Currentsanford health planPolicy 2.2
HIPAA Transaction Standard Companion Guide (270/271)
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Companion guide governing electronic submission of ASC X12N 005010X279A1 Eligibility Benefit Inquiry (270) and Response (271) transactions via HTTPS between Sanford Health Plan and registered trading partners; applies to providers, billing services, and clearinghouses exchanging real-time eligibility inquiries.
Policy Summary
PayerSanford Health Plan
PolicyHIPAA Transaction Standard Companion Guide (270/271)
Policy CodePolicy 2.2
Change TypeNo material changes
Effective DateFeb 1, 2015
Last ReviewJun 1, 2015
Next Review Date
Key ActionTrading partners must enroll and complete a Trading Partner Enrollment Form and Agreement and obtain approval before moving from test to production.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
real-time onlysupported inquiry type
up to 10test transactions allowed
HTTPS/CAQHconnectivity method
18 monthsmax lookback
ediconnect.sanfordhealthplan.comproduction URL
311527032ReceiverID
Eligibility & Transaction Coverage Criteria
Eligibility Inquiry Operational Criteria
Eligibility inquiry support and submitter requirements:
Submitters must have Internet (HTTPS) connection capability to submit a 270 request and receive 271 responses.
Submitter must be associated with at least one provider in the Sanford Health Plan provider database.
Only real-time 270 inquiries are supported.
The system supports inquiries only for registered providers (submitters must be registered trading partners).
During testing, each Trading Partner may submit up to 10 test transactions as part of certification before moving to production.
Testing-to-Production and Transaction Flow
Requirements to move from testing to production and transaction process flow for 270/271 transactions.
Trading Partner testing must satisfy the test plan and the Trading Partner Agreement must be executed before status is changed from test to production.
Once testing is complete and approved, the Trading Partner may begin to submit production 270 transactions and receive 271 responses in the Production environment.
Sanford Health Plan will coordinate test transactions to verify submit/receive capability and TR3 compliance prior to production.
Communication protocols supported for submitting 270 requests to the 270/271 application are SOAP+WSDL and HTTP/MIME multipart; Trading Partner authentication is required and unauthorized partners will receive an appropriate error response.
Submission and envelope criteria
Required elements, formats, and envelope control values for real-time 270 requests and 271 responses.
Supported real-time communication protocols: SOAP+WSDL or HTTP MIME Multipart.
SOAP header must include a timestamp element and SOAP messages must be digitally signed per SOAP+WSDL requirements.
Required SOAP body elements for 270 requests: PayloadType = X12_270_Request_005010X279A1; ProcessingMode = Real-time; PayloadID per CORE structural guidelines; TimeStamp in YYYY-MM-DDTHH:MM:SSZ; SenderID (must be less than 50 characters); ReceiverID = 311527032; CORERuleVersion = 2.2.0; Payload = X12 request (digitally signed and enclosed in CDATA).
Required SOAP body elements for 271 responses: PayloadType = X12_271_Response_005010X279A1; ProcessingMode = Real-time; PayloadID per CORE guidelines; TimeStamp in YYYY-MM-DDTHH:MM:SSZ; SenderID = 311527032; ReceiverID (must be less than 50 characters); CORERuleVersion = 2.2.0; Payload = X12 response.
MIME transactions must use multipart/form-data and mirror SOAP field names; required MIME body elements include: PayloadType = X12_270_Request_005010X279A1, ProcessingMode = RealTime, PayloadID per CORE, TimeStamp in YYYY-MM-DDTHH:MM:SSZ, SenderID (10 characters for MIME), ReceiverID = 311527032, CORERuleVersion = 2.2.0, Payload (digitally signed and enclosed in CDATA).
HTTP MIME multipart transactions must include standard HTTP headers such as POST, HOST, Content-Length, and Content-Type: multipart/form-data.
Production endpoints: transactions must target the Sanford production endpoints published at ediconnect.sanfordhealthplan.com (distinct endpoints for SOAP and MIME as provided in the companion guide).
Security and responsibility: the 270/271 application is accessible via secure HTTPS; Trading Partners are responsible for privacy/security of transactions and must register and authenticate; clearinghouses must establish provider authentication outside the transaction.
ISA (Interchange) envelope requirements include: ISA01=03; ISA02 = Sender's Tax ID (may be padded to 10 characters or blanks, no dashes); ISA03=00; ISA05=ZZ; ISA06 = Sender's Tax ID padded to 15 characters (no dashes); ISA07=ZZ; ISA08 = SHP (padded to 15 characters); ISA12 = 00501; ISA13 = assigned by trading partner (must be unique for 12 months); ISA15 = P or T; ISA16 = component element separator per trading partner.
GS (Functional Group) header requirements include: GS02 = Application Sender's Code = Sender's Tax ID (2-15 characters, no dashes, no padding necessary); GS03 = 00; GS06 = Group Control Number (unique for one year); GS07 = X; GS08 populated by trading partner (version/release identifier).
Eligibility/Benefit response rules
271 responses may include benefit cost-share and deductible details for listed service type codes; generic requests (30) return all service type coverage where available.
When a generic service type code '30' (Health Plan Benefit Coverage) is submitted in the 270, Sanford will process it as a generic request and return all applicable service type coverage (All STC's) when available.
The 271 may report benefit co-pay, co-insurance and/or deductible information for many HIPAA service type codes (for example: 1, 2, 4, 5, 6, 7, 8, 12, 13, 18, 20, 30 and numerous others listed in the guide).
In a generic response (EB03=30), if benefit co-pay/co-insurance/deductible information for '48 - Hospital - Inpatient' and '50 - Hospital - Outpatient' are included, then '47 - Hospital' will not include those amounts in the generic response.
When applicable, an EB segment in loop 2110C/D will be returned with benefit-level co-payments, co-insurance and deductible amounts; remaining deductible and out-of-pocket values will be returned where applicable.
When Sanford Health Plan knows of additional payers and the other payer's name, the other payer name will be sent in the 2110C/D loop with EB01='R' and an NM1 in 2120C/D will be included to identify the other payer.
Date-range validation and search rules: single-date inquiries may require subsequent requests with different dates if an active plan is not found; requests with invalid date ranges will receive a 271 AAA value of 62 or 63; search logic uses Member ID, Last Name, First Name and DOB (submitting First Name is recommended); if no Member ID is provided, the member ID element should be null (not space- or zero-filled).
Transaction, Header, and Code Requirements
TR3 Transaction Setmixed
| 005010X279A1 | ASC X12N Health Care Eligibility Benefit Inquiry and Response (270/271) |
X12N Interchange Header Field Rulesmixed
| ISA02/ISA05/ISA06/ISA07/GS02/GS03 | Field requirements and formatting rules for ASC X12N/005010X279 interchange headers (ISA02 = Senders Tax ID - not required, may be padded to 10 characters with spaces, no dashes; ISA05 = ZZ; ISA06 = Senders Tax ID padded with spaces to 15 characters, no dashes; ISA07 = ZZ; GS02 = Senders Tax ID (2-15 chars, no dashes, no padding necessary); GS03 = 00). |
Service Type Codes returned in 271mixed
| 30 | Health Plan Benefit Coverage (GENERIC REQUEST) |
| 1 | Medical Care |
| 2 | Surgical |
| 48 | Hospital Inpatient |
| 50 | Hospital Outpatient |
| 88 | Pharmacy |
TR3 edit errors — testing block
ThresholdTesting cannot progress until a trading partner's data receives no TR3 edit errors (SHP's TR3 editor determines data integrity).
Testing windowTrading Partner Registration assistance and testing support available Monday–Friday, 9:00 AM to 5:00 PM CST.
Test scopeTests must be performed for each X12 transaction type and follow an agreed test plan with predefined test data and expected results.
Acknowledgment requirementTrading partners must demonstrate the ability to receive acknowledgment and response transactions via the HTTPS channels.
Resolution processIf TR3 edit interpretation differs between SHP and the trading partner, SHP will work with the trading partner to resolve differences on an individual basis.
Sender Tax ID formatting and ISA/GS field rules
ISA02 (Sender Tax ID)Not required; may be padded to 10 characters with spaces; do not include dashes.
ISA06 (Sender Tax ID)Padded with spaces to 15 characters; do not include dashes.
GS02 (Sender Tax ID)No padding necessary; value must be between 2 and 15 characters; do not include dashes.
ISA05 / ISA07Use qualifier 'ZZ' for ISA05 and ISA07 where specified.
GS03Set GS03 to '00' as specified in GS header requirements.
Date range lookback and eligibility request rules
Maximum lookbackStart date must be no greater than 18 months in the past.
End-date ruleEnd date must be no later than the end of the current month.
Validation failure responseRequests with invalid date ranges will receive a 271 AAA value of 62 or 63.
Returned coverageDate-range requests will return all plans that had or have coverage during the requested date range.
Search recommendationsInclude as many search data elements as possible (Member ID, Last Name, First Name, DOB); if no Member ID, send member ID as null (not space or zero-filled).
Enrollment, Testing, and Operational Actions for Trading Partners
Documentation Required
Enroll and Contact Provider Services to Register
Complete and submit the Sanford Health Plan Trading Partner Enrollment Form and the Trading Partner Agreement; contact Provider Services at 800-601-5086 for registration assistance.
- Submit Enrollment Form and Trading Partner Agreement (Appendix A).
- Use Provider Services (800-601-5086) for registration assistance.
Prior Authorization
Complete Testing (up to 10 test transactions) Before Production
Submit test transactions during the coordinated testing phase and complete transaction-specific testing before moving to production; each trading partner may submit up to 10 test transactions and testing support is available Monday–Friday, 9:00 AM–5:00 PM CST.
- Submit up to 10 test transactions during testing.
- Perform tests for each X12 transaction type and resolve TR3 edit errors before progressing.
- Testing coordination and assistance available Monday–Friday, 9:00 AM to 5:00 PM CST.
Documentation Required
Register, Obtain EMP Credentials, and Receive Approval Before Production
Register as a Trading Partner, complete and submit the Trading Partner Agreement, obtain trading partner login credentials (user-ID and password provided by Sanford), and receive SANFORD approval before transitioning from test to production.
- Complete and submit the Trading Partner Agreement (see Getting Started).
- Sanford will verify the Agreement and approve or deny Submitter ID requests.
- Production status is granted only after test results satisfy the test plan and the Trading Partner Agreement is executed.
Documentation Required
Correct and Resubmit Failed Transactions Yourself
If transactions fail, correct the eligibility data and resubmit them yourself; Sanford Health Plan will not edit or resubmit transactions on behalf of a Trading Partner but may assist in researching problems via HealthPlanIT-AS@sanfordhealth.org.
- Trading Partner must correct the transaction and resubmit following the original processes.
- Email HealthPlanIT-AS@sanfordhealth.org for assistance researching transaction problems; SHP will not perform resubmission.
Documentation Required
Provide Maximum Search Data and Follow 18‑Month Date‑Range Rules
Include as many search data elements as possible on 270 requests (Member ID, Last Name, First Name, DOB); if no Member ID is provided send the member ID element as null (do not space- or zero-fill); date-range start cannot be more than 18 months in the past and end date cannot be later than the end of the current month.
- Use Member ID, Last Name, First Name, and DOB for best matching; submitting First Name is recommended.
- If Member ID is not provided, set the member ID element to null (not space- or zero-filled).
- Date-range start date must be within 18 months prior; invalid date ranges return a 271 AAA value of 62 or 63.
Terminology and Connectivity Definitions
inv-16: Companion Guide — definition of Companion Guide (CG)
DefinitionA Companion Guide (CG) clarifies and specifies data content and business rules for electronic exchanges with Sanford Health Plan; it is not a replacement for the ASC X12 TR3 implementation guide.
PurposeUsed in conjunction with ASC X12N Implementation Guides to convey implementation clarifications and guide transmissions.
Scope noteMay be updated by Sanford Health Plan; not intended to convey information beyond the ASC X12N Implementation Guides adopted under HIPAA.
inv-17: CAQH CORE / HTTPS connectivity — CAQH CORE and expected HTTPS transmissions
CAQH CORE expectationSanford expects HTTPS transmissions with CAQH-compliant systems to increase interoperability.
CAQH CORE descriptionCAQH CORE provides voluntary connectivity and operating rules to simplify healthcare administration and increase interoperability.
Connectivity methodSubmissions to the 270/271 application are intended for use with HTTPS connections.
inv-18: Trading Partner Credentials — format and issuance of trading partner user ID (EMP: prefix) and passwords
User ID formatTrading partner user ID must be prefixed with 'EMP:' (example: EMP:PARTNER).
Credential deliveryUser-ID and password are provided by the Sanford security team via secure email.
Registration requirementTrading Partners receive credentials during registration and must use them for authenticated access to the 270/271 application.
inv-19: Communication Protocols — allowed communication protocols (SOAP + WSDL or HTTP MIME Multipart)
Allowed protocolsSupported communication protocols for connecting to the 270/271 application are SOAP + WSDL and HTTP MIME Multipart.
Registration for accessTo use SOAP or MIME, Trading Partners must register with Sanford and receive a login ID and password.
Real-time supportThese protocols are supported for real-time 270/271 transactions to the application.
inv-20: Communication protocols and SOAP signature — SOAP + WSDL and HTTP MIME Multipart details and SOAP signature requirement note
SOAP requirementSOAP messages must be digitally signed: Trading Partners are required to digitally sign the message body and certain header elements (e.g., TimeStamp) per XML signature standards.
Protocol optionsBoth SOAP+WSDL and HTTP MIME Multipart are supported; SOAP requires a digital signature and timestamp in the header.
ReferenceRefer to W3C SOAP-dsig guidance for XML signature details.
inv-21: Clearinghouse and provider responsibility — responsibility for privacy/security and associating inquiries with providers
Responsibility for privacy/securityAll Trading Partners must assume full responsibility for the privacy and security of beneficiary data.
Clearinghouse responsibilitySanford holds Clearinghouse Submitters responsible for privacy/security of eligibility transactions sent directly to them and requires they associate each inquiry with a Provider.
Provider authenticationProvider authentication must be established by the Clearinghouse outside of the transaction.
inv-22: EDI Trading Partner — definition of an EDI Trading Partner
DefinitionAn EDI Trading Partner is any Sanford customer (provider, billing service, software vendor, employer group, financial institution, etc.) that transmits to or receives electronic data from Sanford.
Agreement noteTrading Partner Agreements specify roles and responsibilities related to electronic transactions between the parties.
ScopeIncludes entities involved in transmitting or receiving standard transactions to/from Sanford Health Plan.
inv-23: ISA/GS/ST header requirements — header fields and required values/formats summary
ISA envelope highlightsISA02 may be padded to 10 characters or blanks; ISA06 must be padded to 15 characters; ISA08 is 'SHP' padded to 15 characters; ISA12 must be '00501'.
GS header highlightsGS02 (Application Sender's Code) must be the Sender's Tax ID between 2 and 15 characters with no dashes; GS03 = '00'; GS06 group control number must be unique for one year.
ST header highlightsST03 (Implementation Convention Reference) must be '005010X279A1' for 270/271 transactions.
Policy Summary
PayerSanford Health Plan
PolicyHIPAA Transaction Standard Companion Guide (270/271)
Policy CodePolicy 2.2
Change TypeNo material changes
Effective DateFeb 1, 2015
Last ReviewJun 1, 2015
Next Review Date
Key ActionTrading partners must enroll and complete a Trading Partner Enrollment Form and Agreement and obtain approval before moving from test to production.
SourceLink
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