HIPAA 5010 276/277 Conpanian Guide

HIPAA 5010 276/277 Conpanian Guide

B

LUE

C

ROSS

B

LUE

S

HIELD OF

S

OUTH

C

AROLINA

ASC X12N 276 (005010X212A1)

H

EALTH

C

ARE

C

LAIM

S

TATUS

R

EQUEST

P

HASE

II

S

YSTEM

C

OMPANION

G

UIDE

V

ERSION

1.1

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D

ISCLOSURE

S

TATEMENT

Please note that the information in this guide is subject to change. Any changes will be available at www.SouthCarolinaBlues.com

.

This transaction se t can be used to inquire about the eligibility, coverage or benefits associated with a benefit plan, employer, plan sponsor, subscriber or a dependent under the subscriber’s policy. The transaction set is intended to be used by all lines of insurance such as health, life, and property and casualty.

The information describes specific requirements for processing BlueCross BlueShield of

South Carolina HIPAA ASC X12/005010X212 Health Care Claim Status Requests (276) submitted via EDI (Electronic Data Interchange) (1) (2).

BlueCross BlueShield of South Carolina accepts these general claim status inquiries:

1. All claim header and line information for a specific patient and provider

2. All claim header and line information for a specific patient, provider and claim number

3. All claim header and line information for a specific patient, provider and service date range

4. All claim header and line information for a specific patient, provider and total charge

5. All claim header and line information for a specific patient, provider service date range and total charge

Each request may contain one patient and one provider. Because each request is specific to one patient and one provider, only one DMG segment will appear in each request — either 2000D DMG when the patient is the subscriber, or 2000E DMG when the patient is a dependent. When the subscriber is the patient, the 2200D DTP segments are required.

When the patient is a dependent, the 2200E AMT and DTP segments are required.

If BlueCross BlueShield of South Carolina is able to locate the Subscriber Identification

Number submitted in the request, but cannot determine the applicable patient on the contract, it will return claims for all patients on the contract that match the submitted

Provider Identification Number and fall within the submitted date of service range.

The AMT segment is not required. If it is submitted, the AMT02 element does not include an implied decimal point, and leading zeros are suppressed. For example, to enter a claim amount of $100.00, the value of the AMT02 field will appear as *100*. To enter $100.20, the amount will appear in the data stream as *100.2*. Likewise, $100.01 will appear in the field as *100.01*. A maximum of 10 characters are allowed in this element.

The DTP segment is required even when the requestor does not want the claims filtered according to claim amount or service date. In requests that do not have a total charge specified (numbers 1–3 above) the AMT02 element must contain a single 0 (zero) in the field. Otherwise, the total amount of the claim is entered. The AMT02 element does not include an implied decimal point, and leading zeros are suppressed. For example, to enter a claim amount of $100.00, the value of the AMT02 field will appear as *100*. To enter

$100.20, the amount will appear in the data stream as *100.2*. Likewise, $100.01 will appear in the field as *100.01*. A maximum of 10 characters are allowed in this element.

To ensure that the request does not exclude any claims based upon date of service,

BlueCross recommends that the DTP03 element in the 2200D or 2200E loop begin with

20000101 (January 1, 2000) and end with the last day of the current year request dater. For

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example, when a request for claim status is sent on August 31, 2009, the DTP line should appear as DTP*232*RD8*20000101-20090831~.

This date range ensures that all relevant claims are returned.

BlueCross BlueShield of South Carolina currently accepts one type of transaction per transmission. Therefore, all ST01 elements within the transmission will equal the same transaction number. For example, 14 276 transactions are acceptable within one enveloping sequence, but 13 276s and one 837I within one enveloping sequence is unacceptable.

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P

REFACE

This Companion Guide to the v5010 ASC X12/005010X212 Health Care Claim Status

Requests (276) Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with BlueCross

BlueShield of South Carolina and its subsidiaries’ Health Plan. Transmissions based on this companion guide, used in tandem with the v5010 ASC X12/005010X212 Health Care

Claim Status Requests (276) Implementation Guides, are compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12/005010X212 Health Care Claim Status Requests

(276) Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides.

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Table of Contents

1. INTRODUCTION ........................................................................................................ 7

1.1 Scope ............................................................................................................... 7

1.2 Overview ........................................................................................................... 7

1.2.1 What Is CAQH? .......................................................................................... 7

1.3 References ........................................................................................................ 7

1.3.1 ASC X12 Version 5010A1 Implementation Guides ............................................ 7

1.3.2 BlueCross BlueShield of South Carolina: ......................................................... 7

1.3.3 CAQH ....................................................................................................... 7

1.4 Additional Information .......................................................................................... 7

2. GETTING STARTED .................................................................................................... 8

2.1 Working with BlueCross BlueShield of South Carolina ................................................. 8

2.2 Trading Partner Registration .................................................................................. 8

2.3 Testing Transactions ............................................................................................ 8

3. TESTING WITH THE PAYER .......................................................................................... 9

3.1 Payer Testing ..................................................................................................... 9

3.2 Transition from Test to Production Status ................................................................ 9

4.

CONNECTIVITY/COMMUNICATIONS ............................................................................ 10

4.1 Dial-up REDI .................................................................................................... 12

4.2 Server Connection Using Asynchronous Dial-up ....................................................... 13

4.3 Log In and User Validation .................................................................................. 14

4.3.1 Messages ............................................................................................... 15

4.3.2 Main Menu ............................................................................................. 16

4.3.3 Upload a File ........................................................................................... 17

4.3.4 Download a Response ............................................................................... 18

4.4 List Files in Mailbox for X12 Transactions ............................................................... 19

4.5 Password Change Procedures ............................................................................. 21

4.6 Dial-up FTP ...................................................................................................... 27

4.6.1 Uploading Files Using FTP .......................................................................... 29

4.6.2 Downloading Files Using FTP ...................................................................... 30

4.7 Secure File Transfer Protocol (SFTP) ..................................................................... 31

4.8 Connect Direct: NDM ......................................................................................... 31

4.9 TCPIP ............................................................................................................. 32

4.10 EDIG Proprietary Claim Responses ..................................................................... 32

4.11 Claim Submission Summary Report .................................................................... 33

4.11.1 Error Claim Summary Report .................................................................... 33

4.11.2 Error Claim Summary Report: Batch TA1/999 Process Flow ............................ 34

4.11.3 Error Claim Summary Report: 271 Batch Pickup Process Flow ......................... 35

4.12 Transmission Administrative Procedures .............................................................. 36

4.12.1 Structure Requirements ........................................................................... 36

4.12.2 Response Times ..................................................................................... 36

4.13 Re-Transmission Procedures ............................................................................. 36

4.14 Communication Protocols ................................................................................. 37

4.14.1 Header Requirements ............................................................................. 37

4.14.2 Error Reporting ...................................................................................... 38

4.14.3 Submission/Retrieval .............................................................................. 38

4.14.3.1 Real-time ........................................................................................... 38

4.14.3.2 Batch ................................................................................................ 38

4.14.4 Examples .............................................................................................. 39

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4.15 SOAP + WSDL ................................................................................................. 50

4.15.1 SOAP XML Schema ................................................................................. 50

4.15.2 WSDL Information .................................................................................. 50

4.15.3 SOAP Fault Formatting............................................................................. 50

4.15.4 Error Reporting ...................................................................................... 52

4.15.5 Submission/Retrieval .............................................................................. 53

4.15.5.1 Real-time ........................................................................................... 53

4.15.5.2 Batch ................................................................................................ 53

4.15.5.3 SOAP Header ...................................................................................... 53

4.15.4 SOAP Sample Fault ................................................................................. 54

4.16 General Specifications Applicable to Both Envelope Methods ................................... 55

4.16.1 Request and Response Handling ............................................................... 55

4.16.2 Submitter Authentication and Authorization Handling .................................... 55

5. CONTACT INFORMATION .......................................................................................... 56

5.1 EDI Customer Service and Technical Assistance ...................................................... 56

5.2 Provider Service Number .................................................................................... 56

5.3 Applicable Web/Email Contact Information ............................................................ 56

6. CONTROL SEGMENTS/ENVELOPES ............................................................................ 57

6.1 EDIG Specifications for Enveloping X12 Transactions ............................................... 57

6.2 X12 Outbound Transactions ................................................................................ 58

7. PAYER SPECIFIC BUSINESSS RULES AND LIMITATIONS .................................................. 59

7.1 Supported Service Types .................................................................................... 59

8. ACKNOWLEDGMENTS ............................................................................................. 64

8.1 EDIG Acknowledgment and Response Transactions Matrix ........................................ 64

9. TRADING PARTNER AGREEMENTS ............................................................................. 65

9.1 The Enrollment Process ...................................................................................... 65

9.2 Clearinghouse Trading Partner Agreement ............................................................. 65

9.3 Hospital and Physician Trading Partner Agreement .................................................. 65

9.4 Enrollment Process for Direct Transactions ............................................................ 65

9.5 Enrollment for Providers Using a Clearinghouse ...................................................... 66

10. Transaction-Specific Information .............................................................................. 67

A. APPENDICES.......................................................................................................... 74

A1. Implementation Checklist ................................................................................... 74

B1. Business Scenarios ........................................................................................... 74

C1. Frequently Asked Questions ................................................................................ 75

D1. Trading Partner Enrollment ................................................................................. 76

E1. Clearinghouse Trading Partner Agreement ............................................................. 82

F1. Hospital & Healthcare Professional Agreement ........................................................ 93

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1. INTRODUCTION

This application for real-time and batch 276/277s follows the CAQH Phase II guidelines.

1.1 Scope

Providers, billing services and clearinghouses are advised to use the ASC

X12/005010X212 Health Care Claim Status Requests (276) Implementation Guide as a basis for their submission of Eligibility and Benefit inquiries. This companion document should be used to clarify the business rules for 276/277 data content requirements, batch and real-time acknowledgment, connectivity, response time and system availability, specifically for submissions through the system. These rules differ from the Companion

Guide for submissions via BlueCross BlueShield of South Carolinas EC Gateway connection. This document is intended for use with CAQH compliant systems.

1.2 Overview

The purpose of this document is to introduce and provide information about BlueCross

BlueShield of South Carolinas CAQH solution for submitting real-time 276/277 transactions.

1.2.1 What Is CAQH?

CAQH stands for the Council for Affordable and Quality Healthcare. It is a not-for-profit alliance of health plans, provider networks and associations with a goal to provide a variety of solutions to simplify health care administration.

1.3 References

1.3.1 ASC X12 Version 5010A1 Implementation Guides

: http://www.wpc-edi.com

1.3.2 BlueCross BlueShield of South Carolina:

http://www.hipaacriticalcenter.com/UserFiles/hipaacritical/Documents/GPNet%2011_1%2

0Manual052012.pdf

1.3.3 CAQH

: www.caqh.org/benefits.php

1.4 Additional Information

Submitters must have Internet (HTTPS) connection capability to submit a 276 request and receive 277 responses.

The submitter must be associated with at least one provider in the BlueCross BlueShield of South Carolina provider database.

Both real-time and batch 276 inquiries are supported.

This system supports inquiries for BlueCross BlueShield of South Carolina members only.

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2. GETTING STARTED

2.1 Working with BlueCross BlueShield of South Carolina

Providers, billing services and clearinghouses interested in submitting 276 inquiries and receiving 277 responses via BlueCross BlueShield of South Carolina should contact

BlueCross BlueShield of South Carolina by visiting www.hipaacriticalcenter.com

and clicking on Contact Us on the top right.

2.2 Trading Partner Registration

Enrollment with the EDI Gateway requires prospective trading partners to complete and submit the BlueCross BlueShield of South Carolina EDIG Trading Partner Enrollment

Form and the Trading Partner Agreement. The purpose of the BlueCross BlueShield of

South Carolina EDIG Trading Partner Enrollment Form is to enroll providers, software vendors, clearinghouses and billing services as trading partners and recipients of electronic data. It is important you follow these instructions and complete all the required information. We will return incomplete forms to the applicant, which could delay the enrollment process.

2.3 Testing Transactions

These vendors have successfully tested and implemented their HIPAA version 5010

276/277 X12N 276 Health Care Claim Status Request transactions with us.

Company Contact Information

Athena Health 888-652-8200

Emdeon

MBA Technologies

McKesson

MedData

Med-Vantage

877-363-3666

828-233-0001

800-806-5730

800-877-8577

415-814-7100

Passport Health

RealMed

888-651-5657

877-723-5633

Recondo Technology 888-732-6672

Tera Health Inc. (MPV) 866-930-1230

800-426-3385 ViaTrack

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3. TESTING WITH THE PAYER

There are fewer problems with trading partner exchange of electronic transactions in the production environment when you conduct testing. EDI Gateway requires trading partners test every transaction for every payer prior to approval for production status. This testing includes security validation, connectivity, X12 TR3 edits and front-end payer edits when available in the test environment.

These tests must be performed for each different transaction type that a trading partner is approved to submit to EDIG:

Test Plan

EDIG and the trading partner will agree to a predefined set of test data with expected results. The matrix will vary by transaction and trading partner. Also, we will develop a plan for a test to production transition that considers volume testing and transaction acceptance ratios.

Connectivity

You will find EDIG-supported connectivity protocols in the

“Connectivity” topic in this section. This first level of testing is complete

Security

Data Integrity

when the trading partner has successfully sent to and received from

EDIG a test file via one of the EDIG-supported connectivity options.

EDIG will validate approved trading partners are submitting transactions allowed per our enrollment applications.

When HIPAA X12 transactions are transmitted, data integrity is determined by X12 TR3 edits results performed by EDIG’s TR3 editor.

Testing cannot progress until a trading partner’s data receives no TR3 edit errors. EDIG expects there may be an occasional situation in which a trading partner’s TR3 edit interpretation differs from our interpretation. We will work with our trading partner to resolve such differences on an individual basis. EDIG returns transmission acknowledgment and edit results response transactions from this

Acknowledgment/

Response

process. The trading partner should correct transactions reported as errors and resubmit them.

Trading partners must demonstrate the ability to receive acknowledgment and response transactions from EDIG. EDIG expects

Transactions

trading partners will also implement balancing or reconciliation processes and report transmission discrepancies to us immediately.

Results Analysis

EDIG and the trading partner will review acknowledgment and response transactions for consistency with the predefined expected results.

3.1 Payer Testing

Depending on the line of business and transaction, the payer may require additional testing.

If so, EDIG Operations will inform the trading partner when test plans are discussed.

3.2 Transition from Test to Production Status

When test results have satisfied the test plan and the Trading Partner Agreement has been executed, we will change the trading partner’s submission status from test to production. At this time, the trading partner can begin to send production transaction data to EDIG.

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4.

CONNECTIVITY/COMMUNICATIONS

BlueCross BlueShield of South Carolina provides access to a number of internal processes via Web services.

Partners are issued an identifier known as the Consumer ID by BlueCross BlueShield of

South Carolina during project initiation. The Consumer ID is used for two purposes: to identify the requesting partner for authorization and to track service usage for reporting.

This Consumer ID is tied internally to the public key you provide for authorization.

All BlueCross BlueShield of South Carolina Web services conform to the WS-I Basic

Profile v1.1

, and implement security measures defined within the WS-I Basic Security

Profile v1.0

. The minimum security measures required by BlueCross BlueShield of South

Carolina are:

1. All communication traversing public IP networks must be secured by transport layer encryption. TLS v1.2 is preferred, but TLS v1.0 or SSL v3.0 is acceptable if no alternatives exist. BlueCross BlueShield of South Carolina can support IPSec-based

Virtual Private Networks and link layer encryption dedicated circuits on a case-by-case basis.

2. All messages must contain a unique WS-Security utility Timestamp within a WS-

Security header with the creation time and expiration time. The period of validity for test environments is five minutes. The period of validity for the production environment is one minute.

3. Each web service request must contain a unique Message ID per WS-Addressing standards.

4. All web service requests must be digitally signed by the partner using a standard XML

Digital Signature . The signed elements must include: a) The SOAP body element. b) The WS-Security timestamp element. c) The WS-Addressing Message ID element.

The signature must employ XML Canonicalization v 1.0

With Comments

( http://www.w3.org/TR/2001/REC-xml-c14n-20010315#WithComments ).

All algorithms required by the WS-I Basic Security Profile v1.0

are supported, but our preferred algorithms are:

Block Cipher: AES-256 ( http://www.w3.org/2001/04/xmlenc#aes256-cbc )

Digest: SHA-256 ( http://www.w3.org/2001/04/xmlenc#sha256 )

5. Requests and/or responses may be encrypted if the data contained within the request or response is sufficiently sensitive. If encryption is employed, the encrypted element

must be a child of either the SOAP header or the SOAP body elements.

6. Responses may be digitally signed by BlueCross BlueShield of South Carolina if the partner desires.

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The GPNet communication interface supports asynchronous telecommunications up to 56K bps. It will support numerous asynchronous telecommunication protocols, including Kermit,

Xmodem (Check Sum), Ymodem (Batch) and Zmodem. Most off-the-shelf communication software will support one or all of these protocols. You can select any of the protocols listed here. We recommend Zmodem, however, based on its speed and reliability. The asynchronous user’s modem should be compatible with 56K, V.34 - 28.8 bps, and V.42 -

14.4 bps.

• ProComm Plus, Release 2.11 (Windows)

• Crosstalk, Release 2.2 (Windows)

• QuickLink2, Release 1.4.3 (Windows)

• PC Anywhere, Release 2.0 (Windows)

• Term, Release 6.1, 6.2, and 6.3

• Mlink, Release 6.07

• HyperTerminal, Windows ‘95, ‘98, and NT

The settings you should verify are:

• Terminal emulation – VT100

• Parity – NONE

• Data Bits – 8

• Stop Bits – 1

For Zmodem, ensure that both sender and receiver crash recovery is “OFF” or set to

“OVERWRITE.” When downloading a file, this setting will determine whether Zmodem overwrites an existing file of the same name. Since the response file name will be repeated, we recommend that the downloaded files be renamed or moved to another directory immediately to avoid losing or overwriting a file.

In addition, we encourage the use of PKZIP compatible compression software. GPNet defaults to send uncompressed files. Therefore, if you wish to receive your files in a compressed format, please indicate this on your enrollment form or contact the Technology

Support Center.

The GPNet asynchronous transmission is a dial-up connection. Depending on your operating system, your windows may display differently than those noted in these figures.

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4.1

Dial-up REDI

Initial Set Up Using Asynchronous Dial-up

To submit files using the GPNet asynchronous dial-up, first you must make a connection and log in.

1. Click on Start, then Programs, then

Accessories, and then click on the

HyperTerminal option. This will open the

Connection Description window. Type a name and choose an icon for the connection. Then click on OK. (Figure 1)

Note: If you are unable to locate

HyperTerminal under Accessories, look in the Communications option. If unable to find that option, then look up “Installing

Windows Components” in Windows Help.

2. The Connect To message box (Figure 2) is where you enter the GPNet phone number, and verify your country code, area code and modem. Complete these steps: a) For Country/region, select United

States of America (1) if it does not initially display in the field. b) In the Area code field – Enter 803. c) In the Phone number field – Enter 788-

6147 for production or 788-3362 for test. d) In the Connect using field you should already see a description of your modem. Verify that it is correct or use the menu to select the correct modem. e) Click OK.

Figure 1 – Connection Description Box

Figure 2 – Connect To Message Box

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4.2 Server Connection Using Asynchronous Dial-up

1. The Connect message boxes (Figures 3 and 4) let you dial GPNet and see the status of your call. Complete these steps to make your connection: a) If the Phone number for GPNet and

Your location are correct (Figure 3), click Dial.

Notes:

• If you need to correct the telephone number, modem setting or connection icon, click the Modify button. Click the Dialing Properties button only if you need to correct information about your telephone settings.

• If you have to dial 9 for an outside line, make sure a 9 is displayed in front of the phone number. If not, go to Modify and make appropriate changes.

2. Click on Dial Now. The Connect message box will change to display

Status information. After dialing completes, you are connected to the

GPNet Gateway (Figure 4).

Figure 3 – Connect Message Box

Figure 4 – Connect Message Box

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4.3 Log In and User Validation

Upon connecting to the GPNet system via your communications program, the system will display a banner and prompt for the user ID (Figure 5).

Figure 5 – GPNet Welcome/Login Screen

You must enter the ID and password in capital letters. To log in:

1. Type your User ID and press ENTER. Note: To log into the Test Server, use your user

ID with the “Q” on the end. To log into the Production Server, use your user ID with the number on the end.

2. Type your password. The password will not display on the screen as you type it. When you have finished typing, press ENTER.

3. The system will allow three invalid login attempts before it terminates the session. Also, the system will automatically log you off after approximately two minutes of inactivity.

For assistance with password issues, please contact the BlueCross BlueShield of

South Carolina Technology Support Center at 800-868-2505 or 803-736-5980.

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4.3.1 Messages

After the User ID and password are validated, the Message screen displays (Figure 6).

Figure 6 – GPNet Message Screen

This screen features two distinct parts:

• User login information – displays information about current and previous login activity.

• The system-wide banner – displays important information for all trading partners.

After reading any banner messages, press ENTER to continue to the Main Menu.

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4.3.2 Main Menu

From the Main Menu (Figure 7), you can either choose the number or the first letter of the action you want. Press ENTER.

Figure 7 – GPNet Main Menu

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4.3.3 Upload a File

To upload a file to GPNet:

1. Type 2 (or U) from the Main Menu and then press ENTER.

2. You will be prompted to select the file transfer protocol (Figure 8). Do not press

ENTER after making your selection. Type the letter corresponding to your choice of modem protocol. (If you select Q, you will return to the Main Menu.)

Figure 8 – Upload Protocol Selection Screen

3. Using your communication software procedures, send the file you wish to upload.

4. If the file transfer is successful, “Transfer COMPLETED SUCCESSFULLY” will display on the screen (Figure 9). If the file transfer fails, the message, “Transfer FAILED,” will display.

Figure 9 – Successful Transfer Message

5. Press ENTER to return to the Main Menu.

6. Upon successful transmission of a file, you can exit the system or wait for a response file. a) To exit the system, press 5 (or Q) from the Main Menu and then press ENTER. You can dial in a few minutes later to download the TA1 and IG edit results. b) To stay on the system and check for a response file, press 3 (or L) to go to the

Mailbox and wait for the response file to load. The time between a file upload and the response file availability will vary based on the file size and user volume. Although most responses are available within one hour, please allow 24 hours before contacting the Technology Support Center.

When the response file is available (listed in your Mailbox), return to the Main Menu and proceed to the Download option.

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4.3.4 Download a Response

To download a response file:

1. Type 1 (or D) from the Main Menu and press ENTER.

2. You will be prompted to choose a modem protocol (Figure 10).

Figure 10 – Download Protocol Selection Screen

a) If you select Z (Zmodem), K (Kermit) or Y (Ymodem), the system will ask if you wish to download all files in the mailbox. If you choose “Yes” (press Y), all available files will begin downloading. If you do not want to download all of the files, choose “No” (press

N) and the system will display the list of available files (as shown in step 3). b) If you select X (the Xmodem protocol), the file list will display immediately.

3. From the list of available files (Figure 11), enter the number associated with the desired file to begin the download and press ENTER. (See the List Files in Mailbox section for information on deciphering the files listed in your mailbox.)

Figure 11 – Mailbox File List

If the file transfer is complete and successful, the “Transfer COMPLETED SUCCESSFULLY” message will appear on the screen and the file will be deleted from the mailbox. If the file transfer fails, the “Transfer FAILED” message will display. Files that have not been downloaded successfully will remain in the mailbox for 14 days before being purged.

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4.4 List Files in Mailbox for X12 Transactions

To check on files that you may have available to download from GPNet:

1. Choose List Files in Mailbox by pressing 3 (or L) from the Main Menu and press ENTER.

2. The system will prompt you to enter the name of the file you wish to see. You can type the full or a partial file name combined with an optional wildcard (*). All files matching the search pattern will be displayed. You can also leave the file name field blank and just press ENTER to see a list of all the files in your mailbox. (Note: This same list also displays when you select the Xmodem Protocol from the Download option.)

3. If no matching files are found, the system will display this message: “No files match your specified search pattern. Press RETURN to input new search pattern or q to quit.” If there are more than 15 files in the list, the system will pause and scroll the listing.

All files in your mailbox are presented in a similar format: the 8-byte download file name with a 3-byte extension, followed by a file description. This table shows examples and explanations of files that you can download:

.

This information describes the file segments:

Segment Position Description

Type

1-3 File types are identified using these 3-byte segments:

RSP EDIG proprietary claim responses

RPT EDIG proprietary claim reports

INV Invalid file response

MSG Informational messages

X12 X12 responses (TA1, 999)

EDIG-generated sequential number for each file sent to a mailbox

Sequence

4-8

Number

.

9

ZIP or Type

10-12

Period

3-byte extension:

ZIP Zipped files of any type. “ZIP” will replace the 3-byte extension in the file name based on ZIP flag in our control file.

RSP EDIG proprietary claim responses

RPT EDIG proprietary claim reports

INV Invalid file response

MSG Informational messages

13

X12 X12 responses (TA1, 999)

Period

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Segment Position Description

File

Description

14-32

14

Identifies file’s content:

PTU Production (P), Test (T) or Unknown Indicator (U)

Payer Name for Remittance Advice files (X12 835s)

15-18

19-27

Date Date the input file was received, MMDD format

28-30

Original ISA Control Number: The ISA Control Number of the first interchange group in the file.

Not used

Sample Set 1: Example of 837 claim response, report and acknowledgment files. In this example, the first production file is an 837 sent January 25, 2002, with one ISA/IEA. The file contained 235 claims and the ISA control number is ISACTRL01. Example 1 is the file name containing ASC X12 TA1, example 2 is the file name containing ASC X12 999 returned to the trading partner, example 3 is the file name containing EDIG proprietary claim response records, and example 4 is the file name containing EDIG proprietary claim reports.

Sample Set 2: In this example, the file received was an invalid file (a possible read error or unzip error). The file would contain a text message that describes the error, shown in the Response Example here.

Sample Set 3: If the file received has X12 TR3 edit errors, two files will be returned to the trading partner containing the ASC X12 TA1 and 999, respectively.

Sample Set 4: This is a file name when the file’s content is an informational message.

Sample Set 5: If the file returned to the trading partner is an ASC X12 835 transaction, the file description field will have the payer’s name (Example: “BlueCross BlueShield of

South Carolina” for BlueCross BlueShield of South Carolina commercial remittance advice files).

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4.5 Password Change Procedures

Note: Dial-up FTP does not accommodate password change commands. In order to change passwords, the trading partner should follow the password change procedures instructions in this section of the manual, or get software that allows command line (site) function to change your password.

1. Enter 6 or P from the Main Menu.

2. Once you’re in the password change procedure, select ENTER at any prompt without entering any data to exit the password management option.

3. You’ll receive a message similar to “****, you did not enter anything for ….” and “Press

ENTER to try again, or Q to quit.” Q will take you back to the Main Menu and ENTER will prompt you for the user ID or password, depending on where you are at.

4. The system will prompt you with this screen:

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5. Enter N and you will return to the Main Menu. Or enter Y and follow the instructions on the screens. You will be asked for your User ID and Current Password.

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6. The system will prompt you to enter the new password twice.

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7. If the password is valid, you will get this screen. Then just press ENTER to go back to the Main Menu.

8. If your new password does not follow the masking rule, this screen will appear and you will be sent back to the Main Menu.

• The masking rule is six to eight characters long and made up of alpha numeric characters.

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9. If the password you entered is similar to a previous password, the system will give you this error and return you to the Main Menu. Example: You changed the password for user 1GW0001SCQ from 001SCQ to 111SCQ, and later tried to re-use 001SCQ as a password. The system will not accept it. You then changed it to 001SCQXX and the system accepted the new password.

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Note: BlueCross BlueShield of South Carolina corporate policy requires all passwords to be changed every 30 days. As of June 1, 2011, all Asynchronous and FTP Dial-up trading partners must comply with this policy.

Asynchronous Dial-up users will be prompted to provide new passwords when logging in after their old passwords have expired.

Here are the guidelines for passwords:

• Password length must be six to eight characters.

• Use randomly generated passwords when feasible.

• Avoid any password based on repetition, dictionary words, letter or number sequences, usernames, relative or pet names, or biographical information (e.g., dates, ID numbers, ancestor’s names or dates).

• Include numbers and symbols in passwords.

• These symbols are allowed: ! @ # $ % ^ & * ( ) _ + ~ | - = ‘ [ ] ; : ‘ “ { } < > ? . ,

• Use uppercase and lowercase letters.

• Avoid using the same password for multiple sites or purposes.

If you cannot remember your password, or are experiencing problems with your password, please call the BlueCross BlueShield of South Carolina Technology Support

Center at 803-736-5980 or 800-868-2505 for assistance.

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4.6 Dial-up FTP

The GPNet communication interface also allows an FTP connection. This is a direct dialup connection. All files must be transmitted in binary format. ASCII will not be processed.

The default setting is ASCII so you must issue the Bin command to change the format to binary. You can confirm the change by issuing the Status command and verifying the change was accepted. Depending on your operating system, your windows may display differently than those noted in these figures.

Logging onto GPNet Using FTP

To submit files using the GPNet FTP, first you must make a connection and log in.

1. Create a Windows Dial-Up

Networking session. Open a My

Computer window and double-click the Dial-Up Networking folder

(Figure 12).

Figure 12 – My Computer Window

2. Open Make New Connection

(Figure 13).

Figure 13 – Dial-Up Networking Window

3. The Make New Connection wizard will open (Figure 14). In the first field type GPNet. Confirm that the appropriate modem for your system is chosen in the second field and then click Next.

Figure 14 – Make New Connection Wizard 1

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4.

On the next window (Figure 15), type

803 in the Area code field and 788-6705 for production or 788-3724 for test in the

Telephone number field. Click Next.

5.

The final wizard window will display

(Figure 16). Click Finish to save and create the shortcut for this new connection.

6.

Go back to your Dial-Up Networking folder (Figure 17) and double-click the new GPNet icon.

7. The Connect To window will open

(Figure 18). Type in the GPNet router user name and password (you will receive this information during connectivity testing). Note: The user name and password are case sensitive.

Click Connect.

Figure 15 – Make New Connection Wizard 2

Figure 16 – Make New Connection Wizard 3

Figure 17 – Dial-Up Networking Folder

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Figure 18 – Connect To Window

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8. Your modem will dial and the screen shown in Figure 19 will display when the connection is established. Click Close.

9. Use MS-DOS to make a connection. a) Open a DOS prompt. b) Type ftp at the prompt and press

ENTER. c) At the ftp> prompt, type open

192.168.103.135 2021 for production or 192.168.103.137 2021 for test and press ENTER. You will see the connection information shown in

Figure 20.

Figure 19 – Connection Established Window

Figure 20 – MS-DOS Prompt Window with FTP Connection

d) Type your user name at the User prompt and press ENTER. e) Type your password and press ENTER.

4.6.1 Uploading Files Using FTP

1. To upload a file after connecting: a) At the ftp> prompt, type bin and press ENTER.

ftp> bin

200 Type set to I. b) At the ftp> prompt, type cd inbound and press ENTER.

ftp> cd inbound

250 CWD command successful. c) Type ls and press ENTER.

ftp> ls

200 PORT command successful.

150 opening data connection for… d) Type lcd d:/ and the path name to the file on your local directory. Press ENTER.

Note: The file name you wish to retrieve must exactly match the file name on your local directory. Your local directory drive may be different from the example above.

ftp> lcd d:/(the path name to the file on your local directory)

e) Type put, your file name and CUSTOMER_UPLD!FTP. Then press ENTER.

ftp> put [YOURFILENAME] CUSTOMER_UPLD!FTP

Note: Your file name can be no more than 30 characters in length.

f) After the file has been successfully uploaded, you will receive a “Transmission

Successful” message.

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g) If you would like to retrieve your immediate response, type cd and go to step B of the Download Files Using FTP instructions.

2. To exit the FTP process, type bye and press ENTER.

3. To exit MS-DOS, type exit at the prompt and press ENTER.

4. To end your modem connection, find the blinking modem signal on your

Windows Taskbar (at the bottom right of the screen). Click this symbol and the Connect Status box will open

(Figure 21). Click on Disconnect.

Figure 21 – Connection Status Window

4.6.2 Downloading Files Using FTP

1. To download a file after connecting to the FTP/FXF, begin by changing directories to the outbound mailbox and list the files available for download. a) At the ftp> prompt type bin and press ENTER.

ftp> bin

200 Type set to I.

b) Type cd outbound and press ENTER.

ftp> cd outbound

250 CWD Command Successful

c) Type ls and press ENTER. You will see the file list information:

200 PORT command successful.

150 Opening data connection for...

X1200001.ZIP.ISACTRL0001

X1200002.ZIP.ISACTRL0001

226 Transfer complete. ftp>

d) After determining which file you want to download, enter in the download command

(get and the file name) at the ftp> prompt.

ftp> get X1200001.ZIP.ISACTRL0001

Note: The file name you wish to retrieve must exactly match the file name in the outbound directory (wild cards “*” will be accepted only if “glob” is on). e) When the download is complete, you will get a “Transfer Complete” message. f) To delete files from the outbound mailbox issue a del command at the ftp> prompt

ftp> del X1200001.ZIP.ISACTRL0001

Note: If you do not delete the files after successfully downloading them, they will remain in the outbound directory for 14 days, at which time they will be automatically purged. If you have multiple files to retrieve, you can use the mget * command, which will prompt you to confirm each file prior to the initiation of each file transfer — unless you have prompt turned off.

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4.7 Secure File Transfer Protocol (SFTP)

Trading partners choosing this option will connect through a firewall to a Windows NT server on the BlueCross BlueShield of South Carolina network. You can access this server via the Internet. Additional authentication is done through the use of a unique login

ID and public key file. When this authentication is complete, the trading partner will upload files into the inbound directory where they will be uploaded for EDI Gateway processing.

Trading partners should query the outbound directories to retrieve acknowledgment and response files. When you choose this connectivity option, EDI Gateway will request additional information from the trading partner such as source public IP address and public key.

We will complete all requests within seven to 14 business days.

Our SFTP server accepts SFTP client connections using the SSH2 secure protocol. The client product our Network Operations department recommends using is SecureFX from

VanDyke Software, although any SFTP/SSH2 client that supports public key authentication (SSH2 public key, DSA, 1024-bit) should work.

Files submitted through the SFTP, VPN and NDM communication methods can either be segmented (one segment per line) with a valid non-special character delimiter or a 1000 byte wrapped EDI format with each ISA starting in a new line.

4.8 Connect Direct: NDM

Trading partners choosing this option will connect through AT&T’s AGNS network to

BlueCross BlueShield of South Carolina’s eServer using Sterling Commerce Connect

Direct software. The trading partner must acquire Connect Direct licensing directly from

IBM. Authentication is done with use of a unique login ID and password. When this authentication is complete, the trading partner’s processes can copy files to a BlueCross

BlueShield of South Carolina eServer dataset. Acknowledgment and response files will be returned from BlueCross BlueShield of South Carolina’s eServer to the trading partner.

Connect Direct is a product that moves all types of data. It manages high-performance transfers by providing user-friendly automation, checkpoint/restart error recovery and security. Connect Direct software offers choices in operating systems (UNIX, Windows and Z/OS). EDI files submitted through the SFTP, VPN and NDM communication methods can either be segmented (one segment per line) with a valid non-special character delimiter or a 1000 byte wrapped EDI format with each ISA starting in a new line.

Here are claims dataset naming conventions and attributes for X12 transactions:

X12 Production Dataset Names should be BC.HEDI.NDM.INP.TP-ID, and a generation data group. TP-ID is an eight-character EDIG assigned value associated with the EDIG assigned trading partner ID.

BlueCross BlueShield of South Carolina Commercial Example:

Trading Partner ID: CGW0000SC0; TP-ID: C0000SC0

PGBA Example:

Trading Partner ID: 7GW0000SC0; TP-ID: S0000SC0

X12 Dataset Attributes

DISP: (NEW, CATLG, DELETE)

UNIT: SYSDG

SPACE: (CYL, (75, 10), RLSE)

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DCB: (RECFM=FB, LRECL=1000, BLKSIZE=27000)

4.9 TCPIP

The trading partners choosing this method will connect through a VPN Concentrator or

AT&T’s AGNS network to BlueCross BlueShield of South Carolina’s eServer. The trading partner will deploy an application (for its server) that will initiate a transaction via socket x to socket y on BlueCross BlueShield of South Carolina’s server. This application must acquire the socket connection and send a HIPAA-compliant X12 datastream preceded by a header. The X12 transactions must be enveloped as single transactions, i.e., one

ST/SE per GS/GE per ISA/IEA. The length of the X12 transaction datastream cannot exceed 32K. BlueCross BlueShield of South Carolina corporate policy requires all passwords to be changed every 30 days. As of June 1, 2011, all Real-Time trading partners with non-expiring passwords must comply with this policy.

Here are our guidelines for your user ID and password:

• Each system user will be prompted to change his or her password every 30 days.

• User IDs will be revoked when an incorrect password is entered three consecutive times.

• User IDs will be deleted when not used for 90 or more days.

• The password length must be eight characters and contain at least one alpha character, one numeric character and one of these special characters: @ # $

Previously used passwords will be stored to prevent reuse of previously used passwords for a minimum of 12 prior generations of the password.

4.10 EDIG Proprietary Claim Responses

When you transmit electronic claims to the BlueCross BlueShield of South Carolina EDI

Gateway, the gateway generates responses that advise you of the status of your submission. All trading partners will receive the response file. It consists of one record for each claim processed by EDIG. Also, some trading partners will receive two reports: the

Claims Submission Summary Report and the Error Claim Summary Report. The Claims

Submission Summary Report is a listing of what BlueCross BlueShield of South Carolina

EDI Gateway actually received from you and it indicates whether those claims passed the first set of front-end edits. The Error Claims Summary Report identifies errors on rejected claims so that you can correct and resubmit your claims as soon as possible.

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4.11 Claim Submission Summary Report

The Claims Submission Summary Report shows all claims received from a trading partner and whether they were accepted or rejected. This report may contain multiple pages. The table following the sample report includes a line-by-line description of the data items in the report.

4.11.1 Error Claim Summary Report

The Error Claims Summary Report is generated if there are errors at the claim batch or file level of submitted electronic claims. It provides the trading partner with specific reasons for front-end edit errors. The table following the sample report includes a line-by-line description of the data items in the report.

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4.11.2 Error Claim Summary Report: Batch TA1/999 Process Flow

Here is an example a batch TA1/999 acknowledgment pickup request:

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4.11.3 Error Claim Summary Report: 271 Batch Pickup Process Flow

Here is an example of a 271 batch pickup request:

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4.12 Transmission Administrative Procedures

This table lists protocol and transfer methods for each connectivity option:

Connectivity

SFTP

VPN

NDM

Dial-up

Dial-up

IP

Protocol

SSH2

VPN over TCP/IP

IP

REDI

FTP

TCPIP

Transfer Method

SFTP (software negotiates encryption such as DES, 3DES, CAST-128)

FTP

NDM Proprietary

Proprietary transfer via X, Y or Z modem

Proprietary FTP

This table lists connectivity options available for certain transactions:

Proprietary IP connection via VPN or AGNS

Transaction

X12N 276

Available Connectivity Types

Dial-up, SFTP, NDM, VPN, TCPIP

4.12.1 Structure Requirements

Real-time 276 requests are limited to one inquiry, per patient, per transaction.

Batch 276 requests are limited to 99 ST/SE groupings per transaction. Each batch inquiry must be in its own ST/SE.

4.12.2 Response Times

A response (TA1, 999 reject or 277) to real-time inquiries will be provided within 20 seconds.* A response to the batch inquiry will be provided by 7 a.m. (ET) the following day. Batch requests submitted after 9 p.m. (ET) will be available by 7 a.m. (ET) two days following submission.

*Due to requirements from the Blue Cross and Blue Shield Association, transactions that must be sent to other Blue Cross and Blue Shield Plans for processing may take up to 45 seconds to generate a response.

4.13 Re-Transmission Procedures

If a real-time response message is not received within the 60 second response period, the submitter’s system should send a duplicate transaction no sooner than 90 seconds after the original attempt was sent.

If no real-time response is received after the second attempt, the submitter’s system should submit no more than five duplicate transactions within the next 15 minutes.

If additional attempts result in the same timeout termination, the submitter’s system must notify the submitter to contact the receiver directly to determine if system availability problems exist or if there are known Internet traffic constraints causing the delay.

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4.14 Communication Protocols

BlueCross BlueShield of South Carolina supports standard HTTP MIME messages. The

MIME format used must be that of multipart/form-data. Responses to transactions sent in this manner will also be returned as multipart/form-data.

4.14.1 Header Requirements

The HTTP header requirements for MIME transactions are as follows:

• UserName (eight character max)

• Processing Mode o

Accepted values are:

 Real time – for real time inquiries

 Batch – for batch inquiries (either submission or pickup)

• Password (50 character max)

• Payload Type o

Accepted values are:

 X12_276_Request_005010X212A1

• Real-time and Batch Submission

 X12_005010_Request_Batch_Results_277

• Batch Results Retrieval

 X12_005010_Request_BatchSubmissionMixed

• Mixed Batch

 X12_005010_Request_BatchResultsMixed

• Mixed Batch Pickup

 X12_TA1_SubmissionRequest_00501X231A1

• TA1 Pickup (Batch)

 X12_999_RetrievalRequest_005010X231A1

• 999 Pickup (Batch)

• Payload ID o

Should conform to ISO UUID standards (described at www.rfceditor.org/rfcxx00.html

), with hexadecimal notation, generated using a combination of local timestamp (in milliseconds) as well as the hardware (MAC) address35, to ensure uniqueness.

• Sender ID (50 character max)

• CORE Rule Version o

Accepted value is 2.2.0

• Receiver ID (50 character max)

• Payload o

This contains the X12 request

• Payload Length o

Length of the X12 document, required only if Processing Mode is Batch

• CheckSum o

Checksum of the X12 document, using SHA-1; encoding is hex; required only if

Processing Mode is Batch

• TimeStamp o

In the form of YYYY-MM-DDTHH:MM:SSZ; see www.w3.org/TR/xmlschema11-2/#dateTime

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4.14.2 Error Reporting

There are three levels of error validation involved in a BlueCross BlueShield of South

Carolina MIME multipart transaction:

• HTTP – Errors with connectivity, authorization, etc., will be reported at this level. o

HTTP 200 OK – success o

HTTP 202 Accepted – batch submission accepted (not necessarily processed) o

HTTP 400 Bad Request – error with formatted HTTP headers o

HTTP 500 Internal Server Error – error during processing

• Envelope – Errors regarding the structure or data included within the body of the MIME multipart message will be reported at this level in a response of type multipart/form-data. o

Success – processed successfully o

Payload ID Required – missing Payload ID (or did not conform to format) o

User Name Required – missing User Name (or did not conform to format) o

Password Required – missing Password (or did not conform to format) o

Payload Required – missing Payload (or did not conform to format) o

Sender ID Required – missing Sender ID (or did not conform to format) o

Receiver ID Required – missing Receiver ID (or did not conform to format) o

CORE Rule Version Required – missing CORE Rule Version (or did not conform to expected format)

• Transaction (X12) – Errors concerning ANSI transaction compliancy will be returned as a MIME multipart/form-data message containing the associated ANSI response data

(i.e. TA1 or 999).

4.14.3 Submission/Retrieval

4.14.3.1 Real-time

Real-time requests sent to the BlueCross BlueShield of South Carolina system must be submitted to this type of URL: https://services.bcbssc.com/ENV/REG/SVCNAME

Where:

ENV = Environment (UNIT, SYST, QUAL, PROD)

REG = Region Specific host region if needed, or default value if not

SVCNAME = Name of the Web service to be called (1 for MIME and SOAP)

4.14.3.2 Batch

Batch requests sent to the BlueCross BlueShield of South Carolina system must be submitted to this type of URL: https://services.bcbssc.com/ENV/REG/SVCNAME

Where:

ENV = Environment (UNIT, SYST, QUAL, PROD)

REG = Region Specific host region if needed, or default value if not

SVCNAME = Name of the Web service to be called (1 for MIME and SOAP)

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4.14.4 Examples

Here is an example of a real-time request message using the HTTP MIME Multipart submission:

POST /core/eligibility HTTP/1.1

Host: server_host:server_port

Content-Length: 2408

Content-Type: multipart/form-data; boundary=XbCY

--XbCY

Content-Disposition: form-data; name=“PayloadType”

X12_270_Request_005010X279A1

--XbCY

Content-Disposition: form-data; name=“ProcessingMode”

RealTime

--XbCY

Content-Disposition: form-data; name=“PayloadID” e51d4fae-7dec-11d0-a765-00a0c91e6da6

--XbCY

Content-Disposition: form-data; name=“TimeStamp”

2007-08-30T10:20:34Z

--XbCY

Content-Disposition: form-data; name=“UserName” hospa

--XbCY

Content-Disposition: form-data; name=“Password”

8y6dt3dd2

--XbCY

Content-Disposition: form-data; name=“SenderID”

HospitalA

--XbCY

Content-Disposition: form-data; name=“ReceiverID”

PayerB

--XbCY

Content-Disposition: form-data; name=“CORERuleVersion”

2.2.0

--XbCY

Content-Disposition: form-data; name=“Payload”

<contents of file go here -- 1674 bytes long as specified above>

--XbCY--

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Here is an example of a real-time response message using the HTTP MIME

Multipart method:

HTTP/1.1 200 OK

Content-Length: 2408

Content-Type: multipart/form-data; boundary=XbCY

--XbCY

Content-Disposition: form-data; name=“PayloadType”

X12_271_Response_005010X279A1

--XbCY

Content-Disposition: form-data; name=“ProcessingMode”

RealTime

--XbCY

Content-Disposition: form-data; name=“PayloadID” f81d4fae-7dec-11d0-a765-00a0c91e6da6

--XbCY

Content-Disposition: form-data; name=“TimeStamp”

2007-08-30T10:20:34Z

--XbCY

Content-Disposition: form-data; name=“SenderID”

PayerB

--XbCY

Content-Disposition: form-data; name=“ReceiverID”

HospitalA

--XbCY

Content-Disposition: form-data; name=“CORERuleVersion”

2.2.0

--XbCY

Content-Disposition: form-data; name=“ErrorCode”

Success

--XbCY

Content-Disposition: form-data; name=“ErrorMessage”

None

--XbCY

Content-Disposition: form-data; name=“Payload”

<contents of file go here -- 1674 bytes long as specified above>

--XbCY--

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Here is an example of a Batch Submission message using the HTTP MIME Multipart envelope method.

POST /core/eligibility HTTP/1.1

Host: server_host:server_port

Content-Length: 244508

Content-Type: multipart/form-data; boundary=XbCY

--XbCY

Content-Disposition: form-data; name=“PayloadType”

X12_270_Request_005010X279A1

--XbCY

Content-Disposition: form-data; name=“ProcessingMode”

Batch

--XbCY

Content-Disposition: form-data; name=“PayloadID” f81d4fae-7dec-11d0-a765-00a0d91e6fa6

--XbCY

Content-Disposition: form-data; name=“PayloadLength”

10240

--XbCY

Content-Disposition: form-data; name=“TimeStamp”

2007-08-30T10:20:34Z

--XbCY

Content-Disposition: form-data; name=“UserName” hospa

--XbCY

Content-Disposition: form-data; name=“Password”

8y6dt3dd2

--XbCY

Content-Disposition: form-data; name=“SenderID”

HospitalA

--XbCY

Content-Disposition: form-data; name=“ReceiverID”

PayerB

--XbCY

Content-Disposition: form-data; name=“CORERuleVersion”

2.2.0

--XbCY

Content-Disposition: form-data; name=“Checksum”

6A3FE55946

--XbCY

Content-Disposition: form-data; name=“Payload”

<contents of batch file go here>

--XbCY--

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Here is an example of a synchronous response to a Batch Submission request message using the HTTP MIME Multipart envelope method.

HTTP/1.1 200 OK

Content-Length: 2408

Content-Type: multipart/form-data; boundary=XbCY

--XbCY

Content-Disposition: form-data; name=“PayloadType”

X12_BatchReceiptConfirmation

--XbCY

Content-Disposition: form-data; name=“ProcessingMode”

Batch

--XbCY

Content-Disposition: form-data; name=“PayloadID” f81d4fae-7dec-11d0-a765-00a0c91e6da6

--XbCY

Content-Disposition: form-data; name=“TimeStamp”

2007-08-30T10:20:34Z

--XbCY

Content-Disposition: form-data; name=“SenderID”

PayerB

--XbCY

Content-Disposition: form-data; name=“ReceiverID”

HospitalA

--XbCY

Content-Disposition: form-data; name=“CORERuleVersion”

2.2.0

--XbCY

Content-Disposition: form-data; name=“ErrorCode”

Success

--XbCY

Content-Disposition: form-data; name=“ErrorMessage”

None

--XbCY—

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Here is an example of a Batch Submission Acknowledgement Retrieval request message using the HTTP MIME Multipart envelope method.

POST /core/eligibility HTTP/1.1

Host: server_host:server_port

Content-Length: 244508

Content-Type: multipart/form-data; boundary=XbCY

--XbCY

Content-Disposition: form-data; name=“PayloadType”

X12_999_RetrievalRequest_005010X231A1

--XbCY

Content-Disposition: form-data; name=“ProcessingMode”

Batch

--XbCY

Content-Disposition: form-data; name=“PayloadID” f81d4fae-7dec-11d0-a765-00a0d91e6fa6

--XbCY

Content-Disposition: form-data; name=“TimeStamp”

2007-08-30T10:20:34Z

--XbCY

Content-Disposition: form-data; name=“UserName” hospa

--XbCY

Content-Disposition: form-data; name=“Password”

8y6dt3dd2

--XbCY

Content-Disposition: form-data; name=“SenderID”

HospitalA

--XbCY

Content-Disposition: form-data; name=“ReceiverID”

PayerB

--XbCY

Content-Disposition: form-data; name=“CORERuleVersion”

2.2.0

--XbCY--

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Here is an example of a Batch Submission Acknowledgement Retrieval Response message using the HTTP MIME Multipart envelope method.

HTTP/1.1 200 OK

Content-Length: 12648

Content-Type: multipart/form-data; boundary=XbCY

--XbCY

Content-Disposition: form-data; name=“PayloadType”

X12_999_Response_005010X231A18

--XbCY

Content-Disposition: form-data; name=“ProcessingMode”

Batch

--XbCY

Content-Disposition: form-data; name=“PayloadID” f81d4fae-7dec-11d0-a765-00a0c91e6da6

--XbCY

Content-Disposition: form-data; name=“PayloadLength”

10240

--XbCY

Content-Disposition: form-data; name=“TimeStamp”

2007-08-30T10:20:34Z

--XbCY

Content-Disposition: form-data; name=“SenderID”

PayerB

--XbCY

Content-Disposition: form-data; name=“ReceiverID”

HospitalA

--XbCY

Content-Disposition: form-data; name=“CORERuleVersion”

2.2.0

--XbCY

Content-Disposition: form-data; name=“Checksum”

6A3FE55946

--XbCY

Content-Disposition: form-data; name=“Payload”

<contents of batch file go here>

--XbCY

Content-Disposition: form-data; name=“ErrorCode”

Success

--XbCY

Content-Disposition: form-data; name=“ErrorMessage”

None

--XbCY--

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Here is an example of a Batch Results Retrieval request message using the HTTP

MIME Multipart envelope method.

POST /core/eligibility HTTP/1.1

Host: server_host:server_port

Content-Length: 244508

Content-Type: multipart/form-data; boundary=XbCY

--XbCY

Content-Disposition: form-data; name=“PayloadType”

X12_005010_Request_Batch_Results_271

--XbCY

Content-Disposition: form-data; name=“ProcessingMode”

Batch

--XbCY

Content-Disposition: form-data; name=“PayloadID” f81d4fae-7dec-11d0-a765-00a0d91e6fa6

--XbCY

Content-Disposition: form-data; name=“TimeStamp”

2007-08-30T10:20:34Z

--XbCY

Content-Disposition: form-data; name=“UserName” hospa

--XbCY

Content-Disposition: form-data; name=“Password”

8y6dt3dd2

--XbCY

Content-Disposition: form-data; name=“SenderID”

HospitalA

--XbCY

Content-Disposition: form-data; name=“ReceiverID”

PayerB

--XbCY

Content-Disposition: form-data; name=“CORERuleVersion”

2.2.0

--XbCY--

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Here is an example of a Batch Retrieval Response message using the HTTP MIME

Multipart envelope method.

HTTP/1.1 200 OK

Content-Length: 12648

Content-Type: multipart/form-data; boundary=XbCY

--XbCY

Content-Disposition: form-data; name=“PayloadType”

X12_271_Response_005010X279A1

--XbCY

Content-Disposition: form-data; name=“ProcessingMode”

Batch

--XbCY

Content-Disposition: form-data; name=“PayloadID” f81d4fae-7dec-11d0-a765-00a0c91e6da6

--XbCY

Content-Disposition: form-data; name=“PayloadLength”

10240

--XbCY

Content-Disposition: form-data; name=“TimeStamp”

2007-08-30T10:20:34Z

--XbCY

Content-Disposition: form-data; name=“SenderID”

PayerB

--XbCY

Content-Disposition: form-data; name=“ReceiverID”

HospitalA

--XbCY

Content-Disposition: form-data; name=“CORERuleVersion”

2.2.0

None

--XbCY

Content-Disposition: form-data; name=“Checksum”

6A3FE55946

--XbCY

Content-Disposition: form-data; name=“Payload”

<contents of batch file go here>

--XbCY

Content-Disposition: form-data; name=“ErrorCode”

Success

--XbCY

Content-Disposition: form-data; name=“ErrorMessage”

None

--XbCY--

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Here is an example of a Batch Results Acknowledgement Submission message using the HTTP MIME Multipart envelope method.

POST /core/eligibility HTTP/1.1

Host: server_host:server_port

Content-Length: 244508

Content-Type: multipart/form-data; boundary=XbCY

--XbCY

Content-Disposition: form-data; name=“PayloadType”

X12_999_SubmissionRequest_005010X231A112

--XbCY

Content-Disposition: form-data; name=“ProcessingMode”

Batch

--XbCY

Content-Disposition: form-data; name=“PayloadID” f81d4fae-7dec-11d0-a765-00a0d91e6fa6

--XbCY

Content-Disposition: form-data; name=“PayloadLength”

10240

--XbCY

Content-Disposition: form-data; name=“TimeStamp”

2007-08-30T10:20:34Z

--XbCY

Content-Disposition: form-data; name=“UserName” hospa

--XbCY

Content-Disposition: form-data; name=“Password”

8y6dt3dd2

--XbCY

Content-Disposition: form-data; name=“SenderID”

HospitalA

--XbCY

Content-Disposition: form-data; name=“ReceiverID”

PayerB

--XbCY

Content-Disposition: form-data; name=“CORERuleVersion”

2.2.0

--XbCY

Content-Disposition: form-data; name=“Checksum”

6A3FE55946

--XbCY

Content-Disposition: form-data; name=“Payload”

<contents of batch file go here>

--XbCY--

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Here is an example of a Batch Results Acknowledgement Submission Response message using the HTTP MIME Multipart envelope method.

HTTP/1.1 200 OK

Content-Length: 2408

Content-Type: multipart/form-data; boundary=XbCY

--XbCY

Content-Disposition: form-data; name=“PayloadType”

X12_Response_ConfirmReceiptReceived

--XbCY

Content-Disposition: form-data; name=“ProcessingMode”

Batch

--XbCY

Content-Disposition: form-data; name=“PayloadID” f81d4fae-7dec-11d0-a765-00a0d91e6fa6

--XbCY

Content-Disposition: form-data; name=“TimeStamp”

2007-08-30T10:20:34Z

--XbCY

Content-Disposition: form-data; name=“SenderID”

PayerB

--XbCY

Content-Disposition: form-data; name=“ReceiverID”

HospitalA

--XbCY

Content-Disposition: form-data; name=“CORERuleVersion”

2.2.0

--XbCY

Content-Disposition: form-data; name=“ErrorCode”

Success

--XbCY

Content-Disposition: form-data; name=“ErrorMessage”

None

--XbCY--

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Here is an example of an Envelope Processing Error message using the HTTP

MIME Multipart envelope method.

HTTP/1.1 200 OK

Content-Length: 2408

Content-Type: multipart/form-data; boundary=XbCY

--XbCY

Content-Disposition: form-data; name=“PayloadType”

COREEnvelopeError --XbCY

Content-Disposition: form-data; name=“ProcessingMode”

RealTime

--XbCY

Content-Disposition: form-data; name=“PayloadID” f81d4fae-7dec-11d0-a765-00a0a91e6fa6

--XbCY

Content-Disposition: form-data; name=“TimeStamp”

2007-08-30T10:20:34Z

--XbCY

Content-Disposition: form-data; name=“SenderID”

PayerB

--XbCY

Content-Disposition: form-data; name=“ReceiverID”

HospitalA

--XbCY

Content-Disposition: form-data; name=“CORERuleVersion”

2.2.0

--XbCY

Content-Disposition: form-data; name=“ErrorCode”

VersionMismatch

--XbCY

Content-Disposition: form-data; name=“ErrorMessage”

Expected Version X, received version Y

--XbCY—

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4.15 SOAP + WSDL

BlueCross BlueShield of South Carolina supports transactions formatted according to the

Simple Object Access Protocol (SOAP) compliant to standards set forth by Web Services

Description Language (WSDL) for XML formatting, submission and retrieval.

4.15.1 SOAP XML Schema

The XML schema definition set forth by CORE and used by BlueCross BlueShield of

South Carolina is located at: www.caqh.org/CORE_phase2.php

File name: XML Schema Specification (normative)

This file contains definitions for each type of request or response accepted or sent by

BlueCross BlueShield of South Carolina.

4.15.2 WSDL Information

The WSDL definition set forth by CORE and used by BlueCross BlueShield of South

Carolina is located at: www.caqh.org/CORE_phase2.php

File name: XML Schema Specification (normative)

This file conforms to the XML schema and contains definitions for each message and transaction type accepted by BlueCross BlueShield of South Carolina.

4.15.3 SOAP Fault Formatting

There are two versions of the SOAP specification: 1.1 and 1.2. Each version defines

SOAP Faults in a slightly different manner. All BlueCross BlueShield of South Carolina applications will generate only version 1.1 SOAP Faults. BlueCross BlueShield of South

Carolina will accept both version 1.1 and version 1.2 SOAP Faults from partner-provided services.

BlueCross BlueShield of South Carolina applications populate SOAP faults with information in a specific format, which is designed to make possible programmatic identification of error conditions. The SOAP fault elements emitted are defined as follows:

1. faultcode: This element indicates what kind of error occurred, and with whom the fault lies. The format of the faultcode is <class>.<code>.<appcode> (omitting the namespace prefix). This element is contained within the SOAP namespace

(http://schemas.xmlsoap.org/soap/envelope).

The class indicates on which side of the service transaction the source of the error lies. If the error is caused by missing or incorrect data from the caller, the class shall be the string ‘Client’. If the error is caused for any reason unrelated to the message’s contents, the class shall be the string ‘Server’. The separator between class and code is a period (ASCII 46, UTF-8 0x2E).

The code is a three digit code corresponding to the HTTP status code most closely associated with the condition. For example, passing invalid credentials should result in a faultcode of Client.401, as the message’s contents were the cause of the error, and

401 is the HTTP status code for ‘Unauthorized’.

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HTTP status codes are used as they are familiar to most web service developers, the vast majority of client libraries have constants defined for these status codes, and they allow the aggregation of large numbers of errors into a small number of codes.

While not a comprehensive list, some commonly used error codes are:

Client:

400 (Bad Request) – The data provided by the client is badly formed or not sufficient for the service to process successfully. Clients SHOULD NOT retry service calls that return this code without first modifying the request.

401 (Unauthorized) – The client did not provide valid credentials, or is not permitted to consume this service. Clients SHOULD NOT retry service calls that return this code without first modifying the request.

403 (Forbidden) – The service refuses to perform the requested function for some reason (usually because the consumer is not permitted to consume the service).

The service middleware returns this error code when consumers are not authorized to consume the service they are requesting. Clients SHOULD NOT retry service calls that return this code without first modifying the request.

404 (Not Found) – The service could not locate an appropriate resource to return for the request. This might be returned when a document is requested that the service cannot find. Clients MAY retry service calls that return this code without first modifying the request.

Server:

500 (Internal Server Error) – Indicates a malfunction or technical error during service processing. Examples of 500 errors include an unavailable database, MQ channel, or a generic error thrown by the service itself unrelated to client input.

Clients MAY retry service calls that return this code without first modifying the request.

503 (Service Unavailable) – Indicates a malfunction or technical error during service processing that the server is aware is temporary. This error is typically returned when the service is too busy to service the request at the moment. Clients

SHOULD retry service calls that return this code without first modifying the request after some period of time.

The appcode is an application-specific error code appended to the service fault code using another period. For example, a service wishing to return the application-specific error code ‘ORA-0435’ would create a fault code of ‘Server.500.ORA-0435’. The application-specific code is optional, and not all will services return one. The faultcode is prefixed with the namespace qualifier ‘wrx’, which is mapped to the BlueCross

BlueShield of South Carolina error namespace (http://services.bcbssc.com/error).

2. faultstring: This element presents a short, reasonably friendly explanation of the error. This element is contained within the SOAP namespace

(http://schemas.xmlsoap.org/soap/envelope).

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3. detail: This element contains details relating to the SOAP fault. This element is contained within the SOAP namespace ( http://schemas.xmlsoap.org/soap/envelope ).

The child of the detail element is fault Detail in the BlueCross BlueShield of South

Carolina namespace (http://services.bcbssc.com). a. Transaction UUID: This element contains a 36-character Universally Unique

Identifier that is used by BlueCross BlueShield of South Carolina support personnel to retrieve information about a web service transaction from our tracking databases. The UUID should always be supplied when requesting troubleshooting assistance from BlueCross BlueShield of South Carolina support. This element is contained within the BlueCross BlueShield of South

Carolina namespace (http://services.bcbssc.com). b. Error Date: This element contains the date that the fault occurred in the format

YYYY-MM-DD; e.g. 2010-08-19. The error Date should always be supplied when requesting troubleshooting assistance from BlueCross BlueShield of

South Carolina support. This element is contained within the BlueCross

BlueShield of South Carolina namespace (http://services.bcbssc.com). c. Error Time: This element contains the time that the fault occurred in the format

HH:MM:SS TMZ; e.g. 00:21:38 EDT. The error Time should always be supplied when requesting troubleshooting assistance from BlueCross BlueShield of

South Carolina support. This element is contained within the BlueCross

BlueShield of South Carolina namespace ( http://services.bcbssc.com

).

4.15.4 Error Reporting

There are three levels of error validation involved in a BlueCross BlueShield of South

Carolina SOAP transaction:

• HTTP – Errors with connectivity, authorization, etc., will be reported at this level. o

HTTP 200 OK – success o

HTTP 202 Accepted – batch submission accepted (not necessarily processed) o

HTTP 400 Bad Request – error with formatted HTTP headers o

HTTP 500 Internal Server Error – error during processing

• Envelope – Errors regarding the structure or data included within the body of the SOAP message, respective to the definitions set forth in the SOAP fault specifications, located at: www.w3.org/TR/soap12-part1/#soapfault .

Application specific errors are as follows: o

Success – processed successfully o

Payload ID Required – missing Payload ID (or did not conform to format) o

User Name Required – missing User Name (or did not conform to format) o

Password Required – missing Password (or did not conform to format) o

Payload Required – missing Payload (or did not conform to format) o

Sender ID Required – missing Sender ID (or did not conform to format) o

Receiver ID Required – missing Receiver ID (or did not conform to format) o

CORE Rule Version Required – missing CORE Rule Version (or did not conform to expected format)

• Transaction (X12) – Errors concerning ANSI transaction compliancy will be returned as a SOAP message containing the associated ANSI response data (i.e., TA1 or 999).

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4.15.5 Submission/Retrieval

Detailed SOAP+WSDL envelope standard for CORE Phase II Connectivity can be found at: www.caqh.org/pdf/CLEAN5010/270-v5010.pdf

.

4.15.5.1 Real-time

Real-time requests sent to the BlueCross BlueShield of South Carolina system must be submitted to this type of URL: https://services.bcbssc.com/ENV/REG/SVCNAME

Where:

ENV = Environment (UNIT, SYST, QUAL, PROD)

REG = Region Specific host region if needed, or default value if not

SVCNAME = Name of the Web service to be called (1 for MIME and SOAP)

All payloads (X12 data) must be embedded using the Inline method (CDATA element) for real-time SOAP transactions.

4.15.5.2 Batch

Batch requests sent to the BlueCross BlueShield of South Carolina system must be submitted to this type of URL: https://services.bcbssc.com/ENV/REG/SVCNAME

Where:

ENV = Environment (UNIT, SYST, QUAL, PROD)

REG = Region Specific host region if needed, or default value if not

SVCNAME = Name of the Web service to be called (1 for MIME and SOAP)

All batch payloads must be sent utilizing SOAP Message Transmission Optimization

Mechanism (MTOM) encapsulated MIME part. For more information, please see: www.w3.org/TR/soap12-mtom .

4.15.5.3 SOAP Header

The WS-Security username and password token (shown in 4.15.6 in gray background) is added to the SOAP Header by the platform on which SOAP is run. The SOAP platform’s

Web-Services Security Extensions may be configured to insert these tokens.

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4.15.4 SOAP Sample Fault

Here is an example of a SOAP fault request:

<soap:Envelope xmlns:soap="http://schemas.xmlsoap.org/soap/envelope/" xmlns:bcbs="http://services.bcbssc.com" xmlns:rsp="http://services.bcbssc.com/response" xmlns:wrx="http://services.bcbssc.com/error">

<soap:Body>

<soap:Fault>

<faultcode>wrx:Client.401</faultcode>

<faultstring>Unauthorized<faultstring>

<detail>

<bcbs:faultDetail>

<bcbs:transactionUUID>a58de2da-167c-4779-

8edf-d5b758c62b0e</bcbs:transactionUUID>

<bcbs:errorDate>2010-08-19</bcbs:errorDate>

<bcbs:errorTime>00:21:38

EDT</bcbs:errorTime>

</bcbs:faultDetail>

</detail>

</soap:Fault>

</soap:Body>

</soap:Envelope>

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4.16 General Specifications Applicable to Both Envelope Methods

The following sections specify requirements of the CORE Phase II Connectivity Rule that are applicable to both envelope methods (HTTP MIME Multipart and SOAP+WSDL).

4.16.1 Request and Response Handling

HTTP/S supports a request-response message pattern, meaning that the sender submits a message and then waits for a response from the message receiver. This works well for the submission of both batch and real-time ASC X12 messages, but the response message from the receiver is different depending on whether the sender’s message is a real-time request, batch submission or batch request pickup.

4.16.2 Submitter Authentication and Authorization Handling

X.509 Certificate based authentication over SSL24 (Submitter Authentication Standard D in the Conformance Requirements, §4.1), using the Secure Sockets Layer (SSLv3.0) open standard for client certificate-based authentication.

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5. CONTACT INFORMATION

5.1 EDI Customer Service and Technical Assistance

EDI Gateway’s production environment is accessible 24 hours a day, seven days a week; with the exception of weekly maintenance performed Sundays between 3 p.m. and 10 p.m. EDI Gateway’s test environment is accessible Monday through Saturday from 5 a.m. to 10 p.m.

We send notifications of EDI Gateway outages to trading partners via email. We generally send notifications of scheduled outages with two days prior notice. We send notifications of unscheduled outages as quickly as the outage is reported.

Please call the BlueCross BlueShield of South Carolina Technology Support Center at

803-736-5980 or 800-868-2505 with questions or to report problems.

5.2 Provider Service Number

If you have questions regarding information related to subscribers that are non-technical, please contact BlueCross BlueShield of South Carolina at 800-334-2583.

5.3 Applicable Web/Email Contact Information

Additional information is available online at www.SouthCarolinaBlues.com

.

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6. CONTROL SEGMENTS/ENVELOPES

6.1 EDIG Specifications for Enveloping X12 Transactions

X12 Inbound Transactions

This table lists envelope instructions for inbound (to EDI Gateway) HIPAA X12 transactions.

Segment Id Data Element Description

Authorization Info Qualifier 03 ISA01

ISA02

ISA03

ISA04

ISA05

Authorization Information EDIG assigned Trading Partner ID

Security Information Qualifier 00

Security Information

Interchange ID Qualifier

None

01, 14, 20, 22, 27, 28, 29, 30, 33, ZZ (selected by trading partner)

Assigned by trading partner ISA06

ISA07

ISA08

ISA09

ISA10

ISA11

ISA12

ISA13

ISA14

ISA15

ISA16

GS01

GS02

Interchange Sender ID

Interchange ID Qualifier

Interchange Receiver ID

Interchange Date

Interchange Time

Repetition Separator

30 (qualifier indicating U.S. Federal Tax Identification Number)

Destination Entity U.S. Federal Tax Identification Number*

Populated by trading partner

Populated by trading partner

Assigned by trading partner

00501 Interchange Control Version

Number

Interchange Control Number Assigned by the trading partner (must be unique for 12 months)

Acknowledgment Requested Assigned by the trading partner

Usage Indicator

Component Element

P, T (production or test indicator)

Separator Assigned by the trading partner

Functional Identifier Code Populated by trading partner

Application Sender’s Code EDIG assigned trading partner ID

Application Receiver’s Code Destination Entity U.S. Federal Tax Identification Number. Must be same as ISA08.*

GS03

GS04

GS05

GS06

GS07

GS08

Date

Time

Version/Release/Industry

Populated by trading partner

Populated by trading partner

Group Control Number Assigned by trading partner (value must remain unique for one year)

Responsible Agency Code X

Code populated by trading partner

Identifier

* BlueCross BlueShield of South Carolina and Subsidiaries:

Entity

Carolina Benefit Administrators

Companion Life Insurance Company

Federal TIN

Entity

BlueCross BlueShield of South Carolina

570287419 Thomas H. Cooper & Company (TCC)

BlueChoice

®

HealthPlan

Employee Benefit Administrators

570768835

570523959

Florida Combined Life (FCL)

571001631

PGBA TRICARE

PGBA Bureau of Prisons

Federal TIN

571032566

592876465

571132733

530205705

561939146

PGBA Humana Veteran Healthcare Services 208418853

Planned Administrators, Incorporated

(PAI)

570718839

Note: Additional explanations are available in the ASC X12 Standards for Electronic Data

Interchange Technical Report Type 3. The ASC X12 TR3s that detail the full requirements for these transactions are available at http://store.x12.org/store .

Because Companion Life and Florida Combined Life are separate life insurance companies from BlueCross, Florida Combined Life and Companion Life will be responsible for all services related to life insurance.

PAI and TCC are separate companies that provide third party administrative services on behalf of BlueCross. BlueChoice HealthPlan of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

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6.2 X12 Outbound Transactions

This table lists envelope contents for outbound (from EDI Gateway) HIPAA X12 transactions.

Segment

Identifier

Data Element Description

ISA01

ISA02

ISA03

ISA04

ISA05

ISA06

ISA07

Authorization Info Qualifier 00

Authorization Information

Security Information

Interchange ID Qualifier

Blanks

Security Information Qualifier 00

Blanks

Interchange Sender ID

Interchange ID Qualifier

30 (qualifier indicating U.S. Federal Tax Identification

Number)

Sending entity’s U.S. Federal Tax Identification Number *

If 271, 277 or 278 transaction, ISA07 will be the same value of the associated inbound 270, 276 or 278 ISA05. If

999, TA1 or EDIG claim response, ISA07 will be the same value of the associated inbound transaction’s ISA05.

Otherwise value is ZZ.

ISA08 Interchange Receiver ID If 271, 277 or 278 transaction, ISA08 will be the same value of the associated inbound 270, 276 or 278 ISA06. If

999, TA1 or EDIG claim response, ISA08 will be the same value of the associated inbound transaction’s ISA06. If above ISA07 is ZZ, value is EDIG assigned Trading

ISA09

ISA10

ISA11

Interchange Date

Interchange Time

Repetition Separator

Partner ID.

Populated by EDIG

Populated by EDIG

Populated by EDIG

ISA12

ISA13

ISA14

ISA15

ISA16

GS01

GS02

GS03

GS04

GS05

GS06

GS07

GS08

Interchange Control Version

Number

00501

Interchange Control Number Assigned by EDIG

Acknowledgment Requested 1

Usage Indicator

Component Element

P, T (production or test indicator)

Populated by EDIG

Functional Identifier Populated by EDIG

Application Sender’s Code Sending entity’s U.S. Federal Tax Identification Number or another mutually agreed to sender identifying code*

Application Receiver’s Code If 271, 277 or 278 transaction, GS03 will be the same value of the associated inbound 270, 276 or 278 GS02. If

999, TA1 or EDIG claim response, GS03 will be the same

Date

Time

Version/Release/Industry value of the associated inbound transaction’s GS02.

Otherwise, value is EDIG assigned Trading Partner ID.

Populated by EDIG

Populated by EDIG

Group Control Number Assigned by EDIG

Responsible Agency Code X

Populated by EDIG

Identifier Code

* BlueCross BlueShield of South Carolina and Subsidiaries:

Entity Federal TIN

BlueCross BlueShield of South Carolina (includes FEP, State)

570287419

BlueChoice HealthPlan

PGBA TRICARE

570768835

571132733

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7. PAYER SPECIFIC BUSINESSS RULES AND LIMITATIONS

7.1 Supported Service Types

BlueCross BlueShield of South Carolina supports these 276 Service Types and will respond on the 277 with the noted service types. Requested service types other than the ones listed here will result in a default list of responses in the 277.

276 R

EQUEST

(EQ) 277 R

ESPONSE

03

13

17

1E

1G

1H

1I

1O

1P

1Q

1R

1S

1T

1U

1V

1W

1X

1Y

1Z

28

2A

2B

2D

2E

2I

2K

2P

2Q

2S

2Z

30

36

3A

3C

3D

3E

3F

3G

3H

3I

3J

3K

3L

3M

3N

D

ESCRIPTION

Dependent

Contracted Service Provider

Consultant’s Office

Health Maintenance Organization (HMO)

Oncology Center

Kidney Dialysis Unit

Preferred Provider Organization (PPO)

Acute Care Hospital

Provider

Military Facility

University, College or School

Outpatient Surgicenter

Physician, Clinic or Group Practice

Long Term Care Facility

Extended Care Facility

Psychiatric Health Facility

Laboratory

Retail Pharmacy

Home Health Care

Subcontractor

Federal, State, County or City Facility

Third-Party Administrator

Miscellaneous Health Care Facility

Non-Health Care Miscellaneous Facility

Church Operated Facility

Partnership

Public Health Service Facility

Veterans Administration Facility

Public Health Service Indian Service Facility

Hospital Unit of an Institution (prison hospital, college infirmary, etc.)

Service Supplier

Employer

Hospital Unit Within an Institution for the Mentally

Retarded

Tuberculosis and Other Respiratory Diseases Facility

Obstetrics and Gynecology Facility

Eye, Ear, Nose and Throat Facility

Rehabilitation Facility

Orthopedic Facility

Chronic Disease Facility

Other Specialty Facility

Children’s General Facility

Children’s Hospital Unit of an Institution

Children’s Psychiatric Facility

Children’s Tuberculosis and Other Respiratory Diseases

Facility

Children’s Eye, Ear, Nose and Throat Facility

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5B

5C

5D

5E

5F

5G

5H

5I

4S

4U

4V

4W

4X

4Y

4Z

5A

5J

5K

5L

5M

5N

5O

5P

5Q

5R

5S

4J

4L

4M

4N

4O

4P

4Q

4R

4B

4C

4D

4E

4F

4G

4H

4I

3W

3X

3Y

3Z

40

43

44

4A

3O

3P

3Q

3R

3S

3T

3U

3V

Children’s Rehabilitation Facility

Children’s Orthopedic Facility

Children’s Chronic Disease Facility

Children’s Other Specialty Facility

Institution for Mental Retardation

Alcoholism and Other Chemical Dependency Facility

General Inpatient Care for AIDS/ARC Facility

AIDS/ARC Unit

Specialized Outpatient Program for AIDS/ARC

Alcohol/Drug Abuse or Dependency Inpatient Unit

Alcohol/Drug Abuse or Dependency Outpatient Services

Arthritis Treatment Center

Receiver

Claimant Authorized Representative

Data Processing Service Bureau

Birthing Room/LDRP Room

Burn Care Unit

Cardiac Catherization Laboratory

Open-Heart Surgery Facility

Cardiac Intensive Care Unit

Angioplasty Facility

Chronic Obstructive Pulmonary Disease Service Facility

Emergency Department

Trauma Center (Certified)

Extracorporeal Shock-Wave Lithotripter (ESWL) Unit

Genetic Counseling/Screening Services

Adult Day Care Program Facility

Alzheimer’s Diagnostic/Assessment Services

Comprehensive Geriatric Assessment Facility

Emergency Response (Geriatric) Unit

Geriatric Acute Care Unit

Geriatric Clinics

Respite Care Facility

Patient Education Unit

Community Health Promotion Facility

Worksite Health Promotion Facility

Hemodialysis Facility

Home Health Services

Hospice

Medical Surgical or Other Intensive Care Unit

Hisopathology Laboratory

Blood Bank

Neonatal Intensive Care Unit

Obstetrics Unit

Occupational Health Services

Organized Outpatient Services

Pediatric Acute Inpatient Unit

Psychiatric Child/Adolescent Services

Psychiatric Consultation-Liaison Services

Psychiatric Education Services

Psychiatric Emergency Services

Psychiatric Geriatric Services

Psychiatric Inpatient Unit

Psychiatric Outpatient Services

Psychiatric Partial Hospitalization Program

Megavoltage Radiation Therapy Unit

Radioactive Implants Unit

Therapeutic Radioisotope Facility

60

74

77

7C

80

82

84

85

87

6U

6V

6W

6X

6Y

71

72

73

6L

6M

6N

6O

6P

6Q

6R

6S

6D

6E

6F

6G

6H

6I

6J

6K

DO

DQ

E1

E2

E7

E9

95

CK

CZ

D2

DD

DJ

DK

DN

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5T

5U

5V

5W

5X

5Y

5Z

61

6A

6B

6C

X-Ray Radiation Therapy Unit

CT Scanner Unit

Diagnostic Radioisotope Facility

Magnetic Resonance Imaging (MRI) Facility

Ultrasound Unit

Rehabilitation Inpatient Unit

Rehabilitation Outpatient Services

Performed At

Reproductive Health Services

Skilled Nursing or Other Long-Term Care Unit

Single Photon Emission Computerized Tomography

(SPECT) Unit

Organized Social Work Service Facility

Outpatient Social Work Services

Emergency Department Social Work Services

Sports Medicine Clinic/Services

Hospital Auxiliary Unit

Patient Representative Services

Volunteer Services Department

Outpatient Surgery Services

Organ/Tissue Transplant Unit

Orthopedic Surgery Facility

Occupational Therapy Services

Physical Therapy Services

Recreational Therapy Services

Respiratory Therapy Services

Speech Therapy Services

Women’s Health Center/Services

Cardiac Rehabilitation Program Facility

Non-Invasive Cardiac Assessment Services

Emergency Medical Technician

Disciplinary Contact

Case Manager

Attending Physician

Operating Physician

Other Physician

Corrected Insured

Service Location

Place of Occurrence

Hospital

Rendering Provider

Subscriber’s Employer

Billing Provider

Pay-to Provider

Research Institute

Pharmacist

Admitting Surgeon

Commercial Insurer

Assistant Surgeon

Consulting Physician

Ordering Physician

Referring Provider

Dependent Name

Supervising Physician

Person or Other Entity Legally Responsible for a Child

Person or Other Entity With Whom a Child Resides

Previous Employer

Participating Laboratory

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FA

FD

FE

G0

G3

GB

GD

GI

GJ

GK

GM

GY

HF

HH

I3

IJ

IL

IN

LI

LR

MR

MSC

OB

OD

OX

P0

P2

P3

P4

P6

D

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2012

P7

PRP

PT

PV

PW

QA

QB

QC

QD

QE

QH

QK

QL

QN

QO

QS

QV

QY

RC

RW

S4

SEP

SJ

SU

T4

TL

Facility

Physical Address

Mail Address

Dependent Insured

Clinic

Other Insured

Guardian

Paramedic

Paramedical Company

Previous Insured

Spouse Insured

Treatment Facility

Healthcare Professional Shortage Area (HPSA) Facility

Home Health Agency

Independent Physicians Association (IPA)

Injection Point

Insured or Subscriber

Insurer

Independent Lab

Legal Representative

Medical Insurance Carrier

Mammography Screening Center

Ordered By

Doctor of Optometry

Oxygen Therapy Facility

Patient Facility

Primary Insured or Subscriber

Primary Care Provider

Prior Insurance Carrier

Third Party Reviewing Preferred Provider Organization

(PPO)

Third Party Repricing Preferred Provider Organization

(PPO)

Primary Payer

Party to Receive Test Report

Party performing certification

Pickup Address

Pharmacy

Purchase Service Provider

Patient

Responsible Party

Policyholder

Physician

Managed Care

Chiropractor

Dentist

Doctor of Osteopathy

Podiatrist

Group Practice

Medical Doctor

Receiving Location

Rural Health Clinic

Skilled Nursing Facility

Secondary Payer

Service Provider

Supplier/Manufacturer

Transfer Point

Testing Laboratory

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TQ

TT

TTP

TU

UH

X3

X4

X5

ZZ

Third Party Reviewing Organization (TPO)

Transfer To

Tertiary Payer

Third Party Repricing Organization (TPO)

Nursing Home

Utilization Management Organization

Spouse

Durable Medical Equipment Supplier

Mutually Defined

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8. ACKNOWLEDGMENTS

8.1 EDIG A

cknowledgment and Response Transactions

Matrix

This table lists acknowledgment and response transactions returned to the trading partner when EDI Gateway receives HIPAA X12 transactions.

Transaction

276*

Interchange

Acknowledgement

TA1

TR3 Edit Results

If errors, 999 (X12 TR3 edit results) is returned. If not, edit results are not returned.

999

Payer SIG

Edit Results

277

Payer Appl. Edit

Results

277

276 TA1 277 277

* Batch of one: The most simple, singular request is contained in the ST/SE for a transaction.

** Batch of many: All other record groupings.

X12 Technical Report 3s (also known as Implementation Guides) are available that include format specifications for each transaction. The ASC X12 TR3s that detail the full requirements for these transactions are available at http://store.x12.org/store .

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9. TRADING PARTNER AGREEMENTS

9.1 The Enrollment Process

All clearinghouses and providers who submit claims directly to BlueCross BlueShield of

South Carolina or BlueChoice HealthPlan must complete the appropriate Trading Partner

Agreement and EDIG Enrollment form to receive a Trading Partner ID for claims submission and other transactions. There is one Trading Partner Agreement for

clearinghouses (see below) and another for hospitals and physicians (see below) who wish to transmit claims and other transactions directly with us.

9.2 Clearinghouse Trading Partner Agreement

The Clearinghouse Trading Partner Agreement must be completed by clearinghouses that transmit HIPAA-compliant transactions directly to us on behalf of hospitals, doctors and other health care professionals.

There is also an agreement for hospitals, doctors and other health care professionals who

wish to transmit HIPAA-compliant transactions directly with us. See Appendix D .

9.3 Hospital and Physician Trading Partner Agreement

The Hospital and Physician Trading Partner Agreement is for use by doctors and other health care professionals who intend on transmitting HIPAA-compliant transactions directly to us. Completing this form will allow you to send and receive HIPAA-compliant transactions when you will not be using a clearinghouse to process transactions. Please be sure to complete the entire agreement and Exhibit A, the EDIG Enrollment form, which follows the agreement.

Important Information: If you plan to use a vendor or clearinghouse to conduct your

HIPAA transactions, please have them contact us as soon as possible if they have not

already done so. See Appendix D ,

Appendix E

and Appendix F .

9.4 Enrollment Process for Direct Transactions

1. The clearinghouse or provider completes the appropriate Trading Partner

Agreement and mails it to the address on the bottom of the form.

2. Once the Technology Support Center receives the completed agreement, an authorized representative will review and sign the Trading Partner Agreement, file the original and return a copy of the agreement to the Trading Partner.

3. The EDIG Trading Partner enrollment form is sent to the operations department for assignment of the Trading Partner ID number. Please allow three to four days for processing.

4. After assignment of the Trading Partner ID number, the contact person identified on the EDIG Enrollment form will be notified by email or phone with production and test

Trading Partner ID numbers.

5. Call BlueCross EDIG Operations at 800-868-2505 to request the passwords and all other information required to begin transmitting once the ID numbers are received.

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9.5 Enrollment for Providers Using a Clearinghouse

Providers who will use a vendor or clearinghouse for submission of claims should complete only the Trading Partner Agreement portion of the agreement for health care professionals. Mail the agreement to the address indicated at the bottom of the form.

Once the completed agreement is received by the Technology Support Center, an authorized representative will review and sign the Trading Partner Agreement, file the original and return a copy of the agreement to the Trading Partner.

If you have further questions about the enrollment process, contact us by visiting www.hipaacriticalcenter.com/contactus.aspx

.

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10. Transaction-Specific Information

This section describes how ASC X12N Implementation Guides (IGs) adopted under

HIPAA will be detailed with the use of a table (1) (2). The tables contain a row for each segment that BlueCross BlueShield of South Carolina and its subsidiaries’ health plans have something additional, over and above, the information in the IGs. That information can:

1. Limit the repeat of loops, or segments

2. Limit the length of a simple data element

3. Specify a sub-set of the IGs internal code listings

4. Clarify the use of loops, segments, composite and simple data elements

5. Any other information tied directly to a loop, segment, composite or simple data element pertinent to trading electronically with BlueCross BlueShield of South Carolina and its subsidiaries’ health plans.

In addition to the row for each segment, one or more additional rows are used to describe

BlueCross BlueShield of South Carolina and its subsidiaries’ health plans’ usage for composite and simple data elements and for any other information.

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Page # Loop ID Reference Name

41 2100A NM1 Payer Name

42

42

42

2100A

2100A

2100A

NM108

NM108

NM109

Codes

Identification Code Qualifier

Identification Code Qualifier PI

Identification Code

42 2100A NM109 Identification Code 38520

77828

95741

76031

Notes/Comments

This element must equal “PI.”

Payer Identification

The following codes are accepted:

BlueCross BlueShield of

South Carolina

Companion Life Insurance

Company

BlueChoice HealthPlan

Florida Combined Life

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Page # Loop ID Reference Name

49

51

2100C

2100C

NM1

NM108

Provider Name

Identification Code Qualifier

Codes

51 2100C NM108 Identification Code Qualifier FI

SV

XX

Notes/Comments

All providers eligible under the

Centers for Medicare &

Medicaid Services (CMS) guidelines to receive a

National Provider ID (NPI) number must report the NPI number in element NM109 using the qualifier “XX” in element NM108. If a provider is not eligible to receive an

NPI, either the Federal

Taxpayer Identification

Number (FI) or the provider’s

Service Provider Number (SV) may be used in element

NM109. This can be the

Billing or Rendering provider.

Federal Taxpayer’s

Identification Number

Service Provider Number

Centers for Medicare &

Medicaid Services National

Provider Identifier

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57

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Page # Loop ID Reference Name

54

55

2100D

2100D

DMG

DMG02

Subscriber Demographic

Information

Date Time Period

Codes

2100D

2100D

NM1

NM108

Subscriber Name

Identification Code Qualifier

2100D

2100D

NM108

NM109

Identification Code Qualifier MI

Identification Code

Notes/Comments

Required when the subscriber is the patient.

If the subscriber is the patient, this field must be populated with the subscriber’s date of birth in “CCYYMMDD” format.

Otherwise, do not submit this element as each request should only contain one DMG segment.

This element is required whether the patient is the subscriber or a dependent, and it must equal “MI.”

Member Identification Number

This element is required whether the patient is the subscriber or a dependent and must be populated with the subscriber’s ID number from the member’s ID card.

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Page # Loop ID Reference Name

66

66

2200D

2200D

AMT

AMT02

Claim Submitted Charges

Monetary Amount

Codes

67

68

2200D

2200D

DTP

DTP03

Claim Service Date

Claim Service Date

Notes/Comments

This segment is not required.

If the request does not specify a claim amount, the value of this field may be a single 0

(zero) to return all claims. If an amount is submitted, and it matches a claim or claims found within the date range submitted for the provider specified, all claims matching that dollar amount will be returned. If no claims match that dollar amount, all claims for the provider within the date range submitted will be returned.

This segment is required even when the request does not depend upon the service date.

To request information on claims regardless of date of service, this field may be

“20000101-CCYYMMDD,” where “CCYYMMDD” equals the request date.

This element is required when the subscriber is the patient.

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Page # Loop ID Reference Name

69 2210D SVC Service Line Information

Codes

73 2210D REF

74 2210D DTP

Service Line Item

Identification

Service Line Date

Notes/Comments

BlueCross BlueShield of

South Carolina does not support line-level inquiries.

BlueCross BlueShield of

South Carolina does not support line-level inquiries.

BlueCross BlueShield of

South Carolina does not support line-level inquiries.

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Page # Loop ID Reference Name

89

89

2200E

2200E

AMT

AMT02

Claim Submitted Charges

Monetary Amount

Codes

90

91

2200E

2200E

DTP

DTP03

Claim Service Date

Date Time Period

Notes/Comments

This segment is not required.

If the request does not specify a claim amount, the value of this field may be a single 0

(zero) to return all claims. If an amount is submitted, and it matches a claim or claims found within the date range submitted for the provider specified, all claims matching that dollar amount will be returned. If no claims match that dollar amount, all claims for the provider within the date range submitted will be returned.

This segment is required even when the request does not depend upon the service date.

To request information on claims regardless of date of service, this field may be

“20000101-CCYYMMDD,” where “CCYYMMDD” equals the request date.

This element is required when the subscriber is the patient.

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A. APPENDICES

A1. Implementation Checklist

BlueCross BlueShield of South Carolina suggests entities use this information as a checklist of steps to become a submitter:

• Read and review this guide.

• Contact BlueCross BlueShield of South Carolina Technology Support Center at

803-736-5980 or 800-868-2505 with questions (if any).

• Get user ID and password.

• Send at least one test transaction. (These tests must be performed for each different transaction type that a trading partner is approved to submit to EDIG.)

• Begin submitting transactions.

B1. Business Scenarios

These scenarios are intended to serve as examples of a typical relationship between entities and BlueCross BlueShield of South Carolina in regards to the Blue System.

Clearinghouse A submits transactions for Provider A. Clearinghouse A wishes to

provide real-time services for Provider A, so they register with their current payers to do real-time transactions via their respective implementations. In order to complete registration and successfully submit transactions on behalf of Provider A,

Clearinghouse A must get a copy of the shared secret (§4.5.1) from Provider A to complete registration with BlueCross BlueShield of South Carolina. Once this has occurred, Clearinghouse A can send transactions for Provider A as well as any other clients it has a relationship with that are currently contracted with BlueCross

BlueShield of South Carolina.

Software Vendor A provides practice management systems to Provider A. The

system has the capability to build SOAP-based ANSI transactions for submission to various payers or clearinghouses. Provider A expresses an interest in being able to process real-time ANSI data so Software Vendor A instructs the provider on how to set up this feature. Provider A can then use their credentials they use for the

BlueCross BlueShield of South Carolina Blue Access

®

system to send these transactions.

Provider A wishes to send real-time transactions, but does not have a

clearinghouse relationship or practice management system that supports this feature. They therefore use in-house or contract talent to develop a customized

HTTP MIME multipart submission page that they can then use in conjunction with their Blue Access credentials to submit Blue transactions.

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C1. Frequently Asked Questions

What forms do I need to complete to be able to send HIPAA transactions?

You must complete the Trading Partner Agreement and the EDIG Enrollment Form. If you represent a hospital, or are a doctor or other health care professional who will be

transmitting transactions directly to us, you should complete Appendix F . If you are a

clearinghouse, complete Appendix E .

I use a clearinghouse to process my transactions. So I do not need to do anything,

right?

Clearinghouses must complete and sign Appendix E . If you plan to use a vendor or clearinghouse to conduct your HIPAA transactions, please have them contact us by visiting www.hipaacriticalcenter.com/contactus.aspx

as soon as possible if they have not already done so to ensure their transactions are compatible with our systems. You still must meet the separate HIPAA privacy rules that went into effect on April 14, 2003.

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D1. Trading Partner Enrollment

Enrollment with the EDI Gateway requires prospective trading partners to complete and submit the BlueCross BlueShield of South Carolina EDIG Trading Partner Enrollment Form and the Trading Partner Agreement. The purpose of the BlueCross BlueShield of South

Carolina EDIG Trading Partner Enrollment Form is to enroll providers, software vendors, clearinghouses and billing services as trading partners and recipients of electronic data. It is important you follow these instructions and complete all the required information. We will return incomplete forms to the applicant, which could delay the enrollment process.

The enrollment form is in the Appendix of the EDI Gateway Technical Communications

User’s Manual and is also available at the HIPAA Critical Center.

You should complete enrollment forms electronically and email them to [email protected]

Use your TAB key to move forward through the form fields or click your cursor in a desired field or box. Be sure to save the file after you have completed the form.

The Trading Partner Agreement is a legal document. All trading partners are required to print, complete and return the originally signed hard copy via mail prior to being moved to production status. The BlueCross BlueShield of South Carolina Trading Partner

Agreements can be found at the HIPAA Critical Center.

The PGBA Trading Partner

Agreement can be found on MyTRICARE.com

in the Electronic Claims Filing section.

If you are a prospective BlueCross BlueShield of South Carolina commercial or BlueChoice

HealthPlan trading partner, print and mail a hard copy of the completed Trading Partner

Agreement to:

BlueCross BlueShield of South Carolina

Technology Support Center: EDI Enrollment

I-20 at Alpine Road, AA-E05

Columbia, SC 29219

If you are a prospective PGBA, LLC trading partner, print and mail a hard copy of the completed Trading Partner Agreement to:

Palmetto GBA

Attention: EDIG Operations, AG-280

2300 Springdale Drive, Building One

Camden, SC 29020-1728

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This table will help trading partners complete the enrollment form:

Form Field Name Instructions for Field Completion

Date Enter today’s date.

Action Requested:

New Trading Partner ID

Change

Cancel

Trading Partner Name Enter the name of the entity that will be submitting/receiving electronic transactions with

Trading Partner ID

Federal Tax ID #

BlueCross BlueShield of South Carolina EDIG.

EDIG assigns the Trading Partner ID to identify trading partners in our system.

Enter the trading partner’s federal tax identification number.

Type of Business

Line of Business

Indicate the action to be taken on the enrollment form.

Note: Depending on the requested action, different fields of this form are required. These are identified in the column at right.

1. To apply for a new Trading Partner ID, check New

Trading Partner ID.

2. To change Trading Partner information, check

Change.

3. To cancel your enrollment, check Cancel.

Select the type of primary business the trading partner conducts. If you check “Other,” indicate the type of business on the line provided.

Check one box per enrollment form indicating if transactions are BlueCross BlueShield of South Carolina

Commercial or PGBA.

Start Date

End Date

Compression

Protocol

Service Address

Indicate, in mm/dd/ccyy format, the date the trading partner plans to begin transaction testing with BlueCross

BlueShield of South Carolina EDIG.

If you are using this form to cancel an account, indicate, in mm/dd/ccyy format, the date the trading partner intends to terminate its trading partner account.

If you wish to download your files in a compressed format, check PKZIP or UNIX. If not, check No

Compression.

Check the preferred communication method.

If you select Secure FTP or VPN, complete and return the “SFTP/VPN Customer Parameter Survey” and attach your public key ID file to your email. If you select TCPIP

via VPN, complete and return the “BlueCross BlueShield of South Carolina Commercial TCPIP via VPN Customer

Connectivity Parameter Survey” and/or the “PGBA

TCPIP via VPN Customer Connectivity Parameter

Survey.”

If you select NDM, complete the “BlueCross BlueShield of South Carolina Commercial NDM Customer

Connectivity Parameter Survey” and/or the “PGBA NDM

Customer Connectivity Parameter Survey.”

All Customer Connectivity Parameter Survey forms are in the Appendix of the EDI Gateway Technical

Communications User’s Manual. Please complete and return the form to [email protected]

Enter the trading partner’s complete address (including street, city, state and ZIP). This address must be the physical location for your business.

Req.

1 2 3

1

2

3

1 2 3

2 3

1

1

1

1

3

1

1

1 2

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Billing Address

Primary Contact’s

Information

Technical Contact’s

Information

After Hours Technical

Contact’s Information

On-Call Technical

Contact’s

Information

Transaction Volume

Estimates

If different from the service address, enter the trading partner’s billing (or mailing) address (including street, city, state and ZIP).

The name, email address, telephone number and fax number of the trading partner’s primary contact. This is the person BlueCross BlueShield of South Carolina

EDIG will contact if there are questions regarding the enrollment or future questions about the account.

The name, email address, telephone number and fax number of the trading partner’s technical contact. This is the person BlueCross BlueShield of South Carolina

EDIG will contact if there are technical questions or problems.

The name, email address, telephone number and fax number of the trading partner’s after-hours technical contact. This is the person BlueCross BlueShield of

South Carolina EDIG will contact if there are technical questions or problems after normal business hours.

The name, email address, telephone number and fax number of the trading partner’s on-call technical contact.

This is the person BlueCross BlueShield of South

Carolina EDIG will contact if there are technical questions or problems after normal business hours when it is unable to contact the after-hours technical contact.

Mark yes (Y) or no (N) for each mode. If you mark yes, indicate the average number of transactions you anticipate submitting each week.

1 2

1 2

1 2

1 2

1 2

1

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E1. Clearinghouse Trading Partner Agreement

CLEARINGHOUSE ELECTRONIC TRADING PARTNER AGREEMENT

Agreement No.:

This Electronic Trading Partner Agreement (“Agreement”) is entered into as of the day of

______________________, 2012 (“Effective Date”), by and between BlueCross BlueShield of

South Carolina and its subsidiaries, and _____________________ (“Trading Partner”).

RECITALS

WHEREAS, Trading Partner acts as a Business Associate to certain Providers and submits electronic transactions to BlueCross BlueShield of South Carolina on behalf of such Providers; and

WHEREAS, both Parties are entering into this Agreement to facilitate, through transmission via electronic formats consistent with or otherwise allowed by Social Security Act § 1173 and the

Standards for Electronic Transactions, 45 C.F.R. Parts 160 and 162, as may be amended or modified from time to time (“Transaction Rules”), the submission and payment of claims for medical services and supplies rendered or sold to Covered Individuals by Providers;

NOW, THEREFORE, in consideration for the mutual promises herein, the Parties agree as follows:

I. DEFINITIONS

The following terms with initial capitals have these meanings:

1.1 ANSI means American National Standards Institute; an organization whose Accredited

Standards Committee develops and approves uniform standards for the electronic interchange of business transactions.

1.2 Business Associate means an entity meeting the definition of 45 C.F.R. Part 160.103.

1.3 Confidential Health Information means information relating to specific Individuals, including

Individually Identifiable Health Information and Health Information, that is exchanged by and between BlueCross BlueShield of South Carolina and Trading Partner or Providers for various business purposes, and that is protected from disclosure to unauthorized persons or entities by

Social Security Act § 1171 et seq., the Standards for Privacy of Individually Identifiable Health

Information, 45 C.F.R. Parts 160 and 164, the Privacy Act of 1974 (5 U.S.C. § 552A), or other applicable state and federal statutes and regulations, including statutes and regulations protecting the privacy of general medical, mental health and substance abuse records

(collectively “Privacy Statutes and Regulations”).

1.4 Covered Individual means an Individual who is eligible for payment of certain services or supplies rendered or sold to the Individual or to the Individual’s eligible dependents under the terms, conditions, limitations and exclusions of a health benefit program issued or administered by BlueCross BlueShield of South Carolina or a health benefit program issued or administered by another Payor.

1.5 Data Transmission means automated transfer or exchange of data, pursuant to the terms and conditions of this Agreement, between BlueCross BlueShield of South Carolina and Trading

Partner by means of their respective Operating Systems, which are compatible for that purpose, and includes without limitation Electronic Data Interchange (“EDI”), Electronic Remittance

Advice (“ERA”) and Electronic Media Claims (“EMC”) transmissions.

1.6 Electronic Data Interchange (“EDI”) means the automated exchange of business documents from application to application.

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1.7 Electronic Media Claims (“EMC”) means automated methods of submitting claims for payment of medical services or supplies rendered or sold by a Provider or Supplier to an

Individual.

1.8 Electronic Remittance Advice (“ERA”) means a document containing information pertaining to the disposition of a specific claim for payment of services or supplies rendered to an

Individual that a Provider or Supplier files with BlueCross BlueShield of South Carolina on the

Individual’s behalf. The documents include, without limitation, information such as the Provider or Supplier name and address, Individual’s name, date of service, amount billed, amount paid, whether the claim is approved or denied, and if denied, the reason for the denial.

1.9 Envelope means a control structure in a format required by this Agreement for the electronic interchange of one or more encoded Data Transmissions between BlueCross BlueShield of

South Carolina and Trading Partner.

1.10 Health Information means any information, whether oral or recorded in any form or medium that (i) is created or received by a Provider, health plan, public health authority, employer, life insurer, school, university or health care clearinghouse and (ii) relates to the past, present, or future physical or mental health or condition of an Individual, the provision of health care to an

Individual or the past, present, or future payment for the provision of health care to an

Individual.

1.11 Individual means a person whose claims for services or supplies may be eligible to be paid under the terms of an applicable governmental or private program for which BlueCross

BlueShield of South Carolina processes or administers claims, and specifically includes without limitation Medicare Eligible Individuals, Medicaid Eligible Individuals and Covered

Individuals. Trading Partner acknowledges and agrees that claim payments made according to this Agreement will be made directly either to Providers on behalf of the Individual, or directly to the Individual, at BlueCross BlueShield of South Carolina’s discretion.

1.12 Individually Identifiable Health Information means any Health Information, including demographic information collected from an Individual, that is created or received by a Provider, health plan, employer or health care clearinghouse and either (i) identifies an Individual or (ii) creates a reasonable basis to believe the information can be used to identify the Individual.

1.13 Operating System means the equipment, software and trained personnel necessary for a successful Data Transmission.

1.14 Payor means a business organization that provides benefit payments for certain services or supplies rendered or sold to Covered Individuals or their eligible dependents under the terms, conditions, limitations and exclusions of a health benefit program issued or administered by the

Payor.

1.15 Proprietary Information means information used or created by BlueCross BlueShield of

South Carolina in the conduct of its business activities that is not normally made available to

BlueCross BlueShield of South Carolina’s customers, competitors or third parties, the disclosure of which will or may impair BlueCross BlueShield of South Carolina’s competitive position or otherwise prejudice BlueCross BlueShield of South Carolina’s ongoing business.

1.16 Provider means a customer of Trading Partner that operates as a hospital or professional practitioner duly certified or licensed to provide health care services to Covered Individuals, and includes, without limitation, extended care facilities, skilled nursing facilities, rehabilitation facilities, home health agencies, hospices, physicians, dentists, clinical social workers, ambulance services, and hospitals or professional practitioners specifically certified or approved by HHS to provide reimbursable health care services to Medicare Eligible

Individuals.

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1.17 Security Access Codes mean alphanumeric codes that BlueCross BlueShield of South

Carolina assigns to Trading Partner to allow Trading Partner access to BlueCross BlueShield of

South Carolina’s Operating System for the purpose of successfully executing Data

Transmissions or otherwise carrying out this Agreement.

1.18 Source Documents mean documents containing Data that are or may be required as part of a

Data Transmission concerning a claim for payment of charges for medical services that a

Provider furnishes or medical supplies that a Supplier sells to a Covered Individual. Source

Documents are subject to the security standards of Article V of this Agreement. Examples of

Data contained within a Source Document include, without limitation, Individual’s name and identification number, claim number, diagnosis codes for the services rendered, dates of service, service procedure descriptions, applicable charges for the services rendered, the

Provider’s or Supplier’s name and/or identification number, and signature.

1.19 Supplier means a person or organization that is a customer of Trading Partner and is engaged in the business of selling or leasing durable medical equipment or supplies to Covered

Individuals.

1.20 Trade Data Log means the complete, written summary of Data and Data Transmissions exchanged between the Parties over the period of time this Agreement is in effect and includes, without limitation, sender and receiver information, and transmission date, time and general nature.

II. TERM AND TERMINATION

2.1 Term of Agreement. This Agreement will remain in effect for an initial period of three (3) year(s) from the Effective Date, and will automatically renew for successive periods of three (3) year(s) unless terminated pursuant to Section 2.2 or Section 2.3.

2.2 Voluntary Termination. Either Party may terminate this Agreement upon one hundred twenty

(120) day(s) prior written notice to the other Party.

2.3 Termination for Cause. BlueCross BlueShield of South Carolina will have the unilateral right to terminate this Agreement immediately by providing Trading Partner with written notice of termination in the event of (i) a breach by Trading Partner of any section of Article V or of Article

VII of this Agreement; or (ii) Trading Partner, any of its related business entities or any of its officers, directors, managing employees, Providers or Suppliers is charged with a criminal offense relating to one or more government contracts or government subcontracts or to federal health care programs (as defined in Social Security Act § 1128B(f)), listed by a federal agency as debarred, proposed for debarment, or suspended, or otherwise excluded from federal program participation, including exclusion from participation in a federal health care program (as defined in the Social Security Act § 1128B(f)).

III. OBLIGATIONS OF THE PARTIES

3.1 Mutual Obligations. The mutual obligations of BlueCross BlueShield of South Carolina and

Trading Partner include the following:

(a) Transmission Format. All standard transactions, as defined by Social Security Act §

1173(a) and the Transaction Rules, conducted between BlueCross BlueShield of South

Carolina and Trading Partner, will be conducted electronically and will only use code sets, data elements and formats specified by the Transaction Rules and the then current version of the BlueCross BlueShield of South Carolina Supplemental Implementation Guides. The

BlueCross BlueShield of South Carolina Supplemental Implementation Guides and any updates or amendments thereto may be accessed at www.SouthCarolinaBlues.com

and are incorporated herein by reference. This section will automatically amend to comply with any

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final regulation or amendment to a final regulation adopted by HHS concerning the subject matter of this Section upon the effective date of the final regulation or amendment.

(b) Testing. Prior to the initial Data Transmission, each Party will test and cooperate with the other Party in testing the connectivity and interaction of the Parties’ Operating Systems to ensure the accuracy, timeliness, completeness and confidentiality of each Data

Transmission.

(c) Data Transmission Accuracy. The Parties will take reasonable care to ensure that Data

Transmissions are timely, complete, accurate and secure. Each Party will take reasonable precautions in accordance with Article V of this Agreement to prevent unauthorized access to the other Party’s Operating System, Data Transmissions or the contents of an Envelope transmitted to or from either Party.

(d) Retransmission of Lost or Indecipherable Transmissions. A Party will retransmit the original transmission within three (3) business day(s) of its discovery that a Data

Transmission is a lost or indecipherable Transmission.

(e) Equipment Cost. Each Party will obtain and maintain, at its own expense, its own Operating

System necessary for timely, complete, accurate and secure Data Transmission pursuant to this Agreement. Each Party will pay its own costs related to Data Transmission under this

Agreement, including, without limitation, charges for the Party’s own Operating System equipment, software and services, maintaining an electronic mailbox, connection time, terminals, connections, telephones, modems and applicable minimum use charges. Each

Party will be responsible for its own expenses incurred for translating, formatting and sending or receiving communications over the electronic network to any electronic mailbox of the other Party.

(f) Backup Files. Each Party will maintain adequate backup files, electronic tapes or other sufficient means to recreate a Data Transmission for at least six (6) years from the Data

Transmission’s creation date. Such backup files, tapes or other sufficient means will be subject to the terms of Article V of this Agreement to the same extent as the original Data

Transmission.

(g) Data and Data Transmission Security. BlueCross BlueShield of South Carolina and

Trading Partner will employ security measures necessary to protect Data and Data

Transmissions between them, including authentication, encryption, password use, or other security measures in compliance with Social Security Act § 1173(d) and any HHS implementing regulations or guidelines and as set forth in Article V of this Agreement. Unless

BlueCross BlueShield of South Carolina and Trading Partner agree otherwise, the recipient of data or Data Transmission will use at least the same level of protection for any subsequent transmission as was used for the original transmission.

(h) Security Access Codes. The Security Access Codes that BlueCross BlueShield of South

Carolina issues to Trading Partner will, when affixed to Data Transmissions, be legally sufficient to verify the identity of the transmitter and to authenticate the Data Transmission, thereby establishing the Data Transmission’s validity. Data Transmissions having a Security

Access Code affixed to them will be deemed to have been “written” or “signed” by the sender. Computer printouts of the information contained in such correspondence and documents that have been electronically or magnetically recorded and kept in the normal course of the sender’s or receiver’s business will be considered original business records admissible in any judicial, arbitration, mediation or administrative proceeding to the same extent and under the same conditions as other business records originated and maintained in documentary form.

3.2 Trading Partner Obligations. Trading Partner will:

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(a) Not copy, reverse engineer, disclose, publish, distribute, alter or use Data, Data

Transmission or Envelope for any purpose other than for which BlueCross BlueShield of

South Carolina has specifically authorized Trading Partner under the terms of this

Agreement.

(b) Not obtain access by any means to data, Data Transmission, Envelope, or BlueCross

BlueShield of South Carolina’s Operating System for any purpose other than as BlueCross

BlueShield of South Carolina has specifically granted Trading Partner access under this

Agreement. In the event that Trading Partner receives data or Data Transmissions not intended for Trading Partner, Trading Partner will immediately notify BlueCross BlueShield of South Carolina and make arrangements to retransmit or otherwise return the data or

Data Transmission to BlueCross BlueShield of South Carolina. After such retransmission or return, Trading Partner will immediately delete the data and Data Transmission from its

Operating System.

(c) Protect and maintain the confidentiality of Security Access Codes issued to Trading Partner by BlueCross BlueShield of South Carolina, and limit disclosure of Security Access Codes to authorized personnel on a need-to-know basis.

(d) Provide BlueCross BlueShield of South Carolina in writing all information requested in

Exhibit A to this Agreement not later than Trading Partner’s execution of this Agreement.

While this Agreement is in effect, Trading Partner will notify BlueCross BlueShield of South

Carolina in writing within one (1) business day of any material change in the information on

Exhibit A to this Agreement.

3.3 Obligations. BlueCross BlueShield of South Carolina will:

(a) Make available to Trading Partner, via electronic means, data and Data Transmissions for which this Agreement grants Trading Partner access or authorization, or as provided by law.

(b) Provide Trading Partner with at least sixty (60) days prior written notice of any change or addition to the BlueCross BlueShield of South Carolina Supplemental Implementation

Guides, code sets, data elements or formats for Data Transmissions set forth in Section

3.1(a) of this Agreement.

(c) Provide Trading Partner with Security Access Codes that will allow Trading Partner to exchange Data Transmissions with BlueCross BlueShield of South Carolina’s Operating

System. BlueCross BlueShield of South Carolina reserves the right to change Security

Access Codes at any time and in such manner as BlueCross BlueShield of South Carolina, in its sole discretion, deems necessary.

IV. PROVIDERS AND SUPPLIERS

4.1 Provider and Supplier Obligations. Trading Partner will ensure that Providers and Suppliers will be bound by the mutual obligations of the Parties set forth in Section 3.1 and Trading

Partner’s obligations set forth in Section 3.2, even though Providers and Suppliers are not signatories to this Agreement.

4.2 Responsibility for Providers and Suppliers. Trading Partner is liable to BlueCross

BlueShield of South Carolina for any act, failure, or omission of any Provider and/or Supplier with whom Trading Partner contracts or for whom Trading Partner receives, transmits stores or processes data or Data Transmissions or performs related activities, as though the act, failure or omission were that of Trading Partner.

4.3 Notices Regarding Providers. Trading Partner will notify BlueCross BlueShield of South

Carolina at least fourteen (14) days prior to the addition or deletion of any Provider and/or

Supplier from the list contained in Exhibit A of Providers and Suppliers for whom Trading

Partner submits data or Data Transmissions to BlueCross BlueShield of South Carolina.

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V. CONFIDENTIALITY AND SECURITY

5.1 Data Security. Trading Partner will maintain adequate security procedures to prevent unauthorized access to data, Data Transmissions, Security Access Codes, Envelopes, backup files, Source Documents or BlueCross BlueShield of South Carolina’s Operating System.

Trading Partner will immediately notify BlueCross BlueShield of South Carolina of any unauthorized attempt to obtain access to or otherwise tamper with data, Data Transmissions,

Security Access Codes, Envelopes, backup files, Source Documents or BlueCross BlueShield of South Carolina’s Operating System.

(a) Confidential Health Information. Trading Partner will comply with all applicable Privacy

Statutes and Regulations, guidelines and health care industry customs concerning treatment of Confidential Health Information.

(b) Proprietary Information. Trading Partner will treat BlueCross BlueShield of South Carolina’s

Proprietary Information obtained or learned in connection with this Agreement as confidential and will not use BlueCross BlueShield of South Carolina’s Proprietary Information for Trading

Partner’s own commercial benefit or any other purpose not authorized in this Agreement.

Trading Partner will safeguard BlueCross BlueShield of South Carolina’s Proprietary

Information against unauthorized disclosure and use.

(c) Notice of Unauthorized Disclosures and Uses. Trading Partner will promptly notify

BlueCross BlueShield of South Carolina of any unlawful or unauthorized use or disclosure of

Confidential Health Information or BlueCross BlueShield of South Carolina’s Proprietary

Information that comes to Trading Partner’s attention and will cooperate with BlueCross

BlueShield of South Carolina in the event that any litigation arises concerning the unlawful or unauthorized disclosure or use of Confidential Health Information or BlueCross BlueShield of

South Carolina’s Proprietary Information.

5.2 Operating Systems Security. Each Party will develop, implement and maintain measures necessary to ensure the security of each Party’s own Operating System and each Party’s records relating to its Operating System. Each Party will document and keep current its security measures. Each Party’s security measures will include, at a minimum, the requirements and implementation features set forth in Social Security Act § 1173(d) and all applicable HHS implementing regulations.

VI. RECORDS RETENTION AND AUDIT

6.1 Records Retention. Trading Partner will require Providers and Suppliers to maintain complete, accurate and unaltered copies of all Source Documents from all Data Transmissions Trading

Partner transmits to, or receives from, BlueCross BlueShield of South Carolina for not less than six (6) years from the date that Trading Partner transmits or receives them. All retained records will be subject to the same security measures as data and Data Transmissions.

6.2 Trade Data Log. BlueCross BlueShield of South Carolina and Trading Partner will each establish and maintain a Trade Data Log to record all Data Transmissions between the Parties during the term of this Agreement. Each Party will take necessary and reasonable steps to ensure that its Trade Data Log constitutes a complete, accurate and unaltered record of each

Data Transmission between the Parties. Each Party will retain Data Transmission records for not less than twenty-four (24) month(s) following the date of a Data Transmission. Each Party will maintain its Trade Data Log on computer media or other suitable means that permit timely retrieval and presentation in readable form.

6.3 Right to Audit. BlueCross BlueShield of South Carolina will have the right to audit relevant

Trading Partner’s business records, Trading Partner’s Trade Data Log, and Trading Partner’s

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Operating System as BlueCross BlueShield of South Carolina, in its sole discretion, deems necessary to ensure compliance with this Agreement.

6.4 Government Requests for Information. Trading Partner will notify BlueCross BlueShield of

South Carolina immediately upon Trading Partner’s receipt of any request from a government authority for information or documents relating to this Agreement, except to the extent such notification is prohibited by law.

VII. REPRESENTATIONS AND WARRANTIES

7.1 Government Programs. Trading Partner represents and warrants that:

(a) Neither the United States government, any state or local government, nor any prime contractor, subcontractor or other person has notified Trading Partner, either orally or in writing, that Trading Partner has breached or violated any law, certification, representation, clause, provision or requirement pertaining to or involving any government contract or government subcontract that has resulted or may result in Trading Partner being charged with a criminal offense;

(b) No termination for convenience, termination for default, cure notice or show cause notice is currently in effect or threatened against Trading Partner by the United States government or any state or local government;

(c) Neither Trading Partner nor any of its directors, officers, employees or agents are or have been under criminal investigation or indictment by any government entity;

(d) Trading Partner has not been debarred or suspended from participation in the award of contracts with any government entity (excluding for this purpose ineligibility to bid on certain contracts due to generally applicable bidding requirements);

(e) There exists no fact or circumstance that would warrant the institution of suspension or debarment proceedings or the finding of no responsibility or ineligibility on the part of

Trading Partner or any director, officer or employee of Trading Partner; and

(f) No payment has been made by Trading Partner or by any person on behalf of Trading

Partner in connection with any government contract or government subcontract in violation of or requiring disclosure pursuant to the Foreign Corrupt Practices Act, as amended (15

U.S.C. §§ 78dd-1, 78dd-2).

7.2 Legal Compliance. Trading Partner will use reasonable efforts to comply, and to cause Trading

Partner’s directors, officers, employees and Providers and Suppliers to comply, in all material respects with all requirements of all laws pertaining to government contracts or government subcontracts, the violation of which may result in Trading Partner or its directors, officers or employees, or other persons being charged with a criminal offense. For purposes of this Section

7.2, “laws” mean all applicable statutes, laws, rules, regulations, permits, decrees, injunctions, judgments, orders, rulings, determinations, writs and awards.

7.3 Warranties Regarding Providers and Suppliers. Trading Partner warrants that it will make no changes in the Data content of Data Transmissions or the contents of an Envelope received from Providers and/or Suppliers. Trading Partner further warrants that Trading Partner will advise Providers and Suppliers of this Agreement and that Providers and Suppliers will comply in all respects with the terms of this Agreement.

7.4 Notice of Violations. Trading Partner will notify BlueCross BlueShield of South Carolina in writing within three (3) business days of obtaining knowledge of any criminal investigation, indictment, information or charge by any governmental entity (or communications indicating that the same may be contemplated) related to Trading Partner or any of Trading Partner’s directors, officers, employees, vendors, agents, Providers or Suppliers.

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VIII. INDEMNIFICATION

8.1 Indemnification of BlueCross BlueShield of South Carolina. Trading Partner will indemnify, defend and hold BlueCross BlueShield of South Carolina harmless from any and all claims, actions, damages, liabilities, costs, or expenses, including, without limitation, reasonable attorneys’ fees, arising out of any act or omission of Trading Partner, Providers, Suppliers, or their respective employees, subcontractors or other persons in the performance of this

Agreement. BlueCross BlueShield of South Carolina will have the option at its sole discretion to employ attorneys to defend any such claim, action or proceeding arising out of these acts or omissions, the costs and expenses of which will be Trading Partner’s responsibility. BlueCross

BlueShield of South Carolina will provide Trading Partner with timely notice of the existence of such action. Trading Partner will provide information, documents and other cooperation as reasonably necessary to assist BlueCross BlueShield of South Carolina in establishing its defenses to such action.

8.2 Breach of Warranties. Trading Partner will indemnify and hold BlueCross BlueShield of South

Carolina harmless from and against any and all liability resulting from: (i) any misrepresentation in Trading Partner’s representations and warranties in Article VII of this Agreement; (ii) disputes between BlueCross BlueShield of South Carolina and Providers and/or Suppliers regarding Data

Transmissions that are the subject of this Agreement; (iii) Trading Partner’s failure to notify

BlueCross BlueShield of South Carolina as required in Section 7.4 of this Agreement; or (iv) actual exclusion during the term of this Agreement from any federal health care program (as defined in the Social Security Act § 1128B(f)).

8.3 Participation in Actions. BlueCross BlueShield of South Carolina reserves the right, at its option and expense, to participate in the defense of any suit or action brought against Trading

Partner, Providers or Suppliers arising out of any act or omission in connection with this

Agreement.

8.4 Dispute Assistance. Each Party will reasonably cooperate in providing necessary assistance to the other Party when the other Party is actively involved in a dispute with a third party concerning

Data Transmissions that either are or reasonably could be the source of litigation with that third party.

8.5 Limitation of Liability. Except for the indemnification obligations in Article VII, claims or causes of action related to Trading Partner’s actual or alleged breach of Article V, or fraud by Trading

Partner, neither Party will be liable for any special, incidental, indirect, punitive, exemplary or consequential damages resulting from any claim or cause of action arising out of any delay, omission or error in any Data Transmission or the other Party’s performance or failure to perform in accordance with the terms of this Agreement, including, without limitation, loss of use, revenues, profits or savings, even if a Party has been advised in advance of the possibility of such damages.

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IX. MISCELLANEOUS

9.1 Notices. Any notice pertaining to this Agreement will be in writing. Notice will be deemed given when personally delivered to the Party’s authorized representative listed here, or sent by means of a reputable overnight courier or by certified mail, postage prepaid, return receipt requested. A notice sent by overnight courier or by certified mail will be deemed given on the date of receipt or refusal of receipt. All notices will be addressed to the appropriate Party as follows:

To: BlueCross BlueShield of South Carolina

I-20 Alpine Road, AX-701

Columbia, SC 29219

Attn: Martha Owens Perry

Title: AVP, Health Care Services

To: (Trading Partner) _________________________________

(Address) _______________________________________

(City, State, ZIP Code) _____________________________

Attn: ___________________________________________

Title: ___________________________________________

9.2 Amendments. This Agreement may not be changed or modified except by an instrument in writing signed by each Party’s authorized representative.

9.3 Choice of Law. This Agreement and the Parties’ rights and obligations hereunder are governed by and will be construed under the laws of the State of South Carolina.

9.4 Jurisdiction, Venue and WAIVER OF JURY TRIAL. The Parties agree that any action or proceeding arising out of or related to this Agreement shall be instituted only in the Federal

District Court in Columbia, South Carolina. Each party consents and submits to the jurisdiction of such court and agrees that venue therein shall be proper and convenient. In any such action or proceeding in such court, each party waives any right to raise any objection based upon improper venue, lack of jurisdiction or inconvenient forum, and each party consents to personal jurisdiction of such court and agrees service of process may be effected by United States mail.

EACH PARTY WAIVES ANY RIGHT IT MAY HAVE TO A TRIAL BY JURY IN ANY

LITIGATION ARISING OUT OF, UNDER OR IN CONNECTION WITH THIS AGREEMENT.

9.5 Assignment of Rights and Delegation of Duties. This Agreement is binding upon and inures to the benefit of the Parties and their respective successors and assigns. BlueCross BlueShield of South Carolina retains the right to assign or delegate any of its rights or obligations hereunder to any of its subsidiaries, affiliates or successor companies. Otherwise, neither Party may assign its rights or delegate its obligations under this Agreement without the prior written consent of the other Party, which consent will not be unreasonably withheld or delayed.

9.6 Relationship of BlueCross BlueShield of South Carolina to the Blue Cross and Blue

Shield Association. This Agreement constitutes a contract between Trading Partner and

BlueCross BlueShield of South Carolina. BlueCross BlueShield of South Carolina is an independent corporation operating under a license with the Blue Cross and Blue Shield

Association (“Association”), an association of independent Blue Cross and Blue Shield Plans, permitting BlueCross BlueShield of South Carolina to use the BlueCross and BlueShield service marks in South Carolina. BlueCross BlueShield of South Carolina is not contracting as the agent of the Association. Trading Partner has not entered into this Agreement based upon

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representations by any person other than BlueCross BlueShield of South Carolina, and no person, entity or organization other than BlueCross BlueShield of South Carolina will be held accountable or liable to Trading Partner for any of BlueCross BlueShield of South Carolina’s obligations to Trading Partner under this Agreement.

9.7 Force Majeure. Each Party will be excused from performance for any period of time during this

Agreement that it is prevented from performing any obligation or service, in whole or in part, as a result of causes beyond its reasonable control and without its fault or negligence. Such acts include, without limitation, acts of God, strikes, lockouts, riots, acts of war, epidemics, governmental regulations imposed after the fact, fire, communication line failures, power failures, earthquakes, floods or other natural disasters. Delays in performance because of the occurrence of such events will automatically extend due dates for a period equal to the duration of such events. Such automatic extension will have no effect on the exercise of either Party’s right of voluntary termination of this Agreement under Section 2.2 of this Agreement.

9.8 No Waiver. Failure or delay on the part of either Party to exercise any right, power, privilege or remedy in this Agreement will not constitute a waiver. No provision of this Agreement may be waived by either Party except in a writing signed by an authorized representative of the Party making the waiver.

9.9 No Agency. Nothing in this Agreement will place BlueCross BlueShield of South Carolina and

Trading Partner in a relationship whereby either (i) is the principal or agent of the other for any purpose or (ii) has the authority to bind the other in any way.

9.10 Severability. The provisions of this Agreement are severable. If any provision of this

Agreement is held or declared to be illegal, invalid or unenforceable, the remainder of the

Agreement will continue in full force and effect as though the illegal, invalid or unenforceable provision had not been contained in the Agreement.

9.11 Entire Agreement. This Agreement, together with its Exhibits, and any applicable Riders and

Amendments, constitutes the entire understanding between the Parties with respect to the subject matter of this Agreement and supersedes and cancels all previous written or oral understandings, agreements, negotiations, commitments, and any other writing and communication by or between the Parties on this specific subject matter. In the event of any inconsistency between any provision of this Agreement and any provision of a Rider to this

Agreement, the provision of this Agreement controls.

9.12 Automatic Amendment for Regulatory Compliance. This Agreement will automatically amend to comply with any final regulation or amendment to a final regulation adopted by HHS concerning the subject matter of this Agreement upon the effective date of the final regulation or amendment.

9.13 Survival. The provisions of Sections 3.1(d) and 3.2; Article V; Sections 6.1 and 6.2; and

Article VIII will survive termination of this Agreement.

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SIGNATURES

The Parties will be bound by all the terms, provisions and conditions of this Agreement upon execution of the Agreement by each Party’s authorized representative. Agreed to TRADING PARTNER

Agreed to BLUE CROSS AND BLUE

SHIELD OF SOUTH CAROLINA, INC.

By: _____________________________________ By: _________________________________

Name: __________________________________ Name: ______________________________

Title: ____________________________________ Title: ________________________________

Address: _________________________________ I-20 at Alpine Road, AA-270

City, State, ZIP: ____________________________ Columbia, SC 29219

Date: ____________________________________ Date: _______________________________

Contact: __________________________________ Contact: _____________________________

Title: ____________________________________ Title: ________________________________

Telephone: ( ) ___________________________ Telephone: ( ) ______________________

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F1. Hospital & Healthcare Professional Agreement

Hospital & Healthcare Professional

ELECTRONIC TRADING PARTNER AGREEMENT

Agreement No.:

This Electronic Trading Partner Agreement (“Agreement”) is made as of the day of __________,

2012 (“Effective Date”), by and between BlueCross BlueShield of South Carolina, Inc., a South

Carolina corporation, located at I-20 Alpine Road, AA-270, Columbia, South Carolina 29219, and

(“Trading Partner”) located at ___________.

RECITALS

WHEREAS, Trading Partner is a business entity that transacts business with BlueCross

BlueShield of South Carolina on a regular basis pursuant to the terms of a Business Agreement; and

WHEREAS, both Parties are entering into this Agreement to facilitate, through transmission via electronic formats consistent with or otherwise allowed by Social Security Act § 1173 and the

Standards for Electronic Transactions, 45 C.F.R. Parts 160 and 162, as may be amended or modified from time to time (“Transaction Rules”), the submission and payment of claims for medical services and supplies rendered or sold to Covered Individuals;

NOW, THEREFORE, in consideration for the mutual promises herein, the Parties agree as follows:

I. DEFINITIONS

The following terms with initial capitals have these meanings:

1.1 ANSI means American National Standards Institute, an organization whose Accredited

Standards Committee develops and approves uniform standards for the electronic interchange of business transactions.

1.2 Business Associate means a third-party organization, designated in the Trading Partner

Business Associate Authorization Rider, that contracts with Trading Partner to perform services to facilitate the electronic transfer of Data or funds or to conduct other business functions on behalf of Trading Partner. Examples of Business Associates include, without limitation, clearinghouses, vendors, billing services, service bureaus, accounts receivable management firms and banking institutions.

1.3 Confidential Health Information means information relating to specific Individuals, including Individually Identifiable Health Information and Health Information, that is exchanged by and between BlueCross BlueShield of South Carolina and Trading Partner or

Business Associate for various business purposes, and that is protected from disclosure to unauthorized persons or entities by Social Security Act § 1171 et seq., the Standards for

Privacy of Individually Identifiable Health Information, 45 C.F.R. Parts 160 and 164, the

Privacy Act of 1974 (5 U.S.C. § 552A), or other applicable state and federal statutes and regulations, including statutes and regulations protecting the privacy of general medical, mental health and substance abuse records (collectively “Privacy Statutes and

Regulations”).

1.4 Covered Individual means an Individual who is eligible for payment of certain services or supplies rendered or sold to the Individual or to the Individual’s eligible dependents under the terms, conditions, limitations and exclusions of a health benefit program issued or administered by BlueCross BlueShield of South Carolina or a health benefit program issued or administered by another Payor.

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1.5 Data Transmission means automated transfer or exchange of data, pursuant to the terms and conditions of this Agreement, between BlueCross BlueShield of South Carolina and

Trading Partner or Business Associate by means of their respective Operating Systems, which are compatible for that purpose, and includes without limitation Electronic Data

Interchange (“EDI”), Electronic Remittance Advice (“ERA”) and Electronic Media Claims

(“EMC”) transmissions.

1.6 Electronic Data Interchange (“EDI”) means the automated exchange of business documents from application to application.

1.7 Electronic Media Claims (“EMC”) means automated methods of submitting claims for payment of medical services or supplies rendered or sold by a Provider or Supplier to an

Individual.

1.8 Electronic Remittance Advice (“ERA”) means a document containing information pertaining to the disposition of a specific claim for payment of services or supplies rendered to an Individual that a Provider or Supplier files with BlueCross BlueShield of South Carolina on the Individual’s behalf. The documents include, without limitation, information such as the

Provider or Supplier name and address, Individual’s name, date of service, amount billed, amount paid, whether the claim is approved or denied, and if denied, the reason for the denial.

1.9 Envelope means a control structure in a format mutually agreeable to BlueCross

BlueShield of South Carolina and Trading Partner for the electronic interchange of one or more encoded Data Transmissions between BlueCross BlueShield of South Carolina and

Trading Partner or Business Associate.

1.10 Health Information means any information, whether oral or recorded in any form or medium that (i) is created or received by a Provider, health plan, public health authority, employer, life insurer, school, university or health care clearinghouse and (ii) relates to the past, present, or future physical or mental health or condition of an Individual, the provision of health care to an Individual or the past, present, or future payment for the provision of health care to an Individual.

1.11 Individual means a person whose claims for services or supplies may be eligible to be paid under the terms of an applicable governmental or private program for which BlueCross

BlueShield of South Carolina processes or administers claims, and specifically includes without limitation Medicare Eligible Individuals, Medicaid Eligible Individuals and Covered

Individuals. BlueCross BlueShield of South Carolina and Trading Partner acknowledge and agree that claim payments made according to this Agreement will be made directly to

Trading Partner or Business Associate on behalf of the Individual.

1.12 Individually Identifiable Health Information means any Health Information, including demographic information collected from an Individual, that is created or received by a

Provider, health plan, employer or health care clearinghouse and either (i) identifies an

Individual or (ii) creates a reasonable basis to believe the information can be used to identify the Individual.

1.13 Operating System means the equipment, software and trained personnel necessary for a successful Data Transmission.

1.14 Payor means a business organization that provides benefit payments for certain services or supplies rendered or sold to Covered Individuals or their eligible dependents under the terms, conditions, limitations and exclusions of a health benefit program issued or administered by the Payor.

1.15 Proprietary Information means information used or created by BlueCross BlueShield of

South Carolina in the conduct of its business activities that is not normally made available to

BlueCross BlueShield of South Carolina’s customers, competitors or third parties, the disclosure of which will or may impair BlueCross BlueShield of South Carolina’s competitive position or otherwise prejudice BlueCross BlueShield of South Carolina’s ongoing business.

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1.16 Provider means a hospital or professional practitioner duly certified or licensed to provide health care services to Covered Individuals, and includes, without limitation, extended care facilities, skilled nursing facilities, rehabilitation facilities, home health agencies, hospices, physicians, dentists, clinical social workers, ambulance services, and hospitals or professional practitioners specifically certified or approved by HHS to provide reimbursable health care services to Medicare Eligible Individuals.

1.17 Security Access Codes mean alphanumeric codes that BlueCross BlueShield of South

Carolina assigns to Trading Partner to allow Trading Partner access to BlueCross

BlueShield of South Carolina’s Operating System for the purpose of successfully executing

Data Transmissions or otherwise carrying out this Agreement.

1.18 Source Documents mean documents containing Data that are or may be required as part of a Data Transmission concerning a claim for payment of charges for medical services that a

Provider furnishes or medical supplies that a Supplier sells to a Covered Individual. Source

Documents are subject to the security standards of Article V of this Agreement. Examples of

Data contained within a Source Document include, without limitation, Individual’s name and identification number, claim number, diagnosis codes for the services rendered, dates of service, service procedure descriptions, applicable charges for the services rendered, the

Provider’s or Supplier’s name and/or National Standard Identifier, and signature.

1.19 Supplier means a person or organization engaged in the business of selling or leasing durable medical equipment or supplies to Covered Individuals.

1.20 Trade Data Log means the complete, written summary of Data and Data Transmissions exchanged between the Parties over the period of time this Agreement is in effect and includes, without limitation, sender and receiver information, and transmission date, time and general nature.

II. TERM AND TERMINATION

2.1 Term of Agreement. This Agreement will remain in effect for an initial period of three (3) year(s) from the Effective Date, and will automatically renew for successive periods of three

(3) year(s) unless terminated pursuant to Section 2.2 or Section 2.3.

2.2 Voluntary Termination. Either Party may terminate this Agreement on one hundred twenty

(120) day(s) prior written notice to the other Party.

2.3 Termination for Cause. BlueCross BlueShield of South Carolina will have the unilateral right to terminate this Agreement immediately by providing Trading Partner with written notice of termination in the event of (i) a breach by Trading Partner of any section of Article V or of

Article VII of this Agreement; (ii) termination of any applicable business agreement between the Parties; or (iii) Trading Partner, any of its related business entities or any of its officers, directors, managing employees or Business Associates is charged with a criminal offense relating to one or more government contracts or government subcontracts or to federal health care programs (as defined in Social Security Act § 1128B(f)), listed by a federal agency as debarred, proposed for debarment, or suspended, or otherwise excluded from federal program participation, including exclusion from participation in a federal health care program

(as defined in the Social Security Act § 1128B(f)).

III. OBLIGATIONS OF THE PARTIES

3.1 Mutual Obligations. The mutual obligations of BlueCross BlueShield of South Carolina and

Trading Partner include the following:

(a) Transmission Format. All standard transactions, as defined by Social Security Act §

1173(a) and the Transaction Rules, conducted between BlueCross BlueShield of South

Carolina and Trading Partner or Business Associate, will only use code sets, data elements and formats specified by the Transaction Rules and the then current version of the BlueCross BlueShield of South Carolina Supplemental Implementation Guides.

The BlueCross BlueShield of South Carolina Supplemental Implementation Guides and

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any updates or amendments thereto may be accessed at www.SouthCarolinaBlues.com and are incorporated herein by reference. This section will automatically amend to comply with any final regulation or amendment to a final regulation adopted by HHS concerning the subject matter of this Section upon the effective date of the final regulation or amendment.

(b) Testing. Prior to the initial Data Transmission, each Party will test and cooperate with the other Party in testing each Party’s Operating System to ensure the accuracy, timeliness, completeness and confidentiality of each Data Transmission.

(c) Data Transmission Accuracy. The Parties will take reasonable care to ensure that

Data Transmissions are timely, complete, accurate and secure. Each Party will take reasonable precautions in accordance with Article V of this Agreement to prevent unauthorized access to the other Party’s Operating System, Data Transmissions or the contents of an Envelope transmitted to or from either Party.

(d) Retransmission of Lost or Indecipherable Transmissions. A Party will retransmit the original transmission within three (3) business day(s) of its discovery that a Data

Transmission is a lost or indecipherable Transmission.

(e) Equipment Cost. Each Party will obtain and maintain, at its own expense, its own

Operating System necessary for timely, complete, accurate and secure Data

Transmission pursuant to this Agreement. Each Party will pay its own costs related to

Data Transmission under this Agreement, including, without limitation, charges for the

Party’s own Operating System equipment, software and services, maintaining an electronic mailbox, connection time, terminals, connections, telephones, modems and applicable minimum use charges. Each Party will be responsible for its own expenses incurred for translating, formatting and sending or receiving communications over the electronic network to any electronic mailbox of the other Party.

(f) Backup Files. Each Party will maintain adequate backup files, electronic tapes or other sufficient means to recreate a Data Transmission for at least six (6) years from the Data

Transmission’s creation date. Such backup files, tapes or other sufficient means will be subject to the terms of Article V of this Agreement to the same extent as the original

Data Transmission.

(g) Data and Data Transmission Security. BlueCross BlueShield of South Carolina and

Trading Partner will employ security measures necessary to protect Data and Data

Transmissions between them, including authentication, encryption, password use, or other security measures in compliance with Social Security Act § 1173(d) and any HHS implementing regulations or guidelines and as set forth in Article V of this Agreement.

Unless BlueCross BlueShield of South Carolina and Trading Partner agree otherwise, the recipient of data or Data Transmission will use at least the same level of protection for any subsequent transmission as was used for the original transmission.

(h) Security Access Codes. The Security Access Codes that BlueCross BlueShield of

South Carolina issues to Trading Partner will, when affixed to Data Transmissions, be legally sufficient to verify the identity of the transmitter and to authenticate the Data

Transmission, thereby establishing the Data Transmission’s validity. Data Transmissions having a Security Access Code affixed to them will be deemed to have been “written” or

“signed” by the sender. Computer printouts of the information contained in such correspondence and documents that have been electronically or magnetically recorded and kept in the normal course of the sender’s or receiver’s business will be considered original business records admissible in any judicial, arbitration, mediation or administrative proceeding to the same extent and under the same conditions as other business records originated and maintained in documentary form.

3.2 Trading Partner Obligations. Trading Partner will:

(a) Not copy, reverse engineer, disclose, publish, distribute, alter or use Data, Data

Transmission or Envelope for any purpose other than for which BlueCross BlueShield

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of South Carolina has specifically authorized Trading Partner under the terms of this

Agreement.

(b) Not obtain access by any means to data, Data Transmission, Envelope, or BlueCross

BlueShield of South Carolina’s Operating System for any purpose other than as

BlueCross BlueShield of South Carolina has specifically granted Trading Partner access under this Agreement. In the event that Trading Partner receives data or Data

Transmissions not intended for Trading Partner, Trading Partner will immediately notify

BlueCross BlueShield of South Carolina and make arrangements to retransmit or otherwise return the data or Data Transmission to BlueCross BlueShield of South

Carolina. After such retransmission or return, Trading Partner will immediately delete the data and Data Transmission from its Operating System.

(c) Protect and maintain the confidentiality of Security Access Codes issued to Trading

Partner by BlueCross BlueShield of South Carolina, and limit disclosure of Security

Access Codes to authorized personnel on a need-to-know basis.

(d) Provide BlueCross BlueShield of South Carolina in writing all information requested in

Exhibit A to this Agreement not later than Trading Partner’s execution of this

Agreement. While this Agreement is in effect, Trading Partner will notify BlueCross

BlueShield of South Carolina in writing within one (1) business day of any material change in the information on Exhibit A to this Agreement.

3.3 BlueCross BlueShield of South Carolina Obligations. BlueCross BlueShield of South

Carolina will:

(a) Make available to Trading Partner, via electronic means, data and Data Transmissions for which this Agreement grants Trading Partner access or authorization, or as provided by law.

(b) Provide Trading Partner with at least sixty (60) days prior written notice of any change or addition to the BlueCross BlueShield of South Carolina Supplemental

Implementation Guides, code sets, data elements or formats for Data Transmissions set forth in Section 3.1(a) of this Agreement.

(c) Provide Trading Partner with Security Access Codes that will allow Trading Partner access to BlueCross BlueShield of South Carolina’s Operating System. BlueCross

BlueShield of South Carolina reserves the right to change Security Access Codes at any time and in such manner as BlueCross BlueShield of South Carolina, in its sole discretion, deems necessary.

IV. BUSINESS ASSOCIATES

4.1 Business Associate Obligations. Trading Partner will ensure that Business Associate will be bound by the mutual obligations of the Parties set forth in Section 3.1 and Trading

Partner’s obligations set forth in Section 3.2, even though Business Associate is not a signatory to this Agreement.

4.2 Responsibility for Business Associates. Trading Partner is liable to BlueCross BlueShield of South Carolina for any act, failure, or omission of any Business Associate with which

Trading Partner contracts or that Trading Partner uses to receive, transmit, store or process data or Data Transmissions or perform related activities, as though the act, failure or omission were that of Trading Partner.

4.3 Notices Regarding Business Associates. Trading Partner will, prior to commencement of

Business Associate’s services in connection with this Agreement, submit a complete, executed Trading Partner Business Associate Authorization Rider (“Business Associate

Rider”) designating each Business Associate authorized to send or receive Data or Data

Transmissions to or from BlueCross BlueShield of South Carolina on Trading Partner’s behalf. Trading Partner will notify BlueCross BlueShield of South Carolina at least fourteen

(14) days prior to the date of any material change to the information contained in the

Business Associate Rider. The Business Associate Rider will be effective and incorporated

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into this Agreement on the date it is received by BlueCross BlueShield of South Carolina.

Trading Partner’s designation of any Business Associate for purposes of performing services in connection with this Agreement is subject to BlueCross BlueShield of South Carolina’s approval. BlueCross BlueShield of South Carolina will not unreasonably withhold approval of

Trading Partner’s designated Business Associates.

V. CONFIDENTIALITY AND SECURITY

5.1 Data Security. Trading Partner will maintain adequate security procedures to prevent unauthorized access to data, Data Transmissions, Security Access Codes, Envelope, backup files, Source Documents or BlueCross BlueShield of South Carolina’s Operating

System. Trading Partner will immediately notify BlueCross BlueShield of South Carolina of any unauthorized attempt to obtain access to or otherwise tamper with data, Data

Transmissions, Security Access Codes, Envelope, backup files, Source Documents or

BlueCross BlueShield of South Carolina’s Operating System.

(a) Confidential Health Information. Trading Partner will comply with all applicable

Privacy Statutes and Regulations, guidelines and health care industry customs concerning treatment of Confidential Health Information.

(b) Proprietary Information. Trading Partner will treat BlueCross BlueShield of South

Carolina’s Proprietary Information obtained or learned in connection with this

Agreement as confidential and will not use BlueCross BlueShield of South Carolina’s

Proprietary Information for Trading Partner’s own commercial benefit or any other purpose not authorized in this Agreement. Trading Partner will safeguard BlueCross

BlueShield of South Carolina’s Proprietary Information against unauthorized disclosure and use.

(c) Notice of Unauthorized Disclosures and Uses. Trading Partner will promptly notify BlueCross BlueShield of South Carolina of any unlawful or unauthorized use or disclosure of Confidential Health Information or BlueCross BlueShield of South

Carolina’s Proprietary Information that comes to Trading Partner’s attention and will cooperate with BlueCross BlueShield of South Carolina in the event that any litigation arises concerning the unlawful or unauthorized disclosure or use of Confidential Health

Information or BlueCross BlueShield of South Carolina’s Proprietary Information.

5.2 Operating Systems Security. Each Party will develop, implement and maintain measures necessary to ensure the security of each Party’s own Operating System and each Party’s records relating to its Operating System. Each Party will document and keep current its security measures. Each Party’s security measures will include, at a minimum, the requirements and implementation features set forth in Social Security Act § 1173(d) and all applicable HHS implementing regulations.

VI. RECORDS RETENTION AND AUDIT

6.1 Records Retention. Trading Partner will maintain complete, accurate and unaltered copies of all Source Documents from all Data Transmissions it receives from BlueCross BlueShield of South Carolina for not less than six (6) years from the date that Trading Partner receives them. All retained records will be subject to the same security measures as data and Data

Transmissions.

6.2 Trade Data Log. BlueCross BlueShield of South Carolina and Trading Partner will each establish and maintain a Trade Data Log to record all Data Transmissions between the

Parties during the term of this Agreement. Each Party will take necessary and reasonable steps to ensure that its Trade Data Log constitutes a complete, accurate and unaltered record of each Data Transmission between the Parties. Each Party will retain Data

Transmission records for not less than twenty-four (24) month(s) following the date of a Data

Transmission. Each Party will maintain its Trade Data Log on computer media or other suitable means that permit timely retrieval and presentation in readable form.

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6.3 Right to Audit. BlueCross BlueShield of South Carolina will have the right to audit relevant

Trading Partner’s business records, Trading Partner’s Trade Data Log, Trading Partner’s

Operating System and Business Associate as BlueCross BlueShield of South Carolina, in its sole discretion, deems necessary to ensure compliance with this Agreement.

6.4 Government Requests for Information. Trading Partner will notify BlueCross BlueShield of South Carolina immediately upon Trading Partner’s receipt of any request from a government authority for information or documents relating to this Agreement, except to the extent such notification is prohibited by law.

VII. REPRESENTATIONS AND WARRANTIES

7.1 Government Programs. Trading Partner represents and warrants that:

(a) Neither the United States government, any state or local government, nor any prime contractor, subcontractor or other person has notified Trading Partner, either orally or in writing, that Trading Partner has breached or violated any law, certification, representation, clause, provision or requirement pertaining to or involving any government contract or government subcontract that has resulted or may result in

Trading Partner being charged with a criminal offense;

(b) No termination for convenience, termination for default, cure notice or show cause notice is currently in effect or threatened against Trading Partner by the United States government or any state or local government;

(c) Neither Trading Partner nor any of its directors, officers, employees or agents are or have been under criminal investigation or indictment by any government entity;

(d) Trading Partner has not been debarred or suspended from participation in the award of contracts with any government entity (excluding for this purpose ineligibility to bid on certain contracts due to generally applicable bidding requirements);

(e) There exists no fact or circumstance that would warrant the institution of suspension or debarment proceedings or the finding of non-responsibility or ineligibility on the part of

Trading Partner or any director, officer or employee of Trading Partner; and

(f) No payment has been made by Trading Partner or by any person on behalf of Trading

Partner in connection with any government contract or government subcontract in violation of or requiring disclosure pursuant to the Foreign Corrupt Practices Act, as amended (15 U.S.C. §§ 78dd-1, 78dd-2).

7.2 Legal Compliance. Trading Partner will use reasonable efforts to comply, and to cause

Trading Partner’s directors, officers, employees and Business Associate to comply, in all material respects with all requirements of all laws pertaining to government contracts or government subcontracts, the violation of which may result in Trading Partner or its directors, officers or employees, or other persons being charged with a criminal offense. For purposes of this Section 7.2, “laws” mean all applicable statutes, laws, rules, regulations, permits, decrees, injunctions, judgments, orders, rulings, determinations, writs and awards.

7.3 Warranties Regarding Business Associates. Trading Partner warrants that Business

Associate will make no changes in the Data content of Data Transmissions or the contents of an Envelope. Trading Partner further warrants that Trading Partner will advise Business

Associate of this Agreement and that Business Associate will comply in all respects with the terms of this Agreement.

7.4 Notice of Violations. Trading Partner will notify BlueCross BlueShield of South Carolina in writing within three (3) business days of obtaining knowledge of any criminal investigation, indictment, information or charge by any governmental entity (or communications indicating that the same may be contemplated) related to Trading Partner or any of Trading Partner’s directors, officers, employees, vendors, agents or Business Associate.

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VIII. INDEMNIFICATION

8.1 Indemnification of BlueCross BlueShield of South Carolina. Trading Partner will indemnify, defend and hold BlueCross BlueShield of South Carolina harmless from any and all claims, actions, damages, liabilities, costs, or expenses, including, without limitation, reasonable attorneys’ fees, arising out of any act or omission of Trading Partner, Business

Associate, or their respective employees, subcontractors or other persons in the performance of this Agreement. BlueCross BlueShield of South Carolina will have the option at its sole discretion to employ attorneys to defend any such claim, action or proceeding arising out of these acts or omissions, the costs and expenses of which will be

Trading Partner’s responsibility. BlueCross BlueShield of South Carolina will provide

Trading Partner with timely notice of the existence of such action. Trading Partner will provide information, documents and other cooperation as reasonably necessary to assist

BlueCross BlueShield of South Carolina in establishing its defenses to such action.

8.2 Breach of Warranties. Trading Partner will indemnify and hold BlueCross BlueShield of

South Carolina harmless from and against any and all liability resulting from: (i) any misrepresentation in Trading Partner’s representations and warranties in Article VII of this

Agreement; (ii) Trading Partner’s failure to notify BlueCross BlueShield of South Carolina as required in Section 7.4 of this Agreement; or (iii) actual exclusion during the term of this

Agreement from any federal health care program (as defined in the Social Security Act §

1128B(f)).

8.3 Participation in Actions. BlueCross BlueShield of South Carolina reserves the right, at its option and expense, to participate in the defense of any suit or action brought against

Trading Partner or Business Associate arising out of any act or omission in connection with this Agreement.

8.4 Dispute Assistance. Each Party will reasonably cooperate in providing necessary assistance to the other Party when the other Party is actively involved in a dispute with a third party concerning Data Transmissions that either are or reasonably could be the source of litigation with that third party.

8.5 Limitation of Liability. Except claims or causes of action related to Trading Partner’s actual or alleged breach of Article V of this Agreement or fraud by Trading Partner, neither

Party will be liable for any special, incidental, indirect, exemplary or consequential damages resulting from any claim or cause of action arising out of any delay, omission or error in any

Data Transmission or the other Party’s performance or failure to perform in accordance with the terms of this Agreement, including, without limitation, loss of use, revenues, profits or savings, even if a Party has been advised in advance of the possibility of such damages.

IX. MISCELLANEOUS

9.1 Notices. Any notice pertaining to this Agreement will be in writing. Notice will be deemed given when personally delivered to the Party’s authorized representative listed here, or sent by means of a reputable overnight courier or by certified mail, postage prepaid, return receipt requested. A notice sent by overnight courier or by certified mail will be deemed given on the date of receipt or refusal of receipt. All notices will be addressed to the appropriate Party as follows:

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To: BlueCross BlueShield of South Carolina

I-20 Alpine Road, AX-701

Columbia, SC 29219

Attn: Martha Owens Perry

Title: AVP, Health Care Services

To: _________________________________________ (Trading Partner)

(Address)

(City, State, ZIP Code)

Attn:

Title:

9.2 Amendments. This Agreement may not be changed or modified except by an instrument in writing signed by each Party’s authorized representative.

9.3 Choice of Law. This Agreement and the Parties’ rights and obligations hereunder are governed by and will be construed under the laws of the State of South Carolina.

9.4 Jurisdiction, Venue and WAIVER OF JURY TRIAL. The Parties agree that any action or proceeding arising out of or related to this Agreement shall be instituted only in the federal district court in Columbia, South Carolina. Each party consents and submits to the jurisdiction of such court and agrees that venue therein shall be proper and convenient. In any such action or proceeding in such court, each party waives any right to raise any objection based upon improper venue, lack of jurisdiction or inconvenient forum, and each party consents to personal jurisdiction of such court and agrees service of process may be effected by United States mail. EACH PARTY WAIVES ANY RIGHT IT MAY HAVE TO A

TRIAL BY JURY IN ANY LITIGATION ARISING OUT OF, UNDER OR IN CONNECTION

WITH THIS AGREEMENT.

9.5 Assignment of Rights and Delegation of Duties. This Agreement is binding upon and inures to the benefit of the Parties and their respective successors and assigns. BlueCross

BlueShield of South Carolina retains the right to assign or delegate any of its rights or obligations hereunder to any of its subsidiaries, affiliates or successor companies.

Otherwise, neither Party may assign its rights or delegate its obligations under this

Agreement without the prior written consent of the other Party, which consent will not be unreasonably withheld or delayed.

9.6 Relationship of BlueCross BlueShield of South Carolina to the Blue Cross and Blue

Shield Association. This Agreement constitutes a contract between Trading Partner and

BlueCross BlueShield of South Carolina. BlueCross BlueShield of South Carolina is an independent corporation operating under a license with the Blue Cross and Blue Shield

Association (“Association”), an association of independent Blue Cross and Blue Shield

Plans, permitting BlueCross BlueShield of South Carolina to use the BlueCross and

BlueShield service marks in South Carolina. BlueCross BlueShield of South Carolina is not contracting as the agent of the Association. Trading Partner has not entered into this

Agreement based upon representations by any person other than BlueCross BlueShield of

South Carolina, and no person, entity or organization other than BlueCross BlueShield of

South Carolina will be held accountable or liable to Trading Partner for any of BlueCross

BlueShield of South Carolina’s obligations to Trading Partner under this Agreement.

9.7 Force Majeure. Each Party will be excused from performance for any period of time during this Agreement that it is prevented from performing any obligation or service, in whole or in part, as a result of causes beyond its reasonable control and without its fault or negligence.

Such acts include, without limitation, acts of God, strikes, lockouts, riots, acts of war, epidemics, governmental regulations imposed after the fact, fire, communication line failures, power failures, earthquakes, floods or other natural disasters. Delays in

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performance because of the occurrence of such events will automatically extend due dates for a period equal to the duration of such events. Such automatic extension will have no effect on the exercise of either Party’s right of voluntary termination of this Agreement under

Section 2.2 of this Agreement.

9.8 No Waiver. Failure or delay on the part of either Party to exercise any right, power, privilege or remedy in this Agreement will not constitute a waiver. No provision of this Agreement may be waived by either Party except in a writing signed by an authorized representative of the Party making the waiver.

9.9 No Agency. Nothing in this Agreement will place BlueCross BlueShield of South Carolina and Trading Partner in a relationship whereby either (i) is the principal or agent of the other for any purpose or (ii) has the authority to bind the other in any way.

9.10 Severability. The provisions of this Agreement are severable. If any provision of this

Agreement is held or declared to be illegal, invalid or unenforceable, the remainder of the

Agreement will continue in full force and effect as though the illegal, invalid or unenforceable provision had not been contained in the Agreement.

9.11 Entire Agreement. This Agreement, together with its Exhibits, and any applicable Riders and Amendments, constitutes the entire understanding between the Parties with respect to the subject matter of this Agreement and supersedes and cancels all previous written or oral understandings, agreements, negotiations, commitments, and any other writing and communication by or between the Parties on this specific subject matter. In the event of any inconsistency between any provision of this Agreement and any provision of a Rider to this

Agreement, the provision of this Agreement controls.

9.12 Automatic Amendment for Regulatory Compliance. This Agreement will automatically amend to comply with any final regulation or amendment to a final regulation adopted by

HHS concerning the subject matter of this Agreement upon the effective date of the final regulation or amendment.

9.13 Survival. The provisions of Sections 3.1(d) and 3.2; Article V; Sections 6.1 and 6.2; and

Article VIII will survive termination of this Agreement.

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SIGNATURES

The Parties will be bound by all the terms, provisions and conditions of this Agreement upon execution of the Agreement by each Party’s authorized representative.

Agreed to

TRADING PARTNER

Agreed to

BLUE CROSS AND BLUE SHIELD

OF SOUTH CAROLINA, INC.

By:

Name:

Title:

Address:

City, State, ZIP:

Date:

Contact:

Title:

Telephone: ( )

By:

Name:

Title:

I-20 at Alpine Road, AA-270

Columbia, SC 29219

Date:

Contact:

Title:

Telephone: ( )

PLEASE NOTE: Trading Partner must complete and return Exhibit A with this signed

Electronic Trading Partner Agreement.

1

Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N.

Health Care Claim Status Request (276), 005010X212.

Washington Publishing Company, Apr. 2006.

< http://www.wpc-edi.com

>. 65–71.

2

The ASC X12 TR3s that detail the full requirements for these transactions are available at http://store.x12.org/store/ .

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