Standard Companion Guide

Transcription

1 HealthSmart Benefit Solutions, Inc. Standard Companion Guide Refers to the Implementation Guide Based on X12 Version 00X220A1 Benefit Enrollment and Maintenance () January 2012 Companion Guide Version Number: 1.7 This material is provided on the recipient s agreement that it will only be used for the purpose of describing HealthSmart Benefit Solutions products and services to the recipient. Any other use, copying or distribution without the express written permission of HealthSmart is prohibited.

2 Version # Release Date Change Descriptions v1.0 7/18/2011 Initial Draft v1.1 9/4/2011 Final Draft v1.2 9/5/2011 Updated with Appendix v1.3 11/8/2011 Updated Business Rules and Map with HealthSmart required fields v1.4 5/3/2012 Re-branded to HealthSmart Benefit Solutions, Inc. v1.5 9/17/2012 Updated the Business Rules and Limitations section V1.6 10/15/2012 Updated the Business Rules and Limitations section V1.7 11/6/2012 Updated Qualifiers for department January 2012 HealthSmart Benefit Solutions, Inc. A1

3 Preface This Companion Guide (CG) to the Technical Report Type 3 (TR3) adopted under HIPAA clarifies and specifies the data content when data is transmitted electronically to/from HealthSmart Benefit Solutions, Inc. Transmissions based on this companion guide, used in tandem with the TR3, also called Benefit Enrollment and Maintenance () ASC X12N/00X220A1, are compliant with both X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the TR3 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 TR3. Disclaimer The information in this Companion Guide is provided by HealthSmart Benefit Solutions, Inc. for education and awareness use only. Even though information in this document is believed to be correct at the time of writing, this document is for educational purposes only and should not be construed as legal advice. If you require legal advice, you should consult with an attorney. The information provided here is for reference use only and does not constitute the rendering of legal, financial, or other professional advice or recommendations by HealthSmart Benefit Solutions, Inc. HealthSmart Benefit Solutions, Inc. disclaims any express or implied warranty as to the content, sequence, accuracy, timeliness or completeness of any material contained herein and any liability with respect to thereto. January 2012 HealthSmart Benefit Solutions, Inc. 2

4 Table of Contents Introduction... 4 Purpose... 4 Trading Partners... 4 Testing with HealthSmart... 4 Payer Connectivity/s... 5 File Delimiters... 6 Control Segments/Envelopes... 7 Business Rules and Limitations... 8 Transaction Specific Information Transmission Confirmation Retrieving Files Acknowledgements Contact Information Appendix A January 2012 HealthSmart Benefit Solutions, Inc. 3

5 Introduction In an effort to reduce the administrative costs of health care across the nation, the Health Insurance Portability and Accountability Act (HIPAA) was passed in This legislation requires the health insurance payers in the United States to comply with the electronic data interchange (EDI) standards for health care, established by the Secretary of Health and Human Services (HHS). For the health care industry to achieve the potential administrative cost savings with EDI, standard transactions and code sets have been developed and need to be implemented consistently by all organizations involved in the electronic exchange of data. The ANSI X12N Technical Reports Type 3 (TR3s) and Errata adhere to the final HIPAA Transaction Regulations and have been established as the standards of compliance for electronic transactions. The Technical Reports Type 3 (TR3s) is available electronically at 1. Purpose This Benefit Enrollment and Maintenance Companion Guide is designed for use in conjunction with the ANSI ASC X12N 00X22oA1 Benefit Enrollment and Maintenance Technical Report Type 3 (TR3) and Type 1 Errata. The specifications contained within this Companion Guide define current functions and provide supplemental information specific to HealthSmart Benefit Solutions, Inc. (HealthSmart). The information presented is for clarification and does not contradict any requirements in the ANSI X12N Technical Reports Type 3 (TR3s) and Type 1 Errata. 2. Trading Partners The definition of an EDI trading partner is any business partner (provider, billing service, software vendor, employer group, financial institution, etc.) who transmits to or receives electronic data from HealthSmart. 3. Testing with HealthSmart Benefit Solutions Testing consists of submitting Benefit and Enrollment information, validating the data, and certifying multiple transmissions. ANSI version 00X220A1 Accounts can transmit test files to the destination used today or the secure ftp site that was created. The test file must contain a T in the ISA 15. The test file must follow the file naming convention of: o TEST_ELIG_companyidentifier_ccyymmdd.txt o You may also send a time stamp in the above file name. o An example of your company identifier may be your Company Name or Company Number. The test file must be received by HealthSmart no later than 45 business days before the schedule production go live date. Once the test file has been received by HealthSmart, results of testing will be provided within 7-10 business days. Once you receive certification, you may begin submitting -certified transactions within the production environment. Assignment of the Trading Partner ID and scheduling for testing is done individually. Please contact the HealthSmart EDI Coordinator to determine Trading Partner ID and to schedule testing. All Receiver and Sender ids used for 4010 or flat files will remain in effect for. January 2012 HealthSmart Benefit Solutions, Inc. 4

6 HealthSmart will work closely with its Trading Partners to establish effective communication protocols and to resolve any connectivity issues that may arise regarding the exchange of HIPAA-related electronic transactions. 3.1 Contact Information The following contact information is provided to assist in the processing of Benefit and Enrollment transactions: the HealthSmart EDI Service Desk at 4. Payer Connectivity/s 4.1 Transmission Administrative Procedures HealthSmart will establish logons, passwords and a HIPAA transaction mailbox for each trading partner approved for testing. 4.2 Retransmission Procedures In the event should issues arise that require trading partners to resubmit transactions, HealthSmart Service Desk support personnel will confirm that it is necessary to retransmit the file(s) in question and will forward specific information to the trading partner. 4.3 Protocols All new Trading Partners will be required to communicate with HealthSmart by means of an encrypted file transfer protocol. HealthSmart will establish either a FTPs (SSL) over TCP port 21 or SFTP using SSH over TCP Port 22 and supply the credentials. 4.4 Passwords Direct Connection: Passwords will be sent via secure to the Trading Partner once a profile has been created on HealthSmart s EDI system. Trading Partner access will be verified by the logon ID and password whenever the FTP system is accessed. Operation procedures will assure that logons and passwords are initiated, monitored and maintained in a secure manner. 4.5 System Availability HealthSmart Benefit Solutions, Inc. will accept Benefit and Enrollment submissions from 7am to 4pm, ET, M-F. Any submissions received after 4pm, ET, M-F or on Saturday, Sunday or a holiday will be processed the following business day. Eligibility files are processed at the end of each business day. January 2012 HealthSmart Benefit Solutions, Inc. 5

7 Expectations on turn-around time can vary based upon hardware, connectivity mode and the transaction in question. No changes to current system availability are expected. 5. File Delimiters A delimiter is a character used to separate two data elements or sub-elements, or to terminate a segment. Delimiters are specified in the Interchange header segment, ISA. The ISA segment is a 105 byte fixed length record. The data element separator is byte number 4; the component element separator is byte number 105; and the segment terminator is the byte that immediately follows the component element separator. Once specified in the Interchange header, delimiters are not to be used in a data element value elsewhere in the transaction. Description Default Delimiter Data element separator Asterisk * Sub-element separator Colon : Segment Terminator Tilde ~ Repetition Separator Caret ^ 6. Control Segments/Envelopes 6.1 ISA - IEA Batch submitted transactions are identified by an interchange header segment (ISA) and trailer segment (IEA) which forms the envelope enclosing the data transmission. Each ISA marks the beginning of the transmission and provides sender and receiver identification. The table below represents only those fields that HealthSmart requires insertion of a specific value or has additional guidance on what the value should be. The table does not represent all of the fields necessary for a successful transaction; the TR3 should be reviewed for that information. TR3 Page # ID Reference Name Value Notes/Comments C.3 None ISA ISA Interchange Control Header C.3 ISA08 Interchange Receiver ID HealthSmart Receiver ID C.6 ISA15 Identifier T,P Value indicates data is Test or Production 6.2 GS-GE January 2012 HealthSmart Benefit Solutions, Inc. 6

8 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 GS/GE functional groups that exist in the transmission. The table below represents only those fields that HealthSmart requires insertion of a specific value or has additional guidance on what the value should be. The table does not represent all of the fields necessary for a successful transaction; the TR3 should be reviewed for that information. TR3 Page # ID Reference Name Value Notes/Comments C.7 None GS Functional Group Header Required Header C.7 (60 in Errata) GS03 Application Receiver s Code HealthSmart Receiver ID C.8 (61 GS08 Version/Release/Industry 00X220A1 Version required by in Identifier Code HealthSmart Errata) 6.3 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). The table below represents only those fields that HealthSmart requires insertion of a specific value or has additional guidance on what the value should be. The table does not represent all of the fields necessary for a successful transaction; the TR3 should be reviewed for that information. TR3 Page # ID Reference Name Value Notes/Comments 70 None ST Transaction Set Header Required Header 70 (14 ST03 Implementation Convention 00X220A1 in Reference Errata) 6.4 Control Segment Notes The ISA data segment is a fixed length record and all fields must be supplied. Fields that are not populated with actual data must be filled with space. January 2012 HealthSmart Benefit Solutions, Inc. 7

9 The first element separator (byte 4) in the ISA segment defines the element separator to be used through the entire interchange. The ISA segment terminator (byte 106) defines the segment terminator used throughout the entire interchange. ISA16 defines the component element. 7. HealthSmart Benefit Solutions Specific Business Rules and Limitations 7.1 Validation of the at HealthSmart HealthSmart will apply Level-1 HIPAA Compliance of editing to inbound HIPAA files: o Full levels 1-4. HealthSmart will convert all lower case characters submitted on an inbound to upper case. All TA1 and 999 Acknowledgements outbound to the Trading Partner will also be in upper case. HealthSmart prefers only one GS-GE Functional Group within an ISA-IEA Interchange. HealthSmart can receive one or more ST-SE Transaction Set within a GS-GE Functional Group. Trading Partner s are expected to send production s utilizing the following file naming convention: o ELIG_companyidentifier_ccyymmdd.xxx o You may also send a timestamp in the above file name. o When sending a test file, the word test must precede the naming convention, example test_elig_companyidentifier_ccyymmdd.xxx HealthSmart requests to receive only full file formats of the in test and production. A 999 is returned by HealthSmart for every transmission that is syntactically correct or when an X12 syntax error is found. The Trading Partner can choose not to receive a Ref02 is required by HealthSmart and is assigned by HealthSmart. o If there are multiple companies, each company should be transmitted on a separate file Ref02 If HealthSmart assigns the alternate id, the ref02 is not required. If the client assigns the alternate id, the client s alternate id number must be passed in the ref02 for the member and dependents. January 2012 HealthSmart Benefit Solutions, Inc. 8

10 2000- Ref02 Location and/or Department is required by HealthSmart if client utilizes location and/or departments INS07 is required by HealthSmart when member or dependent terms if HealthSmart is administering COBRA INS02 is required by HealthSmart on Members and Dependents. 2100A DMG03 is required by HealthSmart on Members and Dependents. 2100A DMG04 is required by HealthSmart on new hires and if the employee moves from single to married coverage DTP01 Hire date is required by HealthSmart on Members HD04 - Plan Number is required by HealthSmart on Members and Dependents HD05 Coverage Level Code is required by HealthSmart on Members and Dependents. HealthSmart s goal is to utilize a standard format and limit impacts to Account processing. Please review the following pages for additional clarification. Please let your Account Executive know if you have any questions. January 2012 HealthSmart Benefit Solutions, Inc. 9

11 8. Transaction Specific Information This section describes how TR3s adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that HealthSmart has something additional, over and above, the information in the TR3s. The following are specific rules applicable to Benefit Enrollment and Maintenance transactions: ISA ISA01 ISA02 Interchange Control Header 1 R 1 Authorization Information Qualifier ID 2/2 R 00,03 Constant - '00' Authorization Information AN 10/10 R Blanks ISA03 Security Information Qualifier ID 2/2 R 00,01 Constant - '00' ISA04 Security Information AN 10/10 R Blanks ISA05 ISA06 Interchange ID Qualifier ID 2/2 R 01,14,20,27,28,29,30,33,ZZ Constant - 'ZZ' Interchange Sender ID AN 15/15 R ISA07 ISA08 Interchange ID Qualifier ID 2/2 R 01,14,20,27,28,29,30,33,ZZ Constant - 'ZZ' Interchange Receiver ID AN 15/15 R ISA09 Interchange Date DT 6/6 R YYMMDD YYMMDD ISA10 Interchange Time TM 4/4 R HHMM HHMM ISA11 Repetition Separator 1/1 R Constant - '^' ISA12 Interchange Control Version Number ID 5/5 R Constant - '00501' ISA13 ISA14 ISA15 Interchange Control Number N0 9/9 R Acknowledgement Requested ID 1/1 R 0,1 Interchange Indicator ID 1/1 R P,T No Acknowledgement = '0' Acknowledgement = '1' If 'T' equals Test; If 'P' equals Production. ISA16 Component Separator 1/1 R Constant - '*' GS GS01 Functional Group Header 1 R 1 Functional Identifier Group ID 2/2 R Constant - 'BE' January 2012 HealthSmart Benefit Solutions, Inc. 10

12 GS02 Application Sender's Code AN 2/15 R GS03 Application Receiver's Code AN 2/15 R GS04 Date DT 8/8 R CCYYMMDD CCYYMMDD GS05 Time TM 4/8 R HHMM HHMM GS06 Group Control Number N0 1/9 R GS07 Responsible Agency Code ID 1/2 R X Constant - 'X' GS08 Version/Release/Industry Identifier Code AN 1/12 R 00X220 Constant - '00X220A1' ST Transaction Set Header 1 R 1 ST01 ST02 ST03 Transaction Set Identifier Code ID 3/3 R Constant - '' Transaction Set Control Number AN 4/9 R Implementation Convention Reference AN 1/35 R BGN Beginning Segment 1 R 1 BGN01 Transaction Set Purpose Code ID 2/2 R 00,15,22 Constant - '00' unless sending resubmission. BGN02 Reference Identification AN 1/50 R BGN03 Date DT 8/8 R CCYYMMDD Date of creation of file. January 2012 HealthSmart Benefit Solutions, Inc. 11

13 BGN04 Time TM 4/8 R BGN05 Time Code ID 2/2 S HHMM, HHMMSS, HHMMSSD, HHMMSSDD Transaction Set Creation Time, Prefer HHMMSS Required when not in the same time zone as HealthSmart, Eastern Time zone. BGN06 BGN07 Reference Identification AN 1/50 S Transaction Type Code ID 2/2 NU Not Used BGN08 Action Code ID 1/2 R 2,4,RX Always '4' BGN09 Security Level Code ID 2/2 NU Not Used REF REF01 Transaction Set Policy Number 1 S 1 Reference Identification Qualifier ID 2/3 R 38 Constant - '38' REF02 Reference Identification AN 1/50 R HealthSmart Assigned Company Number REF03 Description AN 1/80 NU Not Used REF04 Reference Identifier NU Not Used DTP File Effective Date S DTP01 Date/Time Qualifier ID 2/3 R 007,090,091,303,382,388 Constant - '007' January 2012 HealthSmart Benefit Solutions, Inc. 12

14 DTP02 Date Time Period Format Qualifier ID 2/3 R D8 Constant 'D8' DTP03 Date Time Period AN 1/35 R CCYYMMDD QTY Transaction Set Control Totals S 3 QTY01 Quantity Qualifier ID 2/2 R DT,ET,TO Provide totals for each qualifier. QTY02 Quantity R 1/15 R QTY03 QTY04 Composite Unit of Measure NU Not Used Free-form Information AN 1/30 NU Not Used N1 Sponsor Name R 1000A 1 N101 Entity Identifier Code ID 2/3 R P5 Constant - 'P5' N102 Name AN 1/60 S Sponsor = The party that ultimately pays for the coverage, benefit, or product. Can be an employer, union, government agency, association or insurance agency. N103 Identification Code Qualifier ID 1/2 R 24,94,FI Constant - 'FI' N104 Identification Code AN 2/80 R Sponsor Tax ID Number N105 Entity Relationship Code ID 2/2 NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 13

15 N106 Entity Identifier Code ID 2/3 NU Not Used N1 Payer R 1000B 1 N101 Entity Identifier Code ID 2/3 R IN Constant 'IN' N102 Name AN 1/60 S Constant - 'HealthSmart Benefit Solutions, Inc. ' N103 Identification Code Qualifier ID 1/2 R 94,FI,XV Constant - 'FI' N104 Identification Code AN 2/80 R Constant - ' ' N105 N106 Entity Relationship Code ID 2/2 NU Not Used Entity Identifier Code ID 2/3 NU Not Used N1 N101 TPA/Broker Name S 1000C 2 Not Used Entity Identifier Code ID 2/3 R BO,TV Not Used N102 Name AN 1/60 R Not Used N103 Identification Code Qualifier ID 1/2 R 94,FI,XV Not Used N104 Identification Code AN 2/80 R Not Used N105 N106 Entity Relationship Code ID 2/2 NU Not Used Entity Identifier Code ID 2/3 NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 14

16 ACT ACT01 TPA/Broker Account Information S 1100C 1 Not Used Account Number AN 1/35 R Not Used ACT02 Name AN 1/60 NU Not Used ACT03 ACT04 ACT05 ACT06 Identification Code Qualifier ID 1/2 NU Not Used Identification Code AN 2/80 NU Not Used Account Number Qualifier ID 1/3 NU Not Used Account Number AN 1/35 S Not Used ACT07 Description AN 1/80 NU Not Used ACT08 ACT09 Payment Method Type Code ID 1/2 NU Not Used Benefit Status Code ID 1/1 NU Not Used INS INS01 Member Level Detail R 2000 >1 Yes/No Condition or Response Code ID 1/1 R N,Y 01,03,04,05,06,07, INS02 Individual Relationship Code ID 2/2 R 08,09,10,11,12,13,14, 15,16,17,18,19,23, 24,25,26,31,38,53,60,D2,G8,G9 See Relationship Matrix for additional information in Appendix. January 2012 HealthSmart Benefit Solutions, Inc. 15

17 INS03 Maintenance Type Code ID 3/3 R 001,021,024,025,030 Constant - '030' INS04 Maintenance Reason Code ID 2/3 S , 10,11,14,15,16,17,18,20,21 22,25,26,27,28,29,31,32,33 37,38,39,40,41,43,59,AA,AB, AC,AD,AE,AF,AG,AH,AI,AJ,AL, EC,XN,XT INS05 Benefit Status Code ID 1/1 R A,C,S,T INS06 Medicare Status Code ID INS06-1 INS06-2 INS06-3 INS06-4 Medicare Plan Code ID 1/1 R A,B,C,D,E Eligibility Reason Code ID 1/1 S 0,1,2 Eligibility Reason Code ID 1/1 NU Not Used Eligibility Reason Code ID 1/1 NU Not Used INS07 INS08 INS09 Consolidated Omnibus Budget Reconciliation Act Qualifying (COBRA) ID 1/2 S 1,2,3,4,5,6,7,8,9,10,ZZ Employment Status Code ID 2/2 S AC,AO,AU,FT,L1,PT,RT,TE Student Status Code ID 1/1 S F,N,P If HealthSmart is administering Cobra, this element is required. January 2012 HealthSmart Benefit Solutions, Inc. 16

18 INS10 INS11 INS12 INS13 Yes/No Condition or Response Code ID 1/1 S N,Y Date Time Period Format Qualifier ID 2/3 S D8 Constant D8 Date Time Period AN 1/35 S CCYYMMDD Confidentiality Code ID 1/1 S R,U INS14 City Name AN 2/30 NU Not Used INS15 State or Province Code ID 2/2 NU Not Used INS16 Country Code ID 2/3 NU Not Used INS17 Number N0 1/9 S REF REF01 Subscriber Identifier R 2000 Reference Identification Qualifier ID 2/3 R 0F Constant - '0F' REF02 Reference Identification AN 1/50 R Social Security Number REF03 Description AN 1/80 NU Not Used REF04 Reference Identifier NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 17

19 REF REF01 Member Policy Number S 2000 Reference Identification Qualifier ID 2/3 R 1L Constant '1L' REF02 Reference Identification AN 1/50 R Company Number assigned by HealthSmart Benefit Solutions, Inc. REF03 Description AN 1/80 NU Not Used REF04 Reference Identifier NU Not Used REF Member Supplemental Identifier S 2000 REF01 Reference Identification Qualifier ID 2/3 R 17,23,3H,4A,60, ABB, D3,DX,F6,P5,Q4,QQ,ZZ This identifier can be used for sending location, department, or alternate id. If used for location, use qualifier of DX. If used for department, use qualifier of QQ. If used for alternate id use qualifier of ZZ. If company only has one location default the location in REF02 to 01, if company has multiple locations, send appropriate location and department in REF02. January 2012 HealthSmart Benefit Solutions, Inc. 18

20 REF02 Reference Identification ID 1/50 R This identifier can be used for sending location, department, or alternate id. If used for location, use qualifier of DX in REF01. If used for department, use qualifier of QQ in REF01. If used for alternate id use qualifier of ZZ in REF01. If company only has one location default the location in REF02 to 01, if company has multiple locations, send appropriate location and department in REF02. REF03 Description AN 1/80 NU Not Used REF04 Reference Identifier NU Not Used DTP Member Level Dates S 2000 DTP01 Date/Time Qualifier ID 3/3 R 050,286,296,297,300,301, 303,336,337,338,339,340, 341,350,351,356,357,383, 385,386,393,394,473,474 HealthSmart will use the Coverage Dates in 2300 instead of the Eligibility Dates in If a change is being made to the location/department/address please use the qualifier of 303 in the DTP01. The hire date of the member is required by HealthSmart, please use qualifier of 336. DTP02 DTP03 Date Time Period Format Qualifier ID 2/3 R D8 Constant - 'D8' Date Time Period AN 1/35 R CCYYMMDD NM1 NM101 NM102 Member Name R 2100A 1 Entity identifier Code ID 2/3 R 74,IL Entity Type Qualifier ID 1/1 R 1 Constant '1' January 2012 HealthSmart Benefit Solutions, Inc. 19

21 NM103 Name Last or Organization Name AN 1/60 R NM104 Name First AN 1/35 S NM105 Name Middle AN 1/25 S NM106 Name Prefix AN 1/10 S NM107 Name Suffix AN 1/10 S NM108 Identification Code Qualifier ID 1/2 S 34,ZZ Constant - '34' NM109 Identification Code AN 2/80 S Populate with Member ssn NM110 Entity Relationship Code ID 2/2 NU Not Used NM111 Entity Identifier Code ID 2/3 NU Not Used NM112 Name Last or Organization Name AN 1/60 NU Not Used PER PER01 Member s Numbers S 2100A 1 Contact Function Code ID 2/2 R IP Constant 'IP' PER02 Name AN 1/60 NU Not Used PER03 Number Qualifier ID 2/2 R AP,BN,CP,EM,EX,FX,HP, TE,WP Prefer - 'HP' PER04 Number AN 1/256 R January 2012 HealthSmart Benefit Solutions, Inc. 20

22 PER05 Number Qualifier ID 2/2 S AP,BN,CP,EM,EX,FX,HP, TE,WP Prefer - 'CP' PER06 Number AN 1/256 S PER07 Number Qualifier ID 2/2 S AP,BN,CP,EM,EX,FX,HP, TE,WP Prefer - 'EM' PER08 Number AN 1/256 S PER09 Contact Inquiry Reference AN 1/20 NU Not Used N3 N301 N302 Member Residence Street Address S 2100A 1 Address Information AN 1/55 R Address Information AN 1/55 S N4 Member City, State, Zip Code R 2100A 1 N401 City Name AN 2/30 S N402 State or Province Code ID 2/2 S N403 Postal Code ID 3/15 S N404 Country Code ID 2/3 S N405 Location Qualifier ID 1/2 S 60,CY Constant - 'CY' January 2012 HealthSmart Benefit Solutions, Inc. 21

23 N406 Location identifier AN 1/30 S Enter County/Parish Name N407 Country Subdivision Code ID 1/3 S DMG DMG01 Member Demographics S 2100A 1 Date Time Period Format Qualifier ID 2/3 R D8 Constant - 'D8' DMG02 Date Time Period AN 1/35 R DMG03 Gender Code ID 1/1 R F,M,U DMG04 Marital Status Code ID 1/1 S I,M Required by HealthSmart for new hires and changes from Single to Married. DMG05 DMG05-1 Composite Race or Ethnicity Information Race or Ethnicity Code ID 1/1 7,8,A,B,C,D,E,F,G,H,I, J,N,O,P,Z DMG05-2 Code List Qualifier Code ID 1/3 S RET Constant - 'RET' DMG05-3 Industry Code AN 1/30 S DMG06 Citizenship Status Code ID 1/2 S 1,2,3,4,5,6,7 DMG07 Country Code ID 2/3 NU Not Used DMG08 Basis of Verification Code ID 1/2 NU Not Used DMG09 Quantity R 1/15 NU Not Used DMG10 Code List Qualifier Code ID 1/3 S REC Constant - 'REC' DMG11 Industry Code AN 1/30 S January 2012 HealthSmart Benefit Solutions, Inc. 22

24 EC EC01 EC02 EC03 Employment Class S 2100A Employment Class Code ID 2/3 R Employment Class Code ID 2/3 S Employment Class Code ID 2/3 S 01,02,03,04,05,06,07,08,09 10,11,12,17,18,19,20,21,22,23 01,02,03,04,05,06,07,08,09, 10,11,12,17,18,19,20,21,22,23 01,02,03,04,05,06,07,08,09, 10,11,12,17,18,19,20,21,22,23 EC04 EC05 EC06 Percentage as Decimal R 1/10 NU Not Used Information Status Code ID 1/1 NU Not Used Occupation Code ID 4/6 NU Not Used ICM Member Income S 2100A ICM01 Frequency Code ID 1/1 R 1,2,3,4,6,7,8,9,B,C,H,Q,S,U HealthSmart requires only the 7 Annual Amount ICM02 Monetary Amount R 1/18 R ICM03 Quantity R 1/15 S ICM04 Location Identifier AN 1/30 S ICM05 Salary Grade AN 1/5 S ICM06 Currency Code ID 3/3 NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 23

25 AMT AMT01 Member Policy Amounts S 2100A Amount Qualifier Code ID 1/3 R B9,C1,D2,EBA,FK,P3,R Please use qualifier of FK when sending Life Amount in AMT02 AMT02 Monetary Amount R 1/18 R Please send Life Amount when needed with qualifier of FK in the AMT01 AMT03 Credit/Debit Flag Code ID 1/1 NU Not Used HLH HLH01 Member Health Information S 2100A Health-Related Code ID 1/1 R N,S,T,U,X HLH02 Height R 1/8 S HLH03 Weight R 1/10 S HLH04 Weight R 1/10 NU Not Used HLH05 Description AN 1/80 NU Not Used HLH06 Current Health Condition Code ID 1/1 NU Not Used HLH07 Description AN 1/80 NU Not Used LUI LUI01 Member Language S 2100A Identification Code Qualifier ID 1/2 S LD,LE January 2012 HealthSmart Benefit Solutions, Inc. 24

26 LUI02 Identification Code AN 2/80 S LUI03 Description AN 1/80 S LUI04 LUI05 Use of Language Indicator ID 1/2 S 5,6,7,8 Language Proficiency Indicator ID 1/1 NU Not Used NM1 NM101 NM102 NM103 Incorrect Member Name S 2100B 1 Entity Identifier Code ID 2/3 R 70 Constant - '70' Entity Type Qualifier ID 1/1 R 1 Constant - '1' Name Last or Organization Name AN 1/60 R NM104 Name First AN 1/35 S NM105 Name Middle AN 1/25 S NM106 Name Prefix AN 1/10 S NM107 Name Suffix AN 1/10 S NM108 Identification Code Qualifier ID 1/2 S 34,ZZ Constant 34 Social Security Number NM109 Identification Code AN 2/80 S January 2012 HealthSmart Benefit Solutions, Inc. 25

27 NM110 NM111 NM112 Entity Relationship Code ID 2/2 NU Not Used Entity Identifier Code ID 2/3 NU Not Used Name Last or Organization Name AN 1/60 NU Not Used DMG DMG01 Incorrect Member Demographics S 2100B 1 Date Time Period Format Qualifier ID 2/3 S D8 Constant - 'D8' DMG02 Date Time Period AN 1/35 S DMG03 Gender Code ID 1/1 S F,M,U DMG04 Marital Status Code ID 1/1 S DMG05 Composite Race or Ethnicity Information X DMG05-1 DMG05-2 Race or Ethnicity Code ID 1/1 S Code List Qualifier Code ID 1/3 S DMG05-3 Industry Code AN 1/30 S DMG06 Citizenship Status Code ID 1/2 S DMG07 Country Code ID 2/3 NU Not Used DMG08 Basis of Verification Code ID 1/2 NU Not Used DMG09 Quantity R 1/15 NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 26

28 DMG10 Code List Qualifier Code ID 1/3 S DMG11 Industry Code AN 1/30 S NM1 NM101 NM102 NM103 Member Mailing Address S 2100C 1 Entity Identifier Code ID 2/3 R 31 Constant 31 Entity Type Qualifier ID 1/1 R 1 Constant - '1' Name Last or Organization Name AN 1/60 NU Not Used NM104 Name First AN 1/35 NU Not Used NM105 Name Middle AN 1/25 NU Not Used NM106 Name Prefix AN 1/10 NU Not Used NM107 Name Suffix AN 1/10 NU Not Used NM108 NM109 NM110 NM111 NM112 Identification Code Qualifier AN 1/2 NU Not Used Identification Code AN 2/80 NU Not Used Entity Relationship Code ID 2/2 NU Not Used Entity Identifier Code ID 2/3 NU Not Used Name Last or Organization Name AN 1/60 NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 27

29 N3 N301 N302 Member Mail Street Address R 2100C Address Information AN 1/55 R Address Information AN 1/55 S N4 Member Mail City, State, Zip Code R 2100C 1 N401 City Name AN 2/30 R N402 State or Province Code ID 2/2 S N403 Postal Code ID 3/15 S N404 Country Code ID 2/3 S N405 N406 N407 Location Qualifier ID ½ Nu Not Used Location Identifier AN 1/30 NU Not Used Country Subdivision Code ID 1/3 S January 2012 HealthSmart Benefit Solutions, Inc. 28

30 NM1 NM101 NM102 NM103 Member Employer S 2100D 3 Entity Identifier Code ID 2/3 R 36 Constant - '36' Entity Type Qualifier ID 1/1 R 1,2 Name Last or Organization Name AN 1/60 S NM104 Name First AN 1/35 S NM105 Name Middle AN 1/25 S NM106 Name Prefix AN 1/10 S NM107 Name Suffix AN 1/10 S NM108 NM109 NM110 NM111 NM112 Identification Code Qualifier ID 1/2 S 24,34 Identification Code AN 2/80 S Entity Relationship Code ID 2/2 NU Not Used Entity Identifier Code ID 2/3 NU Not Used Name Last or Organization Name AN 1/60 NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 29

31 PER PER01 Member Employer s Numbers S 2100D Contact Function Code ID 2/2 R EP Constant - 'EP' PER02 Name AN 1/60 S PER03 PER04 PER05 PER06 PER07 PER08 PER09 Number Qualifier ID 2/2 R AP,BN,CP,EM,EX,FX,TE Prefer - 'TE' Number AN 1/256 R Number Qualifier ID 2/2 S AP,BN,CPEM,EX,FX,TE Prefer - 'FX' Number AN 1/256 S Number Qualifier ID 2/2 S AP,BN,CP,EM,EX,FX,TE Prefer - 'EM' Number AN 1/256 S Contact Inquiry Reference AN 1/20 NU Not Used N3 Member Employer Street Address S 2100D 1 N301 Address Information AN 1/55 R N302 Address Information AN 1/55 S N4 Member Employer City, State, Zip code R 2100D 1 January 2012 HealthSmart Benefit Solutions, Inc. 30

32 N401 City Name AN 2/30 S N402 State or Province Code ID 2/2 S N403 Postal Code ID 3/15 S N404 Country Code ID 2/3 S N405 Location Qualifier ID 1/2 NU Not Used N406 Location Identifier AN 1/30 NU Not Used N407 Country Subdivision Code ID 1/3 S NM1 Member School S 2100E 3 NM101 Entity Identifier Code ID 2/3 R M8 Constant - 'M8' NM102 Entity Type Qualifier ID 1/1 R 2 Constant -'2' NM103 Name Last or Organization Name AN 1/60 R NM104 Name First AN 1/35 NU Not Used NM105 Name Middle AN 1/25 NU Not Used NM106 Name Prefix AN 1/10 NU Not Used NM107 Name Suffix AN 1/10 NU Not Used NM108 Identification Code Qualifier ID 1/2 NU Not Used NM109 Identification Code AN 2/80 NU Not Used NM110 Entity Relationship Code ID 2/2 NU Not Used NM111 Entity Identifier Code ID 2/3 NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 31

33 NM112 Name Last or Organization Name AN 1/60 NU Not Used PER PER01 Member School s Number R 2100E 1 Contact Function Code ID 2/2 SK Constant - 'SK' PER02 Name AN 1/60 S PER03 PER04 PER05 PER06 PER07 PER08 PER09 Number Qualifier ID 2/2 R EM,EX,FX,TE Prefer - 'TE' Number AN 1/256 R Number Qualifier ID 2/2 S EM,EX,FX,TE Prefer - 'FX' Number AN 1/256 S Number Qualifier ID 2/2 S EM,EX,FX,TE Prefer - 'EM' Number AN 1/256 S Contact Inquiry Reference AN 1/20 NU Not Used N3 Member School Street Address S 2100E 1 N301 Address Information AN 1/55 R N302 Address Information AN 1/55 S January 2012 HealthSmart Benefit Solutions, Inc. 32

34 N4 Member School City, State, Zip Code R 2100E 1 N401 City Name AN 2/30 S N402 State or Province Code ID 2/2 S N403 Postal Code ID 3/15 S N404 Country Code ID 2/3 S N405 Location Qualifier ID 1/2 NU Not Used N406 Location Identifier AN 1/30 NU Not Used N407 Country Subdivision Code ID 1/3 S NM1 Custodial Parent S 2100F 1 NM101 Entity Identifier Code ID 2/3 S3 Constant - 'S3' NM102 Entity Type Qualifier ID 1/1 R 1 Constant - '1' NM103 Name Last or Organization Name AN 1/60 R NM104 Name First AN 1/35 R NM105 Name Middle AN 1/25 S NM106 Name Prefix AN 1/10 S NM107 Name Suffix AN 1/10 S NM108 Identification Code Qualifier ID 1/2 S 34,ZZ Constant 34 NM109 Identification Code AN 2/80 S Social Security Number January 2012 HealthSmart Benefit Solutions, Inc. 33

35 NM110 Entity Relationship Code ID 2/2 NU Not Used NM111 Entity Identifier Code ID 2/3 NU Not Used NM112 Name Last or Organization Name AN 1/60 NU Not Used PER PER01 Custodial Parent s Numbers S 2100F 1 Contact Function Code ID 2/2 R PQ Constant - 'PQ' PER02 Name AN 1/60 NU Not Used PER03 Number Qualifier ID 2/2 R AP,BN,CP,EM,EX,FX,HP, TE,WP Prefer - HP PER04 Number AN 1/256 R PER05 Number Qualifier ID 2/2 S AP,BN,CP,EM,EX,FX,HP, TE,WP Prefer CP PER06 Number AN 1/256 S PER07 Number Qualifier ID 2/2 S AP,BN,CP,EM,EX,FX,HP, TE,WP Prefer EM PER08 Number AN 1/256 S PER09 Contact Inquiry References AN 1/20 NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 34

36 N3 Custodial Parent Street Address S 2100F 1 N301 Address Information AN 1/55 R N302 Address Information AN 1/55 S N4 Custodial Parent City, State, Zip Code R 2100F 1 N401 City Name AN 2/30 S N402 State or Province Code ID 2/2 S N403 Postal Code ID 3/15 S N404 Country Code ID 2/3 S N405 Location Qualifier ID 1/2 NU Not Used N406 Location Identifier AN 1/30 NU Not Used N407 Country Subdivision Code ID 1/3 S NM1 Responsible Person S 2100G 13 6Y,9K,E1,EI,EXS,GB,GD, NM101 Entity Identifier Code ID 2/3 R J6,LR,QD,S1,TZ,X4 NM102 Entity Type Qualifier ID 1/1 R 1 Constant - '1' NM103 Name Last or Organization Name AN 1/60 R NM104 Name First AN 1/35 S January 2012 HealthSmart Benefit Solutions, Inc. 35

37 NM105 Name Middle AN 1/25 S NM106 Name Prefix AN 1/10 S NM107 Name Suffix AN 1/10 S NM108 Identification Code Qualifier ID 1/2 S 34,ZZ Constant 34 NM109 Identification Code AN 2/80 S Social Security Number NM110 Entity Relationship Code ID 2/2 NU Not Used NM111 Entity Identifier Code ID 2/3 NU Not Used NM112 Name Last or Organization Name AN 1/60 NU Not Used PER PER01 Responsible Person s Numbers S 2100G 1 Contact Function Code ID 2/2 R RP Constant - 'RP' PER02 Name AN 1/60 NU Not Used PER03 Number Qualifier ID 2/2 R AP,BN,CP,EM,EX,FX, HP,TE,WP Prefer - 'HP' PER04 Number AN 1/256 R PER05 Number Qualifier ID 2/2 S AP,BN,CP,EM,EX,FX, HP,TE,WP Prefer - 'CP' PER06 Number AN 1/256 S January 2012 HealthSmart Benefit Solutions, Inc. 36

38 PER07 PER08 Number Qualifier ID 2/2 S AP,BN,CP,EM,EX,FX,HP,TE,WP Prefer EM Number AN 1/256 S PER09 Contact Inquiry AN 1/20 Nu Not Used N3 N301 N302 Responsible Person Street Address S 2100G 1 Address Information AN 1/55 R Address Information AN 1/55 S N4 Responsible Person City, State, Zip Code R 2100G 1 N401 City Name AN 2/30 S N402 State or Province Code ID 2/2 S N403 Postal Code ID 3/15 S N404 Country Code ID 2/3 S N405 Location Qualifier ID 1/2 NU Not Used N406 N407 Location Identifier AN 1/30 NU Not Used Country Subdivision Code ID 1/3 S January 2012 HealthSmart Benefit Solutions, Inc. 37

39 NM1 Drop Off Location S 2100H 1 NM101 Entity Identifier Code ID 2/3 R 45 Not Used NM102 Entity Type Qualifier ID 1/1 R 1 Not Used NM103 Name Last or Organization Name AN 1/60 R Not Used NM104 Name First AN 1/35 S Not Used NM105 Name Middle AN 1/25 S Not Used NM106 Name Prefix AN 1/10 S Not Used NM107 Name Suffix AN 1/10 S Not Used NM108 Identification Code Qualifier ID 1/2 NU Not Used NM109 Identification Code AN 2/80 NU Not Used NM110 Entity Relationship Code ID 2/2 NU Not Used NM111 Entity Identifier Code ID 2/3 NU Not Used NM112 Name Last or Organization Name AN 1/60 NU Not Used N3 Drop Off Location Street Address S 2100H 1 N301 Address Information AN 1/55 R Not Used N302 Address Information AN 1/55 S Not Used January 2012 HealthSmart Benefit Solutions, Inc. 38

40 N4 Drop Off Location City, State, Zip Code R 2100H 1 N401 City Name AN 2/30 S Not Used N402 State or Province Code ID 2/2 S Not Used N403 Postal Code ID 3/15 S Not Used N404 Country Code ID 2/3 S Not Used N405 Location Qualifier ID 1/2 NU Not Used N406 Location Identifier AN 1/30 NU Not Used N407 Country Subdivision Code ID 1/3 S DSB Disability Information S 2200 >1 DSB01 Disability Type Code ID 1/1 R 1,2,3,4 DSB02 Quantity R 1/15 NU Not Used DSB03 Occupation Code ID 4/6 NU Not Used DSB04 Work Intensity Code ID 1/1 NU Not Used DSB05 Production Option Code ID 1/2 NU Not Used DSB06 Monetary Amount R 1/18 NU Not Used DSB07 Product/Service ID Qualifier ID 2/2 S DX,ZZ DSB08 Medical Code Value AN 1/15 S January 2012 HealthSmart Benefit Solutions, Inc. 39

41 DTP DTP01 DTP02 DTP03 Disability Eligibility Dates S Date/Time Qualifier ID 3/3 R 360,361 Date Time Format Qualifier ID 2/3 R D8 Constant D8 Date Time Period 1/35 R CCYYMMDD HD HD01 HD02 Health Coverage S Maintenance Type Code ID 3/3 R 001,002,021,024,025,026030,032 Maintenance Reason Code ID 2/3 NU Not Used AG,AH,AJ,AK,DCP,DEN,EPO,FAC, HD03 Insurance Line Code ID 2/3 R HE,HLT,HMO,LTC,LTD,MM,MOD, PDG,POS,PPO,PRA,STD,UR,VIS Prefer - 'DEN, HLT, LTC, VIS, HE' HD04 Plan Coverage Description AN 1/50 S HealthSmart Plan Number required. If you do not have the plan numbers please contact your account manager. HD05 Coverage Level Code ID 3/3 S CHD,DEP,E1D,E2D,E3D,E5D,E6D, E7D,E8D,E9D,ECH,EMP,ESP,FAM, IND,SPC,SPO,TWO See Relationship Matrix in Appendix. Required by HealthSmart. HD06 Count N0 1/9 NU Not Used HD07 Count N0 1/9 NU Not Used HD08 Underwriting Decision Code ID 1/1 NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 40

42 HD09 HD10 HD11 Yes/No Condition or Response Code ID 1/1 S Drug House Code ID 2/3 NU Not Used Yes/No Condition or Response Code ID 1/1 NU DTP DTP01 DTP02 DTP03 Health Coverage R Date/Time Qualifier ID 3/3 R 300,303,343,348,349,543,695 Prefer - '348' and '349' Date Time Format Qualifier ID 2/3 R D8,RD8 Constant - 'D8' Date Time Period AN 1/35 R CCCYYMMDD AMT AMT01 AMT02 AMT03 Health Coverage Policy S Amount Qualifier Code ID 1/3 R B9,C1,D2,EBA,FK,P3,R Monetary Amount R 1/18 R Credit/Debit Flag Code ID 1/1 NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 41

43 REF REF01 REF02 Health Coverage Policy Number S Reference Identification Qualifier ID 2/3 R Reference Identification AN 1/50 R 17,1L,9V,CE,E8,M7,PID,RB, X9,XM,XX1,XX2,Zx,ZZ REF03 Description AN 1/80 NU Not Used REF04 Reference Identifier NU Not Used REF REF01 REF02 Prior Coverage Months S Reference Identification Qualifier ID 2/3 R QQ Constant - 'QQ' Reference Identification AN 1/50 R REF03 Description AN 1/80 NU Not Used REF04 Reference Identifier NU Not Used IDC IDC01 IDC02 Identification Card S Plan Coverage Description AN 1/50 R Identification Card Type Code ID 1/1 R D,H,P IDC03 Quantity R 1/15 S January 2012 HealthSmart Benefit Solutions, Inc. 42

44 IDC04 Action Code ID ½ S 1,2,RX LX Provider Information S LX01 Assigned Number N0 1/6 R NM1 Provider Name R NM101 NM102 NM103 Entity Identifier Code ID 2/3 R 1x,3D,80,FA,OD,P3,QA,QN,Y2 Entity Type Qualifier ID 1/1 R 1,2 Name Last or Organization Name AN 1/60 S NM104 Name First AN 1/35 S NM105 Name Middle AN 1/25 S NM106 Name Prefix AN 1/10 S NM107 Name Suffix AN 1/10 S NM108 NM109 NM110 Identification Code Qualifier ID 1/2 S 34,FI,SV,XX Identification Code AN 2/80 S Entity Relationship Code ID 2/2 R 25,26,72 Send SV, if not available send FI NM111 Entity Identifier Code ID 2/3 NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 43

45 NM112 Name Last or Organization Name AN 1/60 NU Not Used N3 Provider Address S N301 Address Information AN 1/55 R N302 Address Information AN 1/55 S N4 Provider City, State, Zip Code R N401 City Name AN 2/30 S N402 State or Province Code ID 2/2 S N403 Postal Code ID 3/15 S N404 Country Code ID 2/3 S N405 Location Qualifier ID 1/2 NU Not Used N406 Location Identifier AN 1/30 NU Not Used N407 Country Subdivision Code ID 1/3 S PER PER01 Provider s Numbers S Contact Function Code ID 2/2 R IC Constant - 'IC' PER02 Name AN 1/60 NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 44

46 PER03 PER04 PER05 PER06 PER07 PER08 PER09 Number Qualifier ID 2/2 R AP,BN,CP,EM,EX,FX,HP,TE,WP Prefer WP Number AN 1/256 R Number Qualifier ID 2/2 S AP,BN,CP,EM,EX,FX,HP,TE,WP Prefer FX Number AN 1/256 S Number Qualifier ID 2/2 S AP,BN,CP,EM,EX,FX,HP,TE,WP Prefer EM Number AN 1/256 S Contact Inquiry References AN 1/20 Nu Not Used PLA Provider Change Reason S PLA01 Action Code ID 1/2 R 2 Constant - '2' PLA02 Entity Identifier Code ID 2/3 R 1P Constant - '1P' PLA03 Date DT 8/8 R PLA04 Time TM 4/8 NU Not Used 14,22,46,AA,AB,AC,AD, AE,AF,AG,AH,AI,AJ PLA05 Maintenance Reason Code ID 2/3 R January 2012 HealthSmart Benefit Solutions, Inc. 45

47 COB COB01 COB02 COB03 Coordination of Benefits S Payer Responsibility Sequence Number Code ID 1/1 R P,S,T,U Reference Identification AN 1/50 S Coordination of Benefits Code ID 1/1 R 1,5,6 1,35,48,50,54,89,90,A4, COB04 Service Type Code ID 1/2 S AG,AL,BB REF Additional Coordination of Benefits Identifiers S REF01 REF02 Reference Identification Qualifier ID 2/3 R 60,6P,SY,ZZ Reference Identification AN 1/50 R REF03 Description AN 1/80 NU Not Used REF04 Reference Identifier Nu Not Used January 2012 HealthSmart Benefit Solutions, Inc. 46

48 DTP Coordination of Benefits Eligibility Dates S DTP01 Date/Time Qualifier ID 3/3 R 344,345 DTP02 Date Time Format Qualifier ID 2/3 R D8 Constant - 'D8' DTP03 Date Time Period AN 1/35 R NM1 Coordination of Benefits Related Entity S NM101 Entity Identifier Code ID 2/3 R 36,GW,IN, NM102 Entity Type Qualifier ID 1/1 R 2 Constant - '2' NM103 Name Last or Organization Name AN 1/60 S NM104 Name First AN 1/35 NU Not Used NM105 Name Middle AN 1/25 NU Not Used NM106 Name Prefix AN 1/10 NU Not Used NM107 Name Suffix AN 1/10 NU Not Used NM108 Identification Code Qualifier ID 1/2 S FI,NI,XV Constant FI NM109 Identification Code AN 2/80 S Tax ID Number NM110 Entity Relationship Code ID 2/2 NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 47

49 NM111 Entity Identifier Code ID 2/3 NU Not Used NM112 Name Last or Organization Name AN 1/60 NU Not Used N3 Coordination of Benefits Related Entity Address S N301 Address Information AN 1/55 R Not Used N302 Address Information AN 1/55 S Not Used N4 Coordination of Benefits Other Insurance Company City, State, Zip Code R N401 City Name AN 2/30 S Not Used N402 State or Province Code ID 2/2 S Not Used N403 Postal Code ID 3/15 S Not Used N404 Country Code ID 2/3 S Not Used N405 Location Qualifier ID 1/2 NU Not Used N406 Location Identifier AN 1/30 NU Not Used N407 Country Subdivision Code ID 1/3 S Not Used PER Administrative s Contact S January 2012 HealthSmart Benefit Solutions, Inc. 48

50 PER01 Contact Function Code ID 2/2 R CN Not Used PER02 Name AN 1/60 NU Not Used PER03 PER04 PER05 PER06 PER07 PER08 PER09 LS Number Qualifier ID 2/2 R TE Not Used Number AN 1/256 R Not Used Number Qualifier ID 2/2 NU Not Used Number AN 1/256 NU Not Used Number Qualifier ID 2/2 NU Not Used Number AN 1/256 NU Not Used Contact Inquiry References AN 1/20 NU Not Used Additional Reporting Categories S LS01 Identifier Code AN 1/4 R 2700 LX Member Reporting Categories R LX01 Assigned Number N0 1/6 R N1 Reporting Category S N101 Entity Identifier Code ID 2/3 R 75 Constant - '75' January 2012 HealthSmart Benefit Solutions, Inc. 49

51 N102 Name AN 1/60 R N103 N104 N105 N106 Identification Code Qualifier ID 1/2 NU Not Used Identification Code AN 2/80 NU Not Used Entity Relationship Code ID 2/2 NU Not Used Entity Identifier Code ID 2/3 NU Not Used REF Reporting Category S REF01 Reference Identification Qualifier ID 2/3 R 00,17,18,19,26,3L,6M,9V, 9X,GE,LU,PID,XX1,XX2,YY,ZZ If you report in the REF02 Disease Management Codes or a Special Persons Flag please use the qualifier of 'XX1 - Special Program Code'. REF02 Reference Identification AN 1/50 R The REF02 can be utilized for Disease Management Codes or a Special Persons Flag. (Example: (SMK = Smoker), (SMN = Non-Smoker), (AST = Asthma)) REF03 Description AN 1/80 NU Not Used REF04 Reference Identifier NU Not Used January 2012 HealthSmart Benefit Solutions, Inc. 50

52 DTP Reporting Category Date S DTP01 Date/Time Qualifier ID 3/3 R 007 Constant 007 DTP02 Date Time Period Format Qualifier ID 2/3 R D8,RD8 DTP03 Date Time Period AN 1/35 R LE Additional Reporting Category Termination S LE01 Identifier Code AN 1/4 R SE SE01 SE02 Transaction Set Trailer R 1 Number of Included Segments N0 1/10 R Calculated Transaction Set Control Number AN 4/9 R Same as ST02 January 2012 HealthSmart Benefit Solutions, Inc. 51

53 1. Transmission Confirmation Transmission confirmation may be received through one or two possible transactions: the TA1 Interchange Acknowledgement or the 999 Functional Acknowledgement. A TA1 Acknowledgement is used at the ISA level of the transmission envelope structure, to confirm a positive transmission or indicate an error at the ISA level of the transmission. The 999 Acknowledgement may be used to verify a successful transmission or to indicate various types of errors. The Error Reporting section and the individual transaction chapters contain additional information about acknowledgement and error messaging. Important Notice: All versions of the appropriate transactions will receive a 999 Acknowledgement by default. 8.1 Retrieving Files Trading Partners are responsible for the timely retrieval and verification of file transmission reports and transaction responses. This includes retrieval of the 999 functional and the TA1 Interchange Acknowledgements. HealthSmart recommends that Trading Partners review the transmission confirmations the first business day after transactions have been submitted. If no confirmation of a transmission has been received, contact HealthSmart EDI Support at multiclaimsupport@healthsmart.com to verify its receipt or to make an inquiry. Trading Partners making inquiries should know their Sender ID (ISA06) to expedite research in file transmissions. 8.2 Acknowledgements Acknowledgements are performed at the ISA (Interchange Control) level, the GS (Functional Group) level, and the ST/SE (Transaction Set) level for each transaction. Trading Partners receive a TA1 Interchange Acknowledgement of a positive or negative confirmation for each ISA/IEA transmitted if requested by the submitter (ISA 14 = 1). A positive TA1 is followed by a 999 Acknowledgement, reporting on the TR3 edits from the Functional Group level and below. The TA1 negative response indicates the rejection of the ISA, and by extension, the Functional Group (GS/GE) and Transaction Sets (ST/SE) below it. If a negative TA1 (TA104 = R) is received, the sender receives no 999 Acknowledgement. The TA105 provides a note code identifying why the transmission was rejected. HealthSmart uses only two values for the Interchange Acknowledgement Code (TA104), A (the ISA/IEA equals accepted with no errors) or R (the ISA/IEA is rejected due to errors). A 999 Acknowledgement is used for all other control segments subordinate to the ISA envelope namely the GS/GE Functional Group and ST/SE Transaction set. Senders should expect to receive a confirmation of receipt within an hour of submitting a transaction. 9. EDI Customer Service Please your EDI Support questions to multiclaimsupport@healthsmart.com. January 2012 HealthSmart Benefit Solutions, Inc. 52

54 Appendix A Scenario Scenario Name REF_RELATIONSHIP Name X12 Relationship Name X12 Relationship Code (INS02) Coverage Level Code (HD05) 1 Employee Only Subscriber Self 18 EMP 2 Employee + Spouse Subscriber Self 18 ESP Spouse Spouse 01 ESP 3 Employee + Children Subscriber Self 18 ECH Child Natural Child 19 ECH Subscriber Self 18 FAM 4 Employee + Spouse + Children Spouse Spouse 01 FAM 5 Employee + Spouse + Adopted Child 6 Employee + Spouse + Foster Child 7 Employee + Spouse + Step Child 8 Employee + Spouse + Child In Member Custody 9 Employee + Spouse + Legal Guardianship 10 Employee + Same-Sex Partner (SSP) 11 Employee + Child + SSP 12 Employee + SSP + Child of SSP Child Natural Child 19 FAM Subscriber Self 18 FAM Spouse Spouse 01 FAM Legally/Foreign/Tribal Adopted Child Adopted Child 09 FAM Subscriber Self 18 FAM Spouse Spouse 01 FAM Foster Child Foster Child 10 FAM Subscriber Self 18 FAM Spouse Spouse 01 FAM Step Child Stepson or Stepdaughter 17 FAM Subscriber Self 18 FAM Spouse Spouse 01 FAM Child In Member Custody Guardian 26 FAM Subscriber Self 18 FAM Spouse Spouse 01 FAM Legal Guardianship Court Appointed Guardian 31 FAM Subscriber Self 18 E1D Same-Sex Partner Life Partner 53 E1D Subscriber Self 18 FAM Same-Sex Partner Life Partner 53 FAM Child Child 19 FAM Subscriber Self 18 FAM Same-Sex Partner Life Partner 53 FAM Child Of Same-Sex Partner Child G8 FAM January 2012 HealthSmart Benefit Solutions, Inc. A1

55 Appendix A (continued) Scenario Scenario Name REF_RELATIONSHIP Name X12 Relationship Name 13 Employee + SSP + Adopted Child 14 Employee + SSP + Foster Child 15 Employee + SSP + Step Child 16 Employee + SSP + Child In Member Custody 17 Employee + SSP + Legal Guardianship G8 - This refers to the SSP Child. X12 Relationship Code (INS02) Coverage Level Code (HD05) Subscriber Self 18 FAM Same-Sex Partner Life Partner 53 FAM Legally/Foreign/Tribal Adopted Child Adopted Child 09 FAM Subscriber Self 18 FAM Same-Sex Partner Life Partner 53 FAM Foster Child Foster Child 10 FAM Subscriber Self 18 FAM Same-Sex Partner Life Partner 53 FAM Step Child Stepson or Stepdaughter 17 FAM Subscriber Self 18 FAM Same-Sex Partner Life Partner 53 FAM Child In Member Custody Guardian 26 FAM Subscriber Self 18 FAM Same-Sex Partner Life Partner 53 FAM Court Appointed Legal Guardianship Guardian 31 FAM January 2012 HealthSmart Benefit Solutions, Inc. 2