The Health Insurance Portability and Accountability Act (HIPAA) requires that Medicaid and all other health insurance payers in the United States, comply with the EDI standards for health care as established by the Secretary of Health Services. The ANSI X12N implementation guides have been established as the standards of compliance for claim transactions.

This page provides access to information intended to serve only as a companion guide to the HIPAA ANSI X12N implementation guides. The use of this guide is solely for the purpose of clarification. The information describes specific requirements to be used for processing data. This companion guide supplements, but does not contradict any requirements in the X12N implementation guide.

Additional information on the Final Rule for Standards for Electronic Transactions can be found at http://aspe.hhs.gov/admnsimp/final/txfin00.htm. The HIPAA Implementation Guides can be accessed at http://www.wpc-edi.com/hipaa/HIPAA_40.asp.

The information in these guides is subject to change. Please check this site periodically to obtain the most current information available from Florida Medicaid. If you have any questions regarding these Companion Guides, please contact EDI Services.

Claim Adjustment and EOB Crosswalk

The HIPAA standard claim adjustment reason codes and remark codes have been cross-walked to the Medicaid EOBs. The HIPAA standard codes do not communicate the same level of detail about the claim as the Medicaid EOBs. Review the Crosswalk of X12 Codes to EOB Codes for more details.

Additional HIPAA information is available on the Agency for Health Care website at ahca.myflorida.com.

EOB Message Codes and Descriptions

The EOB Message Codes and Descriptions document provides a current version of the Explanation of Benefits (EOB) codes and associated messages that are used in the new FMMIS. These codes are provided as a reference and may periodically be revised.

271 Eligibility Responses Update

EDS has made the following modifications on the 271 eligibility responses:

• The address information on the 2100C loop is no longer being returned on 271 responses. Even though it was not in the companion guide, EDS previously returned loop the N3 and N4 segments in the 2100C (subscriber) loop. EDS will no longer be returning that information.
• Previously, on service limitation lines, EDS was returning a negative number when a subscriber had exceeded the limit. This will no longer occur.

Friday, August 29th, EDS is promoting the following modification to the production environment:

Currently, when a 270 request is transmitted to EDS with an ineligible recipient ID number, the system returns an AAA03=75 in the 2100C loop. While this is a compliant response, an alternative approach has been requested.

The Agency for Healthcare Administration has approved a change. Specifically, the system will no longer send the AAA03=75 response. Instead, the 271 will include an EB01=6 in the 2110C loop to indicate an ineligible recipient.

In addition, if an eligibility request is sent with a recipient ID or card control number that is no longer active, the system will return an EB01=7 in the 2110C loop. The EB01=7 will indicate: inactive pending an eligibility update, this indicates that the eligibility information cannot be returned for this request until the updated, active recipient ID is sent.

EDS has made a number of additions to the 270/271 Companion Guide to provide more detail on the handling of the 271 response. An updated companion guide is available below in the Companion Guides datalist. This information will be helpful to organizations that have had difficulty processing the 271 response since the transition.

To access the following documents, you must have Adobe Acrobat Reader installed on your machine.

To save a document from the list below, right-click the link and then select "Save Target As..."