Standardized Membership Eligibility Customized Companion Guide

Transcription

1 Standardized Membership Eligibility Customized Companion Guide HEALTH CARE SERVICE CORPORATION (HCSC) 834 Companion Document BLUESTAR ASC X12N Benefit Enrollment and Maintenance Version Version 5, Release GENA (005010X220) 1

2 Purpose of This Document This companion guide has been written to assist those who will be implementing the ASC X12N 834 Benefit Enrollment and Maintenance Transaction Set, version 5010, for use with Healthcare Service Corporation (HCSC) and/or The Health Information Network (THIN). Our hope is that this companion document will simplify your implementation. Where appropriate, we have included mapping suggestions that reference the electronic file format you are currently sending us. Please note that this guide is intended only as a supplement to and NOT a replacement for the ASC X12N 834 Benefit Enrollment and Maintenance Implementation Guide as mandated under HIPAA. The implementation specifications for the ASC X12N 834 Standard may be obtained from the Washington Publishing Company, NE 33rd Place, Suite 204, Bellevue, WA, 98004; telephone: ; and FAX: They are also available through the Washington Publishing Company on the Internet at Overall Data Architecture In conventional data processing terminology, each 834 is equivalent to an enrollment "file", beginning with an ST segment and ending with an SE segment. Within this "file", each occurrence of the INS loop is equivalent to either one subscriber or one dependent "record". The data elements passed in these "records" are roughly equivalent to "fields". ISA: Interchange Control Header Segment GS: Functional Group Header Segment ST: Transaction Set Header beginning of 834 transaction BGN: Beginning Segment INS: Member Level Detail (max iterations per 834) HD: Health Coverage (max. 99 iterations per INS) HD: Health Coverage INS: Member Level Detail HD: Health Coverage SE: Transaction Set Trailer end of 834 transaction GE: Functional Group Trailer Segment IEA: Interchange Control Trailer Segment Definitions Dependent: A dependent is an individual who is eligible for coverage because of his or her association with a subscriber. Typically, a dependent is a member of the subscriber s family. Enrollment: As defined in the Final Rule for "Standards for Electronic transactions" ( ), the enrollment and disenrollment in a health plan transaction is the transmission of subscriber enrollment information to a health plan to establish or terminate insurance coverage. Flat File: When used in this Companion Document, the term "flat file" refers to the fixed-length electronic enrollment file format that you are currently sending BCBS-IL. Member: When used in this Companion Document, the term "member" can refer to either a subscriber or to a subscriber's dependent. Each looping of the INS segment (Loop 2000) includes information on one member. 834-GENA (005010X220) 2

3 Payer/Insurer: The payer is the party that pays claims and/or administers the insurance cover-age, benefit, or product. For purposes of this guide, the payer is Blue Cross and Blue Shield of IL. Providers: Health care providers are individuals and organizations that provide health care services. Health care providers can include physicians, hospitals, clinics, pharmacies, and long-term care facilities. Sponsor: A sponsor is the party that ultimately pays for the coverage, benefit, or product. A sponsor can be an employer, union, government agency, association, or insurance agency. Subscriber: The subscriber is an individual eligible for coverage because of his or her association with a sponsor. Examples of subscribers include the following: employees; union members; and individuals covered under government programs, such as Medicare and Medicaid. Third Party Administrator (TPA): A sponsor may elect to contract with a Third Party Administrator (TPA) or other vendor to handle collecting insured member data if the sponsor chooses not to perform this function. Linking a Dependent to a Subscriber Subscribers and dependents are sent as separate occurrences of Loop ID The initial enrollment for the subscriber must be sent before sending the initial enrollment for any of the subscriber s dependents. The enrollment of a dependent may follow the subscriber s enrollment in the same transmission, or it may be sent separately in a later transmission. To allow linking between subscribers and dependents, use the code 0F, Subscriber Number, in the REF segment, Loop ID-2000, position 020. The subscriber s unique identifier is sent in this segment in both the subscriber s and the dependent s Loop ID The individual s SSN is sent and identified as such in NM108, Loop ID-2000, position 030. This applies to both subscribers and dependents. If the SSN is used for linking, then the subscriber s SSN is sent in both locations on the subscriber s Loop ID Termination If the termination date is passed at the INS level for a subscriber (Loop 2000, DTP segment, position 040), then all coverage for that subscriber and for all dependents linked to that subscriber will be terminated, effective on that date. If the termination date is passed at the INS level for a dependent (Loop 2000, DTP segment, position 040), then all coverage for that dependent will be terminated, effective on that date. The coverage for the subscriber and any other dependents will not be affected. If the termination date is passed at the HD level for any member (loop 2300, DTP segment, position 270), then coverage for that specific insurance product for that member will be terminated, effective on that date. Coverage for other insurance products for that member will not be affected nor will coverage for other members linked to the same subscriber. Termination dates are not to be sent at both the HD and the INS levels for a particular occurrence of loop Terminating all covered insurance products for a dependent at the HD level is the equivalent of terminating that dependent at the INS level. Terminating all insurance products for a subscriber at the HD level is different, in that there may be dependents that continue to be covered, i.e. - dependent only plans. A subscriber with all insurance product coverage s terminated will be terminated as a member only if there are no dependents linked to that subscriber. In the case of a transfer from one coverage to another, it is necessary to terminate the old coverage and then add the new coverage. An add to a new coverage must never be assumed to result in the automatic termination of the prior coverage. Updates Versus Full File Audits The 834 transaction can be used to provide either updates to the enrollment database or full file audits. 834-GENA (005010X220) 3

4 An update is either an add, terminate or change request. The transaction only contains information about the changed members. This is identified in BGN08 by a code value of 2, Change (Update). A full file audit lists all current members, whether involved in a change or not. This facilitates keeping the sponsor s and payer s systems in sync. This is not intended to contain a history of all previous enrollments. This type of transaction is identified by a BGN08 code value of 4, Verify. The most efficient and preferred method for regular maintenance of enrollment files is to use Change (Update) transactions. Periodic audit files can be used to verify synchronization. When required by sponsor s system limitations, full replacement files can be used to report all enrollees. Because this model is more costly and requires more resources to process, it is not recommended. Verify should not be used for regular, daily, processing. It is recommended that this be used no more frequently than monthly. Loop Usages Loop usage within the ASC X12N 834 transaction can be confusing. Care must be used to read the loop requirements in terms of the context or location within the transaction. The usage designator of a loop s beginning segment indicates the usage of the loop (e.g., Required, Situational). Segments within a loop cannot be sent without the beginning segment of that loop. If the first segment is Required, the loop must occur at least once unless it is nested in a Situational loop that is not being used. Product Identifiers The 834 allows three locations for insurance product identifiers, such as policy numbers and group numbers. If a single policy number applies to an entire transaction set (i.e., all members have the same policy number), then the product identifier should be passed in the situational header REF segment ("Master Policy Number"). This segment should never be passed if a policy number does not apply to the entire transaction. If the policy or group number applies to all coverage data for a given member, then the product identifier should be passed in the situational REF segment at the insured individual (INS) level ("Member Policy Number"). This method should be used when 1) not all members have the same policy number, AND 2) each member has one and only one policy number, regardless of health coverage. Most identifiers should be communicated at the insured level. If a member can have more than one policy number due to multiple coverage types, then the product identifier should be passed in the situational REF segment at the health insurance product (HD) level ("Health Coverage Policy Number"). This segment should be used to identify a policy or group number for a particular insurance product if this number has not already been passed at the header or INS levels. NOTE: If the sender is conveying coordination of benefit information in Loop 2320, the policy number of the coordinating benefits can be sent, if know, via COB02. Delimiters We recommend the use of the following delimiters: CHARACTER NAME DELIMITER * Asterisk Data Element Separator : Colon Sub-element Separator ~ Tilde Segment Terminator Date Formats All 834 dates are 8-character dates in the format CCYYMMDD. The only date data element that is in format YYMMDD is the Interchange Date data element in the ISA segment. 834-GENA (005010X220) 4

5 Legend: By looking in the segments and elements areas of the companion document, you can see whether each item should be included in your data. You can see the requirements according to the agreement you have with your trading partner (user attributes on fair left of document) and according to the published standard on which the guideline or MIG is based (requirement designator Req. Des. column). >> on left X12: User attribute is specifically set to "Must be Used" or the requirement designator is mandatory for this item. Also (Must Use on Page 1). A on left EDIFACT: User attribute is specifically set to "Advised." D on left User attribute is specifically set to "Dependent." Its usage depends on something else. Please see Business Rules Overview. Also (Dep on page 1) NA on left NR on left R on left X on left M on left EDIFACT: User attribute is specifically set to "Not Advised." X12: User attribute is specifically set to "Not Recommended." X12: User attribute is specifically set to "Recommended." EDIFACT: User attribute is "Required." Also (Rec on page 1) User attribute is specifically set to "Not Used" for this item. It will also have faded text. User attribute is specially set to Mandatory since the Requirement Designator is also set to Mandatory. Symbols that are according to the published standard are denoted on page 1 with the Req. Des. Column, or are listed under the Attributes column on the detailed pages. M Requirement for this item is mandatory. If you choose M, the User Attributes area in the Edit dialog box is automatically set to "Used" and faded. Segments with a Req. Des. of M will be preceded with arrows (>>) and the ID or tag will be enclosed in a shaded block on the editing screen. These indicate that it must be used. O Requirement for this item is optional. O is for X12 transactions and is equivalent to C in EDIFACT. C (EDIFACT) Requirement for this item is conditional. This is equivalent to O for X12. F (X12 segments only) Requirement for this segment is floating. The use of F is discouraged; it is usually limited to the ASC X12 NTE segment in Table 1. X (X12 elements and composites) Requirement for this item depends on the presence of another item. Starting with X , X means this is the dependent of an element relational (also known as a syntax rule in X12 or dependency note in EDIFACT) such as "if that element is used, then this may not be used." 834 Benefit Enrollment and Maintenance Introduction: 834-GENA (005010X220) 5 Functional Group ID=BE This X12 Transaction Set contains the format and establishes the data contents of the Benefit Enrollment and Maintenance Transaction Set (834) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to establish communication between the sponsor of the insurance product and the payer. Such transaction(s) may or may not take place through a third party administrator (TPA). For the purpose of this standard, the sponsor is the party or entity that ultimately pays for the coverage, benefit or product. A sponsor can be an employer, union, government agency, association, or insurance agency. The payer refers to an entity that pays claims, administers the insurance product or benefit, or both. A payer can be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Champus, etc.), or an entity that may be contracted by one of these former groups. For the purpose of the 834 transaction set, a third party administrator (TPA) can be contracted by a sponsor to handle data gathering from those covered by the sponsor if the sponsor does not elect to perform this function itself. Heading:

6 Pos. Seg. Req. Loop Notes and No. ID Name Des. Max.Use Repeat Comments 0050 ISA Interchange Control Header O GS Functional Group Header O 1 M 0100 ST Transaction Set Header M 1 M 0200 BGN Beginning Segment M DTP File Effective Date O >1 LOOP ID A 1 M 0700 N1 Sponsor Name M 1 n1 LOOP ID B 1 M 0700 N1 Payer M 1 Detail: LOOP ID C N1 TPA/Broker Name O 1 Pos. Seg. Req. Loop Notes and No. ID Name Des. Max.Use Repeat Comments LOOP ID >1 Must 0100 INS Member Level Detail O 1 n2 Use M 0200 REF Subscriber Identifier M 1 n REF Member Supplemental Identifier O DTP Member Level Dates O 24 LOOP ID A 1 M 0300 NM1 Member Name M PER Member Communications Numbers O N3 Member Residence Street Address O N4 Member City, State, ZIP Code O DMG Member Demographics O HLH Member Health Information O 1 LOOP ID C NM1 Member Mailing Address O 1 M 0500 N3 Member Mail Street Address M 1 M 0600 N4 Member Mail City, State, ZIP Code M 1 LOOP ID F NM1 Custodial Parent O PER Custodial Parent Communications O 1 Numbers 0500 N3 Custodial Parent Street Address O N4 Custodial Parent City, State, ZIP Code O 1 LOOP ID G NM1 Responsible Person O PER Responsible Person Communications O 1 Numbers 0500 N3 Responsible Person Street Address O N4 Responsible Person City, State, ZIP Code O 1 LOOP ID > DSB Disability Information O 1 LOOP ID HD Health Coverage O 1 M 2700 DTP Health Coverage Dates M REF Health Coverage Policy Number O X220ER (005010X220A1) 6

7 LOOP ID LX Provider Information O 1 n4 M 3200 NM1 Provider Name M 1 n5 LOOP ID COB Coordination of Benefits O DTP Coordination of Benefits Eligibility Dates O 2 LOOP ID NM1 Coordination of Benefits Related Entity O LS Additional Reporting Categories O 1 LOOP ID > LX Member Reporting Categories O 1 LOOP ID N1 Reporting Category O REF Reporting Category Reference O DTP Reporting Category Date O LE Additional Reporting Categories Loop Termination O 1 M 6900 SE Transaction Set Trailer M GE Functional Group Trailer O IEA Interchange Control Trailer O 1 Transaction Set Notes 1. At least one iteration of loop 1000 is required to identify the sender or receiver. 2. A Subscriber is a person who elects the benefits and is affiliated with the employer or the insurer. A Dependent is a person who is affiliated with the subscriber, such as a spouse, child, etc., and is therefore entitled to benefits. Subscriber information must come before dependent information. The INS segment is used to note if information being submitted is subscriber information or dependent information. 3. The REF segment is required to link the dependent(s) to the subscriber. 4. Loop 2310 contains information about the primary care providers for the subscriber or the dependent, and about the beneficiaries of any employer-sponsored life insurance for the subscriber. 5. Either NM1 or N1 will be included depending on whether an individual or organization is being specified. 834-X220ER (005010X220A1) 7

8 Segment: ISA Interchange Control Header Position: 0050 Loop: Level: Heading Usage: REQUIRED Max Use: 1 Syntax Notes: Comments: Notes: Example: ISA*00* *01* *ZZ*MTX123456A *ZZ*G84980 *130101*1253*^*00501* *1*T*:~ Data Element Summary Ref. Data Des. Element Name Attributes M ISA01 I01 Authorization Information Qualifier M 1 ID 2/2 Code identifying the type of information in the Authorization Information 00 Required to be sent as '00'. 00 No Authorization Information Present (No Meaningful Information in I02) M ISA02 I02 Authorization Information M 1 AN 10/10 Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) 10 blanks Required to be sent as ' ' (10 blanks). M ISA03 I03 Security Information Qualifier M 1 ID 2/2 Code identifying the type of information in the Security Information 01 Required to be sent as '01. M ISA04 I04 Security Information M 1 AN 10/10 This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) 10 blanks Required to be sent as ' ' (10 blanks). M ISA05 I05 Interchange ID Qualifier M 1 ID 2/2 Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified Required to be sent as ZZ. ZZ ZZ Mutually Defined M ISA06 I06 Interchange Sender ID M 1 AN 15/15 Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element This segment is used for the submitter ID that is unique to This segment is used for the submitter ID that is unique to every group that has a membership eligibility file transmitted. every group that has a membership eligibility file transmitted. Example: MIL123456A (for an IL account) It will be provided by HCSC to the sender at the time in which a new eligibility file feed is setup. Position 1 = M Position 2 & 3 = State Corp Code of either TX, IL, NM, OK, or MT Position s 4 through 9 = Account Number Position 10 = Unique alpha denotation to identify each eligibility feed M ISA07 I05 Interchange ID Qualifier M 1 ID 2/2 Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified ZZ Required to be sent as ZZ. ZZ Mutually Defined M ISA08 I07 Interchange Receiver ID M 1 AN 15/ X220ER (005010X220A1) 8

9 Receiver ID Values: G84980 = Texas G00790 = New Mexico G00840 = Oklahoma G00621 = Illinois Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them Required to be sent as one of the below values depending upon the state corp that a group is covered under. This is a left justified field with blanks filling in after the 6 byte receiver ID. M ISA09 I08 Interchange Date M 1 DT 6/6 Date of the interchange YYMMDD format Required Segment. This data element is not setup in the standard 8 byte CCYYMMDD format. It has the 6 byte YYMMDD format. M ISA10 I09 Interchange Time M 1 TM 4/4 HHMM format Time of the interchange HCSC recommends sending the Receive time in this data element. This is the time in which Account sent the file. Note: This data element is not setup in the standard 8 byte HHMMSSDD format. It has the 4 byte HHMM format. M ISA11 I65 Repetition Separator M 1 AN 1/1 Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator ^ Required to be sent as a carat symbol (^). M ISA12 I11 Interchange Control Version Number M 1 ID 5/5 Code specifying the version number of the interchange control segments Required to be sent as Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 M ISA13 I12 Interchange Control Number M 1 N0 9/9 A control number assigned by the interchange sender Unique 9 digit number Required to be sent as a nine digit unique number. This value and the IEA02 segment must match. Example: M ISA14 I13 Acknowledgment Requested M 1 ID 1/1 Code indicating sender's request for an interchange acknowledgment 1 Required to be sent as '1'. M ISA15 I14 Interchange Usage Indicator M 1 ID 1/1 Code indicating whether data enclosed by this interchange envelope is test, production or information T = Testing P = Production When sending a test file, it should always be sent to the test Gateway server with a T in this segment. When sending a production file, it should always be sent to the production Gateway server with a P in this segment. P Production Data T Test Data M ISA16 I15 Component Element Separator M 1 AN 1/1 Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator > or : Required to be sent as any special character except '*'. HCSC preference is >. 834-X220ER (005010X220A1) 9

10 834-X220ER (005010X220A1) 10

11 Segment: GS Functional Group Header Position: 0075 Loop: Level: Heading Usage: MANDATORY Max Use: 1 Syntax Notes: Comments: 1 A functional group of related transaction sets, within the scope of X12 standards, consists of a collection of similar transaction sets enclosed by a functional group header and a functional group trailer. Notes: Example: GS*BE*123456*G84980* *0802*1*X*005010X220A1~ Data Element Summary Ref. Data Des. Element Name Attributes M GS Functional Identifier Code M 1 ID 2/2 Code identifying a group of application related transaction sets BE Required to be sent as 'BE'. BE Benefit Enrollment and Maintenance (834) M GS Application Sender's Code M 1 AN 2/15 Code identifying party sending transmission; codes agreed to by trading partners 6 byte account number Required to have the 6 byte account number. M GS Application Receiver's Code M 1 AN 2/15 Code identifying party receiving transmission; codes agreed to by trading Receiver ID Values: G84980 = Texas G00790 = New Mexico G00840 = Oklahoma G00621 = Illinois partners Required to be sent as one of the below values depending upon the state corp that a group is covered under. This is a left justified field with blanks filling in after the 6 byte receiver ID. M GS Date M 1 DT 8/8 Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year CCYYMMDD Required to be sent in the CCYYMMDD format to represent the file transmission date. M GS Time M 1 TM 4/8 Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) HHMM, or HHMMSS, or HCSC recommends sending the Receive time in this data element. This is the HHMMSSD, or HHMMSSDD time that the account sent the file. M GS06 28 Group Control Number M 1 N0 1/9 Assigned number originated and maintained by the sender Unique Control Number Required to send a unique control number in this field that is no less than 1 byte in size, but also no greater than 9 bytes. M GS Responsible Agency Code M 1 ID 1/2 Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 X HCSC recommends sending 'X' in this data element. X Accredited Standards Committee X12 M GS Version / Release / Industry Identifier Code M 1 AN 1/12 Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally 834-X220ER (005010X220A1) 11

12 005010X220A1 assigned by user); if code in DE455 in GS segment is T, then other formats are allowed Required to be sent as '005010X220A1' X220A1 Standards Approved for Publication by ASC X12 Procedures Review Board through October X220ER (005010X220A1) 12

13 Segment: ST Transaction Set Header Position: 0100 Loop: Level: Heading Usage: MANDATORY Max Use: 1 Syntax Notes: Comments: Notes: Example: ST*834*0001*005010X220A1~ Data Element Summary Ref. Data Des. Element Name Attributes M ST Transaction Set Identifier Code M 1 ID 3/3 Code uniquely identifying a Transaction Set 834 Required to be sent as '834'. 834 Benefit Enrollment and Maintenance M ST Transaction Set Control Number M 1 AN 4/9 Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Unique number that the SE02 must match. The number must be minimally 4 digits in length, but no more than 9 digits. HCSC recommends sending a number that will uniquely identify each ST segment. The transaction set control numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. For example, start with the number 0001 and increment from there. This number must be unique within a specific group and interchange, but the number can repeat in other groups and interchanges. >> ST Implementation Convention Reference O 1 AN 1/35 Reference assigned to identify Implementation Convention X220A1 Required to be sent as '005010X220A1' in this field X220A1 834-X220ER (005010X220A1) 13

14 834-X220ER (005010X220A1) 14

15 Segment: BGN Beginning Segment Position: 0200 Loop: Level: Heading Usage: MANDATORY Max Use: 1 Syntax Notes: 1 If BGN05 is present, then BGN04 is required. Comments: Notes: Example: BGN*00*11227* *1200*ES***2~ Data Element Summary Ref. Data Des. Element Name Attributes M BGN Transaction Set Purpose Code M 1 ID 2/2 Code identifying purpose of transaction set Original 15 Re-Submission 22 Information Copy M BGN Reference Identification M 1 AN 1/50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 6 byte account number Required to be sent as the 6 byte account number. M BGN Date M 1 DT 8/8 CCYYMMDD Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year >> BGN Time X 1 TM 4/8 HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99) >> BGN Action Code O 1 ID 1/2 RX or 4 = Full Files 2 = Changes Only Files Code indicating type of action Required to be sent as RX or 4 for full files. Required to be sent as 2 for changes only files that do not contain the full membership population. 2 Change (Update) 4 Verify RX Replace 834-X220ER (005010X220A1) 15

16 834-X220ER (005010X220A1) 16

17 Segment: DTP File Effective Date Position: 0400 Loop: Level: Heading Usage: MANDATORY Max Use: >1 Syntax Notes: Comments: Notes: Example: DTP*007*D8* ~ Example: DTP*382*D8* ~ -OR- Example: DTP*007*D8* ~ Example: DTP*382*D8* ~ Data Element Summary Ref. Data Des. Element Name Attributes M DTP Date/Time Qualifier M 1 ID 3/3 Code specifying type of date or time, or both date and time Required to be sent on all files. There are two options of sending the DTP segment. The first is with both DTP*007 & DTP*382 reflecting the FROM and TO dates. The second is with both the DTP*007 & DTP*382 reflecting the file creation date. 007 Effective 090 Report Start 091 Report End 303 Maintenance Effective 382 Enrollment 388 Payment Commencement M DTP Date Time Period Format Qualifier M 1 ID 2/3 Code indicating the date format, time format, or date and time format D8 Required to be sent as 'D8' in this field. D8 Date Expressed in Format CCYYMMDD M DTP Date Time Period M 1 AN 1/35 Expression of a date, a time, or range of dates, times or dates and times CCYYMMDD Required to be sent in the CCYYMMDD format. 834-X220ER (005010X220A1) 17

18 834-X220ER (005010X220A1) 18

19 Segment:N1 Sponsor Name Position: 0700 Loop: 1000A MANDATORY Level: Heading Usage: MANDATORY Max Use: 1 Syntax Notes: 1 At least one of N102 or N103 is required. 2 If either N103 or N104 is present, then the other is required. Comments: 1 This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 2 N105 and N106 further define the type of entity in N101. Notes: Example: N101*P5*ABC Company*24* ~ Data Element Summary Ref. Data Des. Element Name Attributes M N Entity Identifier Code M 1 ID 2/3 Code identifying an organizational entity, a physical location, property or an individual P5 Required to be sent as 'P5'. P5 Plan Sponsor N Name X 1 AN 1/60 Free-form name Group Name Required for the name of the group to be sent. >> N Identification Code Qualifier X 1 ID 1/2 Code designating the system/method of code structure used for Identification Code (67) 24 Required to be sent as '24'. 24 Employer's Identification Number >> N Identification Code X 1 AN 2/80 Code identifying a party or other code EIN Required for the EIN of the group to be sent. 834-X220ER (005010X220A1) 19

20 834-X220ER (005010X220A1) 20

21 Segment: N1 Payer Position: 0700 Loop: 1000B MANDATORY Level: Heading Usage: MANDATORY Max Use: 1 Syntax Notes: 1 At least one of N102 or N103 is required. 2 If either N103 or N104 is present, then the other is required. Comments: 1 This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 2 N105 and N106 further define the type of entity in N101. Notes: N1*Health Care Service Corporation*FI* ~ Data Element Summary Ref. Data Des. Element Name Attributes M N Entity Identifier Code M 1 ID 2/3 Code identifying an organizational entity, a physical location, property or an individual IN Required to be sent as 'IN' in this field. IN Insurer N Name X 1 AN 1/60 Free-form name Health Care Service Corporation Required to be sent as 'Health Care Service Corporation' in this field. >> N Identification Code Qualifier X 1 ID 1/2 Code designating the system/method of code structure used for Identification Code (67) FI Required to be sent as 'FI' in this field. FI Federal Taxpayer's Identification Number >> N Identification Code X 1 AN 2/80 Code identifying a party or other code Required to be sent as ' ' in this field. 834-X220ER (005010X220A1) 21

22 834-X220ER (005010X220A1) 22

23 Segment:N1 TPA/Broker Name Position: 0700 Loop: 1000C Optional Level: Heading Usage: OPTIONAL Max Use: 1 Syntax Notes: 1 At least one of N102 or N103 is required. 2 If either N103 or N104 is present, then the other is required. Comments: 1 This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party. 2 N105 and N106 further define the type of entity in N101. Notes: Example: N1*TV*MONEY TALKS BROKERAGE*FI* ~ HCSC recommends sending this segment if a Third Party Vendor is involved. Data Element Summary Ref. Data Des. Element Name Attributes M N Entity Identifier Code M 1 ID 2/3 Code identifying an organizational entity, a physical location, property or an individual TV Send 'TV' in this data element BO Broker or Sales Office TV Third Party Administrator (TPA) >> N Name X 1 AN 1/60 Free-form name TPA Name Send the Third Party Name in this data element. >> N Identification Code Qualifier X 1 ID 1/2 Code designating the system/method of code structure used for Identification Code (67) FI HCSC recommends sending 'FI" in this data element. FI Federal Taxpayer's Identification Number >> N Identification Code X 1 AN 2/80 Code identifying a party or other code Federal Tax ID HCSC recommends sending the Third Party's Federal Tax ID in this data element. 834-X220ER (005010X220A1) 23

24 834-X220ER (005010X220A1) 24

25 Segment:INS Member Level Detail Position: 0100 Loop: 2000 REQUIRED Level: Detail Usage: REQUIRED Max Use: 1 Syntax Notes: 1 If either INS11 or INS12 is present, then the other is required. Comments: Notes: Example: INS*Y*18*030**A***FT~ (Active Employee Example) Example: INS*Y*18*030*08*A***FT~ (Terminated Employee Example) Example: INS*N*01*030**A~ (Active Spouse Example) Example: INS*N*01*030*01*A***FT~ (Terminated Spouse Example) Data Element Summary Ref. Data Des. Element Name Attributes M INS Yes/No Condition or Response Code M 1 ID 1/1 Code indicating a Yes or No condition or response Y N Required to be sent as either a Y or N. "Y" = the member is the subscriber "N" = the member is a dependent N No Y Yes M INS Individual Relationship Code M 1 ID 2/ Code indicating the relationship between two individuals or entities The minimum required values to be sent are: 01 = Spouse 18 = Subscriber 19 = Child Dependent If court ordered children dependents are being sent on the file to be identified as such, it is required that the INS02 value be sent with a 15 as the value. (Note: If 15 is sent, then the 2100F loop for the custodial address must also be sent.) If a group permit s other types of eligibility, the following values should be sent: 23 = Sponsored Child Dependent 53 = Domestic Partner G8 = Civil Union Spouse 01 Spouse 03 Father or Mother 04 Grandfather or Grandmother 05 Grandson or Granddaughter 06 Uncle or Aunt 07 Nephew or Niece 08 Cousin 09 Adopted Child 10 Foster Child 11 Son-in-law or Daughter-in-law 12 Brother-in-law or Sister-in-law 13 Mother-in-law or Father-in-law 14 Brother or Sister 15 Ward 16 Stepparent 17 Stepson or Stepdaughter 18 Self 19 Child 834-X220ER (005010X220A1) 25

26 23 Sponsored Dependent 24 Dependent of a Minor Dependent 25 Ex-spouse 26 Guardian 31 Court Appointed Guardian 38 Collateral Dependent 53 Life Partner 60 Annuitant D2 Trustee G8 Other Relationship G9 Other Relative >> INS Maintenance Type Code O 1 ID 3/3 Code identifying the specific type of item maintenance 030 Minimum required value to be sent is Change 021 Addition 024 Cancellation or Termination 025 Reinstatement 030 Audit or Compare INS Maintenance Reason Code O 1 ID 2/3 Code identifying the reason for the maintenance change Required when HCSC is the COBRA admin. When HCSC is the COBRA administrator, the values highlighted in yellow need to be supplied to advise of the reason for the members termination. 01 Divorce 02 Birth 03 Death 04 Retirement 05 Adoption 06 Strike 07 Termination of Benefits 08 Termination of Employment 09 Consolidation Omnibus Budget Reconciliation Act (COBRA) 10 Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid 11 Surviving Spouse 14 Voluntary Withdrawal 15 Primary Care Provider (PCP) Change 16 Quit 17 Fired 18 Suspended 20 Active 21 Disability 22 Plan Change 25 Change in Identifying Data Elements 26 Declined Coverage 27 Pre-Enrollment 28 Initial Enrollment 29 Benefit Selection 31 Legal Separation 32 Marriage 33 Personnel Data 37 Leave of Absence with Benefits 38 Leave of Absence without Benefits 39 Lay Off with Benefits 40 Lay Off without Benefits 41 Re-enrollment 43 Change of Location 834-X220ER (005010X220A1) 26

27 59 Non Payment AA Dissatisfaction with Office Staff AB Dissatisfaction with Medical Care/Services Rendered AC Inconvenient Office Location AD Dissatisfaction with Office Hours AE Unable to Schedule Appointments in a Timely Manner AF Dissatisfaction with Physician's Referral Policy AG Less Respect and Attention Time Given than to Other Patients AH Patient Moved to a New Location AI No Reason Given AJ Appointment Times not Met in a Timely Manner AL Algorithm Assigned Benefit Selection EC Member Benefit Selection XN Notification Only XT Transfer >> INS Benefit Status Code O 1 ID 1/1 The type of coverage under which benefits are paid A C S Required to be sent with one of the following values: A = Active C = COBRA S = Survivor A Active C Consolidated Omnibus Budget Reconciliation Act (COBRA) S Surviving Insured T Tax Equity and Fiscal Responsibility Act (TEFRA) INS06 C052 Medicare Status Code O 1 To provide Medicare coverage and associated reason for Medicare eligibility Optional to send. Not required. The INS06 is optional to send, but if sent please note that it is only processed for a member that is a new add due to HCSC receiving Medicare information directly from CMS. When passing this field, please send the code that describes the type of Medicare coverage a member has. Please note that if Medicare indication is going to be sent, it has to indicate the Medicare Part (A, B, or C) and the eligibility reason code for the C05202 must also be supplied. This helps to avoid partial Medicare data from appearing on a member record and generating an error a new member. Example of what the C05201 and C05202 would look like: INS*Y*18*030**A*C>0**RT~ INS0601 = "C" - Both Medicare A and B INS0602 = "0" - Aged M C Medicare Plan Code M ID 1/1 A, B, C, E, or an asterisk (*) Code identifying the Medicare Plan element separator. A Medicare Part A B Medicare Part B C Medicare Part A and B D Medicare E No Medicare C Eligibility Reason Code O ID 1/1 0, 1, 2 Code specifying reason for eligibility 0 Age 834-X220ER (005010X220A1) 27

28 1 Disability 2 End Stage Renal Disease (ESRD) INS Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code O 1 ID 1/2 A Qualifying Event is any of the following which results in loss of coverage for a Qualified Beneficiary * Asterisk (*) element separator should be sent to act as a placeholder. INS Employment Status Code O 1 ID 2/2 Code showing the general employment status of an employee/claimant Any of the values below can be sent. AC Active AO Active Military - Overseas AU Active Military - USA FT Full-time L1 Leave of Absence PT Part-time RT Retired TE Terminated INS Student Status Code O 1 ID 1/1 Code indicating the student status of the patient if 19 years of age or older, not handicapped and not the insured * This segment is no longer needed due to ACA permitting all children dependents to be covered to the age of 26. Asterisk (*) element separator should be sent to act as a placeholder. F Full-time N Not a Student P Part-time INS Yes/No Condition or Response Code O 1 ID 1/1 Y N D8 Code indicating a Yes or No condition or response Required to send Y for disabled children dependents, else send N. This segment is solely for identifying disabled children dependents. N No Y Yes INS Date Time Period Format Qualifier X 1 ID 2/3 Code indicating the date format, time format, or date and time format Required when the date of death for a member is being sent in the INS12. Please note that the date of death is not required to be sent; however, by sending 03 in the INS04 along with the date of death in the INS11 & INS12 it helps to prevent a Certificate of Creditable Coverage letter from going out to the deceased member. D8 Date Expressed in Format CCYYMMDD INS Date Time Period X 1 AN 1/35 Expression of a date, a time, or range of dates, times or dates and times Date of Death Send in CCYYMMDD format when the date of death is being sent for a member. Please note that this field does not replace sending the 2300 loop, DTP*349 benefit termination date segment. ***The INS13, INS14, INS15, and INS16 are not used.*** INS Number O 1 N0 1/9 A generic number 1-9 Optional. If known that there are children dependents on the file that are a part of a set of twins, triplets, etc., please send a consecutive number in the INS17 starting with 1. This helps to differentiate between the children dependents that are a part of a multiple. This segment should not be sent on any member that is not a child dependent and is not a part of a multiple. 834-X220ER (005010X220A1) 28

29 Segment: REF Subscriber Identifier Position: 0200 Loop: 2000 MANDATORY Level: Detail Usage: REQUIRED Max Use: 1 Syntax Notes: 1 At least one of REF02 or REF03 is required. 2 If either C04003 or C04004 is present, then the other is required. 3 If either C04005 or C04006 is present, then the other is required. Comments: Notes: Example: REF*0F* ~ Data Element Summary Ref. Data Des. Element Name Attributes M REF Reference Identification Qualifier M 1 ID 2/3 Code qualifying the Reference Identification 0F Required to be sent as 0F (the number zero & the letter F). 0F Subscriber Number >> REF Reference Identification X 1 AN 1/50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Employee SSN Or Required to be sent as the employee SSN for groups that BCBS assigns the unique ID. This is the normal standard. Unique ID Required to be sent as the unique ID for groups that assign their own unique ID. (***Please note that BCBS will advise when the REF*0F should be sent as the unique ID.***) 834-X220ER (005010X220A1) 29

30 834-X220ER (005010X220A1) 30

31 Segment: REF Member Supplemental Identifier Position: 0200 Loop: 2000 Optional Level: Detail Usage: OPTIONAL Max Use: 13 Syntax Notes: 1 At least one of REF02 or REF03 is required. 2 If either C04003 or C04004 is present, then the other is required. 3 If either C04005 or C04006 is present, then the other is required. Comments: Notes: Example s: REF*6O* ~ (Elevated dependent becoming a subscriber.) REF*F6* B~ (HIC Number) Data Element Summary Ref. Data Des. Element Name Attributes M REF Reference Identification Qualifier M 1 ID 2/3 Code qualifying the Reference Identification 6O = Original Employee SSN 6O Cross Reference Number F6 = HIC Number F6 Health Insurance Claim (HIC) Number >> REF Reference Identification X 1 AN 1/50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Original Employee SSN Or HIC Number When a dependent is being elevated to become a subscriber due to being a survivor or any other reason, the original subscriber SSN that they were previously covered under with at HCSC should be sent in the REF02 and with 6O as the qualifier in the REF01. When Medicare information is being sent on a members record, the HIC number should be sent in the REF02 and with F6 as the qualifier in the REF X220ER (005010X220A1) 31

32 834-X220ER (005010X220A1) 32

33 Segment: DTP Member Level Dates Position: 0250 Loop: 2000 Mandatory Level: Detail Usage: REQUIRED Max Use: 24 Syntax Notes: Comments: Notes: Example: (Subscriber) DTP*393*D8* ~ (Original Effective Date with HCSC) DTP*303*D8* ~ (File Creation Date) DTP*336*D8* ~ (Hire Date) (Dependent) DTP*393*D8* ~ (Original Effective Date with HCSC) DTP*303*D8* ~ (File Creation Date) (Member with Medicare Part A Only) DTP*338*D8* ~ (Medicare A Effective Date) (Member with Medicare Part A & B) DTP*338*D8* ~ (Medicare A Effective Date) DTP*338*D8* ~ (Medicare B Effective Date) (Member with Medicare Part A & Part B is ended) DTP*338*D8* ~ (Medicare A Effective Date) DTP*338*D8* ~ (Medicare B Effective Date) DTP*339*D8* ~ (Medicare B End Date) (Member with Medicare Part A & Part B both ended) DTP*338*D8* ~ (Medicare A Effective Date) DTP*339*D8* ~ (Medicare A End Date) DTP*338*D8* ~ (Medicare B Effective Date) DTP*339*D8* ~ (Medicare B End Date) Data Element Summary Ref. Data Des. Element Name Attributes M DTP Date/Time Qualifier M 1 ID 3/3 Code specifying type of date or time, or both date and time = Original Effective Date This date should reflect when a member begins coverage with HCSC. This date should not change = Hire Date This should be the current hire date. The HCSC membership system only processes this date upon a new subscriber add or a subscriber readd (gap in coverage). 303 = File Creation Date Used to track demographic and/or personal history changes for a member. 303 Maintenance Effective 336 Employment Begin 338 Medicare Begin 339 Medicare End 393 Plan Participation Suspension M DTP Date Time Period Format Qualifier M 1 ID 2/3 Code indicating the date format, time format, or date and time format D8 Required to be sent as 'D8'. 834-X220ER (005010X220A1) 33

34 D8 Date Expressed in Format CCYYMMDD M DTP Date Time Period M 1 AN 1/35 Expression of a date, a time, or range of dates, times or dates and times CCYYMMDD Required to be sent in the CCYYMMDD format. 834-X220ER (005010X220A1) 34

35 Segment: NM1 Member Name Position: 0300 Loop: 2100A Mandatory Level: Detail Usage: REQUIRED Max Use: 1 Syntax Notes: 1 If either NM108 or NM109 is present, then the other is required. 2 If NM111 is present, then NM110 is required. 3 If NM112 is present, then NM103 is required. Comments: 1 NM110 and NM111 further define the type of entity in NM NM112 can identify a second surname. Notes: (Subscriber Example) NM1*IL*1*SMITH*JOHN*M***34* ~ (Dependent w/o SSN Example) NM1*IL*1*SMITH*JOHN~ (Dependent w/ SSN Example) NM1*IL*1*SMITH*JANE*A***34* ~ Data Element Summary Ref. Data Des. Element Name Attributes M NM Entity Identifier Code M 1 ID 2/3 Code identifying an organizational entity, a physical location, property or an individual IL Required to be sent as IL. IL Insured or Subscriber M NM Entity Type Qualifier M 1 ID 1/1 Code qualifying the type of entity 1 Required to be sent as 1. 1 Person >> NM Name Last or Organization Name X 1 AN 1/60 **MANDATORY** Individual last name or organizational name Please note that HCSC is only able to process the first 20 bytes. Any special characters will convert to spaces when the name is processed. Numeric values are not permitted and will generate an error. NM Name First O 1 AN 1/35 **MANDATORY** Individual first name Please note that HCSC is only able to process the first 20 bytes. Any special characters will convert to spaces when the name is processed. Numeric values are not permitted and will generate an error. NM Name Middle O 1 AN 1/25 Optional. Please note that only Individual middle name or middle initial the initial first letter is processed. Numeric values are not permitted and will generate an error. NM Name Prefix O 1 AN 1/10 Optional. Please note that only Prefix to individual name the first 5 bytes will process. Numeric values are not permitted and will generate an error. 834-X220ER (005010X220A1) 35

36 NM Name Suffix O 1 AN 1/10 Optional. Please note that only Suffix to individual name the first 3 bytes will process. Numeric values are not permitted and will generate an error. NM Identification Code Qualifier X 1 ID 1/2 Code designating the system/method of code structure used for Identification Code (67) 34 Required to be sent as 34 when the SSN is being sent in the NM109 segment. If SSN is not being sent, the NM1 segment should terminate after the last field with name information in it is passed. 34 Social Security Number NM Identification Code X 1 AN 2/80 Code identifying a party or other code SSN Required for the SSN to be sent on all subscribers. Required for the SSN to be sent on dependents that are age 45 or older per CMS 111 federal mandates. If the SSN is known on any dependent, it is strongly recommended to pass over on the eligibility file. 834-X220ER (005010X220A1) 36

37 Segment: PER Member Communications Numbers Position: 0400 Loop: 2100A Mandatory Level: Detail Usage: OPTIONAL Max Use: 1 Syntax Notes: 1 If either PER03 or PER04 is present, then the other is required. 2 If either PER05 or PER06 is present, then the other is required. 3 If either PER07 or PER08 is present, then the other is required. Comments: Notes: Example: PER*IP**HP* *WP* *EM*JSMITH@Company.com~ Data Element Summary Ref. Data Des. Element Name Attributes M PER Contact Function Code M 1 ID 2/2 Code identifying the major duty or responsibility of the person or group named IP If the PER segment is being sent on a member record, this data element is required to be sent as 'IP'. IP Insured Party >> PER02 93 Name O 1 AN 2/60 * Required to send an asterisk element (*) separator. >> PER Communication Number Qualifier X 1 ID 2/2 Code identifying the type of communication number EM HP If the PER segment is being sent on a member record, the only values that HCSC is able to process during the file translation is EM, HP, or WP. WP EM Electronic Mail HP Home Phone Number WP Work Phone Number >> PER Communication Number X 1 AN 1/256 Complete communications number including country or area code when applicable Address Work Phone Home Phone EM HP WP If PER03 = EM, then send the address in this segment. If PER03 = HP, then send the home phone number in this segment. If PER03 = WP, then send the work phone number in this segment. Please note that only the 10 digit numeric value for the phone number should be sent so that it is able to be fully processed. PER Communication Number Qualifier X 1 ID 2/2 Code identifying the type of communication number If the PER segment is being sent on a member record, the only values that HCSC is able to process during the file translation is EM, HP, or WP. EM Electronic Mail HP Home Phone Number WP Work Phone Number PER Communication Number X 1 AN 1/256 Complete communications number including country or area code when applicable Address If PER05 = EM, then send the address in this segment. If PER05 = HP, Work Phone then send the home phone number in this segment. If PER05 = WP, then send Home Phone the work phone number in this segment. Please note that only the 10 digit numeric value for the phone number should be sent so that it is able to be fully processed. PER Communication Number Qualifier X 1 ID 2/2 EM If the PER segment is being sent on a member record, the only values that HP HCSC is able to process during the file translation is EM, HP, or WP. 834-X220ER (005010X220A1) 37