Attachment Ia EDI 834 Healthcare Provider Information Companion Guide.pdf

July 2025 005010 1.0

Nm101VA OFFICE OF COMMUNITY CARE COMPANION GUIDE

Department of Veterans Affairs Office of Community Care Programs HIPAA Transaction Standard Companion Guide

Refers to the TR3 for ASC X12 version 005010x220A1 for Realtime Accumulator Update from FSC to Payer Electronic Data Interchange (EDI) Gateway Companion Guide

July 2025

VA OFFICE OF COMMUNITY CARE COMPANION GUIDE

Exhibit 1. Version HistoryICN

Version Date Version Description Author

0.1 05/08/2025 Document Creation Laura Nelson

0.2 05/16/2025 Updated Mapping Brian Matthews

0.3 06/11/2025 Final Draft for comment Brian Matthews

0.4 07/01/2025 Responses and updates based on FSC comments

Brian Matthews

0.5 07/03/2025 Additional updates based on comments received 07/02/2025

Brian Matthews

1.0 07/07/2025 Final for signature Brian Matthews

Disclosure Statement

Copyright 2020 by the Department of Veterans Affairs (VA) Office of Integrated Veteran Care (IVC) health care programs. All rights reserved. It may be freely redistributed in its entirety provided that this copyright is not removed.

It may not be sold for profit or used in commercial documents without the prior written permission of the copyright holder. This document is provided “as is” without any expressed or implied warranty. Note that the copyright on the underlying Accredited Standards Committee (ASC) X12 Standards is held by the Data Interchange Standards Association (DISA) on behalf of ASC X12.

Preface

This Companion Guide to the v005010x220A1 ASC X12N TR3 and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with the Department of Veterans Affairs (VA) Office of Integrated Veteran Care (IVC) health care programs. Transmissions based on this companion guide, used in tandem with the v5010 ASC X12N TR3, are compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N TR3 adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the TR3.

Table of Contents

1. INTRODUCTION

1.1. SCOPE

1.2. OVERVIEW

1.3. REFERENCES

1.4. ADDITIONAL INFORMATION

1.4.1. Assumptions Regarding the Reader

2. GETTING STARTED

2.1. CERTIFICATION AND TESTING OVERVIEW

3. TESTING WITH THE PAYER

4. CONNECTIVITY WITH THE PAYER/COMMUNICATIONS PROCESS FLOWS

4.1. TRANSMISSION ADMINISTRATIVE PROCEDURES

4.2. RE-TRANSMISSION PROCEDURE

4.3. COMMUNICATION PROTOCOL SPECIFICATIONS

5. CONTACT INFORMATION EDI CUSTOMER SERVICE

5.1. EDI TECHNICAL ASSISTANCE

5.2. EDI BUSINESS ASSISTANCE

6. CONTROL SEGMENTS AND ENVELOPES

ISA-IEA

6.2 GS-GE

6.3 ST-SE

7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS

8. ACKNOWLEDGEMENTS AND/OR REPORTS

9. TRADING PARTNER AGREEMENTS

10. TRANSACTION SPECIFIC INFORMATION

11. APPENDICES

11.1. Appendix A: 834 Mapping

11.2. Glossary

12. Approval Signatures

1. INTRODUCTION

This companion guide is intended to assist in development and deployment of applications to transmit standard files electronically for the exchange of healthcare benefits and accumulators. This companion guide serves as an addendum to any technical documentation supplied by the IVC Payer EDI Team when establishing a trading partner agreement.

1.1. SCOPE

This document covers business and technical processes enacted by the VA IVC which vary from expectations governed by the EDI 834x220A1 v5010 when processing ASC X12 benefit and enrollment maintenance transmissions.

1.2. OVERVIEW

This document is intended to supplement the EDI 834 TR3 and any additional Errata guides published by the ASC and any additional companion guide supplied by the IVC Payer EDI Team. All requirements or directives in this document are HIPAA compliant and intended to improve facilitation of EDI transmissions and notify trading partners of EDI rules unique to the VA IVC EDI processing and business environment.

1.3. REFERENCES

This companion guide is written to support any companion guide delivered by the IVC Payer EDI Team during the interchange on-boarding process. Additionally, this companion guide supports the EDI 834 TR3 and any additional Errata guides published by the ASC.

To purchase the EDI 834 implementation guide (TR3), contact: admin@wpc-edi.com

1.4. ADDITIONAL INFORMATION

1.4.1. Assumptions Regarding the Reader

The VA IVC assumes the reader of this guide has access to the EDI 834 TR3.

2. GETTING STARTED

2.1. CERTIFICATION AND TESTING OVERVIEW

All certification and testing of a new trading partnership must be coordinated with the IVC Payer EDI Team.

3. TESTING WITH THE PAYER

The IVC Payer EDI Team will coordinate with the trading partner to test system related changes and transactions, including initial operating capability (IOC). The test strategy will encompass Component Integration Testing (CIT), Independent Validation and Verification testing (IVV) and User Acceptance Testing (UAT). Required documentation from the trading partner will include a test plan, test cases, requirements traceability matrix (RTM) and defect log.

4. CONNECTIVITY WITH THE PAYER/COMMUNICATIONS PROCESS FLOWS

All EDI communication is further detailed in the VFMP ECM 834 Interface Control Document (ICD).

FSC-eCAMS Payer EDI

Inbound Accumulator

From FSC eCAMS

Outbound 999 from Payer EDI

4.1. TRANSMISSION ADMINISTRATIVE PROCEDURES

FSC transmits outbound EDI 834 transmissions and receives inbound EDI X12 999 acknowledgements in a real time connection.

4.2. RE-TRANSMISSION PROCEDURE

Retransmissions of the EDI 834 will be coordinated with IVC Payer EDI Team in order to avoid corruption of Accumulator System of Record.

mailto:admin@wpc-edi.com

4.3. COMMUNICATION PROTOCOL SPECIFICATIONS

All communication should be coordinated with the IVC Payer EDI Team. Communication contacts will be sent in the following order:

Primary Email Address: CCPP-PST@va.gov

Secondary Email Address: VHAOIVCPMDPayerEDI@va.gov

5. CONTACT INFORMATION EDI CUSTOMER SERVICE

5.1. EDI TECHNICAL ASSISTANCE

IVC Contacts Email

Community Care Provider Payment, Production Support Team

CCPP-PST@va.gov

Payer EDI Team, Program Management Directorate

VHAOIVCPMDPayerEDI@va.gov

5.2. EDI BUSINESS ASSISTANCE

IVC Contacts Email

Payer EDI Team, Program Management Directorate

VHAOIVCPMDPayerEDI@va.gov mailto:CCPP-PST@va.gov mailto:VHAOIVCPMDPayerEDI@va.gov mailto:CCPP-PST@va.gov

6. CONTROL SEGMENTS AND ENVELOPES

Any specific requirements for dealing with ISA-IEA, GS-GE, or ST-SE needs to be coordinated through the IVC Payer EDI Team.

ISA-IEA

ISA01 of 834 will contain the value ‘00’ ISA02 of 834 will contain the value of 10 spaces ISA03 of 834 will contain the value ‘00’ ISA04 of 834 will contain the value of 10 spaces ISA05 of 834 will contain the value ‘ZZ’ ISA06 of 834 will contain the value 'VAFSCVFMP' ISA07 of 834 will contain the value ‘ZZ’ ISA08 of 834 will contain the value 'PayerEDI' ISA09 of 834 will contain the Interchange Date in the format YYMMDD ISA10 of 834 will contain the Interchange Time in the format HHMM ISA11 of 834 will contain the value ‘^’ ISA12 of 834 will contain the value ‘00501’ ISA13 of 834 will contain the Interchange Control Number that must be a positive 9-digit unassigned number and must be identical to the value in IEA02 ISA14 of 834 will contain the value ‘0’ ISA15 of 834 will contain the value 'P' for all production files ISA16 of 834 will contain the value ':'

The Segment Delimiter will be '~'

6.2 GS-GE

GS01 of 834 will contain the value ‘BE’ GS02 of 834 will contain the value 'VAFSCVFMP' GS03 of 834 will contain the value 'PayerEDI' GS04 of 834 will contain the Functional Group Creation Date in the format CCYYMMDD GS05 of 834 will contain the Functional Group Creation Time in the format HHMMSSDD GS06 of 834 will contain the Group Control Number that must be 9 digits. Zero left padded if necessary.

GS07 of 834 will contain the value ‘X’ GS08 of 834 will contain the value ‘005010X220A1

6.3 ST-SE

ST01 of 834 will contain the value ‘834’ ST02 of 834 will contain the Transaction Set Control Number that must be between 4 and 9 digits and match the value found in the SE02 ST03 of 834 will contain the value '005010X220A1'

7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS

Values assigned to Monetary Accumulators can be negative in the case of rebilled or reprocessed claims

BGN01 of the Header will be ‘00’ BGN02 of the Header will contain value sent in the 277CA 2200D Loop REF02 where REF01 = '1K', or the new claim number for a rebilled/reprocessed claim (Payer Claim Number) BGN03 of the Header will contain the Transaction Set Creation Date in the format CCYYMMDD BGN04 of the Header will contain the Transaction Set Creation Time in the format HHMMSS BGN05 of the Header will contain the Time Zone Code of ‘UT’ BGN08 of the Header will contain the value of ‘2’

N101 of the 1000A loop will contain the value of ‘P5’ N102 of the 1000A loop will contain the value of ‘IVC Payer EDI’ N103 of the 1000A loop will contain the value of ‘FI’ N104 of the 1000A loop will contain the value of ‘841469824’

N101 of the 1000B loop will contain the value of ‘IN’ N102 of the 1000B loop will contain the value of ‘'FSC eCAMS’ N103 of the 1000B loop will contain the value of ‘94’ N104 of the 1000B loop will contain the value of 'VAFSCVFMP'

INS01 of the 2000 loop will contain the value of ‘Y’ INS02 of the 2000 loop will contain the value of ‘18’ INS03 of the 2000 loop will contain the value of ‘001’ INS05 of the 2000 loop will contain the value of ‘A’ INS08 of the 2000 loop will contain the value of ‘AC’

REF01 of the 2000 loop will contain the value of ‘0F’ REF02 of the 2000 loop will contain the value sent in the REF02 where REF01 = ‘6P’ of the 2100C loop in the 271 (Sponsor ICN)

DTP01 of the 2000 loop will contain the value of ‘303’ DTP02 of the 2000 loop will contain the value of ‘D8 DTP03 of the 2000 loop will contain the value of DTP03 sent in the DTP03 where DTP03 = ‘102’ of the 2100C loop in the 270 (Last Date of Service)

NM101 of the 2100A loop will contain ‘IL’ NM102 of the 2100A loop will contain ‘1’ NM103 of the 2100A loop will contain the Beneficiary Last Name NM104 of the 2100A loop will contain the Beneficiary First Name NM108 of the 2100A loop will contain the value of ‘ZZ’ NM109 of the 2100A loop will contain the Beneficiary ICN

AMT01 of the 2100A loop will contain the value of ‘D2’ AMT02 of the 2100A loop where AMT01 = ‘D2’ will contain the value assigned to Individual Deductible

AMT01 of the 2100A loop will contain the value of ‘FK’ AMT02 of the 2100A loop where AMT01 = ‘FK’ will contain the value assigned to Family Deductible

AMT01 of the 2100A loop will contain the value of ‘R’ AMT02 of the 2100A loop where AMT01 = ‘R’ will contain the value assigned to Individual CAT CAP

8. ACKNOWLEDGEMENTS AND/OR REPORTS

EDI Gateway will return an EDI 999 transaction for the receipt of each EDI X12 834 transaction received. A value of ‘A’ for Accept or ‘R’ for Reject will be placed in the AK901 based on 834 validation. If ‘R’ is used, then AK905 will be populated with ‘18’ “Message Authentication Code Failed”

9. TRADING PARTNER AGREEMENTS

All trading partner agreements are to be coordinated through the IVC Payer EDI Team.

10. TRANSACTION SPECIFIC INFORMATION

Page

Loop

ID

Reference Name Codes Length Comments/ Notes

32 Header BGN Beginning Segment

BGN01

BGN02

BGN03

BGN04

BGN05

‘00’ Payer Claim Number

‘UT’

39 1000A N1 Sponsor Name N102 N104

IVC Payer EDI 841469824

41 1000B N1 Payer Name N102 N104

FSC eCAMS

VAFSCVFMP

47 2000 INS

Member Level Detail

INS01 – ‘Y’

INS02 – ‘18’

INS03 – ‘001’

INS05 – ‘A’

INS08 – AC

INS08- will always have a value of ‘AC’

55 REF*0F

Subscriber Identifier

REF02 –Sponsor ICN Sponsor ICN will be sent in REF02 where REF01 = ‘6P’ of the 2100C loop in the 271

59 DTP*303

Maintenance Affective Date

DTP03 – Date of Service

62 2100A NM1 Member Name

NM108 – ZZ

NM109

Beneficiary ICN

AMT

Member Policy Amounts

AMT01 – D2

AMT01 – FK

AMT01 – R

D2- Individual Deductible

FK- Family Deductible

R- Individual CAT CAP

11. APPENDICES

11.1. Appendix A: 834 Mapping

Loop Segment/Element Name Value Required Element

ISA ISA01AUTH_QUAL Authorization Information Qualifier

00 R

ISA02AUTH_INFO Authorization Information

10 spaces R

ISA03SCR_INFO_QUAL Security Information Qualifier

00 R

ISA04SCR_INFO Security Information 10 spaces R

ISA05SND_ID_QUAL Interchange ID Qualifier

ZZ R

ISA06SND_ID Interchange Sender ID VAFSCVFMP R

ISA07RCV_ID_QUAL Interchange ID Qualifier

ZZ R

ISA08RCV_ID Interchange Receiver

ID

PayerEDI R

ISA09INTCHG_DT Interchange Date YYMMDD R

ISA10INTCHG_TM Interchange Time HHMM R

ISA11INTCHG_STD Interchange Control Standards ID

$ R

ISA12INTCHG_VER Interchange Control Version Number

00501 R

ISA13INTCHG_NBR Interchange Control Number

XXXXXXXXX

R

ISA14ACK_RQST Acknowledgement Requested

0 R

ISA15USE_IND Usage Indicator P R

ISA16CPNT_ELE_SEP Component Element Separator

: R

Segment Delimiter ~ ~

GS GS01 Functional Identifier Code

BE R

GS02 Application Sender Code

VAFSCVFMP R

GS03 Application Receiver Code

PayerEDI R

GS04 Date CCYYMMDD R

GS05 Time HHMMSSDD R

GS06 Group Control Number XXXXXXXXX R

GS07 Responsible Agency Code

X R

GS08 Version Identifier Code 005010X220A1 R

Header ST01 Transaction Set Identifier Code

834 R

ST02 Transaction Set Control Number

00000001 + 1 R

ST03 Implementation Convention Reference

005010X220A1 R

BGN01 Transaction Set Purpose Code

00 R

BGN02 Reference Identification eCAMS claim number

R

BGN03 Transaction Set Creation Date

CCYYMMDD R

BGN04 Transaction Set Creation Time

HHMMSS R

BGN05 Time Zone Code UT R

BGN08 Action Code 2 R

Functional 1000A

Sponsor Name

N101 Entity Identifier Code P5 R

N102 Name IVC Payer EDI R

N103 Identification Code Qualifier

FI R

N104 Sponsor Identifier 841469824 R

1000B Payer

N101 Entity Identifier Code IN R

N102 Name FSC_eCAMS R

N103 Identification Code Qualifier

94 R

N104 Sponsor Identifier VAFSCVFMP R

Member Level

INS01 Subscriber Indicator Y R

INS02 Individual Relationship Code

18 R

INS03 Maintenance Type Code

001 R

INS05 Benefit Status Code A R

INS08 Employment Status Code

AC

REF01 Subscriber Number 0F R

REF02 Subscriber Identifier Sponsor ICN R

2100A Member Name

NM101 Entity Identifier Code IL R

NM102 Entity Type Qualifier 1 R

NM103 Name Last or Organization Name

Beneficiary Last Name

R

NM104 Name First Beneficiary First Name

NM108 Identification Code Qualifier

ZZ R

NM109 Identification Code Beneficiary ICN

AMT01 Amount Qualifier Code D2 R

AMT02 Monetary Amount Individual Deductible

AMT01 Amount Qualifier Code FK R

AMT02 Monetary Amount Family Deductible

AMT01 Amount Qualifier Code R R

AMT02 Monetary Amount Individual CAT CAP

SE

Transaction Set Trailer

SE01 Number of Included Segments

Total Count from the ST to SE

SE02 Transaction Set Control Number

00000001 + 1

GE

Functional

Group Trailer

GE01 Number of Transaction Sets Included

GE02 Group Control Number NEEDS TO BE THE

SAME NUMBERS

AS GS06

R

IEA

Interchange Control Trailer

IEA01 Number of Included Functional Groups

R

IEA02 Interchange Control Number

NEEDS TO BE THE

SAME NUMBER AS

ISA13

R

11.2. Glossary

Term Definition CAT CAP Out of pocket maximum.

Component Integration Testing (CIT) A form of putting together all the components (programs or units) of an application which are unit tested and all other components that make for the whole system.

EDI 834 A standard file format in the United States for electronically exchanging health plan enrollment data between employers and health insurance carriers.

EDI 999 An Implementation Acknowledgement document.

The 999 is used to confirm that a file was received.

EDI Gateway The EDI system used to as the internal clearinghouse to the VA.

EDI TAS (Transaction Application Suite) The suite of EDI systems that the IVC Payer EDI Team owns and maintains.

Financial Management System (FMS) Vendor File

Vendor information required for payments at Treasury.

Health Insurance Portability and Accountability Act (HIPAA)

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) developed regulations to protect the privacy and security of certain health information.

Independent Validation and Verification testing (IVV)

An independent system assessment that analyzes and tests the target system to 1) ensure that it performs its intended functions correctly, 2) ensure that it performs no unintended functions, and 3) measure its quality and reliability.

Initial Operating Capability (IOC) The state achieved when a capability is available in its minimum usefully deployable form.

Interface Control Document (ICD) Provides a record of all interface information generated for a project. The underlying interface documents provide the details and describe the interface or interfaces between subsystems or to a system or subsystem.

OCC (Office of Community Care) IVC works closely with Veterans and their families, community providers, and VA staff to ensure Veterans can get care from community providers when needed.

IVC Payer Electronic Data Interchange (EDI) Team

The project team that maintains the EDI Gateway.

Requirements Traceability Matrix (RTM) A document that links requirements throughout the validation process. The purpose of the Requirements Traceability Matrix is to ensure that all requirements defined for a system are tested in the test protocols.

Technical Report Type 3 (TR3) The TR3, or also-known-as HIPAA Implementation Guides, are the ultimate reference manuals for the EDI standards in the Health Care Industry.

User Acceptance Testing (UAT) The last phase of the software testing process.

During UAT, actual software users test the software to make sure it can handle required tasks in real-world scenarios, according to specifications.

VHA (Veterans Health Administration) The Veterans Health Administration (VHA) is the largest integrated health care system in the United States, providing care at 1,255 health care facilities, including 170 VA Medical Centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics) to over 9 million Veterans enrolled in the VA health care program.

VFMP (Veteran Family Member Program) Includes the ChampVA, Spina Bifida and Children of Women of Vietnam Veterans (CWVV) programs.

VFMP (Veteran Family Member Program) ECM (Eligibility and Claims Modernization)

The project will create a system to adjudicate the VFMP claims.

12. Approval Signatures

This section is used to record the approval of the Payer EDI Companion Guide during the Formal Review.

Conduct the review face-to-face where signatures can be obtained ‘live’ during the review. If unable to conduct a face-to-face meeting, conduct the review via a teleconferencing medium and capture concurrence during the meeting or if approved by all parties, through email. The Scribe should add names by each position cited.

The following members governing the document are required to sign. Please annotate signature blocks accordingly.

X__________________ James Plastow

Payer EDI Product Line Manager or Delegate

X__________________ Ferenc Ayer Payer EDI Product Owner or Delegate

X__________________ Derek Muller

FSC Project Manager or Delegate

X__________________ Nadia Afifi

VA VHA VFMP Program Office

Program Management Officer or Delegate

12. Approval Signatures