Attachment-F FSCJ Current System Technical Specifications

Attachment-F FSCJ Current System Technical Specifications The College utilizes PeopleSoft HCM 9.2 for Benefits Administration. The below describes the process currently utilized that may potentially have reusability. The college technical team will require specifications and requirements for mapping of fields to create the necessary file format for transfer. PeopleSoft has provided a base SQR that uses the Benefits Snapshot tables to build interface files. For Health plans the SQR is BEN102. The College has used this delivered functionality as the baseline to build a custom program by changing the field values as needed. These files are in the HIPAA compliant 834 format. That is what the BEN102 SQR will create, so changes to the program should consist exclusively of what values populate the fields. Record layouts and records creates should remain consistent with the delivered program. 2.5 Envelope Header Records DDBENX00 is an Example of an assigned Sender for entry into the EDI Enterprise System. The other fields depicted are as described in the Traders Handbook. EDI ISA INTERCHANGE CONTROL HEADER EXAMPLE EDI Envelope ments ISA*00* *00* *ZZ*DDBENX00 *ZZ*942411167 *021011*2142*^*00501*000000021*0*P*>~ GS*BE*DDBENX00*942411167*20021011*2142*000000021*X*005010X220A1~ ST*834*000000021*005010X220A1~ Note: The shading in the above ISA header implies the spacing is to remain in the ISA 1

1.1 Envelope Trailer Records EDI ISA INTERCHANGE TRAILER EXAMPLE EDI Envelope ments SE*18508*000000021~ GE*1*000000021~ IEA*1*000000021~ 1.2 Separators Sub-element Separators, Elements Separators and ment Terminator: Separators are used between fields in a segment and between segments in the transmission file to allow for field compression and block transmission. Once specified in the Interchange Header, the characters are not to be used in any data element (see HIPAA Guides Appendix A.1.2.7). Misuse of these fields will cause the file to be rejected. EDI Sub-element, Element and Terminator EDI Separators CHARACTER NAME Sub-element Separator- ISA16: : (Colon or any other character not contained within file) Element Separator......: * (Asterisk) ment Terminator.....: ~ (Tilde) 1.3 Telecommunications Files can be transmitted using SFTP or some other mutually agreeable secure transfer protocol. 2

HEADER (Rept) / Name Min/ Max /Purpose Example/Values/ Delta Usage Trading Partner Header ISA Interchange Control Header REQUIRED Fixed Record ment that identifies key control components of the interchange. ISA*00*.*00*.*ZZ* DDPPGGGGG*ZZ*94241167 *YYMMDD*HHMM*^*00501*23 4567234*1*T*:~ ISA01 Authorization Information R 2/2 Identifies the type of information in ISA02 Authorization Information 00 No Auth Info Present ISA02 Authorization Information R AN 10/10 Additional identification or authorization information about the Sender. Blanks ISA03 Security Information R 2/2 Identifies the type of information in ISA04 Security Information 00 No Sec Info Present ISA04 Security Information R AN 10/10 Additional security information about the Sender Blanks ISA05 Interchange R 2/2 Identifies the system/method of code structure used to designate the sender or receiver element being qualified ZZ Mutually Defined ISA06 Interchange Sender R AN 15/15 Sender code DDPPGGGGG where PP is plan code and GGGGG is the group number ISA07 Interchange R 2/2 Identifies the system/method of code structure used to designate the sender or receiver element being qualified ZZ Mutually Defined

(Rept) / Name Min/ Max /Purpose Example/Values/ Delta Usage Trading Partner ISA08 Interchange Receiver R AN 15/15 Receiver code 942411167 ISA09 Interchange Date R DT 6/6 Date of interchange YYMMDD Date file was created ISA10 Interchange Time R TM 4/4 Time of interchange HHMM Time file was created ISA11 Interchange Control Standards Identifier R 1/1 Identifies agency responsible for control standard in headers/trailers ^ US EDI Community (ASC,TDCC,UCS) ISA12 Interchange Control Version R 5/5 Identifies the version number of the control standards 00501 Draft Publication for ASC ISA13 Interchange Control R N0 9/9 Control number assigned by sender. Must be identical to the Interchange Trailer (IEA02) Sender Defined - Unique control number assigned by originator. Begin submitting transactions using the number 0001 in this element and increment from here. ISA14 Acknowledgeme nt uested R 1/1 sent by sender to request interchange acknowledgement (TA1) 0 No acknowledgement requested ISA15 Usage Indicator R 1/1 Identifies whether interchange data is test (T) or production (P) data T Test P Production ISA16 Component Element Separator R 1/1 Identifies the delimiter used to separate multiple component data elements : pg. 4

(Rept) / Name Min/ Max /Purpose Example/Values/ Delta Usage Trading Partner within a composite data structure Header GS Functional Group Header GS01 Functional Identifier REQUIRED Identifies the beginning of the functional group and provides interchange control information. R 2/2 Identifies the a group of related translations sets GS*BE*SENDER CODE*RECEIVER CODE*19990101*0915*1*X*00 5010X220A1~ BE GS02 Applications Sender s R AN 2/15 Identifies party sending transmission; agreed to by trading partners Sender Same as ISA06 GS03 Applications Receivers R AN 2/15 Identifies party receiving transmission; agreed to by trading partners Receiver Same as ISA08 GS04 Date R DT 8/8 Transmission creation date format CCYYMMDD GS05 Time R TM 4/8 Transmission creation time format HHMM GS06 GS07 Group Control Responsible Agency R N0 1/9 Assigned number originated and maintained by the sender. This number must be identical to GE02 R 1/2 used to identify the issuer of the standard, used with GS08 below Sender - Same as GE02 suppressing leading zeroes X Accredited Standards Committee pg. 5

(Rept) / Name Min/ Max /Purpose Example/Values/ Delta Usage Trading Partner GS08 Version/Release / Industry Header ST Transaction Set Header R AN 1/12 indicating the version, release, sub-release, and industry identifier of the EDI standard being used, including GS and GE segments R 1 REQUIRED - Indicate start of a transaction set and to assign a control number 005010X220A1 ST*834*0001*005010X220A1~ ST01 Transaction Set R 3/3 Used by translation routines of the interchange partners to select the appropriate transaction set definition 834 Benefit Enrollment ST02 Transaction Set Control R AN 4/9 Unique control number assigned by originator. Begin submitting transactions using the number 0001 in this element and increment from here. ST02 and SE02 must be identical. 0001 ST03 Implementation Convention Reference S AN 1/35 Reference assigned to identify the implementation convention Sender Same as GS08 pg. 6

DETAIL Header BGN BGN01 BGN02 Name Beginning ment Beginning ment Transaction Set Purpose Reference /Purpose Example Trading Partner REQUIRED HEADER R 1 Indicates the beginning of the transaction set. (BGN) R 2/2 Identifies the purpose of the transactions. Initial submission, Re-submission or Correction ( Change), or Informational / Lost / Copy (Same ) R AN 1/30 Transaction set identifier code, Assigned by the sending application BGN03 Date R DT 8/8 Identifies the date the submitter created this file (CCYYMMDD) BGN04 Time R TM 4/8 Identifies time of day that submitter created this file. Unique Time Stamp (HHMM) BGN05 Time S 2/2 Utilized to identify time zone changes If needed. Identifies sender time zone BGN06 Reference S AN 1/50 BGN07 Not Used Place Holder Asterisk * BGN*00*11227*19990101*1200*ESIf sending multiple ***4*~ groups on one file, send each group within their own BGN segments 00 - Original Sender Define - Unique control number assigned by originator. Begin submitting transactions using the number 0001 in this element and increment from here. CCYYMMDD HHMM ET Eastern Time CT Central Time MT Mountain Time PT Pacific Time BGN08 Action R 1/2 Used to identify file action. Update records only file or 2 - Update (Changes Only) 4 - Verify (Full File) RX Replacement File pg. 7 Adding qualifier RX to signify replacement file.

Name audit / verify full enrollment file. BGN09 Not Used Place Holder Asterisk * /Purpose Example Trading Partner REF REF01 REF02 Transaction Set Policy Reference Reference S 1 Utilized when a unique group number applies to the entire transaction set R 2/3 Master policy number reference code - 38 REF*38*PA12345 R AN 1/50 Master group number Delta required values: 38 PPGGGGG PP=Delta Assigned Plan GGGGG = 5 Digit numeric Group number DTP File Effective Date S >1 Identifies the start of the eligibility reporting for all transactions in the file. DTP01 DTP02 Date Time Date Time Period Format DTP*007*D8*19990101~ R 3/3 007 - Effective Date R 2/3 D8 The start date of the eligibility reporting period. This date can vary by group or division. Separate files are to be sent for separate reporting periods. Please contact your Delta Enrollment representative for further information. pg. 8

Name /Purpose Example Trading Partner DTP03 Date Time Period R AN 1/35 CCYYMMDD Header 1000A (1) Sponsor Name REQUIRED LOOP - This loop identifies the group N1 Sponsor Name R 1 Utilized to identify the plan sponsor (employer, union, etc) N1*P5**FI*91042134~ N101 Entity R 2/3 Plan Sponsor Entity = P5 P5 N102 Name S AN 1/60 Sender Name (Free Text) Sender defined N103 R 1/2 Until HIPAA EIN finalized use Federal Tax Payers identifier (FI), Once HIPAA EIN finalized use (ZZ) N104 R AN 2/80 If N103 = FI then Fed. Taxpayer (9 AN) FI Federal Taxpayer's Header 1000B (1) Payer REQUIRED LOOP - This loop identifies Delta N1 Payer R 1 Identifies the payer. Delta N1*IN**FI*942411167~ Dental Member Plans that pay claims or administer the services N101 Entity R 2/3 Insurer = IN IN N102 Name S AN 1/60 Payer Name (Free Text) Delta Dental of California Delta Dental Insurance Company Delta Dental of Pennsylvania Delta Dental of New York Delta Dental of West Virginia Delta Dental of Delaware Delta Dental of Washington DC pg. 9

Header 1000C (1) N103 Name R 1/2 Until HIPAA National Plan finalized, use Federal Tax Payers identifier (FI), once HIPAA Plan finalized use (XV) N104 R AN 2/80 If N103 = FI then Fed. Taxpayer (9 AN) If N103 = XV then HIPAA National Plan TPA/Broker Name /Purpose Example Trading Partner SITUATIONAL LOOP - This loop is required if a TPA/broker is involved N1 TPA/Broker Name S 1 If the loop is required, this segment is required N101 Entity R 2/3 If Broker utilize BO If TPA utilize TV N102 Name S AN 1/60 Payer Name (Free Text) FI 942411167 N1*TV**FI*123345456~ BO Broker or Sales Office TV Third Party Administrator N103 R 1/2 Until HIPAA National Plan finalized, use Federal Tax Payers identifier (FI), once HIPAA Plan finalized use (XV), or 94 for organization code FI pg. 10

Header 1100C (1) Name N104 R AN 2/80 If N103 = FI then Fed. Taxpayer (9 AN) If N103 = XV then HIPAA National Plan If N103 = 94 then organization defined code ACT TPA/Broker Account Information TPA/Broker Account Information /Purpose Example Trading Partner SITUATIONAL LOOP - This loop is required if the account number of TPA or Broker is different than the plan sponsor S 1 If the loop is required, this segment is required ACT01 Account R AN 1/35 TPA or Broker Account ACT02 Not Used Place Holder Asterisk * ACT03 Not Used Place Holder Asterisk * ACT04 Not Used Place Holder Asterisk * ACT05 Not Used Place Holder Asterisk * ACT06 Account R AN 1/35 Secondary TPA or Broker Account (If more than 1) Federal Tax Payers ACT*1234*****45678~ Detail 2000 INS Member Detail Member Detail SITUATIONAL LOOP - In this loop, subscriber information must precede dependent information or the subscriber information must have been submitted to the receiver in a previous transmission S 1 If the loop is required, this INS*Y*18*030**A*E**FT~ segment is required pg. 11

INS01 INS02 Name Yes/No Condition Response Individual Relationship R 1/1 Insured Indicator. A "Y" value indicates insured is a subscriber R 2/2 indicating the relationship between two individuals or entities /Purpose Example Trading Partner Y-Subscriber N-Dependent 18 - Self (subscriber) 01 - Spouse 19 - Child 53 - Life Partner 05 - Grandchild 07 - Nephew/Niece 09 - Adopted Child 10 - Foster Child 11 - Son/Daughter In law 15 - Ward 17 - Stepchild 23 - Sponsored Dependant 24 - Dependant of Dependant 25 - Ex Spouse 38 - Collateral Dependant INS03 INS04 Maintenance Maintenance Reason R 3/3 identifying the specific type of item maintenance S 2/3 identifying the reason for a maintenance change 021 - Add subscriber or dependent 001 - Change subscriber or dependent 024 - Terminate Member 025 - Reinstatement 030 - Audit or compare Not uired INS05 Benefit Status R 1/1 The type of coverage under which benefits are paid A - Active C - COBRA S - Surviving Insured T - TEFRA pg. 12

INS06 INS07 INS08 Name Medicare Plan Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Employment Status S 1/1 identifying the Medicare Plan (required if a member is being enrolled or disenrolled in Medicare or has terminated or changed their Medicare enrollment) S 1/2 A qualifying event which results in a loss of coverage for a Qualified Beneficiary (required if a member is being or is enrolled for a benefit covered by COBRA) S 2/2 showing the general employment status of an employee/claimant (required for a subscriber) /Purpose Example Trading Partner Not utilized in Delta processing Not utilized in Delta processing AO Active Oversees AU Active Military FT Full Time L1 Leave of Absence PT Part Time RT Retired TE Terminated INS09 Student Status S 1/1 Note: Delta processes P Part time student as equal to N Not a Student. F Full-time Student N Not a Student P Part Time Student INS10 INS11 Handicapped Indicator Date Time Period Format S 1/1 indicating a Yes or No Y Yes condition or response. A "Y" N - No value indicates an individual is handicapped S 2/3 Not utilized in Delta processing. INS12 Date Time Period S AN 1/35 Not utilized in Delta processing. INS13 Not Used Place Holder Asterisk * pg. 13

Name INS14 Not Used Place Holder Asterisk * INS15 Not Used Place Holder Asterisk * INS16 Not Used Place Holder Asterisk * /Purpose Example Trading Partner INS17 S NO 1/9 Birth Sequence. A Birth Sequence generic number (required if reporting family members with the same birth date, when needed for proper reporting, tracking or response to benefits) 2000 REF Subscriber REF01 Reference R 1 This is the subscriber s REF*0F*NNNNNNNNN~ identification number (typically the SSN), used to link the subscriber with dependents. R 2/3 qualifying the Reference 0F - Subscriber 17 - Member Alternate 3H - Case REF*17 to be used when REF*0F represents the subscriber SSN REF02 Subscriber R AN 1/50 Provide the subscriber s SSN Subscriber s SSN for all members (Subscriber & Dependants) REF*3H to be used for non-commercial (ie, children s health) plans only 2000 REF Member Policy S 1 This segment should be used if the policy or group number applies to all coverage data that apply for this member (required unless the policy number is sent in the REF segment, loop 2300) REF*1L*PPGGGGGDDDDD~ Preference is always to have the Group and Division s passed in the 2000 loop versus the 2300 loop pg. 14

REF01 REF02 Name Reference Reference /Purpose Example Trading Partner R 2/3 qualifying the Reference 1L R AN 1/50 Reference information as defined for a particular Transaction Set or as specified by the Reference Delta required values: PPGGGGGDDDDD. Example: PA1234500001 Indicator identifying number of prior months insurance coverage that may apply under the portability provisions of HIPAA PP=Delta Assigned Plan GGGGG = 5 Digit numeric Group number assigned by Delta DDDDD = 5 digit Sub-location/Division 2000 REF Member REF01 Reference S 5 This segment is used to pass further identifying information on the member. It should be used if the data is available. S 2/3 qualifying the Reference DX REF*DX*SSSSS~ REF02 Reference S AN 1/50 Additional Identifying information Store Location/Employer Specific Reference 2000 DTP Member Dates DTP01 DTP02 Date/Time Date Time Period Format S 20 Identifies the eligibility begin and end dates for a member. R 3/3 specifying type of date or time, or both date and time R 2/3 indicating the date format, or date and time format DTP*356*D8*19960705~ 356 Benefit Begin 357 Benefit End D8 pg. 15

Name DTP03 Date Time Period R AN 1/35 Expression of a date, a time, or range of dates, times or dates and times /Purpose Example Trading Partner CCYYMMDD Detail 2100A (1) Member Name REQUIRED LOOP - This loop is used to identify a member. NM1 Member Name R 1 NM1*IL*1*SMITH*JOHN*M**SR*34 *999999999~ NM101 NM102 NM103 NM104 Entity Identifier Entity Member s Last Name Member s First Name Member s Middle Name R 2/3 identifying an organizational entity, a physical location, property or an individual IL R 1/1 qualifying the type of 1 (Person) entity R AN 1/60 Member s Last Name Omit leading spaces S AN 1/35 Member s first name Omit leading spaces NM105 S AN 1/25 Member s middle name or Omit leading spaces initial NM106 Not Used Place Holder Asterisk * NM107 Name Suffix S AN 1/10 Suffix to individual name (if supplied by subscriber) NM108 S 1/2 34 (NM109 must equal Member SSN) pg. 16

Name /Purpose Example Trading Partner NM109 S AN 2/80 SSN The member s SSN (do not default to employee SSN, if unknown do not send NM108 and NM109) 2100A PER Member Communications S 1 PER*IP*Joe Smith*EM*jsmith@email.com~ PER01 Contact Function R 2/2 IP Insured Party PER02 Member Name S AN 1/60 PER03 Communication S 2/2 Communication type identifier CP Cellular Telephone EM Electronic Mail HP Home Phone WP Work Phone TE Telephone AP Alternate Telephone PER04 Communication S AN 1/256 PER05 PER06 PER07 PER08 PER09 Communication Communication Communication Communication Contact Inquiry Reference S 2/2 Communication type identifier CP Cellular Telephone EM Electronic Mail HP Home Phone WP Work Phone TE Telephone AP Alternate Telephone S AN 1/256 S 2/2 Communication type identifier CP Cellular Telephone EM Electronic Mail HP Home Phone WP Work Phone TE Telephone AP Alternate Telephone S AN 1/256 S AN 1/20 pg. 17

Name /Purpose Example Trading Partner 2100A N3 Member Residence Street Address N301 N302 Address Information Address Information 2100A N4 Member Residence City, State, ZIP S 1 This segment is required when enrolling subscriber, when enrolling a dependent and the dependent's address is different from subscriber, and when changing a member's address. R AN 1/55 First line of street address. Delta uses only the first 30 bytes. S AN 1/55 Second line of street address. Delta uses only the first 30 bytes. S 1 This segment is required when enrolling subscriber, when enrolling a dependent and the dependent's address is different from subscribers and when changing a member's address. N401 City Name R AN 2/30 Free-form text for city name N3*50 ORCHARD STREET~ N4*HARRISBURG*PA*99999~ N402 State or Province R 2/2 (Standard State/Province) as defined by appropriate government agency N403 Postal R 3/15 defining international postal zone code excluding punctuation and blanks (zip code for United States) pg. 18

Name N404 Country S 2/3 Identifying the country (required only if country is not USA) N405 Location S 1/2 identifying type of location /Purpose Example Trading Partner Not utilized in Delta processing N406 Location Identifier S AN 1/30 which identifies a specific location (required when under the insurance Not utilized in Delta processing contract between sponsor and payer and allowed by federal and state regulations) 2100A DMG Member Demographics S 1 This segment is required DMG*D8*19450915*F*M~ when enrolling a new member or when changing a member's demographic information DMG01 Date Time Period Format R 2/3 indicating the date format, or date and time format D8-Date Expressed in Format DMG02 Date Time Period R AN 1/35 Member birth date. Expression of a date, a time, or range of dates, times or dates and times DMG03 Gender R 1/1 indicating the gender of the individual DMG04 Marital Status S 1/1 defining the marital status of a person CCYYMMDD F Female M Male DMG05 Race or Ethnicity S 1/1 indicating the racial or ethnic background of a person. pg. 19

DMG06 Name Citizenship Status S 1/2 indicating citizenship status /Purpose Example Trading Partner 2100A EC Employment Class S 1 Not utilized in Delta processing Refer to employment status (INS08) in INS ment 2100A ICM Member Income S 1 Not utilized in Delta processing 2100A AMT Member Policy Amounts S 5 Not utilized in Delta processing 2100A HLH Member Health Information S 1 Not utilized in Delta processing 2100A LUI Member Language S 5 LUI01 R 1/2 LD NISO Z39.53 LE ISO 639 LUI02 R AN 2/80 Language LUI03 LUI04 LUI05 Language Description Use of Language Indicator Language Proficiency Indicator R AN 1/80 Language Description S 1/2 5 - Reading 6 - Writing 7 - Speaking 8 - Native Language S 1/1 pg. 20

2100B 2100B Detail 2100C (1) NM1 NM101 NM102 N3 N301 N302 N3 Name Incorrect Member Name Incorrect Member Demographics Member Mailing Address Member Mailing Address Entity Identifier Entity Member Mail Street Address Address Information Address Information Member Mail City, State, Zip /Purpose Example Trading Partner SITUATIONAL LOOP - This loop is to be sent if the member has a mailing address different from the residence address sent in loop 2100A (send when enrolling a dependent and the dependent's address is different from the subscriber and when changing a member's address). S 1 If the loop is required, this NM1*31*1~ segment is required R 2/3 identifying an organizational entity, a physical location, property or an individual R 1/1 qualifying the type of entity S 1 Send when needed for address in loop 2100C R AN 1/55 Address Information S AN 1/55 Address Information (required if a second address line exists) S 1 Send when needed for address in loop 2100C N401 City Name R AN 2/30 Free-form text for city name Not utilized in Delta Processing Not utilized in Delta Processing 31 1 N402 State or Province R 2/2 (Standard State/Province) as defined by pg. 21

Detail 2100D (3) Detail 2100E (3) Detail 2100F (1) Detail 2100G (1) Name /Purpose Example Trading Partner appropriate government agency N403 Postal R 3/15 defining international postal zone code excluding punctuation and blanks (zip code for United States) N404 Country S 2/3 Identifying the country (required only if country is not U.S.A.) Member Employer Member School Custodial Parent Not utilized in Delta processing Not utilized in Delta processing Not utilized in Delta processing Not utilized in Delta processing Responsible Party To be used in cases where sender plan is a non commercial (i.e., Children s Health Plan) NM1 Member Name R 1 NM1*QD*1*SMITH*JOHN*M**SR*3 4~ NM101 NM102 NM103 NM104 NM105 Entity Identifier Entity Member s Last Name Member s First Name Member s Middle Name R 2/3 identifying an organizational entity, a physical location, property or an individual R 1/1 qualifying the type of entity QD Responsible Party 1 (Person) R AN 1/60 Member s Last Name Omit leading spaces S AN 1/35 Member s first name Omit leading spaces S AN 1/25 Member s middle name or initial Omit leading spaces pg. 22

Name NM106 Not Used Place Holder Asterisk * NM107 Name Suffix S AN 1/10 Suffix to individual name (if supplied by subscriber) NM108 /Purpose Example Trading Partner S 1/2 Not uired for Responsible Party NM109 S AN 2/80 Not uired for Responsible Party 2100G PER Responsible Persons Communications PER01 Contact Function PER02 Responsible Persons Name PER03 PER04 PER05 PER06 Responsible Persons Communication Responsible Persons Communication Responsible Persons Communication Responsible Persons Communication S 1 To be used in cases where sender plan is a non commercial (i.e., Children s Health Plan) PER*RP***HP*5555555555~ R 2/2 RP Responsible Party S AN 1/60 S 2/2 Communication type identifier CP Cellular Telephone EM Electronic Mail HP Home Phone WP Work Phone TE Telephone AP Alternate Telephone S AN 1/256 S 2/2 Communication type identifier CP Cellular Telephone EM Electronic Mail HP Home Phone WP Work Phone TE Telephone AP Alternate Telephone S AN 1/256 pg. 23

PER07 Name Responsible Persons Communication PER08 Responsible Persons Communication PER09 Responsible Persons Contact Inquiry Reference 2100G N3 Responsible Persons Residence Street Address N301 Responsible Persons Address Information N302 Responsible Persons Address Information 2100G N4 Responsible Persons Member Residence City, State, ZIP N401 N402 Responsible Persons City Name Responsible Persons State or Province /Purpose Example Trading Partner S 2/2 Communication type identifier CP Cellular Telephone EM Electronic Mail HP Home Phone WP Work Phone TE Telephone AP Alternate Telephone S AN 1/256 S AN 1/20 S 1 To be used in cases where sender plan is a non commercial (i.e., Children s Health Plan) R AN 1/55 First line of street address. Delta uses only the first 30 bytes. S AN 1/55 Second line of street address. Delta uses only the first 30 bytes. S 1 This segment is required when enrolling subscriber, when enrolling a dependent and the dependent's address is different from subscribers and when changing a member's address. R AN 2/30 Free-form text for city name R 2/2 (Standard State/Province) as defined by appropriate government agency N3*50 ORCHARD STREET~ N4*HARRISBURG*PA*99999~ pg. 24

N403 N404 N405 N406 Name Responsible Persons Postal Responsible Persons Country Responsible Persons Location Responsible Persons Location Identifier R 3/15 defining international postal zone code excluding punctuation and blanks (zip code for United States) S 2/3 Identifying the country (required only if country is not USA) S 1/2 identifying type of location /Purpose Example Trading Partner Not utilized in Delta processing S AN 1/30 which identifies a specific location (required when under the insurance Not utilized in Delta processing contract between sponsor and payer and allowed by federal and state regulations) Detail 2200 (1) Detail 2300 (99) Disability Information Health Coverage SITUATIONAL LOOP - This loop is required when enrolling a new member or when adding, updating or removing coverage from an existing member. HD Health Coverage S 99 If the loop is required, this segment is required. HD01 Maintenance R 3/3 identifying the specific type of item maintenance Not utilized in Delta processing HD*021**HLT*PLAN A BCD*FAM~ 021 - Add subscriber or dependent 001 - Change subscriber or dependent 024 - Terminate Member 025 - Reinstatement 030 - Audit or Compare (full roster) INS10 uses to qualify handicapped dependant pg. 25

Name HD02 Not Used Place Holder Asterisk * /Purpose Example Trading Partner HD03 Insurance Line R 3/3 identifying a group of insurance products DEN Dental DCP Dental HMO VIS Vision HD04 HD05 Plan Coverage Description Coverage 2300 DTP Health Coverage Dates DTP01 Date/Time S AN 1/50 A description or number that identifies the plan or coverage S 3/3 indicating the level of coverage being provided for this insured. R 10 This segment contains the date that maintenance was performed or effective, and the benefit begin and end dates for the coverage or line of business. R 3/3 specifying type of date or time, or both date and time DTP*348*D8*19961001~ 303 - Maintenance Effective 348 - Benefit Begin 349 - Benefit End Not utilized in Delta Processing. For sender purposes only Not utilized in Delta Processing; Delta Dental will autocalculate all coverage options When sending benefit end date, DTP*349 must be accompanied with a corresponding DTP*348 segment. DTP02 Date Time Period Format R 2/3 indicating the date format, time format, or date and time format DTP03 Date Time Period R AN 1/35 Expression of a date, a time, or range of dates, times or dates and times D8 - Date Expressed in Format CCYYMMDD pg. 26

AMT REF REF01 REF02 Name Health Coverage Policy Health Coverage Policy Reference Reference /Purpose Example Trading Partner S 3 This data should only be transmitted when such Not utilized in Delta processing. transmission is required under the insurance contract between the sponsor and payer. S 2 This segment should be used REF*1L*PA1234500001 to identify a policy or group number for a particular insurance product if it has not already been identified in either REF02, position 1-030 or REF02, position 2-020. This is necessary when not all coverage types have the same group or policy number. R 2/3 qualifying the Reference 1L R AN 1/50 Delta required values: PPGGGGGDDDDD Example: PA1234500001 Note that Delta Dental preference is for the group and division to be passed in the 2000 loop. PP=Delta Assigned Plan GGGGG = 5 Digit numeric Group number assigned by Delta DDDDD = 5 digit Sub-location/Division C Card S 10 Not utilized in Delta processing pg. 27

Name /Purpose Example Trading Partner Detail 2310 (30) Detail 2310 (30) LX Provider Information 1 SITUATIONAL LOOP - Use this loop to provide information about primary care or capitated physicians and pharmacies chosen by the enrollee in a managed care plan when that selection is made through the sponsor. Use one iteration of the loop to identify each applicable health care service provider. LX01 Assigned R N0 1/6 Represents the number of loops for the insured person NM Provider Name 1 Used to supply the full name of the individual or organizational entity NM101 Entity Identifier LX*1~ R 2/3 QN Dentist Y2 Managed Care Organization FA Facility 1X Laboratory NM102 Entity R 1/1 1 Person 2 Non-Person Entity NM103 Last Name or Organization Name S AN 1/60 uired when NM102 = 1 or 2 NM104 First Name S AN 1/35 Provider first name Omit leading spaces 1 NM105 Middle Name S AN 1/25 Provider middle name or initial Omit leading spaces NM106 Name Prefix Place Holder Asterisk * NM107 Name Suffix Place Holder Asterisk * pg. 28

NM108 NM109 NM110 NM111 NM112 Name Entity Relationship Entity Identifier Last Name or Organization Name S 1/2 SV Service provider /Purpose Example Trading Partner S AN 2/80 Sender must send 6- digit Delta Care Provider. S 2/2 25 Established Patient 26 Non-Established Patient 72 - Unknown Place Holder Asterisk * Place Holder Asterisk * TRAILER / Name Min/ Max /Purpose Example/Values/ Delta Usage Trading Partner Trailer Trans SE Transaction Set Trailer R 1 REQUIRED - Indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning ST and ending SE segments). SE*211*0001~ SE01 of Included ments R N0 1/10 Transaction ment Count. pg. 29

SE02 Transaction Set Control R AN 4/9 The Transaction Set Control s in ST02 and SE02 must be identical. This number is assigned by the originator and must be unique within a functional group (GS-GE) and interchange (ISA-IEA). This unique number also aids in error resolution research. 0001 Count the number of segments between and including the ST & SE segments. Do not count the ISA or GS segments. Limit only 10,000 segments may be within a ST/SE loop. Trailer Funct. Group GE Functional Group Trailer REQUIRED Defines end of a Functional Group GE*1*1~ GE01 of Transaction Sets Included R N0 1/6 Total number of transactions sets included in the functional group or interchange group terminated by this trailer GE02 Group Control R N0 1/9 Control number assigned by sender. Must be identical to the Functional Group Header (GS06) Trailer Env IEA Interchange Control Trailer REQUIRED Defines end of Interchange IEA*1*234567234~ IEA01 of Included Functional Groups R N0 1/5 A count of the number of functional groups included in this interchange IEA02 Interchange Control R N0 9/9 Control number assigned by sender. Must be identical to the Interchange Header (ISA13) pg. 30