ELECTRONIC ENROLLMENT GUIDE TO SENDING ELIGIBILITY FILES TO BML. Standard HIPAA 834V5010

Transcription

1 ELECTONIC ENOLLMENT GUE TO ENDING ELIGIBILITY FILE TO BML tandard HIPAA 834V5010

2 DECIPTION DECIPTION IA 01 Authorization Info 00 No Auth Info IA 02 Authorization Info BLANK IA 03 ecurity Info Qualifer 00 No ecurity Info IA 04 ecurity Info BLANK IA 05 ender 01 = Duns BMI prefers = Duns Plus uffix 20 = HIN 27 = Carrier - HCFA 28 = Fiscal Intermediary 29 = Medicare Provider 30 = Federal Tax Id 33 = NAIC ZZ = Mutually Defined IA 06 ender xxxxxxxxx IA 07 eceiver 30 IA 08 eceiver IA 09 Interchange Date YYMMDD IA 10 Interchange Time HHMM IA 11 Interchange Control ^ IA 12 Interchange Control Ver # IA 13 Interchange Control # The Interchange Control, IA13, must be identical to the associated Interchange Trailer IEA02 IA 14 Acknowledgement equested 0 = No Acknowledgement equested IA 15 Usage Indicator P = Prod T = Test EQUIED O OP08_EEI 1703 Page 1

3 DECIPTION IA 16 Component Element eperator <MENT TEMINATO> DECIPTION " * " Component Element eperator may not be a Carriage eturn, Line Feed, New Line or any combination thereof. " ~ " egment terminator may not be a Carriage eturn, Line Feed, New Line or any combination thereof. G 01 Functional BE G 02 ender AME A IA06 G 03 eceiver AME A IA08 G 04 Date G 05 Time HHMM G 06 Group Control G 07 esponsible Agency X G 08 Version/elease 00501X220A1 T 01 Transaction 834 T 02 Transaction et Control # T 03 Implementation 00501X220A1 Convention eferenc BGN 01 Transaction et 00 00=Original Purpose BGN 02 eference Unique eference code BGN 03 Date Transaction set creation date BGN 04 Time HHMM Transaction set creation time EQUIED O OP08_EEI 1703 Page 2

4 DECIPTION BGN 08 Action 4 = total population/full file DECIPTION Indicates whether file is updates only or a full replace or refresh of the membership population. EF 01 eference = Master Qualifer Policy EF 02 eference 1000A N1 01 Entity Identifier P5 Plan ponsor - /ponsor The party that ultimately pays for the coverage N1 02 Name Free Form Name (IN ALL CAP) N1 03 Identification FI Federal Taxpayer's Identification N1 04 Identification ponsor's Federal Tax 1000C N1 01 Entity Identifier BO = Broker /Payer TV = TPA N1 02 Name Benefit Management LLC N1 03 Identification Insurer/Payer is the party that pays claims and/or administers the insurance benefit. Free Form Name (IN ALL CAP) Federal Taxpayer's Identification N1 04 Identification N1 01 Entity Identifier TV = Third Party Administrator(TPA) N1 02 Name TPA or Broker name Free Form Name (IN ALL CAP) EQUIED O OP08_EEI 1703 Page 3

5 DECIPTION N1 03 Identification FI DECIPTION Federal Taxpayer's Identification N1 04 Identification TPA or Broker's Federal Taxpayer's Identification 2000 IN 01 Yes/No Condition N = No Y = Yes IN 02 Individual elationship IN 03 Maintenance Type 18 = elf 01 = pouse 19 = Child 38 = Collateral Dependent 53 = Life Partner 030 = Full eplace File IN 05 Benefit tatus A = Active C = Cobra = urviving Insured IN 08 Employment tatus FT = Full-time PT = Part-time L1 = Leave of Absence T = etired TE = Terminated ubscriber Indicator When BGN08 = 4, 030 should be used in all IN03 segments in the file, to indicate a full replace/audit file. When BGN08 = 2, IN03 can be 001, 021 or 024 to indicate the proper maintenance type. Benefit tatus Use only on the subscriber record. EQUIED O OP08_EEI 1703 Page 4

6 DECIPTION DECIPTION IN 09 tudent tatus F = Full-time N = Not a student P = Part-time IN 10 Yes/No Condition N = No Handicap Y = Yes indicator. EF 01 eference 1L Group EF 02 eference ubscriber EF 02 eference 2100A NM1 01 Entity Identifier IL IL = Insured or ubscriber NM1 02 Entity Type 1 1 =Person NM1 03 Name Last Last Name NM1 04 Name First First Name NM1 05 Name Initial Middle Initial NM1 08 Identification = ocial ecurity NM1 09 Identification Dependent N when entity is a dependent PE 01 Contact Function IP Insured Home Phone PE 03 Communication HP Home Phone PE 04 Communication Home Phone N3 01 Address Line 1 Address Line 1 N3 02 Address Line 2 Address Line 2 N4 01 City City N4 02 tate tate N4 03 Zip ZIP or ZIP + 4 (DO NOT INCLUDE ANY PUNCTUATION) DMG 01 Date/Time Format D8 Date expressed in Format DMG 02 Date/Time Period Date of Birth = DMG 03 Gender M = Male Gender F = Female U = Unknown EQUIED O OP08_EEI 1703 Page 5

7 DECIPTION DMG 04 Marital tatus B=egistered Domestic Partner D=Divorced I=ingle M=Married =epearated W=Widowed X = Legally eperated DMG 05 ace or Ethnicity DMG 06 Citizenship tatus 1=U.. Citizen 2=Non-esident Alien 3=esident Alien 4=Illegal Alien 5=Alien 6=U.. Citizen-Non resident 7=U.. Citizen- esident DECIPTION 2100C NM1 01 Entity Identifier NM1 02 Entity identifier N3 01 Mailing Address Line 1 N3 02 Mailing Address Line 2 N4 01 Mailing Address City N4 02 Mailing Address tate N4 03 Mailing address Zip N4 04 Country Provide only if country is not UA 2300 HD 01 Maintenance Type 030 = Full eplace File When BGN08 = 4, 030 should be used in all IN03 segments in the file, to indicate a full replace/audit file. When BGN08 = 2, IN03 can be EQUIED O OP08_EEI 1703 Page 6

8 DECIPTION DECIPTION 001, 021 or 024 to indicate the proper maintenance type. HD 03 Insurance Line H HD 04 Plan Name included in the group availabe HD 05 Coverage Level IND = Individual FAM = Family E1D = Employee + 1 Dep O EP = Employee + 1 Dep ECH = Emp + Child(ren) DTP 01 Date/Time 348 = Benefit Begin 349 = Benefit End 303 = Maintenance coverage listing Coverage. equired when entity is the subscriber. DO NOT UE WHEN ENTITY I DEPENDENT. Effective DTP 02 Date/Time Format D8 Date expressed in Format DTP 03 Date/Time Period Coverage Begin Date = Coverage End Date = E 01 of Included egments E 02 Transaction et Control Numer GE 01 of Transaction ets Included GE 02 Group Control IEA 01 of Functional Groups Included EQUIED O OP08_EEI 1703 Page 7

9 DECIPTION DECIPTION EQUIED O IEA 02 Interchange Control OP08_EEI 1703 Page 8