  	Rabies Ig human	  	 
	 90376
	  	34	  	 	  	RIg-HT	  	RIg-HT	  	Rabies Ig heat treated human	  	 
	 90379
	  	71	  	 	  	RSV-IgIV	  	RSV-IgIV	  	Respiratory syncytial virus Ig IV	  	 
	 90389
	  	13	  	 	  	TIg	  	TIg	  	Tetanus Ig human	  	 
	 	  	 	  	 	  	 	  	Hyper-TET	  	Tetanus Ig human	  	 
	 90393
	  	79	  	 	  	Vaccinia-Ig	  	Vaccinia-Ig	  	Vaccinia Ig human (VIg)	  	 
	 90396
	  	36	  	 	  	VZIg	  	VZIg	  	Varicella-zoster Ig human	  	 
	 90655
	  	15	  	Influenza	  	FLU-PF 6-35 Months	  	 Fluzone-PF 6-35
 Months
	  	Influenza split virus, preservative free, 6-35 month	  	PMC
							
	 90656
	  	 	  	 	  	FLU-PF > 3 Years	  	Fluzone-PF > 3 Years	  	Influenza split virus, preservative free, 3 years and above	  	PMC
	 90657
	  	 	  	 	  	FLU 6-35 Months	  	Fluvirin 6-35 Months	  	Influenza split virus, 6-35 month	  	PWJ
							
	 	  	 	  	 	  	 	  	Fluzone 6-35 Months	  	 	  	PMC
	 	  	 	  	 	  	 	  	Fluogen 6-35 Months	  	 	  	PD
	 	  	 	  	 	  	 	  	Flu-Imune 6-35	  	 	  	 
	 	  	 	  	 	  	 	  	Months	  	 	  	 
	 	  	 	  	 	  	 	  	Flu-Shield 6-35	  	 	  	 
	 	  	 	  	 	  	 	  	Months	  	 	  	WAL
							
	 90658
	  	 	  	 	  	FLU > 3 Years	  	Fluvirin > 3 Years	  	Influenza split virus, 3 years and above	  	PWJ
							
	 	  	 	  	 	  	 	  	Fluzone > 3 Years	  	 	  	PMC
	 	  	 	  	 	  	 	  	Fluogen > 3 Years	  	 	  	PD

  

 Page 306 of 326 









													
	 CPT

	  	CVX

	  	Group

	  	 Vaccine

	  	 Trade Name

	  	 Description

	  	MFG


	 	  	 	  	 	  	FLU > 3 Years	  	Flu-Imune > 3 Years	  	Influenza split virus, 3 years and above	  	 
	 	  	 	  	 	  	 	  	Flu-Shield > 3 Years	  	 	  	WAL
							
	 90659
	  	16	  	 	  	FLU > 12 Years	  	Fluvirin > 12 Years	  	Influenza whole virus	  	 
	 	  	 	  	 	  	 	  	 	  	 	  	PWJ
							
	 	  	 	  	 	  	 	  	Fluzone > 12 Years	  	 	  	PMC
	 	  	 	  	 	  	 	  	Fluogen > 12 Years	  	 	  	PD
	 	  	 	  	 	  	 	  	Flu-Imune > 12 Years	  	 	  	 
	 	  	 	  	 	  	 	  	Flu-Shield > 12 Years	  	 	  	 
	 	  	 	  	 	  	 	  	 	  	 	  	WAL
	 90660
	  	111	  	 	  	Flu-LAIV	  	FluMist	  	Influenza live, for intranasal use	  	WAL
	 	  	 	  	 	  	 	  	Flu-Nasal	  	 	  	 
	 90724
	  	88	  	 	  	 	  	 	  	 	  	 
							
	 	  	 	  	 	  	 	  	 	  	Deleted Influenza code	  	 
							
	 	  	15	  	 	  	Flu-PF > 4 Years	  	Fluvirin-PF > 4 Years	  	Influenza split virus, preservative free	  	MED
	 90665
	  	66	  	Lyme	  	Lyme	  	LYMErix	  	Lyme disease	  	SKB
	 90705
	  	05	  	Measles	  	Measles	  	Attenuvax	  	Measles live	  	MSD
	 	  	 	  	 	  	 	  	Measles	  	Measles live 1964-1974 (Eli Lilly-EL)	  	 
	 	  	 	  	 	  	 	  	Measles	  	Measles inactivated 1963-1966 (Eli Lilly - EL)	  	 
	 90708
	  	04	  	 	  	Measles-Rubella	  	M-R-VAX	  	Measles and rubella live	  	MSD
	 	  	 	  	 	  	 	  	Measles-Rubella	  	Measles and rubella	  	 
	 	  	 	  	 	  	 	  	(MERU)	  	 	  	 
	 90707
	  	03	  	 	  	MMR	  	MMR II	  	 	  	MSD
							
	 	  	 	  	 	  	 	  	 	  	Measles, mumps and rubella live (will also accept MMR as tradename)	  	 
	 90710
	  	94	  	 	  	MMRV	  	MMRV	  	Measles, mumps, rubella, varicella live	  	 
	 90733
	  	32	  	Meningo	  	Meningococcal	  	MENOMUNE	  	Meningococcal polysaccharide	  	PMC
	 	  	108	  	 	  	Meningococcal-Unspecified	  	 	  	Meningococcal-Unspecified	  	 
	 90704
	  	07	  	Mumps	  	Mumps	  	Mumpsvax	  	Mumps live	  	MSD
	 	  	 	  	 	  	 	  	Mumps	  	Mumps 1950-1978	  	 
	 90709
	  	38	  	 	  	Rubella-Mumps	  	Biavax II	  	Rubella and mumps live	  	MSD

  
  

 Page 307 of 326 









													
	 CPT

	  	CVX

	  	Group

	 	 Vaccine

	  	 Trade Name

	  	 Description

	  	MFG


	 	  	 	  	 	 	 	  	Mumps-Rubella (MURU)	  	Rubella and mumps	  	 
							
	 90707
	  	03	  	 	 	MMR	  	MMR II	  	 	  	MSD
							
	 	  	 	  	 	 	 	  	 	  	Measles, mumps and rubella live (will also accept ‘MMR’ as tradename)	  	 
							
	 90710
	  	94	  	 	 	MMRV	  	MMRV	  	Measles, mumps, rubella, varicella live	  	 
							
	 90712
	  	02	  	Polio	 	Polio oral	  	ORIMUNE	  	Poliovirus OPV live oral	  	 
							
	 	  	 	  	 	 	 	  	 	  	 	  	WAL
							
	 90713
	  	10	  	 	 	Polio injectable	  	IPOL	  	Poliovirus inactivated IPV	  	PMC
							
	 90723
	  	110	  	 	 	DTaP-Hep B-IPV	  	Pediarix	  	DTaP-Hep B-IPV combination	  	SKB
	 	  	89	  	 	 	Polio-Unspecified	  	 	  	Polio-Unspecified	  	 
	 90727
	  	23	  	Plague	 	Plague	  	Plague	  	Plague	  	 
							
	 90669
	  	100	  	(Pneumococca1)
PCV	 	Pneumo-conjugate	  	Prevnar	  	Pneumococcal conjugate polyvalent (will also accept ‘pneumococcal’ as tradename)	  	WAL
							
	 90732
	  	33	  	(Pneumo-
poly)
PPV	 	Pneumococcal 23	  	PNU-IMUNE 23	  	Pneumococcal polysaccharide 23 valent (will also accept ‘pneumo-poly’ as tradename)	  	WAL
	 	  	 	  	 	 	 	  	Pneumovax 23	  	 	  	MSD
	 90675
	  	18	  	Rabies	 	Rabies-intramuscular	  	Imovax Rabies IM	  	Rabies intramuscular	  	PMC
	 90676
	  	40	  	 	 	Rabies-intradermal	  	Imovax Rabies ID	  	Rabies intradermal	  	PMC
							
	 90726
	  	90	  	 	 	 	  	 	  	 	  	 
							
	 	  	 	  	 	 	Rabies-Unspecified	  	 	  	Rabies-Unspecified	  	 
							
	 90680
	  	74	  	Rotavirus	 	Rotavirus	  	RotaShield	  	Rotavirus tetravalent live oral	  	WAL
	 90706
	  	06	  	Rubella	 	Rubella	  	Meruvax II Rubella	  	Rubella live	  	MSD
	 90709
	  	38	  	 	 	Rubella-Mumps	  	Biavax II	  	Rubella and mumps live	  	MSD
	 	  	 	  	 	 	 	  	 Mumps-Rubella (MURU)
	  	Rubella and mumps	  	 
	 90708
	  	04	  	 	 	Measles-Rubella	  	M-R-VAX	  	Measles and rubella live	  	MSD
	 	  	 	  	 	 	 	  	Measles-Rubella (MERU)	  	Measles and rubella	  	 

  

 Page 308 of 326 









													
	 CPT

	  	CVX

	  	Group

	  	 Vaccine

	  	 Trade Name

	  	 Description

	  	MFG


	90707	  	03	  	 	  	MMR	  	MMR II	  	 	  	MSD
							
	 	  	 	  	 	  	 	  	 	  	Measles, mumps and rubella live (will also accept ‘MMR’ as tradename)	  	 
							
	90710	  	94	  	 	  	MMRV	  	MMRV	  	Measles, mumps, rubella, varicella live	  	 
	 	  	75	  	Smallpox	  	Vaccinia	  	Dryvax	  	Vaccinia (Smallpox) dry	  	 
	 	  	 	  	 	  	 	  	 	  	 	  	WAL
							
	 	  	105	  	 	  	 	  	Vaccinia-Diluted	  	Vaccinia (Smallpox), diluted	  	 
	90718	  	09	  	Td	  	Td	  	Td	  	Tetanus and diphtheria adult	  	PMC
	90703	  	35	  	Tetanus	  	Tetanus	  	TT	  	Tetanus	  	 
	90690	  	25	  	Typhoid	  	Typhoid-oral	  	 	  	Typhoid oral (will also accept tradenames	  	 
	 	  	 	  	 	  	 	  	Vivotif Berna/Ty21a	  	‘Vivotif Berna’ or ‘Ty21a’)	  	BPC
							
	90691	  	101	  	 	  	Typhoid-ViCPs	  	Typhim Vi	  	Typhoid VI capsular polysaccharide	  	PMC
							
	90692	  	41	  	 	  	Typhoid-H-P	  	Typhoid	  	Typhoid heat and phenol inactivated	  	 
							
	 	  	 	  	 	  	 	  	 	  	 	  	WAL
							
	90693	  	53	  	 	  	Typhoid-AKD	  	Typhoid-AKD	  	Typhoid acetone-killed, dried (military)	  	 
							
	90714	  	91	  	 	  	 	  	 	  	 	  	 
							
	 	  	 	  	 	  	 Typhoid-
 Unspecified
	  	 	  	Typhoid-Unspecified	  	 
							
	90716	  	21	  	Varicella	  	Varicella	  	Varivax	  	Varicella live	  	MSD
	90710	  	94	  	 	  	MMRV	  	MMRV	  	Measles, mumps, rubella, varicella live	  	 
	90717	  	37	  	Yellow Fever	  	Yellow Fever	  	YF-VAX	  	Yellow Fever live	  	PMC

  

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 Attachment L.5.11 
  
 

 
  
 HMO Query for 
 HEDIS Reporting 
  

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 Using GRITS HMO Query for HEDIS Reporting 
  
 Overview of the HEDIS Reporting Using GRITS 
  
 Providers and insurers will send and receive data from GRITS. The provider or insurer must
do a Legacy (historical) load of data into GRITS. This step will load the clients and their chart numbers into the GRITS system. A client chart number can be any unique identifier, such as a member number. The Legacy load data must be in flat file
format. (Please see the GRITS flat file specifications, Version 5.0.). 
  
 After
loading the legacy data, a query is performed on the GRITS databases to obtain client and immunization information. The query will be done by submitting a file to GRITS. The HMO Query will extract each client found in GRITS and all of that
client’s immunization records. The file format is discussed later in this document. 
  
 Legacy Load Testing Background: 
  
 The
Data Exchange Legacy Load interface for each organization has been set-up as a bi-directional interface. This allows an organization to send data to GRITS and receive data back on any of the organization’s clients who have been updated since
the last data exchange. 
  
 GRITS Data Exchange testing is done in Staging
environment. Each organization will use their production organization number in both Staging and Production. 
  
 Testing in the Staging environment will load the data into GRITS and will produce a job output that will list new and updated records as well as error and warning messages. Multiple test cycles will be run in the
Staging environment until most errors are corrected. Once this happens, the testing will move to the Production system. The first production test will not load the Production databases. 
  
 Each insurer or provider will need to populate the ‘Sending Organization’ field on the flat file with the GRITS organization
number.. 
  
 Staging Test Routine: 
  

	 	1.	Login into GRITS Staging, 

  
 Staging URL https://www.grits.state.ga.us/pls/gritsstage/!security_ui.postRedirect 
  
  

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 NOTE: Your log in information will
be provided in an email. 
  

	2.	Select Data Exchange – Exchange Data from the menu. 

  

	3.	To submit your job do the following: 

  

	 	•	 	Create a job name. (You may enter anything as a job name but the GRITS team recommends the following: 

  
 Org Code + today’s date + 1 , Example CALHD 6/24 1. Should you need to resubmit the test data, increment the last
number. 
  

	 	•	 	Enter your client file or use Browse to select your file 

  

	 	•	 	Enter your immunization file or Browse to select your file 

  
 NOTE: Data Exchange has a file size limit of 230MB. The combined size of your client and immunization file cannot exceed this limit. 
  
  

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	 	•	 	Submit job by clicking the Upload button. The Exchange Data screen will remain visible until the data files are loaded into GRITS. 

  
 Exchange Data Screen 
  
 

 
  
  

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	 	•	 	Once the data has been loaded into GRITS, the Exchange Data Results screen will appear 

  
 Exchange Data Result Screen 
  



 
  

	 	•	 	To view the job click Check Status. The job will most likely be in a status of ‘Processing’. 

  

	 	•	 	Click the Refresh button. When the job has completed processing, the status will change to ‘Complete’ or ‘Error’. 

  

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	 	•	 	If the job has a status of ‘ERROR’, contact the GRITS Interface team. 

  
 Exchange Data Status Screen 
  
 

 
  
  

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	4.	Check the Job Response File 

  

	 	•	 	On the Exchange Data Status screen, click on your job. The Job Summary page will be displayed. 

  

	 	•	 	If any clients or immunization in your organization have been updated since the last Data Exchange, 3 files will be listed under Down Files: Response File, Client File and
Immunization File. 

  

	 	•	 	To view updated clients or immunizations, select either the Client file or Immunization File. 

  

	 	•	 	To view errors and warning messages, click on Response File 

  
 Response Summary Screen 
  
 

 
  
  

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 Response File 
 :

 The Response File contains a job summary, error and warning messages for each Data Exchange.  
  
 Summary 
  

							
	 DESCRIPTION

	  	CLIENT

	  	IMMUNIZATION

	  	COMMENT


	 Processed
	  	17522	  	254102	  	0
	 Accepted
	  	17516	  	252859	  	0
	 New
	  	17511	  	252859	  	0
	 Updated
	  	5	  	0	  	0
	 Already in GRITS
	  	0	  	64	  	0
	 Rejected
	  	6	  	1179	  	0
	 Pending
	  	0	  	0	  	0

  
 Response File
Detail 
  
 The following are samples of messages in the
detail section of the Response file: 
  
 Clients that rejected. 
 85840 * Client (Client Name) Born 12211993 
 Record rejected. Client does not have any valid immunizations. 
 * Record ID from input file 
  
 Clients that were accepted, though had one or more immunizations that were rejected. 
 150919 Client (Client Name) Born 06171993 
  

Clients that were accepted, though had one or more optional fields that were invalid 
 201935 (Client Name) Born 09101994 
 Inaccurate or missing data. No value stored. [RESPONSIBLE PERSON FIRST NAME] 
  
 Common Errors: 
  

	1.	Record rejected. This immunization matches another immunization in incoming file. The incoming immunization that this system retained may be identified by the following
characteristics -> Vaccination Date: 01071999 CPT Code: 90716. [N/A] 


	2.	Record Rejected. A valid vaccination date must be entered. 

  

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 Correct Errors: 
  

	 	1.	Error correction may be needed to fix data issues in the originating system. 

  

	 	2.	Some errors such as ‘Record rejected. This immunization matches another immunization in incoming file’ are acceptable. 

  
 Resubmit Job: 
  

	 	1.	If corrections were made, re-extract the data and repeat steps 2-4 of the Testing Routine 

  

	 	2.	Once most errors have been corrected, the testing can proceed to the Production environment. 

  
 The steps listed above are repeated until the Data Exchange processes successfully with a minimum of errors. 
  
 Production Test Routine: 
  
 Note: Data is not loaded into the Production area until all testing is complete. 

 

	 	5.	Login into GRITS Production.  

  
 Production URL 
  
 https://www.grits.state.ga.us/pls/gritsprod/security_ui.showLogin 
  
 Follow the testing steps listed for the Staging area. Once the Data Exchange processes successfully and with a minimum of errors, the Data Exchange can be moved to full production load phase. 
  

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 Extracting Data from GRITS 
  
 When an insurer wants to receive information on clients in the GRITS system, they can do so by submitting a query. The query is done by
creating a file containing the following information: 
  

				
	Query file	 
		
	 *Type of client (C or M)
	  	Char	(1)
	 **Medicaid or Chart #
	  	Char	(20)
	 First Name
	  	Char	(25)
	 Middle Name
	  	Char	(25)
	 Last Name
	  	Char	(35)
	 ***Birth Date
	  	Date	(8)



	*	The “Type of client” determines whether to search the providers own clients (C) or to search the Medicaid clients (M) 


	**	This number needs to be an exact match to the number in the registry associated with this client. 


	***	The Birth Date must be in the format MMDDYYYY 

  
 How to Run the Query File: 
  
 Select ‘Submit HMO Query’ under the Data Exchange menu option. The following screen will be displayed 
  

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 Exchange Data Screen 
  
 

 
  
 Enter your query
file or use Browse to select your file 
 and press the Upload button. The screen below will appear. 
  

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 Press the ‘Check Status’ Button.

  

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 Click on your job to view query results.

  

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 Demographic file: Contains clients requested in
Query 
  
 Immunization file: Contains the immunization records for the clients

  
 Both the Client and Immunization files are in GRITS flat file format.

  
 Exception File: Contains any errors, such as clients that were not found in
the GRITS database. 
  

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 GRITS will create the following files from the HMO supplied file: 
  
 Identifying details file 
  

			
	 Medicaid or Chart #
	  	Char(20)
	 First Name
	  	Char(25)
	 Middle Name
	  	Char(25)
	 Last Name
	  	Char(35)
	 Birth Date
	  	Date(8)

  
 Immunization file

  

			
	 Medicaid or Chart # (link to details file)
	  	Char(20)
	 CPT Code
	  	Char(5)
	 Vaccine Group
	  	Char(16)
	 Vaccination Date
	  	Date(8)

  
 Exception file

  
 Text file containing those clients not
matched, with a reason supplied. This file will only be created if there are exceptions to be reported back to the HMO. 
  
 The data returned will contain a child’s complete immunization history from all providers on the IR, in the above file format. The GRITS staff has requested a change
to the client and immunization file. This change will produce a client and immunization file in the GRITS flat file layout. 
  

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 Saving GRITS Files: 
  
 Client and Immunization files can be saved as text documents and used to update the sending system. To save a client, immunization or comment file, the
following steps should be performed: 
  

	 	1.	From the Response file, right click on the file you wish to save as a text file. 

  

	 	2.	Click on Save Target As 

  
 Note: If the file is saved as a text document in Notepad, the columns will not be lined up but the file can be used for processing. If you wish to see the
file with all columns lines up, open the file in WordPad. 
  

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 Georgia Cares Program (GCS) 
 Care Management Organization (CMO) Contract 
 Attachment L6: Citations for Information Security Standards and Guidelines 

 
 - FIPS PUB 31: Automatic Data Processing Physical Security and Risk Management

  
 - FIPS PUB 41: Computer Security Guidelines for Implementing the Privacy Act
of 1974 
  
 - FIPS PUB 73: Guidelines for Security of Computer Applications

  
 - Federal Regulations at 45 CFR 95.621 
  

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