ASSURANT HEALTH COMPANION GUIDE
© 2012 Assurant, Inc. All rights reserved. 1

ASSURANT HEALTH COMPANION GUIDE
Disclosure Statement
This document is subject to change. Changes will be posted to the Assurant Health website. See http://www.assuranthealth.com/corp/ah/Providers/HipaaTransactions.htm
for updates.
The 271 Response returned by Assurant Health should not be interpreted as a guarantee of payment.
The payment of benefits remains subject to all health benefit terms, limits, conditions, exclusions and the member’s eligibility at the time services are rendered.
© 2012 Assurant, Inc. All rights reserved. 2

ASSURANT HEALTH COMPANION GUIDE
Preface
This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with
Assurant Health. Transmissions based on this companion guide, used in tandem with the v5010 ASC
X12N 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 X12N
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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ASSURANT HEALTH COMPANION GUIDE
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ASSURANT HEALTH COMPANION GUIDE
Table of Contents
1 INTRODUCTION.......................................................................................................................... 6
SCOPE ........................................................................................................................................ 6
OVERVIEW ................................................................................................................................. 6
REFERENCES ............................................................................................................................ 6
ADDITIONAL INFORMATION..................................................................................................... 6
2 GETTING STARTED ................................................................................................................... 6
WORKING WITH ASSURANT HEALTH..................................................................................... 6
TRADING PARTNER REGISTRATION ...................................................................................... 7
3 TESTING WITH THE PAYER...................................................................................................... 7
4 CONNECTIVITY WITH PAYER/COMMUNICATIONS................................................................ 7
PROCESS FLOWS ..................................................................................................................... 7
TRANSMISSION ADMINISTRATIVE PROCEDURES ............................................................... 8
RE-TRANSMISSION PROCEDURE........................................................................................... 8
COMMUNICATION PROTOCOL SPECIFICATIONS................................................................. 9
PASSWORDS ............................................................................................................................. 9
MAINTENANCE .......................................................................................................................... 9
5 CONTACT INFORMATION ....................................................................................................... 10
EDI CUSTOMER SERVICE / TECHNICAL ASSISTANCE....................................................... 10
PROVIDER SERVICE NUMBER .............................................................................................. 10
APPLICABLE WEBSITES/E-MAIL............................................................................................ 10
6 CONTROL SEGMENTS/ENVELOPES ..................................................................................... 10
ISA-IEA ...................................................................................................................................... 10
GS-GE ....................................................................................................................................... 12
ST-SE ........................................................................................................................................ 14
7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ................................................... 14
Transaction Limitations ............................................................................................................. 14
Supported Service Type Codes ................................................................................................ 14
Supported AAA Codes .............................................................................................................. 16
8 ACKNOWLEDGEMENTS AND/OR REPORTS........................................................................ 16
9 TRADING PARTNER AGREEMENTS...................................................................................... 16
10 TRANSACTION SPECIFIC INFORMATION............................................................................ 17
APPENDICES ................................................................................................................................ 22
IMPLEMENTATION CHECKLIST ............................................................................................. 22
BUSINESS SCENARIOS .......................................................................................................... 22
TRANSMISSION EXAMPLES................................................................................................... 22
FREQUENTLY ASKED QUESTIONS....................................................................................... 25
CHANGE SUMMARY................................................................................................................ 25
© 2012 Assurant, Inc. All rights reserved. 5

ASSURANT HEALTH COMPANION GUIDE
1 INTRODUCTION
Federal regulations of the Patent Protection and Affordable Care Act (PPACA) require expanded support of the HIPAA Eligibility Benefit Inquiry and Response transaction.
SCOPE
Providers, billing services and clearinghouses are advised to use the ASC X12N 270/271
(005010x279A1) Implementation Guide as a basis for their submission of Eligibility and Benefit
Inquiries. This companion document should be used to clarify the CORE Business rules for
270/271 data content, transaction acknowledgment, connectivity, response time and system availability requirements.
OVERVIEW
The purpose of this document is to assist those responsible for testing and implementing electronic eligibility transactions. This document provides information about Assurant Health’s implementation of the Eligibility and Benefit Inquiry transaction (270/271) and supplements requirements specified in the ASC X12N 270/271 (005010x279A1) Implementation Guide.
REFERENCES
•
ASC X12N 270/271 (Version 005010x279A1) Technical Report Type 3 guide for Health Care
Eligibility Benefit Inquiry and Response: http://wpc-edi.com/
•
Assurant Health Companion Guide: http://www.assuranthealth.com/corp/ah/Providers/HipaaTransactions.htm
•
CAQH/CORE Rules: http://www.caqh.org/benefits.php
•
CORE XML Schema: http://www.caqh.org/SOAP/WSDL/CORERule2.2.0.xsd
•
WSDL: http://www.w3.org/TR/wsdl
•
SOAP: http://www.w3.org/TR/soap/
•
MIME Multipart: http://www.w3.org/Protocols/rfc1341/7_2_Multipart.html
ADDITIONAL INFORMATION
Submitters must obtain a valid Assurant Health userID and password in order to submit an
Eligibility and Benefit Inquiry (270) and receive an Eligibility and Benefit Inquiry Response (271).
Assurant Health supports the Eligibility and Benefit Inquiry and Response in real time mode only.
Real time 270s should have a single ST/SE loop, one information source, one information receiver, one subscriber loop, one dependent loop when needed, and a single EQ loop. If inquiring on multiple Service Type Codes, it is recommended that the submitter submit a Service
Type Code of “30”.
2 GETTING STARTED
WORKING WITH ASSURANT HEALTH
Providers, billing services and clearinghouses interested in submitting Eligibility and Benefit
Inquiries (270) and receiving Eligibility and Benefit Inquiry Responses (271) should submit a completed EDI Enrollment form to Assurant Health via email at EnrollEDI@assurant.com
.
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ASSURANT HEALTH COMPANION GUIDE
TRADING PARTNER REGISTRATION
1. Complete the EDI Enrollment form and email to Assurant Health at EnrollEDI@assurant.com
.
The form is available at http://www.assuranthealth.com/corp/ah/Providers/HipaaTransactions.htm
2. Assurant Health will provide a user ID and password.
3. Provider / trading partner should configure their system following the connection instructions provided by Assurant Health.
4. Verify connectivity by submitting an Eligibility and Benefit Inquiry (270) and evaluating the
Eligibility and Benefit Inquiry Response (271).
3 TESTING WITH THE PAYER
Assurant Health does not support a test environment for testing the submission of Eligibility and
Benefit Inquiries (270) and receiving Eligibility and Benefit Inquiry Responses (271).
Once you have completed the Trading Partner registration process, you should submit a transaction to validate that connectivity has been successfully established and that you can process the returned response. If you encounter any errors during this process, please contact the EDI Services group for technical assistance.
4 CONNECTIVITY WITH PAYER/COMMUNICATIONS
PROCESS FLOWS
•
The user application submits a CORE compliant HTTPS request to https://biztalk.assurant.com/RealTimeWeb/ProcessRequest.ashx
or CORE compliant
SOAP request to http://biztalk.assurant.com/ProviderRealTimeSvc/CoreManager.svc?wsdl
•
The Assurant Health system authenticates the account. If the account is not authorized, an HTTP 401-Unauthorized response is returned.
•
If the account is authorized, an HTTP 200-OK status response is returned to the user and one of the following will be returned: o TA1 (if a problem with the ISA/IEA segments exist) o 999 Reject (if a problem occurs within the 270 request) o 271 Eligibility and Benefit Response
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ASSURANT HEALTH COMPANION GUIDE
Figure 1: Real Time Transaction Flow
TRANSMISSION ADMINISTRATIVE PROCEDURES
Real time Eligibility and Benefit Inquiry (270) transactions should have a single ST/SE loop, one information source, one information receiver, one subscriber loop, one dependent loop when needed, and a single EQ loop. If inquiring on multiple Service Type Codes, it is recommended that the submitter submit a Service Type Code of “30”.
RE-TRANSMISSION PROCEDURE
A duplicate transaction may be sent by the user’s CORE compliant system if the HTTP post reply message is not received within the 60 second response period. If no response is received after the second attempt, the user’s CORE compliant system should submit no more than 5 duplicate transactions within the next 15 minutes. If the additional attempts result in the same timeout termination, the user should contact Assurant Health to determine if system availability problems exist.
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ASSURANT HEALTH COMPANION GUIDE
COMMUNICATION PROTOCOL SPECIFICATIONS
Assurant Health supports two options for submitting Eligibility and Benefit Inquiry (270) transactions directly to Assurant Health. Sending these transactions directly eliminates the need for an intermediary and is offered to providers at no cost per transaction.
Our supported options are:
•
CAQH SOAP – Assurant Health supports the use of HTTP SOAP + WSDL envelope standards as defined in the CAQH CORE Phase II Connectivity standards (see http://caqh.org/pdf/CLEAN5010/270-v5010.pdf
)
The following is a list of technical standards and versions for the HTTP SOAP + WSDL envelope standards: o SOAP XML Schema: http://caqh.org/SOAP/WSDL/CORERule2.2.0.xsd
o WSDL Definition: http://caqh.org/SOAP/WSDL/CORERule2.2.0.wsdl
o HTTP Version 1.1 o SOAP Version 1.2 o SSL Version 3.0 o Health Care Eligibility and Benefit Inquiry and Response version 005010X279A1
The submitter of the Eligibility and Benefit Inquiry will need an Assurant Health issued userID and password to connect to Assurant Health.
•
CAQH MIME – Assurant Health supports the use of HTTP MIME Multipart existing envelope standards as defined in the CAQH CORE Phase II Connectivity standards (see http://caqh.org/pdf/CLEAN5010/270-v5010.pdf
)
The following is a list of technical standards and versions for the HTTP MIME Multipart envelope and eligibility payload: o HTTP Version 1.1 o MIME Version 1.0 o SSL Version 3.0 o Health Care Eligibility and Benefit Inquiry and Response version 005010X279A1
The submitter of the Eligibility and Benefit Inquiry will need an Assurant Health issued userID and password to connect to Assurant Health.
PASSWORDS
A userID and password must accompany each Eligibility and Benefit Inquiry (270) submitted to
Assurant Health. The method in which it is passed to the system for authentication is dependent upon the transaction type used.
MAINTENANCE
Routine maintenance is performed on Sunday mornings between 6 – 9 a.m. Central time.
Transactions submitted during this time may receive rejection messages indicating that Assurant
Health is unable to process their transaction at that time. Please check the Assurant Health website for any additional planned outages.
Notification of any non-routine or unscheduled downtime will be sent to the email address(es) provided in the enrollment process and posted on the Assurant Health website.
© 2012 Assurant, Inc. All rights reserved. 9

ASSURANT HEALTH COMPANION GUIDE
5 CONTACT INFORMATION
PROVIDER SERVICE NUMBER / CUSTOMER SERVICE
If you have questions regarding claim adjudication results, claim status, member eligibility or referral/authorization, contact the Assurant Health Customer Service department:
Phone: 800.553.7654
EDI CUSTOMER SERVICE / TECHNICAL ASSISTANCE
If the answers to questions you have are not found in this Companion Guide, please contact the
Assurant Health EDI team:
Phone: 888.647.9708
Assurant Help Desk – ask to open a ticket with Assurant Health EDI Services group
Email: ediserve@assurant.com
APPLICABLE WEBSITES/E-MAIL
Assurant Health Website: http://www.assuranthealth.com
6 CONTROL SEGMENTS/ENVELOPES
Listed below are Assurant Health specific requirements for the exchange of a Health Care Eligibility and Benefit Inquiry and Response (270/271) transaction.
ISA-IEA
The ISA segment terminator, which immediately follows the component separator, must consist of only one character code. The same character code must be used as the segment terminator for each segment in the ISA-IEA segment set.
Expected inbound values:
Page # Reference
C.3
C.4
C.4
C.4
C.4
C.4
C.4
C.5
ISA
ISA01
ISA02
ISA03
ISA04
ISA05
ISA06
ISA07
Name
Interchange Control
Header
Authorization Information
Qualifier
Authorization Information
Security Information
Qualifier
Security Information
Interchange ID Qualifier
Interchange Sender ID
Interchange ID Qualifier
Codes
‘00’
‘00’
‘ZZ’
‘ZZ’
Expected Value
All positions within each of the data elements must be filled.
‘00’ (zero zero) – No
Authorization Information
Present (no meaningful information in ISA02)
Blank (fill with 10 spaces)
‘00’ – No Authorization
Information Present (no meaningful information in
ISA04)
Blank (fill with 10 spaces)
ZZ (Mutually Defined)
Electronic Transmitter
Identification Number (ETIN)
ZZ (Mutually Defined)
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ASSURANT HEALTH COMPANION GUIDE
Page # Reference
C.5 ISA08
C.5
C.5
C.5
C.5
C.5
C.6
C.6
C.6
C.10
ISA09
ISA10
ISA11
ISA12
ISA13
ISA14
ISA15
ISA16
IEA
Name
Interchange Receiver ID
Interchange Date
Interchange Time
Interchange Repetition
Separator
Interchange Control
Version Number
Interchange Control
Number
Acknowledgement
Requested
Usage Indicator
Component Element
Separator
Interchange Control Trailer
Codes Expected Value
‘390658730’ ‘390658730’ This field must be filled with 15 spaces and be left justified.
Interchange Creation Date in
YYMMDD format
‘^’
Interchange Creation Time in
HHMM format
Assurant Health will utilize the carrot symbol ^ as the repetition separator.
‘00501‘
‘1’
Indicates version number
Assigned by your software
(usually sequential integer), no leading zeros allowed
1 - Interchange
Acknowledgment Requested
‘P’
‘:’
P - Production data
A : (colon) must be sent in this field.
C.10
C.10
IEA01
IEA02
Number of Included
Functional Groups
Interchange Control
Number
Count of the number of functional groups included in an interchange.
Control number assigned by the interchange sender that should be nine characters and be identical to the value in ISA13.
Outbound values:
Page # Reference
C.3
C.4
C.4
C.4
C.4
C.4
C.4
ISA
ISA01
ISA02
ISA03
ISA04
ISA05
ISA06
Name
Interchange Control
Header
Authorization Information
Qualifier
Authorization Information
Security Information
Qualifier
Security Information
Interchange ID Qualifier
Interchange Sender ID
Codes
‘00’
Expected Value
All positions within each of the data elements must be filled.
‘00’ (zero zero) – No
Authorization Information
Present (no meaningful
‘00’ information in ISA02)
Blank (fill with 10 spaces)
‘00’ – No Authorization
Information Present (no meaningful information in
‘ZZ’
ISA04)
Blank (fill with 10 spaces)
ZZ (Mutually Defined)
‘390658730’ ‘390658730’ This field must be filled with 15 spaces and
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ASSURANT HEALTH COMPANION GUIDE
Page # Reference
C.5
C.5
C.5
C.5
C.5
ISA07
ISA08
ISA09
ISA10
ISA11
C.5
C.5
C.6
C.6
C.6
C.10
ISA12
ISA13
ISA14
ISA15
ISA16
IEA
Name
Interchange ID Qualifier
Interchange Receiver ID
Interchange Date
Interchange Time
Interchange Repetition
Separator
Interchange Control
Version Number
Interchange Control
Number
Acknowledgement
Requested
Usage Indicator
Component Element
Separator
Interchange Control Trailer
Codes
‘ZZ’
‘^’
‘00501‘
‘0’
‘P’
‘:’
Expected Value be left justified.
ZZ (Mutually Defined)
Value submitted in ISA06 of the 270 Request
Interchange Creation Date in
YYMMDD format
Interchange Creation Time in
HHMM format
Assurant Health will utilize the carrot symbol ^ as the repetition separator.
Indicates version number
Assigned by your software
(usually sequential integer), no leading zeros allowed
0 – No Acknowledgment
Requested
P - Production data
A : (colon) must be sent in this field.
C.10
C.10
IEA01
IEA02
Number of Included
Functional Groups
Interchange Control
Number
Count of the number of functional groups included in an interchange.
Control number assigned by the interchange sender that should be nine characters and be identical to the value in ISA13.
GS-GE
Files must contain a single GS-GE per real time transaction.
Expected inbound values:
Page # Reference Name Codes
C.7
C.7
C.7
C.7
C.8
GS
GS01
GS02
GS03
GS04
Functional Group Header
Functional Identifier Code
Application Sender Code
Application Receiver Code
Date
Expected Value
All positions within each of the data elements must be
‘HS’ or Benefit Inquiry
Same value as ISA06.
‘390658730’ Same value as ISA08. filled.
HS – Eligibility, Coverage
Functional Group Creation
Date in CCYYMMDD format
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ASSURANT HEALTH COMPANION GUIDE
Page #
C.8
C.8
C.8
Reference
GS05
GS06
GS07
Time
Name
Group Control Number
Responsible Agency Code
Codes
‘X’
005010X279A1
Expected Value
Functional Group Creation
Time in HHMM format
Unique number within interchange. Will begin with 0001, and will be identical to GE02.
X - Accredited Standards
Committee X12
Version and transaction number
C.8
C.9
C.9
C.9
GS08
GE
GE01
GE02
Version/Release/Industry
Identifier Code
Functional Group Trailer
Number of Transaction
Sets Include
Group Control Number
1
Total number of transaction sets included in the functional group.
Unique number assigned by the sender that must be identical to GS06.
Outbound values:
Page # Reference
C.7
C.7
C.7
C.7
C.8
C.8
C.8
C.8
C.8
C.9
GS
GS01
GS02
GS03
GS04
GS05
GS06
GS07
GS08
GE
Name
Functional Group Header
Functional Identifier Code
Application Sender Code
Application Receiver Code
Date
Time
Group Control Number
Responsible Agency Code
Version/Release/Industry
Identifier Code
Functional Group Trailer
Codes
‘HB’
‘390658730’ Same value as ISA06.
Same value as ISA08.
HB – Eligibility, Coverage or Benefit Information
Functional Group Creation
Date in CCYYMMDD format
Expected Value
All positions within each of the data elements must be filled.
Functional Group Creation
Time in HHMM format
Unique number within interchange. Will begin with 0001, and will be identical to GE02.
‘X’
005010X279A1
X - Accredited Standards
Committee X12
Version and transaction number
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ASSURANT HEALTH COMPANION GUIDE
Page #
C.9
C.9
Reference
GE01
GE02
Name
Number of Transaction
Sets Include
Group Control Number
Codes
1
Expected Value
Total number of transaction sets included in the functional group.
Unique number assigned by the sender that must be identical to GS06.
ST-SE
Each real-time request should contain a single 270 Eligibility and Benefit Inquiry wrapped in a single ST-SE.
Page #
61
61
61
Reference
ST
ST01
ST02
Name
Transaction Set Header
Transaction Set Identifier
Code
Transaction Set Control
Number
Codes
270 270
Expected Value
Nine-digit number starting with 1 and increasing sequentially. Must match the number in SE02.
62 ST03 005010X279A1
61
61
SE
SE01
Implementation Convention
Reference
Transaction Set Trailer
Transaction Segment
Count
This element contains the same value as GS08.
Total numbers of segments included in a transaction set (including the ST and SE segments).
7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS
Transaction Limitations
Assurant Health supports the Eligibility and Benefit Inquiry and Response in real time mode only.
Real time 270s should have a single ST/SE loop, one information source, one information receiver, one subscriber loop, one dependent loop when needed, and a single EQ loop. If inquiring on multiple Service Type Codes, it is recommended that the submitter submit a Service
Type Code of “30”.
All data contained within the Eligibility and Benefit Inquiry should be submitted in UPPER CASE.
Supported Service Type Codes
Assurant Health supports the following Service Type Codes:
270 Request (EQ01)
1 - Medical Care
2 - Surgical
4 Diagnostic X-ray
5 Diagnostic Lab
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ASSURANT HEALTH COMPANION GUIDE
270 Request (EQ01)
6 - Radiation Therapy
7 - Anesthesia
8 - Surgical Assistance
12 - Durable Medical Equipment Purchase
13 - Ambulatory Service Center Facility
18 - Durable Medical Equipment Rental
20 - Second Surgical Opinion
30 - General Request
33 - Chiropractic
35 - Dental Care
40 - Oral Surgery
42 - Home Health Care
45 - Hospice
47 - Hospital
48 - Hospital - Inpatient
49 - Hospital - Room and Board
50 - Hospital - Outpatient
51 - Hospital - Emergency Accident
52 - Hospital - Emergency Medical
53 - Hospital - Ambulatory Surgical
62 - MRI/CAT Scan
65 - Newborn Care
68 - Well Baby Care
73 - Diagnostic Medical
76 - Dialysis
78 - Chemotherapy
80 - Immunizations
81 - Routine Physical
82 - Family Planning
86 - Emergency Services
88 - Pharmacy
93 - Podiatry
98 - Professional (Physician) Visit - Office
99 - Professional (Physician) Visit - Inpatient
A0 - Professional (Physician) Visit - Outpatient
A3 - Professional (Physician) Visit - Home
A6 - Psychotherapy
A7 - Psychiatric - Inpatient
A8 - Psychiatric - Outpatient
AD - Occupational Therapy
AE - Physical Medicine
AF - Speech Therapy
AG - Skilled Nursing Care
AI - Substance Abuse
AL - Vision (Optometry)
MH - Mental Health
UC - Urgent Care
BG - Cardiac Rehabilitation
BH- Pediatric
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ASSURANT HEALTH COMPANION GUIDE
Supported AAA Codes
Assurant Health supports the following AAA codes for error reporting:
Loop Error Condition AAA03 Value
04 2100A Authorized quantity exceeded
2100C
2100D
Will occur when the number of patient requests submitted exceed 1.
Required Application Data Missing 15
57 2100C
2100D
2100C
2100D
Invalid/Missing Date(s) of Service
Date of Service not within allowable inquiry period
2100D Invalid/Missing Patient ID
2100D Invalid/Missing Patient Name
2100D
2100C
2100D
Patient Not Found
Patient Birth Date does not batch Patient DOB in database
62
64
65
67
71
72 2100C
2100D
2110C
2110D
Invalid/Missing Subscriber/Insured ID
2100C Invalid/Missing Subscriber/Insured Name
2100C Subscriber/Insured Not Found
Invalid/Missing Date(s) of Service
2110C
2110D
Date of Service not within allowable inquiry period
73
75
57
62
8 ACKNOWLEDGEMENTS AND/OR REPORTS
For each 270 Eligibility and Benefit Inquiry submitted to Assurant Health, one of the following will be returned:
•
TA1 Interchange Acknowledgement if the ISA/IEA envelope cannot be processed.
•
999 Implementation Acknowledgement if the 270 transaction contains HIPAA compliancy errors within the ST/SE segments.
•
271 Eligibility and Benefit Inquiry Response containing the requested member’s coverage and benefits.
9 TRADING PARTNER AGREEMENTS
A completed EDI Enrollment form is required for all providers, clearinghouses and software vendors wishing to connect directly with Assurant Health to exchange Eligibility and Benefit Inquiry and
Response (270/271) transactions.
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ASSURANT HEALTH COMPANION GUIDE
10 TRANSACTION SPECIFIC INFORMATION
Listed below are specific requirements that Assurant Health requires for Eligibility and Benefit
Inquiries where the patient is the subscriber:
Page
#
Loop
ID
Reference Name Codes Length Expected Value
69
69
2100A
2100A
NM1
NM101
Information
Source Name
This is the source of information contained in the
271, i.e. Assurant Health
PR
70 2100A NM102
Entity Identifier
Code
Entity Type
Qualifier
2B,36,GP,
P5,PR
1,2 2
71 2100A NM108 PI PI
71
75
75
2100A
2100B
2100B
NM109
NM1
NM101
Identification
Code Qualifier
Identification
Code
Information
Receiver Name
Entity Identifier
Code
390658730
1P, 2B, 36,
80, FA,
GP, P5, PR
9 390658730
75
76
76
77
2100B
2100B
2100B
2100B
NM102
NM103
NM104
NM108
Entity Type
Qualifier
Name Last or
Organization
Name
Name First
1,2
XX
1P = Provider
2B = Third-Party
Administrator
36 = Employer
80 = Hospital
FA = Facility
GP = Gateway Provider
P5 = Plan Sponsor
PR = Payer
1 = Person
2 = Nonperson entity
Information receiver’s last name or organization name.
Information receiver’s first name.
This is required when the value in NM102 is 1.
XX = National Provider ID
78
90
91
92
92
2100B
2000C
2000C
2100C
2100C
NM109
TRN
TRN02
NM1
NM101
Identification
Code Qualifier
Identification
Code
Subscriber Trace
Number
Reference
Identification
Subscriber Name
IL
Should contain the National
Provider ID
Allows submitter tracking of the eligibility information
Include at least one TRN segment in either the subscriber or dependent loop
Subscriber identification information
IL
93 2100C NM102
Entity Identifier
Code
Entity Type
Qualifier
1,2 1
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ASSURANT HEALTH COMPANION GUIDE
Page
#
93
Loop
ID
Reference
2100C NM103
93
95
96
2100C
2100C
2100C
NM104
NM108
NM109
Name
Name Last or
Organization
Name
Name First
Identification
Code Qualifier
Identification
Code
MI
107 2100C DMG
Codes Length Expected Value
Subscriber last name
Subscriber first name
MI = Member ID
Subscriber ID number should contain the policy number and certificate number separated by a dash if a cert number is applicable or just policy number if cert number is not applicable.
Example:
#########-#######
The policy number can be up to 10 characters in length. Leading zeroes are not required.
The certificate number can be up to 7 characters in length. Leading zeroes are not required.
Subscriber demographics
108 2100C DMG02
Subscriber
Demographic
Information
Date Time Period
108
122
123
123
123
2100C
2100C
2100C
2100C
2100C
DMG03
DTP
DTP01
DTP02
DTP03
Gender Code
Subscriber Date
Date/Time
Qualifier
Date Time Period
Format Qualifier
Date Time Period
291
D8
Subscriber DOB (not required if dependent is patient)
Subscriber gender (not required if dependent is patient)
291 = Plan Date
D8 = Date expressed in
CCYYMMDD
If RD8 is submitted, the response will be based on the From date submitted in
DTP03
Date expressed in
CCYYMMDD
If a date range is submitted, the response will be based on the from date.
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ASSURANT HEALTH COMPANION GUIDE
Page
#
124
Loop
ID
Reference
2110C EQ
125 2110C EQ01
Name
Subscriber
Eligibility or
Benefit
Information
Service Type
Code
Codes Length Expected Value
Defines type of information requested
If unsupported service types and/or multiple service type codes are submitted, the system will respond with the default service type = “30”
Listed below are specific requirements that Assurant Health requires for Eligibility and Benefit
Inquiries where the patient is a dependent:
Page
#
Loop
ID
Reference Name Codes Length Expected Value
69
69
2100A
2100A
NM1
NM101
Information
Source Name
This is the source of information contained in the
271, i.e. Assurant Health
PR
70 2100A NM102
Entity Identifier
Code
Entity Type
Qualifier
2B,36,GP,
P5,PR
1,2 2
71 2100A NM108 PI PI
71
75
75
2100A
2100B
2100B
NM109
NM1
NM101
Identification
Code Qualifier
Identification
Code
Information
Receiver Name
Entity Identifier
Code
390658730
1P, 2B, 36,
80, FA,
GP, P5, PR
9 390658730
75
76
76
77
2100B
2100B
2100B
2100B
NM102
NM103
NM104
NM108
Entity Type
Qualifier
Name Last or
Organization
Name
Name First
1,2
XX
1P = Provider
2B = Third-Party
Administrator
36 = Employer
80 = Hospital
FA = Facility
GP = Gateway Provider
P5 = Plan Sponsor
PR = Payer
1 = Person
2 = Nonperson entity
Information receiver’s last name or organization name.
Information receiver’s first name.
This is required when the value in NM102 is 1.
XX = National Provider ID
78 2100B NM109
Identification
Code Qualifier
Identification
Code
Should contain the National
Provider ID
© 2012 Assurant, Inc. All rights reserved. 19

ASSURANT HEALTH COMPANION GUIDE
92
92
93
93
Page
#
90
Loop
ID
Reference
2000C TRN
91 2000C TRN02
Name
Subscriber Trace
Number
Reference
Identification
Codes
95
96
151
151
152
152
2100C
2100C
2100C
2100C
2100C
2100C
2100D
2100D
2100D
2100D
NM1
NM101
NM102
NM103
NM108
NM109
NM1
NM101
NM102
152 2100D NM103
NM104
Subscriber Name
Entity Identifier
Code
Entity Type
Qualifier
Name Last or
Organization
Name
Identification
Code Qualifier
Identification
Code
Dependent Name
Entity Identifier
Code
Entity Type
Qualifier
Name Last or
Organization
Name
Name First
IL
1,2
MI
03
1,2
Length Expected Value
Allows submitter tracking of the eligibility information
Include at least one TRN segment in either the subscriber or dependent loop
Subscriber identification information
IL
1
Subscriber’s last name
Submitters must use value
MI
Subscriber ID number should contain the policy number and certificate number separated by a dash if a cert number is applicable or just policy number if cert number is not applicable.
Example:
#########-#######
The policy number can be up to 10 characters in length. Leading zeroes are not required.
The certificate number can be up to 7 characters in length. Leading zeroes are not required.
Dependent identification information
03 = Dependent
1
Dependent last name (not required if subscriber is patient)
Dependent first name (not required if subscriber is patient)
© 2012 Assurant, Inc. All rights reserved. 20

ASSURANT HEALTH COMPANION GUIDE
Page
#
Loop
ID
Reference
164 2100D DMG
165 2100D DMG02
Name
Dependent
Demographic
Information
Date Time Period
Codes
166 2100D DMG03 Gender Code
167
181
182
183
2100D
2110D
2110D
INS
EQ
EQ01
Dependent
Relationship
Dependent
Eligibility or
Benefit
Information
Service Type
Code
Length Expected Value
Dependent demographics
Dependent DOB (not required if subscriber is patient)
Dependent gender (not required if subscriber is patient)
DO NOT SEND – Indicates dependent relationship to
Subscriber; Alternate
Search Option is not in use therefore this segment should not be sent
Defines type of information requested
If unsupported service types and/or multiple service type codes are submitted, the system will respond with the default service type = “30”
© 2012 Assurant, Inc. All rights reserved. 21

ASSURANT HEALTH COMPANION GUIDE
APPENDICES
IMPLEMENTATION CHECKLIST
□ Complete the EDI Enrollment form and email to Assurant Health at EnrollEDI@assurant.com
.
The form is available at http://www.assuranthealth.com/corp/ah/Providers/HipaaTransactions.htm
□ Assurant Health will provide a user ID and password.
□ Provider / trading partner should configure their system following the connection instructions provided by Assurant Health.
□ Verify connectivity by submitting an Eligibility and Benefit Inquiry (270) and evaluating the
Eligibility and Benefit Inquiry Response (271).
BUSINESS SCENARIOS
Example 1 – Generic request for a patient’s (subscriber) eligibility
Example 2 – Specific Service Type Category request for a patient’s (subscriber) eligibility
TRANSMISSION EXAMPLES
Example 1 – Generic request for a patient’s (subscriber) eligibility
ISA*00* *00* *ZZ*TESTHARNESS *ZZ*390658730
*121213*0748*^*00501*111111111*0*T*:~
GS*HS*TESTHARNESS*390658730*20121213*0748*123456789*X*005010X279A1~
ST*270*1234*005010X279A1~
BHT*0022*13*TRANSA*20121213*0748~
HL*1**20*1~
NM1*PR*2*TIME*****PI*390658730~
HL*2*1*21*1~
NM1*1P*1*TTEE*TTEE****XX*1000001010~
HL*3*2*22*0~
NM1*IL*1*DOE*JOHN****MI*0001093418~
DMG*D8*19680206~
DTP*291*RD8*20121213-20121213~
EQ*30~
SE*12*1234~
GE*1*123456789~
IEA*1*111111111~
Example 1 – Response to a generic request for a patient’s (subscriber) eligibility
ISA*00* *00* *ZZ*390658730 *ZZ*533052274
*121213*0748*^*00501*000001586*0*T*:~
GS*HB*390658730*533052274*20121213*0748*1586*X*005010X279A1~
ST*271*1586*005010X279A1~
BHT*0022*11*TRANSA*20121213*0748~
HL*1**20*1~
NM1*PR*2*TIME INSURANCE COMPANY*****PI*390658730~
PER*IC*CUSTOMER SERVICE*TE*8003284316~
HL*2*1*21*1~
NM1*1P*1*TTEE*TTEE****XX*1000001010~
HL*3*2*22*1~
NM1*IL*1*DOE*JOHN****MI*0001093418-0000002~
N3*HITACHI STREET21*LANE 58~
N4*ALBERT*KS*67511~
DMG*D8*19650206*F~
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ASSURANT HEALTH COMPANION GUIDE
INS*Y*18*001*25~
DTP*346*D8*20110925~
HL*4*3*23*0~
NM1*03*1*DOE*JOHN~
N3*HITACHI STREET21*LANE 58~
N4*ALBERT*KS*67511~
DMG*D8*19680206*M~
DTP*346*D8*20110925~
EB*1**30*GP*CLEAR CHOICE~
EB*C*IND*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^
A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*23*1*****U~
EB*1**1^88~
EB*6**A6^A7^A8^AI^MH~
EB*A*IND*11^12^13^18^2^20^33^4^42^45^47^48^49^5^50^51^52^53^6^62^65^68^7^73^
76^78^8^86^93^98^99^A0^A3^A9^AD^AE^AF^AG^BG^BH^UC*GP*CLEAR
CHOICE*23**0.2****Y~
EB*A*IND*11^12^13^18^2^20^33^4^42^45^47^48^49^5^50^51^52^53^6^62^65^68^7^73^
76^78^8^86^93^98^99^A0^A3^A9^AD^AE^AF^AG^BG^BH^UC*GP*CLEAR
CHOICE*23**0.5****N~
EB*B*IND*98*GP*CLEAR CHOICE*23*0*****Y~
DTP*348*D8*20050101~
EB*B*IND*98*GP*CLEAR CHOICE*23*0*****Y~
EB*C*FAM*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^
A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*23*4800*****Y~
EB*C*FAM*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^
A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*29*4800*****Y~
EB*U**65^68^80~
MSG*Benefits may be limited based on the age of the claimant.~
EB*C*IND*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^
A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*23*2400*****N~
EB*C*IND*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^
A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*23*2400*****Y~
EB*C*IND*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^
A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*29*1*****U~
EB*C*IND*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^
A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*29*2400*****N~
EB*C*IND*11^12^13^18^2^20^4^47^48^49^5^50^51^52^53^6^62^65^7^73^76^86^93^99^
A0^A3^AF^BG^BH^UC*GP*CLEAR CHOICE*29*2400*****Y~
EB*F*IND*AG*GP*CLEAR CHOICE*23***DY*30**U~
DTP*348*D8*20050101~
EB*F*IND*42*GP*CLEAR CHOICE*23***HS*160**U~
DTP*348*D8*20050101~
EB*F*IND*33^AD^AE*GP*CLEAR CHOICE*23***VS*20**U~
DTP*348*D8*20050101~
EB*G*FAM*11^12^13^18^2^20^33^4^42^45^47^48^49^5^50^51^52^53^6^62^65^68^7^73^
76^78^8^86^93^98^99^A0^A3^A9^AD^AE^AF^AG^BG^BH^UC*GP*CLEAR
CHOICE*23*3000*****U~
EB*I**40^AL~
EB*G*IND*11^12^13^18^2^20^33^4^42^45^47^48^49^5^50^51^52^53^6^62^65^68^7^73^
76^78^8^86^93^98^99^A0^A3^A9^AD^AE^AF^AG^BG^BH^UC*GP*CLEAR
CHOICE*23*1500*****U~
EB*U**80^81^82~
SE*49*1586~
GE*1*1586~
IEA*1*000001586~
© 2012 Assurant, Inc. All rights reserved. 23

ASSURANT HEALTH COMPANION GUIDE
Example 2 – Specific Service Type Category request for a patient’s (subscriber) eligibility
ISA*00* *00* *ZZ*TESTHARNESS *ZZ*390658730
*121213*0750*^*00501*111111111*0*T*:~
GS*HS*TESTHARNESS*390658730*20121213*0750*123456789*X*005010X279A1~
ST*270*1234*005010X279A1~
BHT*0022*13*TRANSA*20121213*0750~
HL*1**20*1~
NM1*PR*2*TIME*****PI*390658730~
HL*2*1*21*1~
NM1*1P*1*TTEE*TTEE****XX*1000001010~
HL*3*2*22*0~
NM1*IL*1*DOE*JOHN****MI*0001093418~
DMG*D8*19680206~
DTP*291*RD8*20121213-20121213~
EQ*7~
SE*12*1234~
GE*1*123456789~
IEA*1*111111111~
Example 2 – Response to a specific Service Type Category request for a patient’s eligibility
ISA*00* *00* *ZZ*390658730 *ZZ*533052274
*121213*0750*^*00501*000001591*0*T*:~
GS*HB*390658730*533052274*20121213*0750*1591*X*005010X279A1~
ST*271*1591*005010X279A1~
BHT*0022*11*TRANSA*20121213*0750~
HL*1**20*1~
NM1*PR*2*TIME INSURANCE COMPANY*****PI*390658730~
PER*IC*CUSTOMER SERVICE*TE*8003284316~
HL*2*1*21*1~
NM1*1P*1*TTEE*TTEE****XX*1000001010~
HL*3*2*22*1~
NM1*IL*1*DOE*JOHN****MI*0001093418-0000002~
N3*HITACHI STREET21*LANE 58~
N4*ALBERT*KS*67511~
DMG*D8*19650206*F~
INS*Y*18*001*25~
DTP*346*D8*20110925~
HL*4*3*23*0~
NM1*03*1*DOE*JOHN~
N3*HITACHI STREET21*LANE 58~
N4*ALBERT*KS*67511~
DMG*D8*19680206*M~
DTP*346*D8*20110925~
EB*1**30*GP*CLEAR CHOICE~
EB*C*IND*7*GP*CLEAR CHOICE*23*1*****U~
EB*A*IND*7*GP*CLEAR CHOICE*23**0.5****N~
EB*C*FAM*7*GP*CLEAR CHOICE*23*4800*****Y~
EB*C*FAM*7*GP*CLEAR CHOICE*29*4800*****Y~
EB*A*IND*7*GP*CLEAR CHOICE*23**0.2****Y~
EB*C*IND*7*GP*CLEAR CHOICE*23*2400*****N~
EB*C*IND*7*GP*CLEAR CHOICE*23*2400*****Y~
EB*C*IND*7*GP*CLEAR CHOICE*29*1*****U~
EB*C*IND*7*GP*CLEAR CHOICE*29*2400*****N~
EB*G*FAM*7*GP*CLEAR CHOICE*23*3000*****U~
EB*C*IND*7*GP*CLEAR CHOICE*29*2400*****Y~
EB*G*IND*7*GP*CLEAR CHOICE*23*1500*****U~
SE*34*1591~
GE*1*1591~
IEA*1*000001591~
© 2012 Assurant, Inc. All rights reserved. 24

ASSURANT HEALTH COMPANION GUIDE
FREQUENTLY ASKED QUESTIONS
Q. Is there a charge for a provider to submit 270 requests and receive 271 responses back from
Assurant Health?
A. This is a free service offered by Assurant Health to providers, clearinghouses and billing services and there are no fees associated with the use of this service.
Q. Once a request is submitted when will a response be received back from Assurant Health?
A. A single real-time request will receive a response back within 20 seconds.
Q. Who do I call for support if a problem arises?
A. If the answers to questions you have are not found in this Companion Guide, please contact the Assurant Health EDI team:
Phone: 888.647.9708
Assurant Help Desk – ask to open a ticket with Assurant Health EDI Services group
CHANGE SUMMARY
Version 0.1 – 10/3/2012
•
Initial draft
Version 1.0 – 12/14/2012
•
First published version
© 2012 Assurant, Inc. All rights reserved. 25