Attachment Ie Pre-Adjudication 277CA Community Care Network Companion Guide.pdf

PRE-DECISIONAL

DEPARTMENT OF VETERANS AFFAIRS

INTEGRATED VETERAN CARE (IVC)

HIPAA Transaction Standard Companion Guide Health Care

Information Status Notification

Based on ASC X12 version 005010X214 (277CA)

Preadjudication 277CA from Community Care Network Third Party

Administrator to VA IVC

July 2025

Document Information

Version History

Version Date Version Description

1.0 08/01/2025 Document creation

Disclosure Statement

Copyright 2025 by the Department of Veterans Affairs (VA) Integrated Veterans 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 v005010x214 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) Integrated Veterans 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

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

5.3. VETERANS HEALTH ADMINISTRATION (VHA) CUSTOMER SERVICE NUMBER

5.4. APPLICABLE WEBSITES/E-MAIL

6. CONTROL SEGMENTS AND ENVELOPES

7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS

8. ACKNOWLEDGEMENTS AND/OR REPORTS

9. TRADING PARTNER AGREEMENTS

10. TRANSACTION SPECIFIC INFORMATION

11. APPROVAL SIGNATURES

1.0 Introduction

This companion guide is intended to assist in development and deployment of transmitting Pre- Adjudication Health Care Information Status Notification to support the Integrated Veteran Care (IVC) Community Care Network (CCN). Pre-Adjudication refers to those claims that are submitted by Community Care Providers to the Community Care Network Third-Party Administrator (CCN TPA) for adjudication and reimbursement. The companion guide serves as an addendum to any technical documentation supplied by the health care clearinghouse when establishing a trading partner agreement.

The VA IVC follows the ASC X12N/005010X214, Health Care Information Status Notification: Claims Acknowledgement (277CA) Technical Report Type 3 (TR3) documentation and does not introduce any additional segments or limitations in segment data in the transmission

1.1 Scope

This document covers business and technical processes enacted by the VA IVC Community Care Network Third Party Administrator which vary from expectations governed by the 837 Professional TR3 when processing ASC X12N/005010X214, Health Claim: Professional transactions.

1.2 Overview

This document is intended to supplement the EDI 277CA TR3 and any additional Errata guides published by the ASC and any additional companion guide supplied to CCN TPA. 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.

CCN TPA -to- CCN Provider

Step 1. CCN TPA will validate CCN X12 837 batches to SNIP 3 through 6 after creating X12 999 after receiving batches from the TPA HCCH.

• X12 837 batches from the HCCH to CCN will be restricted to claims for the CCN contract. (Restricted to a single Payer ID)

Step 2. The CCN TPA will create an X12 277CA transaction for each X12 837 that is validated

Step 3. The CCN TPA will create a single X12 277 X214 batch for each X12 837 batch received.

Step 4. The CCN TPA will transmit X12 277 X12 batch to HCCH within 24 hours.

Step 5. TPA HCCH will transmit a copy of X12 277 X214 to IVC HCCH.

1.3 References

This companion guide supports the EDI 277CA TR3 and any additional Errata guides published by the ASC.

The 837P implementation guide (TR3) can be purchased at: https://x12.org/

The CAQH COR Payer Operating rules can be found at: https://www.caqh.org/core/operating-rules

2.0 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.

3.0 Testing with the Payer

3.1 Testing

All payer testing of a new trading partnership must be coordinated with the HCCH. The VHA will conduct end-to-end testing from the CCN TPA through the HCCH to the VHA prior to Production.

https://x12.org/ https://www.caqh.org/core/operating-rules

4.0 Connectivity with the Payer/ Communications

Process Flows

VA Parallel with HCCH as source of all transactions to VA

T P A

H C

C H

C C

N P ro v id e r

T P A

V A

V A

H C

C H

Start Sends claim to

HCCH

Sends a copy of the batch to both the TPA and VA

TPA 277CA

process

Provider Receives

277CA

End

HCCH creates batch for single

Payer ID

VA Process Store

837 batch (F.E.E., EPRS, CDR)

277CA sent to

Provider and VA

HCCH Pass through 277CA

TPA Adjudicate claim

TPA creates and send 835

TPA creates and send 837COB for reimbursement

835 sent to

Provider and VA

Provider Receives

VA Receives pass through Provider

837COB sent to

VA

VA Receives

837COB

VA verifies and sends 277CA for

837COB

VA creates final disposition and sends 835

TPA recieves 835 for 837COB

TPA receives

277CA for 837COB

HCCH pass thru

VA Receives

Provider 835

VA Receives 277CA

All EDI communication is further detailed in the EDI Gateway 277CA Interface Control Document

(ICD).

4.1 Transmission Administrative Procedures

All timing and transmission of EDI communication is to be coordinated with the Health Care Clearing

House. Details will be agreed upon in a signed Interface Control Document (ICD).

4.2 Re- Transmission Procedure

Retransmissions of EDI, regardless of cause, should be coordinated with the Health Care Clearing House.

4.3 Communications Protocol Specifications

All communication should be coordinated with the clearinghouse contracted to the VA IVC.

5.0 Contact Information EDI Customer Service

5.1 EDI Technical Assistance

All EDI technical assistance should be coordinated with the clearinghouse contracted to the VA IVC.

Email groups for VA transmission inquiries: CCPP-PST@va.gov

5.2 EDI Business Assistance

Email group for Integrated Veteran Care Payer EDI Team: VHAOIVCPMDPayerEDI@va.gov mailto:CCPP-PST@va.gov mailto:VHAOIVCPMDPayerEDI@va.gov

5.3 Applicable Websites/ E-Mail

Homepage for iEDI Clearinghouse: https://www.optum.com

Homepage for the Department of Veterans Affairs: https://www.VA.gov

Homepage for the VA IVC: https://www.VA.gov/communitycare

Email group for Integrated Veteran Care Payer EDI Team: VHAOIVCPMDPayerEDI@va.gov

Email groups for VA transmission inquiries: CCPP-PST@va.gov

CCRS POC Email

Anil Kowatra Anil.Kowatra@va.gov

Brendan Hoar Brendan.Hoar@va.gov

Elizabeth Curfman Elizabeth.Curfman@va.gov

Eric Budde Eric.Budde@va.gov

Jacquilyn Kilo Jacquilyn.Kilo@va.gov

Jennifer DaSilva Jennifer.DaSilva@va.gov

Lam Ly Lam.Ly@va.gov

Michael Larson Michael.Larson2@va.gov

6.0 Control Segments/Envelopes

6.1 ISA-IEA/GS-GE

The ISA and IEA values for Pre-Adjudication transactions sent from the CCN TPA to the TPA HCCH will be decided between the HCCH and the TPA. The CCN TPA will need to provide documentation on the Sender and Receiver IDs to the HCCH representing IVC and the Payer EDI team. An example of that documentation in found in 6.3.

6.2 Example of a 277 ISA and GS

The GS and GE values for Provider 277CA batches sent from the CCN TPA to the TPA HCCH will be decided between the TPA and the HCCH. The CCN TPA will need to provide documentation on the

Sender and Receiver IDs the HCCH representing IVC and the Payer EDI team. An example of that documentation in found in 6.3.

https://www.optum.com/ https://www.va.gov/ https://www.va.gov/communitycare file:///C:/Users/vhahacmatthb/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/HUTJWDBK/VHAOIVCPMDPayerEDI@va.gov mailto:CCPP-PST@va.gov mailto:Anil.Kowatra@va.gov mailto:Brendan.Hoar@va.gov mailto:Elizabeth.Curfman@va.gov mailto:Eric.Budde@va.gov mailto:Jacquilyn.Kilo@va.gov mailto:Jennifer.DaSilva@va.gov mailto:Lam.Ly@va.gov mailto:Michael.Larson2@va.gov

6.3 837 Envelope Format

EDI 837\837COB

File Type: 277CA Institutional

Data Element Separator Delimiter:

Loop 2320

Repetition Separator: ̂

Component Element Delimiter: :

Segment Terminator Delimiter: ~

ISA01 value: 0

ISA02 value: 10 spaces

ISA03 value: 0

ISA04 value: 10 spaces

ISA05 value: ZZ

ISA06 value: VACCN

ISA07 value: ZZ

ISA08 value: TPA HCCH ID

ISA09 value: yymmdd

ISA10 value: hhmm

ISA11 value: $

ISA12 value: 00501

ISA13 value: must match IEA02 Unique ID

ISA14 value: 0

ISA15 value: P

ISA16 value: :

GS01 value: HN

GS02 value: must match ISA06 VACCN

GS03 value: must match ISA08 TPA HCCH ID

GS04 value: ccyymmdd

GS05 value: hhmm

GS06 value: Unique ID

GS07 value: X

GS08 value: 005010X214

2100A NM103: VHA Community Care Network

2100A NM109: CCN Payer ID

2100B NM103: VACCN

2100B NM109: VACCN

7.0 Payer Specific Business Rules and Limitations

The CCN TPA will respond to each X12 837 transaction received with an X12 277CA transaction.

This will create a one-to-one ratio of X12 837 transactions to X12 277CA transactions.

The CCN TPA will create a separate X12 277CA batch for each CCN batch received from the TPA HCCH. This will create a one-to-one ratio of CNN X12 837 batches received to X12 277CA batches created.

Because the requirement to limit the CCN X12 837 batches to contain only transactions for CCN then the CNN 277CA batch will contain only transactions for CCN. This will help avoid HIPAA violations.

The CCN TPA will populate the REF*1K of the 2200D loop with a globally unique value (no other 837 2300 loop will be assigned the same value)

The CCN TPA will populate the REF*D9 of the 2200D loop with the REF*D9 value that was sent in the 837 2300 loop (The REF*D9 is required on all X12 837 sent from the TPA HCCH to the TPA for

CCN)

8.0 Acknowledgements/Reports

8.1 Acknowledgements

No acknowledgements will be returned upon receipt of a CCN X12 277CA batch received by the IVC

Payer EDI Gateway.

9.0 Trading Partner Agreements

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

10.0 Transaction Specific Information

This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that VHA has something additional, over and above, the information in the IGs.

In addition to the row for each segment, one or more additional rows are used to describe VHA usage for composite and simple data elements and for any other information.

The following table specifies transaction information for the EDI 277CA:

Page # Loop

ID

Reference Name Codes Length Comments/ Notes

231 ISA

Interchange Control Header

ISA06 = Clearing House Receiver ID

ISA08 = CCN TPA

Sender ID

ISA11 = $

ISA15 = P

ISA16 = >

Delimiter = ~

235 GS

Functional Group Header

GS02= Clearing House Receiver ID

GS03= CCN TPA

Sender ID

85 2200D REF

Payer Claim Control Number

REF01=1K

REF02

REF02 will be populated with the Internal Control Number (ICN)/Claim Control Number of the CCN TPA. This will be a unique value for each X12 837 2300 loop received.

86 REF

Claim Identification Number for Clearinghouses and Other Transmission Intermediaries

REF01=D9

REF02

REF02 will be populated with the value found in the corresponding 837 2300 loop in the REF02 element where REF01=D9.

11.0 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__________________