Specialty Benefits Dental. Standard Companion Guide

Transcription

1 Specialty Benefits Dental Standard Companion Guide Refers to the Technical Report Type 3 (TR3) (Implementation Guide) Based on X12N (Version X220A1) Companion Guide Version [EDI - 834] Benefit Enrollment and Maintenance Version Number: 2.0 October 1, 2010 Page 1 of 25

2 UnitedHealthcare Healin health care. To ether:" Change Log Version Release Date Changes Initial External Release Updated for Specialty Benefits Dental This material is provided on the recipient's agreement that it will only be used for the purpose of describing UnitedHealthcare Page 2 of25

3 Preface This Companion Guide to the ASC X12N Technical Report Type 3 (TR3), also known as Implementation Guides (IGs), adopted under HIPAA, clarifies and specifies the data content when exchanging electronically with UnitedHealthcare. Transmissions based on this Companion Guide, used in tandem with the X12N Implementation Guides, are compliant with both X12N 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. This transaction set can be used by employers, unions, government agencies, associations, or insurance agencies to enroll members to a payer. The payer is a healthcare organization that pays claims, administers insurance or benefit or product. Examples of payers include an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicaid, Medicare etc.) or any organization that may be contracted by one of these former groups. Improvements have been made to the layout that include updates throughout the X12N Implementation Guide with semantic notes that more clearly define the transaction. Page 3 of 25

4 Table of Contents 1. INTRODUCTION SCOPE OVERVIEW REFERENCE ADDITIONAL INFORMATION GETTING STARTED WORKING WITH UnitedHealthcare TRADING PARTNER REGISTRATION CERTIFICATION AND TESTING OVERVIEW TESTING WITH THE TRADING PARTNER CONNECTIVITY WITH THE PAYER / COMMUNICATIONS PROCESS FLOWS TRANSMISSION ADMINISTRATIVE PROCEDURES RE-TRANSMISSION PROCEDURE COMMUNICATION PROTOCOL SPECIFICATIONS PASSWORDS SYSTEM AVAILABILITY & DOWNTIME CONTACT INFORMATION EDI CUSTOMER SERVICE EDI TECHNICAL ASSISTANCE _Toc APPLICABLE WEBSITES / CONTROL SEGMENTS / ENVELOPES ISA-IEA GS-GE ST-SE PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ACKNOWLEDGEMENTS AND OR REPORTS ACKNOWLEDGEMENTS REPORT INVENTORY TRADING PARTNER AGREEMENTS TRADING PARTNERS TRANSACTION SPECIFIC INFORMATION APPENDECIES IMPLEMENTATION CHECKLIST BUSINESS SCENARIOS TRANSMISSION EXAMPLES FREQUENTLY ASKED QUESTIONS CHANGE SUMMARY DEFINITIONS Page 4 of 25

5 1. INTRODUCTION This section describes how X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The table contains a row for each segment that UnitedHealthcare has 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, and composite or simple data element pertinent to trading electronically with UnitedHealthcare In addition to the row for each segment, one or more additional rows are used to describe UnitedHealthcare s usage for composite and simple data elements and for any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set Companion Guides. The table contains a row for each segment that UnitedHealthcare has something additional, over and above, the information in the IGs. Following is just an example of the type of information that would be spelled out or elaborated on in: Section 9 Transaction Specific Information (see below). Page Loop Id Reference Name Codes Length Notes/Comments C NM1 Subscriber Name This type of row always exists to indicate that a new segment has begun. It is always shaded at 10% and notes or comment about the segment itself goes in this cell C NM109 Subscriber Primary Identifier C REF Subscriber Additional Identification C REF01 Reference Identification Qualifier Plan Network Identification Number C EB Subscriber Eligibility or Benefit Information 15 This type of row exists to limit the length of the specified data element. 18, 49, 6P, HJ, N6 These are the only codes transmitted by Acme Health Plan. N6 This type of row exists when a note for a particular code value is required. For example, this note may say that value N6 is the default. Not populating the first 3 columns makes it clear that the code value belongs to the row immediately above it C EB13-1 Product/Service ID Qualifier AD This row illustrates how to indicate a component data element in the Reference column and also how to specify that only one code value is applicable. Page 5 of 25

6 1.1. SCOPE The purpose of this document is to provide the information necessary to submit Benefit Enrollment and Maintenance transactions electronically to/from UnitedHealthcare. This Companion Guide is to be used in conjunction with the ASC X12N Implementation Guides. The Companion Guide supplements, but does not contradict or replace any requirements in the Implementation Guide. The Companion Guide specifications define current functions and other information specific to UnitedHealthcare in processing electronic eligibility via the transaction OVERVIEW This Companion Guide will replace, in total, the previous UnitedHealthcare Companion Guide for Benefit Enrollment and Maintenance (LFC-since the full name of the 834 has been addressed in section 1.1-I would suggest just saying 834 or in the remainder of the document.), including the latest release dated February 2007 and all previous releases. This UnitedHealthcare Benefit Enrollment and Maintenance Companion Guide has been written to assist you in designing and implementing Benefit Enrollment transactions to meet UnitedHealthcare s processing standards. This Companion Guide must be used in conjunction with the Benefit Enrollment and Maintenance instructions as set forth by the ASC X12N Standards for Electronic Data Interchange Addenda A1 (Version X220A1), June 2010 (referred to hereafter as the Implementation Guide or IG). The UnitedHealthcare Companion Guide identifies key data elements from the transaction set that we request you provide to us and response we will return. The recommendations made are to enable you to more effectively complete EDI transactions with UnitedHealthcare. Updates to this Companion Guide will occur periodically and new documents will be posted on > News. These updates will also be available at and distributed to all registered trading partners with reasonable notice, or a minimum of 30 days, prior to required Implementation. In addition, Trading partners can sign up for alerts on > News > Register to receive important news and updates including the Network Bulletin. Information will be included in these alerts anytime an updated document is posted online REFERENCE For more information regarding the ASC X12N Standards for Electronic Data Interchange Benefit Enrollment and Maintenance (Version X220A1) and to purchase copies of these documents, consult the Washington Publishing Company web site at: ADDITIONAL INFORMATION Assumptions For more information on whether an employer group or Third-Party Administrator (TPA) acting on behalf of the employer group needs to submit enrollment data in compliance with the transaction standard, please consult counsel or refer to the U.S. Department of Health and Human Services website at: Health Care Benefit Enrollment and Maintenance transactions submitted to UnitedHealthcare are assumed to be production-ready. Although the 834 file may be compliant in format, UnitedHealthcare specific data will still need to be tested, so any files submitted to UnitedHealthcare will not be considered production ready until implementation is complete (e.g., Plan data submitted in HD04, Customer and Policy specific data submitted in the REF segments in Loop 2000 and 2300, etc.). The employer groups, TPA, and system vendor(s) will have completed testing prior to submission to ensure HIPAA compliance. Page 6 of 25

7 2. GETTING STARTED 2.1. WORKING WITH UnitedHealthcare Below are general guidelines that should be followed when working with UnitedHealthcare. General File Submission Requirements 1. UnitedHealthcare strongly recommends that employer groups or TPA representing the employer group obtain certification from an approved Third-Party Certification System and Service (TPCSS), stipulating that its transactions are HIPAA compliant. For more information about certification and certification vendors, speak to the appropriate Electronic Eligibility Analyst at UnitedHealthcare. 2. While UnitedHealthcare supports all of the characters in the extended character set, it is recommended that incoming data use the basic character set as defined in Appendix B of the Implementation Guide. 3. Some of the segments and data elements labeled as Not Used in this Companion Guide, but labeled as Situational in the Implementation Guide, may still be accepted and validated to ensure HIPAA compliance. However, UnitedHealthcare will not actually process these segments and data elements. 4. Data submitted to UnitedHealthcare in ASC HIPAA standard format may be translated into a proprietary format for purposes of internal processing. 5. Only multiple data loops or segments should be populated with the first occurrence, and each loop or segment populated consecutively thereafter. There should be no loops or segments without data. 6. UnitedHealthcare prefers to receive only one transaction type (records group) per interchange (transmission). A submitter should only submit one GS-GE (Functional Group) within an ISA-IEA (Interchange), however, UnitedHealthcare does allow multiple ST/SEs within a transaction for multicustomer files to be submitted. 7. Trading Partners cannot send test and production information within the same transaction file, regardless of the transaction. Test data and production data must be submitted in separate files. Notify your Electronic Eligibility Analyst at UnitedHealthcare regarding submission of test data. 8. As of the release of this document (October 2010), UnitedHealthcare accepts the following versions of the Implementation Guide, and any future versions as specified by the regulation: ASC X12N 834 (Version X220A1) Causes for Rejection of File Submission 1. Delimiters must be consistently applied throughout the transmissions. Any delimiter can be used as long as the same one is used throughout the transaction. Printable characters are preferred. A carriage return/linefeed will cause an interchange/transmission to be rejected. 2. Only loops, segments, and data elements valid for the Implementation Guide will be translated. Submission of data that is not valid based on the Implementation Guide will cause files to be rejected. 3. If a segment or data element within a segment is specified in the Implementation Guide as Not Used, yet is present in the transaction, it will be rejected as an error. 4. UnitedHealthcare will reject an interchange transmission that is not submitted with unique values in the ST02 (Transaction Set Control Number) or GS06 (Group Control Number) elements within the interchange transmission. Page 7 of 25

8 Third-Party Administrators For employer groups EDI enrollment requests, it is necessary to contact the TPA directly. They will provide all the necessary testing and submission information required. Direct Submissions For direct submission to UnitedHealthcare or for details regarding communication protocols, contact the Electronic Eligibility Analyst at UnitedHealthcare who will then send the Employer or TPA an EDI transmission questionnaire and set up the connection. Privacy and Security Protection UnitedHealthcare will comply with the privacy and confidentiality requirements as outlined in the HIPAA Privacy and Security regulations regarding the need to protect health information. All Trading Partners are also expected to comply with these regulations. Encryption Requirements UnitedHealthcare will comply with the data encryption policy as outlined in the HIPAA Privacy and Security regulations regarding the need to encrypt health information and other confidential data. All data within a transaction that is included in the HIPAA definition of Electronic Protected Health Information (ephi) will be subject to the HIPAA Privacy and Security regulations and UnitedHealthcare will adhere to such regulations and the associated encryption rules. All Trading Partners are also expected to comply with these regulations and encryption policies TRADING PARTNER REGISTRATION Please refer to your on-boarding process/protocol, which is available by contacting your Electronic Eligibility Analyst at UnitedHealthcare CERTIFICATION AND TESTING OVERVIEW All trading partners who wish to submit Benefit Enrollment and Maintenance transactions electronically to/from UnitedHealthcare via the ASC X12N 834 (Version X220A1) and receive corresponding EDI responses must complete testing to ensure that their systems and connectivity are working correctly before any production transactions can be processed. Page 8 of 25

9 2.4. TESTING WITH THE TRADING PARTNER Testing Requirements EDI Trading Partner Testing UnitedHealthcare has adopted the Workgroup for Electronic Data Interchange (WEDI) Strategic National Implementation Process (SNIP) Testing Sub-Workgroups recommendations on the types of testing that need to occur in order to remain in line with the health care industry s testing recommendations. Initially, the types of testing that UnitedHealthcare strongly recommends for the Transaction Set includes: Type 1: EDI syntax integrity testing Testing of the EDI file for valid segments, segment order, element attributes, testing for numeric values in numeric data elements, validation of X12N or NCPDP syntax, and compliance with X12N and NCPDP rules. This will validate the basic syntactical integrity of the EDI submission. Type 2: HIPAA syntactical requirement testing Testing for HIPAA Implementation Guide-specific syntax requirements, such as limits on repeat counts, used and not used qualifiers, codes, elements and segments. Also included in this type is testing for HIPAA required or intrasegment situational data elements, testing for non-medical code sets as laid out in the Implementation Guide, and values and codes noted in the Implementation Guide via an X12N code list or table. Type 3: Other Testing Requirements 1) We require live data for testing - not dummy data - whenever possible 2) A full file (All members) is required which includes ISA thru IEA control Segments 3) Eligibility scenarios should be tested - COBRA, Survivors, plan changes, Dependent Only coverage, termination processing, enrollments 4) Electronic transfer must be utilized to submit the file - we can not accept a test file via secure since we use WTX for validation and translation Third-Party Certification Systems and Services (TPCSS) TPCSS vendors provide test data and testing services for anyone in need of testing compliance of their HIPAA transactions. UnitedHealthcare requests that Trading Partners test with a TPCSS and provide evidence of such testing. EDI submitters that have tested their Transaction Set with a certification system may provide a certificate of compliance. The certificate should specify the different types of testing passed or provide us with a certification website that indicates you have successfully passed certain types of certification testing. Standard Group and Eligibility Test Cases. Page 9 of 25

10 3. CONNECTIVITY WITH THE PAYER / COMMUNICATIONS 3.1. PROCESS FLOWS All trading partners who wish to submit 834 transactions to UnitedHealthcare must complete testing to ensure that their systems and connectivity are working correctly before any production transactions can be processed. For issues or questions related to EDI Customer Service, please contact the [Electronic Eligibility Analyst] at UnitedHealthcare TRANSMISSION ADMINISTRATIVE PROCEDURES The on-boarding process can be used in batch mode (FTP or SFTP). Using these types of connections, will allow you to either choose a manual process or automate your system RE-TRANSMISSION PROCEDURE When a file needs to be retransmitted, the trading partner will contact the [Electronic Eligibility Analyst] at UnitedHealthcare. At that time, procedures will be followed for UnitedHealthcare to accept the retransmitted file COMMUNICATION PROTOCOL SPECIFICATIONS The on-boarding process currently supports the following communications methods: FTP with PGP for Batch SFTP for Batch 3.5. PASSWORDS Passwords for your communication protocol will be supplied upon completion of the communication set up. This information will be sent via secure SYSTEM AVAILABILITY & DOWNTIME UnitedHealthcare s normal business hours for 834 processing are as follows: Monday thru Saturday 7:00 a.m. thru 11:59 p.m. EST Sunday 1:00 p.m. thru 11:59 p.m. EST Outside these windows, UnitedHealthcare systems may be down for general maintenance and upgrades. During these times, our ability to process incoming 834 transactions may be impacted. In addition, unplanned system outages may also occur occasionally and impact our ability to accept or immediately process incoming 834 transactions. We will send an communication for scheduled and unplanned outages. Page 10 of 25

11 4. CONTACT INFORMATION 4.1. EDI CUSTOMER SERVICE For issues or questions related to EDI Customer Service, please contact the Electronic Eligibility Analyst at UnitedHealthcare. See FREQUENTLY ASKED QUESTIONS 4.2. EDI TECHNICAL ASSISTANCE For issues or questions related to EDI Technical Assistance, please contact the Electronic Eligibility Analyst at UnitedHealthcare APPLICABLE WEBSITES / For a copy of the 5010 Implementation Guide for Benefit Enrollment and Maintenance, please visit the following: Publication Washington Publishing Company Website(s) Washington Publishing Company (Implementation Guides) Page 11 of 25

12 5. CONTROL SEGMENTS / ENVELOPES Below is the current interchange that reviews the usage of all included elements according to the X12N Implementation Guide ISA-IEA Transactions transmitted during a session or as a batch are identified by an interchange header segment (ISA) and trailer segment (IEA) which form the envelope enclosing the transmission. Each ISA marks the beginning of the transmission (batch) and provides sender and receiver identification. Communications transport protocol interchange control header segment. This segment within the X12N Implementation Guide identifies the start of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file header segment. Page Loop Id Reference Name Codes Length Notes/Comments C.3 ISA INTERCHANGE CONTROL HEADER C.4 ISA01 Authorization 00 = No authorization 00 ID 2/2 Information Qualifier information present C.4 ISA03 Security Information 00 = No security 00 ID 2/2 Qualifier information present C.4 ISA05 Interchange ID Qualifier ZZ or 30 ID 2/2 ZZ = Mutually Defined C.4 ISA06 Interchange Sender ID Client/TPA to UHC = User defined value AN 15/15 Interchange Sender ID. Left justify and pad with spaces to 15 characters. C.5 ISA07 Interchange ID Qualifier ZZ ID 2/2 ZZ = Mutually Defined C.5 ISA08 Interchange Receiver ID Client/TPA to UHC = AN 15/15 C.5 ISA11 Repetition Separator * 1/1 C.6 ISA16 Component Element Separator : 1/1 Receiver ID. Left justify and pad with spaces to 15 characters. The delimiter in ISA11 must be an asterisk The delimiter in ISA16 must be a colon Communications transport protocol interchange control trailer segment. This segment within the X12N Implementation Guide defines the end of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file trailer record. Page 12 of 25

13 5.2. GS-GE EDI transactions of a similar nature and destined for one trading partner may be gathered into a functional group, identified by a functional group header segment (GS) and a functional group trailer segment (GE). Each GS segment marks the beginning of a functional group. There can be many functional groups within an interchange envelope. The number of functional groups that exist in the transmission could be found in IEA01 element. Communications transport protocol functional group header segment. This segment within the X12N Implementation Guide indicates the beginning of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch header record. Page Loop Id Reference Name Codes Length Notes/Comments C.7 GS C.7 GS02 C.7 GS03 FUNCTIONAL GROUP HEADER Application Sender s Code Application Receiver s Code Direct to UHC Vision = User Defined Direct to UHC = AN 2/15 AN 2/15 To indicate the beginning of a functional group and to provide control information The value will be sent by the trading partner This is the same value as the Receiver s Interchange ID from ISA08 (do not pad with spaces). Communications transport protocol functional group trailer segment. This segment within the X12N Implementation Guide indicates the end of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch trailer record ST-SE The beginning of each individual transaction is identified using a transaction set header segment (ST). The end of every transaction is marked by a transaction set trailer segment (SE). Communications transport protocol transaction set header segment. This segment within the X12N Implementation Guide indicates the start of the transaction set and assigns a control number to the transaction. This segment may be thought of traditionally as the eligibility header record. Communications transport protocol transaction set trailer. This segment within the X12N Implementation Guide indicates the end of the transaction set and provides the count of transmitted segments (including the beginning (ST) and ending (SE) segments). This segment may be thought of traditionally as the eligibility trailer record. 6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS Future Terminations - When sending a full file you must send the termed record through the physical termination date. For example; if the file is sent on Aug 2nd and a record contains an Aug 31st term date, UHC must receive the same record with the same term date until the termination date passes. If the record falls off the next file sent (before the actual term date) the record will terminate on the date the file is loaded. Effective Dates - If a record is sent without an effective date the system will insert the date the file is loaded as the effective date. Once an effective date is received on a file for the first time and loaded in our system that effective date will remain in our system and will not be overwritten by a different effective date on a future file. Page 13 of 25

14 7. ACKNOWLEDGEMENTS AND OR REPORTS 7.1. ACKNOWLEDGEMENTS For every transaction received, there is an expected response. The available responses include: [999] A Functional Acknowledgement Once the transaction has passed the front end compliance check it then goes through a syntax compliance edit. This edit is to verify the compliance within the ASC X12N syntax according to the HIPAA Implementation Guides. The transaction will receive a Functional Acknowledgement [999] to provide feedback on the transaction. The [999] functional acknowledgement contains accepted or rejected information. If the transaction contains any syntactical errors, the segments and elements in which the error occurred will be reported in a rejected acknowledgement. If the transaction contained no syntactical errors, a positive [999] response will be generated and the transaction is passed on for subsequent processing REPORT INVENTORY An edit report will produce after each file load highlighting changes such as additions and terminations as well as any errors that may have occurred during the file load. If a file load contains errors the edit report will be sent by the assigned eligibility analyst to the identified contact. The contact can also request a copy of the edit report for all file loads regardless if an error occurs. An Error report template is attached below. Group Error Report-Template.xls Elig Error Report- Template.xls 8. TRADING PARTNER AGREEMENTS This section contains general information concerning Trading Partner (External Access) Agreements (TPA), which is available by contacting your [Electronic Eligibility Analyst] at UnitedHealthcare TRADING PARTNERS Direct Connection The Trading Partner (External Access) Agreement must be signed and completed prior to set up. 9. TRANSACTION SPECIFIC INFORMATION This section is reserved for any additional information, over and above the information contained in the IGs, that UnitedHealthcare requires in order to electronically submit Benefit Enrollment and Maintenance transactions. 834 Transaction Set Detail: Page Loop Id Reference Name Codes Length Notes/Comments INS01 Subscriber indicator Y,N 1 Y = Subscriber / N = Dependent.This identifies whether the enrollee is the Page 14 of 25

15 Page Loop Id Reference Name Codes Length Notes/Comments INS02 Relationship Code 01,03,04,05,06,07,08, 09, 10,11,12,13,14,15,17, 18, 19,23,24,25,26,31, INS03 Maintenance Type Code 001, 021, 024, INS04 Maintenance Reason Code and , 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 14, 15, 16, 17, 18, 20, 21, 22, 25, 26, 27, 28, 29, 31, 32, 33, 37, 38, 39, 40, 41, 43, AI, XN, XT, 59, AA, AB, AC, AD, AE, AF, AG, AH, AJ, AL, EC subscriber or dependant 2 Subscriber information(ins02= 18 ) must precede dependent information 3 2/ INS05 Benefit Status Code A,C,S T INS07 COBRA Event Code 1, 2, 3, 4, 5, 6, 7, 8, 1/2 9, 10 and ZZ INS08 Employment Status AO,AU,FT,L1,PT,R 2 Code T,TE INS09 Student Status Code F,N,P 1 Used when describing a Non-spouse dependent. F=Full-time/N=Not a Student P=Part-time INS10 Handicap Indicator Y,N 1 N =No / Y =Yes INS17 Birth Sequence Number 1/ REF02 Will have SSN when REF01 is OF Will have group or company code/subcode when REF01 is 1L A NM103 Last Name This element contains the last name of the enrollee A NM104 First Name This element contains the first name of the enrollee A NM105 Middle Name This element contains the middle name of the enrollee A NM109 Identification Code When NM108 is 34 and INS01 = Y, this would contain the subscriber SSN. When NM108 is 34 and INS01 = N, this element would contain the dependant SSN A PER Member Communication Numbers A PER03 Communication Number Qualifier CP- Cellular Phone HP- Home Phone Number This segment contains the work phone, home phone and cell phone numbers of the members 2 This element contains the qualifier indicating whether the Page 15 of 25

16 Page Loop Id Reference Name Codes Length Notes/Comments WP- Work Phone Number communication number in the following element is a cell phone, work phone or home phone number A PER04 Communication Number 256 This element contains the appropriate phone number(cell phone, home phone or work phone) Our system can store only the 10 characters communication number A PER05 Communication Number Qualifier CP- Cellular Phone HP- Home Phone Number WP- Work Phone Number 2 This element contains the qualifier indicating whether the communication number in the following element is a cell phone, work phone or home phone number A PER06 Communication Number 256 This element contains the appropriate phone number(cell phone, home phone or work phone). Our system can store only the 10 characters communication number A PER07 Communication Number Qualifier CP- Cellular Phone HP- Home Phone Number WP- Work Phone Number 2 This element contains the qualifier indicating whether the communication number in the following element is a cell phone, work phone or home phone number A PER08 Communication Number 256 This element contains the appropriate phone number(cell phone, home phone or work phone) Our system can store only the 10 characters communication number A N301 Address1 55 Member's Address or Dependents address if different from member. Our system can store only 30 characters of address 1 data, rest of the data will be truncated A N302 Address2 55 Member's Address or Dependents address if different from member. Our system can store only 30 characters of address 2 data, rest of the data will be truncated A N401 City 30 Member's City or Dependents city if different from member. Our system can store only 20 characters of city data, rest of the data will be truncated A N402 State 2 Member's State or dependents state if different from member Page 16 of 25

17 Page Loop Id Reference Name Codes Length Notes/Comments A N403 Zip+4 15 Member's Zip Code or dependents zip if different from member include leading zeros. The maximum length for the zip code field in system for the US address is 9 (Zip5 + Zip 4), but foreign address zip code can be up to 15 digit alphanumeric A DMG02 Birth date 8 DOB Required for both member and dependent. Format is CCYYMMDD A DMG03 Gender M-Male F-Female U-Unknown A DMG04 Marital Status B -Registered Domestic Partner D -Divorced I -Single M -Married R -Unreported S -Separated U -Unmarried (Single or Divorced or Widowed) W -Widowed X- Legally Separated Page 17 of 25 1 M-Male F-Female U-Unknown 1 For member only A EC Employment Class This segment contains the member employment class details A EC01 Employment Class Code 01 Union 02 Non-Union 03 Executive 04 Non-Executive 05 Management 06 Non-Management 07 Hourly 08 Salaried 09 Administrative 10 Non- Administrative 11 Exempt 12 Non-Exempt 17 Highly Compensated 18 Key-Employee 19 Bargaining 20 Non-Bargaining 21 Owner 22 President 23 Vice President A EC02 Employment Class Code 01 Union 02 Non-Union 03 Executive 04 Non-Executive 05 Management 06 Non-Management 07 Hourly 08 Salaried 09 Administrative 10 Non- Administrative 11 Exempt 2 Contains the employment class code of the employee 2 Contains the employment class code of the employee

18 Page Loop Id Reference Name Codes Length Notes/Comments 12 Non-Exempt 17 Highly Compensated 18 Key-Employee 19 Bargaining 20 Non-Bargaining 21 Owner 22 President 23 Vice President A EC03 Employment Class Code 01 Union 02 Non-Union 03 Executive 04 Non-Executive 05 Management 06 Non-Management 07 Hourly 08 Salaried 09 Administrative 10 Non- Administrative 11 Exempt 12 Non-Exempt 17 Highly Compensated 18 Key-Employee 19 Bargaining 20 Non-Bargaining 21 Owner 22 President 23 Vice President 2 Contains the employment class code of the employee A LUI Member Language This segment would contain the member language details A LUI01 Identification Code Qualifier A LUI02 Language Identification Code A LUI04 Use of Language Indicator LD,LE 2 LD - NISO Z39.53 Language Codes LE - ISO 639 Language Codes 2 It contains the Member language identification code. 5,6,7,8 1 It contains skills of the language usage for the person. 5- Language Reading 6 -Language Writing 7 -Language Speaking 8 -Native Language B NM109 Incorrect SSN 9 When NM101 is 70. Old or incorrect SSN Used when previously sent SSN needs to be corrected B DMG02 Incorrect DOB 9 When NM101 is 70. Used when previously sent DOB needs to be corrected HD05 Coverage Level Code EMP/IND-Employee only E1D-Employee and 1 dependent ECH-Employee and Children 3 Page 18 of 25

19 Page Loop Id Reference Name Codes Length Notes/Comments DTP03 Hire Date/Employment Begin Date/Employment End date FAM-Family ESP-Employee and Spouse Others converted to FAM When DTP01 is "336" means Hire date, When DTP01 is 356 means Employment Begin date and When DTP01 is 357 means Employment End date DTP03 Coverage Begin Date when DTP01 is "348" DTP03 Coverage End Date when DTP01 is "349" 834 Transaction Set Header : Page Loop Id Reference Name Codes Lengt h Notes/Comments 31 ST 01=834 Transaction Set Id Code 3 Header, Transaction Set Identifier Code 31 ST 02 Transaction Set Control Number 31 ST03 Implementation Convention Reference 32 BGN 01 Transaction Set Purpose Code 9 Header, Transaction Set Control Number 35 This will contain the version number X220A1 4 Header, Transaction Set Purpose Code, 00=Original, 15=Re-submission and 22=Information Copy 33 BGN 02 BGN Reference ID BGN 03 BGN Date 8 Transaction Date, Format is CCYYMMDD 33 BGN 04 BGN Time 6 Transaction Time, Format is HHMM 35 BGN 08 Transaction Action Code 2 2=Change, 4=Verify and RX = Replace (if the value is 4 or RX, then the file will be considered as Full file) 36 REF 02 Transmission Type ID 30 when REF 01=38 (Master Policy Number) 40 N104 Sponsor Federal Tax ID 80 when N101=P5 and N103=FI 40 N104 Payer Federal Tax ID 80 when N101=IN and N103=FI 834 Transaction Set Trailer : Page Loop Id Reference Name Codes 184 SE 01 Number of Included Segments 184 SE 02 Transaction Control Number Lengt h Notes/Comments 10 Trailer, Number of Included Segments 9 Trailer, Transaction Control Number which is match in ST02 A Generic Example of HIPAA Compliant Enrollment Transaction Set: Page 19 of 25

20 UnitedHealthcare Healin health care. To ether:" This material is provided on the recipient's agreement that it will only be used for the purpose of describing UnitedHealthcare Page 20 of25

21 10. APPENDECIES IMPLEMENTATION CHECKLIST Your trading partners are the organizations with which you exchange transactions. The final step before going live with the 5010 transactions will be to complete testing with your trading partners. The testing will involve sending test transactions through the channels you use today, such as to the clearinghouses or payers. Sending test transactions is an opportunity to see if they will be received successfully, both by your trading partner s system and your system. Be aware, however, that in some instances, testing will be done in live production environments with a subset of your transaction data. Use the following steps to prepare for the Implementation of 5010: 1. Talk to your current practice management system vendor. 2. Talk to your clearinghouses or billing service, if you use either one, and health insurance payers. 3. Identify changes to data reporting requirements. 4. Identify potential changes to existing practice work flow and business processes. 5. Identify staff training needs. 6. Test with your trading partners, (e.g., payers and clearinghouses). 7. Budget for Implementation costs, including expenses for system changes, resource materials, consultants, and training BUSINESS SCENARIOS Please refer to Section 4.4 above, which points to the appropriate Website where the reader can view the Implementation Guide, which contains various business scenario examples TRANSMISSION EXAMPLES Please refer to Section 4.4 above, which points to the appropriate Website where the reader can view the Implementation Guide, which contains various transmission examples FREQUENTLY ASKED QUESTIONS 1) Will UHC test my data when it is received? Yes, the Eligibility Team will run each production file through testing and Quality Assurance to ensure that your file was transmitted and loaded as expected. 2) Who should I notify if there would be a large increase or decrease in membership (example: open enrollment period)? Notify your assigned Eligibility Analyst (Eligibility Team) as soon as you are aware of when the increase/decrease will take place. UHC appreciates advance notice and can override systems checks and error reporting that notifies us of such results outside of normal tolerances. 3) Who do we notify if there is an address or contact name change for the group? Please notify your UHC Account Executive/Account Manager. 4) How often should I send my file? Most groups send full eligibility files once every month. You may send an eligibility file more frequently depending on the amount of changes you have to report. The frequency of file submissions should be coordinated with your UHC Eligibility Analyst (Eligibility Team) and your Account Page 21 of 25

22 Executive/Account Manager so that we may monitor the frequency of your file loads and notify when files are overdue. 5) How quickly will UHC load my file? Data that is incorrect in terms of file/record layout or that contains other errors may be subject to a delay in loading. UHC s standard is to load files within business hours of receipt. If the file cannot be loaded at all due to a physical defect or other error conditions, you will be notified as soon as possible in order to provide a replacement file. 6) What is the difference between full file and a transaction (trans)/change file? A full replacement file contains records of all eligible members (and dependents). UHC recommends a full replacement file for every file transmission. The full replacement file is used as a reference for any eligibility verification questions. A transaction (trans)/change file would include changes only and is not the preferred file type. 7) What is Data Encryption? Encryption is a process that re-formats your data in to a format that can only be read by the receiver after the use of a decryption key. This protects the content of your file from anyone who may obtain it in an unauthorized fashion. UHC Vision strongly recommends encryption of files. PGP is an encryption/decryption product that is in use by UHC Vision CHANGE SUMMARY For those business segments for which previous Companion Guide(s) do exist, the current Companion Guide refers to the 5010 Implementation of the transaction set, whereas the previous Companion Guide(s) refer to earlier HIPAA release standards such as [4010/4010A1]. Page 22 of 25

23 10.6. DEFINITIONS Term Qualifier Definition Inbound file containing Benefit Enrollment and Maintenance data or Functional Acknowledgement for HIPAA 834 file. A functional acknowledgement will be sent by the receiver to the sender when an 834 file is received The October 1997 ASC X12N standard format, Version 4, Release 1, Sub-release 0 (00[4010]) 4010A1 4010A1 The version of the transactions named in HIPAA is Version (4010) and its subsequent addenda, A1 (4010A1), are collectively referred to as 4010A1. These electronic transactions were developed by the standards development organization Accredited Standards Committee X12N (ASC X12N). Standards development organizations are bodies that develop standards used in various industries, such as banking standards that enable you to use your ATM card in any ATM The August 2006 ASC X12N standard format, Version 5, Release 1, Sub-release 0 (005010). Acknowledgement ASC X12N B2B Acknowledgement The Acknowledgement is the electronic response, or 999, or Functional Acknowledgement for HIPAA 834 file. ASC X12N is the official designation of the U.S. national standards body for the development and maintenance of Electronic Data Interchange (EDI) standards. EDI X12N (Electronic Data Interchange) is a data format based on ASC X12N standards. It is used to exchange specific data between two or more trading partners. B2B Business-to-business, or "B2B," is a term commonly used to describe electronic commerce transactions between businesses, as opposed to those between businesses and other groups, such as business and individual consumers (B2C) or business and government (B2G). CAQH Companion Guide CORE EDI EDI 834 B2B is also commonly used as an adjective to describe any activity, be it marketing, sales, or ecommerce that occurs between businesses and other businesses rather than between businesses and consumers. CAQH is an unprecedented nonprofit alliance of health plans and trade associations, and is a catalyst for industry collaboration on initiatives that simplify healthcare administration. CAQH solutions promote quality interactions between plans, providers, and other stakeholders; reduce costs and frustrations associated with healthcare administration; facilitate administrative healthcare information exchange and encourage administrative and clinical data integration. Companion Guide A handbook that assists with giving information and instructions on the EDI 834 transactions. CORE Committee on Operating Rules for Information Exchange a segment of CAQH whose mission is to promote interoperability of transactions among healthcare payers. EDI Electronic Data Interchange is the computer-to-computer exchange of business or other information between two organizations (trading partners). The data may be either in a standardized or proprietary format. Also known as electronic commerce. EDI 834 The 834 EDI Transactions can be used by employers, unions, government agencies, associations or insurance agencies to enroll members to a payer. The payer is a healthcare organization that pays claims, administers insurance or benefit or product. Examples of payers include an insurance company, health care professional (HMO), preferred provider organization (PPO), government agency (Medicaid, Medicare etc.) on any organization that may be contracted by one of these former groups. Page 23 of 25

24 Term Qualifier Definition EDI X12N Standards and Releases EDI X12N Standards and Releases EDI X12N is governed by standards released by ASC X12N (The Accredited Standards Committee). Each release contains set of message types like invoice, purchase order, healthcare claim, etc. Each message type has specific number assigned to it instead of name. For example: an invoice is 810, purchase order is 850 and healthcare claim is 837, Eligibility is 834 Every new release contains new version number. Version number examples: 4010, 4020, 4030, 5010, 5030, etc. Major releases start with new first number. For example: 4010 is one of the major releases, so is However 4020 is minor release. Minor releases contain minor changes or improvements over major releases. Understanding the difference between major and minor releases is important. Let say you have working translation for some messages for release 4010, and if you want to upgrade to 4020 you will notice only a few changes between the two, and if you want to upgrade to release 5010 you might need to make a lot of modifications to current translation. At the time of this writing 4010 is most widely used release. It is the first release that is Y2K compliant. Most of HIPAA based systems know and use Conclusion: to translate or validate EDI X12N data you need to know transaction number (message numeric name) and release version number. Both of those numbers are inside the file. HIPAA HIPAA Health Insurance Portability and Accountability Act of 1996 is a federal law intended to improve the availability and continuity of health insurance coverage that, among other things, places limits on exclusions for pre-existing medical conditions; permits certain individuals to enroll for available group health care coverage when they lose other health coverage or have a new dependent; prohibits discrimination in group enrollment based on health status; provides privacy standards relating to individuals' personally identifiable claimrelated information; guarantees the availability of health coverage to small employers and the renewability of health insurance coverage in the small and large group markets; requires availability of non-group coverage for certain individuals whose group coverage is terminated; and establishes standards for electronic transmissions. ICD-9 ICD-10 Protocols Qualifier Segment ICD-9 ICD-9 is an acronym used in the medical field that stands for International Classification of Diseases, ninth revision. In the United States, the ICD-9 covered the years 1979 to Currently, ICD-10, which is the tenth revision, is in effect as the most current database of disease classifications. ICD-9 was used in the US until the 10th revision became fully implemented in 1998, though the actual revision was concluded some years earlier. ICD-10 The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) is a coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as classified by the World Health Organization (WHO). The code set allows more than 155,000 different codes and permits tracking of many new diagnoses and procedures, a significant expansion on the 17,000 codes available in ICD-9. Protocols Protocols are codes of correct conduct for a given situation. Qualifier A qualifier is a word, number, or characters that modifies or limits the meaning of another word or group of words or dates. Segment a string of data elements that contain specific values based on the loop and data element on file which is separated into specific sections. Page 24 of 25

25 Term Qualifier Definition Third Party Administrator (TPA) Third party administrator TPA s are prominent players in the managed care industry and have the expertise and capability to administer all or a portion of the claims process. They are normally contracted by a health insurer or self-insuring companies to administer services, including claims administration, premium collection, no enrollment and other administrative activities. A hospital or provider organization desiring to set up its own health plan will often outsource certain responsibilities to a TPA. Trading Partner Trading Partner Requirements Trading Partner A Trading Partner may represent an organization, group of organizations or some other entity. In most cases it is just an organization or company. Trading Partner Requirements EDI X12N standard covers number of requirements for data structure, separators, control numbers, etc. However many big trading partners impose they own even more strict rules and requirements. It can be everything: specific data format requirements for some elements, requirement to contain specific segments (segments that are not mandatory in EDI X12N standard being made mandatory), etc. In HIPAA those specific trading partner requirements are usually listed in separate document called Companion Guide. It is essential to follow these documents to the letter when implementing EDI systems. Page 25 of 25