Anthem Blue Cross and Blue Shield. 834 Companion Guide

Anthem Blue Cross and Blue Shield 834 Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance Transactions Incoming to the Electronic Enrollment System (EES) Anthem Blue Cross and Blue Shield Southeast Region IG Version: 004010X095A1 CG Release: 1.0 (September 2003)

This page is intentionally blank.

Chapter 1: Introduction...1 1.1 HIPAA Purpose... 1 1.2 Overview of ANSI ASC X12 Transactions... 1 1.3 ASC X12N Implementation Guides (IGs)... 2 1.4 ASC X12N 834 Implementation Guide (IG)... 2 1.5 834 Companion Guide (CG) Use along with the IG... 2 1.6 Version and Release Numbers... 2 1.7 Anthem Electronic Enrollment System Implementation Cycle... 2 1.8 Conventions for Charts... 3 1.8.1 Normal Text... 3 1.8.2 Italics... 3 1.8.3 Parentheses... 4 1.8.4 Shaded Cells...4 Chapter 2: Envelope Control Segments 5 2.1 Interchange Control Header (ISA)...5 2.2 Interchange Control Trailer (IEA)...6 2.3 Functional Group Header (GS)...7 2.4 Functional Group Trailer (GE)...7 Chapter 3: Acknowledgments...8 3.1 Functional Acknowledgment (997)...8 3.1.1 997 Delimiters...8 3.1.2 997 Transaction...8 3.1.3 997 Error Code Description...9 3.2 Interchange Acknowledgment (TA1). 10 3.2.1 TA1 Delimiters... 10 3.2.2 TA1 Transaction... 10 3.2.3 TA1 Error Code Description... 11 Chapter 4: 834 Transaction Set...13 4.1 Basic Instructions... 13 4.1.1 Receipt Time for Same Day Processing... 13 4.1.2 834 Send Frequency... 13 4.1.3 Full 834 Transactions... 13 4.1.4 Policy/834 Agreement for Spouse/Dependent Coverage. 14 Table of Contents 4.1.5 Changing PCP...14 4.1.6 Changing Insurance Line...14 4.2 834 Header...15 4.3 834 Detail...16 4.4 834 Trailer...20 Chapter 5: Common Errors & FAQs... 21 5.1 Common Errors...22 5.1.1 Full 834 Transactions...22 5.1.2 Accurate Group Number...22 5.1.3 Always Enter a Health Coverage Date...22 5.1.4 New Policy Effective Date to Change: Coverage Level Code Plan Coverage Description Group Number Insurance Line Code...23 5.1.5 Keep Existing Policy Date Effective when: Adding a Member Changing an Address...23 5.1.6 To Change Insurance Line, Send Two 834 Transactions...23 5.1.7 Policy/834 Agreement for Spouse/Dependent Coverage...24 5.1.8 ID PCP when Adding Members to a POS or HMO Policy...24 5.1.9 To Change PCP, Employee Calls Anthem Customer Service...24 5.2 Frequently Asked Questions (FAQs)..25 5.2.1 Type of File HIPAA- Compliant 834 Transaction...25 5.2.2 No Charge for Electronic Enrollment...25 5.2.3 ID Cards...25 5.2.4 ID Card Replacement...25 5.2.5 File Transfer Methods...25 5.2.6 Full 834 Files Only...25 5.2.7 Anthem Contact...25 5.2.8 834 Send Frequency...26 5.2.9 997s...26 5.2.10 TA1s...26 IG Version 004010X095A1 Anthem Blue Cross Blue Shield CG Release 1.0 (September 2003) Southeast Region i

Group-Specific Data Elements Values for the following data elements are specific for each group. Ask your Marketing Representative to provide the appropriate values and note them below. 834 Envelope Control Segment Reference Designator/Name Value ISA Interchange Control Header (834 IG Page B.3) GS Functional Group Header (834 IG Page B.8) 834 Detail Level ISA06 Interchange Sender ID GS02 Application Sender s Code (Insert value on page 5.) Note: The Interchange Sender ID is the same value as the Application Sender s Code in GS02. (Insert value on page 7.) Note: The Application Sender s Code is the same value as the Interchange Sender ID in ISA06. Loop Segment Reference Designator/Name Value(s) 2000 Member Level Detail INS Member Level Detail (834 IG Page 43) INS02 Individual Relationship Code (Insert values on page 16.) 2000 Member Level Detail REF Member Policy Number (834 IG Page 53) REF02 Insured Group or Policy Number (Insert value on page 17.) 2300 Health Coverage HD Health Coverage (834 IG Page 128) HD04 Plan Coverage Description (Insert value on page 18.) 2300 Health Coverage HD Health Coverage (834 IG Page 128) HD05 Coverage Level Code (Insert values on page 18.) Anthem Blue Cross Blue Shield IG Version 004010X095A1 ii Southeast Region CG Release 1.0 (September 2003)

Chapter 1 Introduction Anthem Blue Cross and Blue Shield (Anthem) is pleased to provide this Companion Guide (CG) to help employer groups or their representatives to produce a HIPAA-compliant 834 Benefit Enrollment and Maintenance transaction. The purpose of this Companion Guide is to simplify the implementation of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 provisions for administrative simplification that support the electronic exchange of benefit enrollment and maintenance information. Use this Companion Guide in conjunction with the ASC X12N 834 Implementation Guide. This chapter is divided into the following sections: Section 1.1 HIPAA Purpose... 1 1.2 Overview of ANSI ASC X12N Transactions... 1 1.3 ASC X12N Impleme ntation Guides (IGs)... 2 1.4 ASC X12N 834 Implementation Guide (IG)... 2 1.5 834 Companion Guide Use along with the IG... 2 1.6 Version and Release Numbers... 2 1.7 Anthem Electronic Enrollment System Implementation Cycle... 2 1.8 Conventions for Charts... 3 Page 1.1 HIPAA Purpose The primary purpose of HIPAA is to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs. To this end, the legislation covers two key areas, health insurance portability and administrative simplification. 1.2 Overview of ANSI ASC X12N Transactions The American National Standards Institute (ANSI) is the recognized coordinator and clearinghouse for regional standards. ANSI approves standards for Electronic Data Interchange (EDI) developed by the Accredited Standards Committee (ASC) X12. The ASC X12N subcommittee develops standards for insurance. The ANSI ASC X12N subcommittee developed the nine standard health care transactions to support HIPAA requirements for administrative simplification. Organizations using electronic commerce to perform transactions covered by HIPAA must consistently comply with the applicable ANSI ASC X12N standards. The nine ANSI ASC X12N standards that specify health care transactions include the following: 270/271 Health Care Eligibility Benefit Inquiry and Response 276/277 Health Care Claim Status Request and Response 278 Health Care Service Review Request for Review and Response 820 Payroll Deducted and Other Group Premium Payment for Insurance Products 834 Benefit Enrollment and Maintenance 835 Health Care Claim Payment/Advice 837 Health Care Claim (One each for Professional, Institutional, and Dental transactions) IG Version 004010X095A1 Anthem Blue Cross Blue Shield CG Release 1.0 (September 2003) Southeast Region 1

1.3 ASC X12N Implementation Guides (IGs) An ASC X12N Implementation Guide (IG) is developed for each ANSI ASC X12N standard transaction. The IGs explain the proper use of a standard for a specific business purpose. The ASC X12N IGs are the primary reference documents used by organizations implementing the associated transactions. 1.4 ASC X12N 834 Implementation Guide (IG) The ASC X12N 834 IG provides standard data requirements and content for users of ANSI ASC X12.84 Benefit Enrollment and Maintenance (834), hereafter called the 834 or the 834 transaction. The 834 transaction transfers benefit enrollment and maintenance information from the group or vendor to a payer. 1.5 834 Companion Guide (CG) Use along with the IG Use the information in this Companion Guide in conjunction with the ASC X12N 834 Implementation Guide; hereafter referred to as the 834 Implementation Guide or 834 IG. This Companion Guide is intended to simplify implementation. As explained in the 834 IG, this document does not: Modify the definition, condition, or use of a data element or segment in the standard Implementation Guide, Add additional data elements or segments to the standard, Utilize any code or data values which are not valid in the standard Implementation Guide, or Change the meaning or intent of the standard Implementation Guide. 1.6 Version and Release Numbers For this Companion Guide, the version number corresponds with the version number of the 834 IG. The version and release for this document are as follows: IG Version: 004010X095A1 CG Release: 1.0 (September 2003) As Anthem updates this Companion Guide, the new version number will correspond with the new version number of the updated 834 IG. If Anthem updates this Companion Guide with changes that do not result from an updated 834 IG, the version number will remain the same as for the 834 IG, but the release number will change. 1.7 Anthem Electronic Enrollment System Implementation Cycle Groups or vendors interested in transmitting 834 transactions to Anthem should discuss the process with their Marketing Representative. Basically, the process is as follows: 1. The Marketing Representative discusses electronic enrollment with the group to assess the group s ability to generate a compliant 834. Anthem Blue Cross Blue Shield IG Version 004010X095A1 2 Southeast Region CG Release 1.0 (September 2003)

2. The Marketing Representative provides the group with this Companion Guide and other pertinent data such as the group number and the contact number(s) for their Anthem Enrollment Coordinator. 3. Anthem and the group or vendor undergo a testing process. During this phase, the Marketing Representative and the Enrollment Coordinator work with the group/vendor to resolve any issues and keep them informed of the testing status. Once all issues are resolved, the group/vendor can begin production. 1.8 Conventions for Charts Most segments and data elements are fully explained in the 834 IG and require no additional information. This Companion Guide provides information only about data elements that require specific instructions to efficiently process through our systems. This Companion Guide presents data elements in a chart format and in the same order as in the 834 IG. If a data element does not need specific information for processing, then it is not documented in the charts. The charts in this Companion Guide show values in the following ways: 1.8.1 Normal text (No Italics or Parentheses) Enter values written in normal text, exactly as they appear in the Value column. In the following example, the value for the 1000B, N104 is the Federal Taxpayer Identification Number. Enter the value exactly as shown in the chart. Loop 1000B Reference Designator/Name Value N104 54-0357120 Insurer Identification Code 1.8.2 Italics Information printed in italics provides instruction or definition for the value. In the following example, the first line, For Anthem, enter one of the following codes: provides instructions. Beside each potential value (DEN, HMO, POS, or PPO), italicized terms define the value s meaning. Loop 2300 Reference Designator/Name Value HD03 Insurance Line Code For Anthem, select the code for your line of business: DEN HMO POS PPO Dental Benefit Health Maintenance Organization Point of Service Preferred Provider Organization IG Version 004010X095A1 Anthem Blue Cross and Blue Shield CG Release 1.0 (September 2003) Southeast Region 3

1.8.3 Parentheses ( ) Values written in parentheses explain the data to be entered. In the following example, enter the group number assigned by Anthem. Loop 2000 Reference Designator/Name Value REF02 (Group Number) Insured Group or Policy Number 1.8.4 Shaded Cells If a cell within the chart is shaded, then no additional notes or definitions are necessary. The value is self-explanatory. In the following example, no additional notes or definitions are necessary for Anthem. Loop 2100A Reference Designator/Name NM109 Subscriber Identifier Value (Member s Social Security Number) Definitions and Notes Anthem Blue Cross Blue Shield IG Version 004010X095A1 4 Southeast Region CG Release 1.0 (September 2003)

Chapter 2 Envelope Control Segments This chapter provides information on electronic enveloping that will help you when sending enrollment information to Anthem. Electronic envelopes control and track interchanges. One interchange may contain many transaction sets grouped into functional groups. This chapter is divided into the following sections: Section 2.1 834 Interchange Control Header (ISA)...5 2.2 834 Interchange Control Trailer (IEA)...6 2.3 834 Functional Group Header (GS)...7 2.4 834 Functional Group Trailer (GE)...7 Page 2.1 834 Interchange Control Header (ISA) The ISA segment is the beginning, outermost level of the interchange. It contains authorization and security information, and it identifies the sender, receiver, date, time, and interchange control number. Please use the following chart in conjunction with the 834 IG. The chart provides information that is specific to Anthem. This information is supplemental and does not modify or add to information in the 834 IG. Interchange Control Header (ISA) 834 Benefit Enrollment and Maintenance This chart includes only segments and data elements requiring specific information. (834 IG Page B.3) Reference Designator/Name Value Required Notes ISA01 Authorization Information Qualifier ISA02 Authorization Information ISA03 Security Information Qualifier ISA04 Security Information ISA05 Interchange ID Qualifier ISA06 Interchange Sender ID ISA07 Interchange ID Qualifier 00 No Authorization Information Present (No Meaningful Information in 102) The value must equal 00. (10 Spaces) Enter 10 spaces. 00 No Security Information Present (No Meaningful Information in 104) The value must equal 00. (10 Spaces) Enter 10 spaces. ZZ Mutually Defined (Sender ID) 30 U.S. Federal Tax ID Number The value must equal ZZ. The Sender ID is assigned by Anthem. Copy this value from page ii, or ask your Marketing Representative. The value must equal 30. IG Version 004010X095A1 Anthem Blue Cross and Blue Shield CG Release 1.0 (September 2003) Southeast Region 5

Interchange Control Header (ISA) 834 Benefit Enrollment and Maintenance This chart includes only segments and data elements requiring specific information. (834 IG Page B.3) Reference Designator/Name Value Required Notes ISA08 Interchange Receiver ID ISA13 Interchange Control Number ISA14 Acknowledgment Requested 54-0357120 This code represents Anthem Health Plans of Virginia, Inc. This 10-byte code is left justified and followed by 5 trailing spaces. (Unique Control Number assigned by sender) Enter one of the following values: 0 No Acknowledgment Requested 1 Interchange Acknowledgment Requested Always send a unique control number in this data element to avoid duplications. The value must be identical to IEA02. As of September 2003, the only X12 acknowledgement available from Anthem for the 834 is the 997 Functional Acknowledgment. Anthem generates a 997 when the Interchange Envelope is accepted. If you would like to receive the 997, contact your Marketing Representative. At this time, the TA1 Interchange Acknowledgment is not available. 2.2 834 Interchange Control Trailer (IEA) The IEA segment is the ending, outermost level of the interchange. It indicates the number of functional groups included with the interchange and the interchange control number (the same number indicated in the ISA segment). Please use the following chart in conjunction with the 834 IG. The chart provides information that is specific to Anthem. This information is supplemental and does not modify or add to information in the 834 IG. Interchange Control Trailer (IEA) 834 Benefit Enrollment and Maintenance This chart includes only segments and data elements requiring specific information. (834 IG Page B.7) Reference Designator/Name Value Required Notes IEA01 Number of Included Functional Groups IEA02 Interchange Control Number (Number of functional groups) (Unique Control Number assigned by sender) The value is a 1 to 5-byte numeric. This value is left justified with no leading or trailing zeros. The value must equal the number of GS/GE pairs included in the interchange. Always send a unique control number in this data element to avoid duplications. The value must be identical to ISA13. Anthem Blue Cross Blue Shield IG Version 004010X095A1 6 Southeast Region CG Release 1.0 (September 2003)

2.3 834 Functional Group Header (GS) The GS segment identifies the group of transaction sets that are included within the functional group. More specifically, the GS segment identifies the functional control group, sender, receiver, date, time, group control number and version/release/industry code for the transaction sets. Please use the following chart in conjunction with the 834 IG. The chart provides information that is specific to Anthem. This information is supplemental and does not modify or add to information in the 834 IG. Functional Group Header (GS) 834 Benefit Enrollment and Maintenance This chart includes only segments and data elements requiring specific information. (834 IG Page B.8) Reference Designator/Name Value Required Notes GS02 Application Sender s Code GS03 Application Receiver s Code GS06 Group Control Number GS08 Version/Release/Industry Identifier Code (Sender ID) 058916206MEMEES (Unique control number assigned by the sender) 004010X095A1 The Sender ID is assigned by Anthem. Copy this value from page ii, or ask your Marketing Representative. This code represents Anthem Health Plans of Virginia, Inc. (DUNS plus a suffix). Always send a unique control number in this data element to avoid duplications. The value must be identical to GE02. This entry represents the X12N Benefit Enrollment and Maintenance Implementation Guide, originally published May 2000, incorporating the changes identified in the 10/2002 Addenda. 2.4 834 Functional Group Trailer (GE) The GE segment indicates the end of the functional group and provides control information. Please follow the directions in the 834 IG on page B.10. Please use the following chart in conjunction with the 834 IG. The chart provides information that is specific to Anthem. This information is supplemental and does not modify or add to information in the 834 IG. Functional Group Header (GE) 834 Benefit Enrollment and Maintenance This chart includes only segments and data elements requiring specific information. (834 IG Page B.10) Reference Designator/Name Value Required Notes GE01 Number of Transaction Sets Included GE02 Group Control Number (Total number of transaction sets) (Unique control number assigned by the sender) The value equals a 1 to 6-byte numeric. The value is left justified with no leading zeros. Always send a unique control number in this data element to avoid duplications. The value must be identical to GS06. IG Version 004010X095A1 Anthem Blue Cross and Blue Shield CG Release 1.0 (September 2003) Southeast Region 7

Chapter 3 Acknowledgments This chapter provides information about electronic acknowledgments that you may receive from Anthem. This chapter is divided into the following sections: Section 3.1 Functional Acknowledgment (997)...8 3.2 Interchange Acknowledgment (TA1)...10 Page 3.1 Functional Acknowledgment (997) When an Interchange Envelope is accepted, Anthem generates a Functional Acknowledgment (997), which provides the results of the syntactical analysis of each document included in the envelope. If you would like to receive the 997, contact your Marketing Representative. 3.1.1 Delimiters When sending a 997 or other ANSI ASC X12N transmission, Anthem will use the following delimiters to separate data elements or subelements or to terminate a segment: Delimiter Character Name Character Data Element Separator Backslash \ Subelement Separator Colon : Segment Terminator Tilde ~ 3.1.2 997 Transaction The 997 is fully explained in the 834 IG beginning on page B.15. No specific information is required for Anthem. If a Trading Partner receives a 997 indicating errors were detected, the transaction was not processed. The transaction should be corrected and resubmitted. If the 997 data element, AK901 (Functional Group Acknowledge Code) equals R (Rejected), then AK905 (Functional Group Syntax Error Code) will display an error code. The chart in the next section provides data descriptions for error codes that may display in AK905. Anthem Blue Cross Blue Shield IG Version 004010X095A1 8 Southeast Region CG Release 1.0 (September 2003)

3.1.3 997 Error Code Data Description If AK901 (Functional Group Acknowledge Code) equals R (Rejected because of errors), then AK905 (Functional Group Syntax Error Code) will display an error code. The chart that begins below provides data descriptions for error codes that may display in AK905. Use the data descriptions to help you correct and resend the interchange. 997 Error Code Data Description If AK901 (Functional Group Acknowledge Code) equals R (Rejected), then AK905 (Functional Group Syntax Error Code) will indicate one of the error codes in the first column below. If AK905 equals: 001 Functional Group Not Supported 002 Functional Group Version Not Supported 003 Functional Group Trailer Missing 004 Group Control Number in the Functional Group Header and Trailer Do Not Agree 005 Number of Included Transaction Sets Does Not Match Actual Count then the following Segment/Data Element needs to adhere to the Data Description in the next column. GS01 (Functional Identifier Code) GS07 (Responsible Agency Code) GS08 (Version/Release/Industry Identifier Code) GE Segment (Functional Group Trailer) GE02 (Group Control Number) GE01 (Number of Transaction Sets Included) Data Description For 834 transactions, the value must equal BE (Benefit Enrollment and Maintenance). Must equal X (Accredited Standards Committee X12) Must equal a valid, authorized version code Must equal the appropriate version code for the transaction type found in GS01 One GE segment must exist at the end of the functional group Must equal the value in GS06 (Group Control Number) Must be numeric 006 GE02 (Group Control Number) Must be numeric Group Control Number Violates Must be greater than 0 (zero) Syntax Functional Group Functional Group Duplication Check 010 Authentication Key Name Unknown 013 Unknown Security Recipient GS02 (Application Sender s Code) GS03 (Application Receiver s Code) Key = GS01 + GS02 + GS06 Functional Group Control Number (GS06) must be unique for the Trading Partner ID (GS02) over 45 calendar days. Must equal a valid Trading Partner ID assigned by Anthem If GS01 (Functional Identifier Code) equals BE (Benefit Enrollment and Maintenance), GS03 must equal 058916206MEMMEES. 015 Syntax Error in Decrypted Text GS04 (Date) GS05 (Time) Must equal a valid date in CCYYMMDD format Must equal a valid time HHMM format (HH = 00-23 and MM = 00-59) IG Version 004010X095A1 Anthem Blue Cross and Blue Shield CG Release 1.0 (September 2003) Southeast Region 9

3.2 Interchange Acknowledgment (TA1) As of September 2003, the only X12 acknowledgement available from Anthem for the 834 is the 997 Functional Acknowledgment. Anthem generates a 997 when the Interchange Envelope is accepted. If you would like to receive the 997, contact your Marketing Representative. At this time, the TA1 Interchange Acknowledgment is not available. At a future time, Anthem may send the Interchange Acknowledgment (TA1) if the Interchange Envelope and its contents contain errors and are therefore rejected. 3.2.1 Delimiters When sending a TA1 or other ANSI ASC X12N transaction, Anthem will use the following delimiters to separate data elements or subelements or to terminate a segment: Delimiter Character Name Character Data Element Separator Backslash \ Subelement Separator Colon : Segment Terminator Tilde ~ 3.2.2 TA1 Transaction The following chart provides information that is specific to Anthem. The information is supplemental to information in the Implementation Guide. Data Element Interchange Acknowledgment (TA1) This chart includes only data elements requiring specific information for Anthem. (834 IG Page B.11) Name Value Definitions and Notes Specific to Anthem TA104 Interchange Acknowledgment Code R Definition: The Transmitted Interchange Control Structure Header and Trailer are rejected because of errors. TA105 Interchange Note Code See the IG See the chart in the next section for error code data descriptions. Anthem Blue Cross Blue Shield IG Version 004010X095A1 10 Southeast Region CG Release 1.0 (September 2003)

3.2.3 TA1 Error Code Data Description If TA104 (Interchange Acknowledgment Code) equals R (Rejected because of errors), then TA105 (Interchange Note Code) will display an error code. The chart that begins below provides data descriptions for each TA1 Note Code (TA105). Use the data descriptions to help you correct and resend the interchange. TA1 Error Code Data Description If TA104 (Interchange Acknowledgment Code) equals R (Rejected because of errors), then TA105 (Interchange Note Code) will indicate one of the error codes in the first column below. If TA105 equals: 001 The Interchange Control Number in the header and trailer do not match. The value from the header is used in the Acknowledgment. 002 This standard as noted in the Control Standards Identifier is not supported. 004 The Segment Terminator is invalid. 005 Invalid Interchange ID Qualifier for Sender 006 Invalid Interchange Sender ID 007 Invalid Interchange ID Qualifier for Receiver 008 Invalid Interchange Receiver ID 010 Invalid Authorization Information Qualifier Value 011 Invalid Authorization Information Value 012 Invalid Security Information Qualifier Value 013 Invalid Security Information Value 014 Invalid Interchange Date Value then the following Segment/Data Element needs to adhere to the Data Description in the next column. IEA02 (Interchange Control Number) ISA11 (Interchange Control Standards Identifier) ISA Segment Terminator ISA05 (Interchange ID Qualifier) ISA06 (Interchange Sender ID) ISA07 (Interchange ID Qualifier) ISA08 (Interchange Receiver ID) ISA01 (Authorization Information Qualifier) ISA02 (Authorization Information) ISA03 (Security Information Qualifier) ISA04 (Security Information) ISA09 (Interchange Date) Data Description Must equal the value in ISA13 (Interchange Control Number) Must equal U (U.S. EDI Community of ASC X12, TDCC, and UCS) Byte 107 must adhere to the following: Must equal a one-byte alpha character in the basic or extended character set, excluding A-Z, a-z, 0-9, and space; and Must not equal byte 4 or ISA16 (Component Element Separator) Must equal ZZ (Mutually Defined) Must have nine trailing spaces following the Submitter ID Must equal 30 (U.S. Federal Tax Identification Number) Must equal 54-0357120 plus five trailing spaces Must equal 00 (two zeros) (No Authorization Information Present) Must equal spaces Must equal 00 (two zeros) (No Security Information Present) Must equal spaces Must equal a valid date in YYMMDD format IG Version 004010X095A1 Anthem Blue Cross and Blue Shield CG Release 1.0 (September 2003) Southeast Region 11

(Continued) TA1 Error Code Data Description If TA104 (Interchange Acknowledgment Code) equals R (Rejected because of errors), then TA105 (Interchange Note Code) will indicate one of the error codes in the first column below. If TA105 equals: 015 Invalid Interchange Time Value 017 Invalid Interchange Version ID Value 018 Invalid Interchange Control Number Value 019 Invalid Acknowledgment Requested Value 020 Invalid Test Indicator Value 021 Invalid Number of Included Groups value 022 Invalid Control Structure then the following Segment/Data Element needs to adhere to the Data Description in the next column. ISA10 (Interchange Time) ISA12 (Interchange Control Version Number) Data Description Must equal a valid time in HHMM format (HH = 00-23 and MM = 00-59) Must equal 00401 ISA13 (Interchange Control Number) Must be a numeric value and greater than 0. ISA14 (Acknowledgment Requested) ISA15 (Usage Indicator) IEA01 (Number of Included Functional Groups) GS (Functional Group Header)/GE (Functional Group Trailer) Loop ISA Segment (Interchange Control Header) IEA Segment (Interchange Control Trailer) Must equal 0 (zero) (No Acknowledgment Requested) or 1 (Acknowledgment Requested) Must equal either P (Production) or T (Testing) Must equal the number of functional groups (GS/GE) within the interchange envelope. The number of GS and GE segments must be the same (equal) within the interchange envelope. Must be the first segment on the input file A GS (Functional Group Header) segment must follow the ISA segment. Must have a coordinating ISA segment 025 Duplicate Interchange Control Number 026 Invalid Data Element Separator 027 Invalid Component Element Separator Interchange Envelope ISA Segment (Interchange Control Header) ISA16 (Component Element Separator) Envelope Duplication Check Key = ISA06 + ISA13 Interchange Control Number (ISA13) must be unique for the Interchange Sender ID (ISA06). Byte 4 (Data Element Separator) must equal a 1-byte alpha character in the Basic or Extended Character set, excluding A-Z, 0-9, a-z, and space. Byte 4 must not equal ISA16 (Component Element Separator) Must equal a 1-byte alpha character in the Basic or Extended Character set, excluding A-Z, 0-9, a-z, and space. Must not equal byte 4 Anthem Blue Cross Blue Shield IG Version 004010X095A1 12 Southeast Region CG Release 1.0 (September 2003)

Chapter 4 834 Companion Document Insurance coverage sponsors or groups use the 834 transaction to send enrollment information to Anthem. This chapter provides information and instructions to create an 834 transaction. Use the information in this chapter in conjunction with the 834 Implementation Guide (IG). This chapter is divided into the following sections: Section 4.1 Basic Instructions...13 4.2 834 Header...15 4.3 834 Detail...16 4.4 834 Trailer...20 Page 4.1 Basic Instructions In order to electronically enroll members using Anthem s Electronic Enrollment System, groups must be able to produce a HIPAA-compliant 834 full file transaction. This section provides basic requirements needed before starting the transaction. The remaining sections of this chapter provide detailed instructions regarding specific segments and data elements within the 834 transaction that require specific information for Anthem. 4.1.1 Receipt Time for Same- Day Processing 4.1.2 834 Send Frequency 4.1.3 Full 834 Transactions If an 834 transaction arrives by a specified time, Anthem can usually process it on the same day. The Anthem Electronic Enrollment Coordinator can tell you what the specified time is. Anthem prefers that you send the enrollment file no more than once a week. Some groups elect to send files every two weeks or once a month, depending on the transaction volume. If there is an emergency, call your Membership Representative for manual keying. As long as you make the same changes on your system, when you send in your next file, the Electronic Enrollment System will reconcile and synchronize the files. 834 Electronic Enrollment files are processed as they are received, usually within 24 business hours. If a group transmits two files, within the same week, the system will fully complete the process cycle on the first file, then proceed to the second. Always send full 834 enrollment transactions. Do not send transactions with only change information. All transaction files transmitted need to be full files. If there are additions, terminations, or changes to the current enrollment, send the entire enrollment file updated with the changes. If you are not able to send full files, please discuss alternatives with your Marketing Representative. IG Version 004010X095A1 Anthem Blue Cross and Blue Shield CG Release 1.0 (September 2003) Southeast Region 13

To indicate the full transaction, always enter the value 4 in the 834 header, BGN (Beginning Segment) BGN08 (Action Code); and in the Functional Group Header, GS03 (Application Receiver s Code), enter 058916206MEMEES. Failure to send a full file will result in delays to update enrollment for group members 4.1.4 Policy/834 Agreement for Spouse/Dependent Coverage If the policy does not include a spouse and/or dependents, then the transmission must only include an 834 transaction for the employee. It must not include transactions for a spouse and/or dependents. If the policy does include a spouse and/or dependents, then the transmission must include an 834 transaction for the employee and spouse and each dependent. 4.1.5 Changing the Primary Care Physician (PCP) Anthem does not currently use the Electronic Enrollment System for PCP changes. To change a PCP, the member calls Anthem Customer Service. 4.1.6 Changing the Insurance Line (PPO, HMO, or POS) To change the insurance line, send a transmission with two 834 transactions one to cancel the existing policy and one to add the new one. 1. Create an 834 transaction to cancel the existing or previous policy. Include information from the following chart: Key Data Elements to Cancel Existing Insurance Line Segment Reference Designator/Name Loop 2000 Member Level Detail INS INS04 Member Level Detail (834 IG Page 43) Loop 2300 Health Coverage HD HD01 Health Coverage (834 IG Page 128) HD03 DTP Health Coverage Dates (834 IG Page 132) Maintenance Reason Code Maintenance Type Code Insurance Line Code DTP01 Date/Time Qualifier DTP03 Coverage Period Value (Policy Cancel Reason Code) 024 Cancellation or Termination (Existing Insurance Line) Example: To change from PPO to HMO, enter PPO. 349 Benefit End (Policy Cancel Date) Anthem Blue Cross Blue Shield IG Version 004010X095A1 14 Southeast Region CG Release 1.0 (September 2003)

2. Create a second 834 transaction to add the new insurance line code. Include information from the following chart: Key Data Elements to Add a New Insurance Line Segment Reference Designator/Name Value Loop 2300 Health Coverage HD HD01 Health Coverage (834 IG Page 128) DTP Health Coverage Dates (834 IG Page 132) Maintenance Type Code HD03 Insurance Line Code DTP01 Date/Time Qualifier DTP03 Coverage Period 021 Addition (New Insurance Line) Example: To change from PPO to HMO, enter HMO. 348 Benefit Begin (Policy Effective Date) 4.2 834 Header The 834 header identifies the beginning of the transaction, the policy, the sponsor, and the payer. The following chart provides information to complete the 834 header for Anthem. Only data elements that require instructions to efficiently process through Anthem systems are included. If a data element does not need specific information for Anthem processing, then it is not documented in the chart below. Use this information in conjunction with the 834 IG. Header Segment BGN Beginning Segment (834 IG Page 28) Loop 1000B Payer N1 Payer (834 IG Page 37) 834 Benefit Enrollment and Maintenance This chart includes only data elements requiring specific information for Anthem processing. Reference Designator/Name BGN08 Action Code N103 Identification Code Qualifier N104 Insurer Identification Code Value 4 Verify Use to identify a full enrollment transaction. FI Federal Taxpayer s Identification Number Definitions and Notes 4 designates a full enrollment transaction file. 54-0357120 This value is Anthem s Federal Taxpayer Identification Number IG Version 004010X095A1 Anthem Blue Cross and Blue Shield CG Release 1.0 (September 2003) Southeast Region 15

4.3 834 Detail This section explains how to send the 834 detail level to Anthem. The following chart provides information needed to complete the 834 detail level for Anthem. Only data elements that require specific instructions to efficiently process through Anthem systems are included. If a data element does not need specific information for Anthem processing, then it is not documented in the chart below. Use this information in conjunction with the 834 IG. Detail Level 834 Benefit Enrollment and Maintenance This chart includes only data elements requiring specific information for Anthem processing. Segment Reference Definitions and Notes Designator/Name Value Loop 2000 Member Level Detail INS INS01 Enter appropriate Member Insured code: Level Detail Indicator Y Employee (834 IG Yes/No N Dependent Page 43) Condition or Response Code INS02 Individual Relationship Code INS04 Maintenance Reason Code Choose from the following Individual Relationship Codes: If INS01 is: and 2300 (Health then a date entered into Coverage Dates) 2300 DTP03 (Coverage DTP01 (Date Time Period) indicates: Qualifier) equals: Y (Employee) 348 (Benefit Begin) Policy Effective Date Y (Employee) 349 (Benefit End) Policy Cancel Date N (Dependent) N (Dependent) Policy Cancel Date will not transmit without a Policy Cancel Reason. Therefore, if DTP01 is 349 and INS04 is blank, the transaction will error. 348 (Benefit Begin) Member Effective Date for the particular member 349 (Benefit End) Member Cancel Date for the particular member Note: INS04 is blank for dependent cancel. then a date entered into equals: 2300 DTP03 indicates: If INS04 is: and 2300 DTP01 Not blank 349 (Benefit End) Policy Cancel Date Policy Cancel Date will not transmit without a Policy Cancel Reason. Therefore, if DTP01 is 349 and INS04 is blank, the transaction will error. Copy this/these value(s) from page ii, or ask your Marketing Representative. Only the relationship codes listed are valid for your group. Submitting other relationship codes may cause ineligible members to be enrolled. If INS01 equals Y (Employee), then INS02 must equal 18 (Self). Enter appropriate If INS04 is not blank and 2300 DTP01 equals 349 (Benefit End), code: a date entered into 2300 DTP03 indicates Policy Cancel Date. 03 Death Policy Cancel Date will not transmit without a Policy Cancel Reason. Therefore, if 2300 DTP01 is 349 and INS04 is blank, the 04 Retirement 06 Strike transaction will error. 07 Termination of INS04 is blank for dependent cancel. Benefits 14 Voluntary Withdrawal 16 Quit 17 Fired 18 Suspended 26 Declined Coverage 38 Leave of Absence without Benefits 40 Lay Off without Benefits Anthem Blue Cross Blue Shield IG Version 004010X095A1 16 Southeast Region CG Release 1.0 (September 2003)

(Continued) Detail Level 834 Benefit Enrollment and Maintenance This chart includes only data elements requiring specific information for Anthem processing. Segment (Continued) Loop 2000 Member Level Detail REF Subscriber Number (834 IG Page 51) REF Member Policy Number (834 IG Page 53) DTP Member Level Dates (834 IG Page 59) Reference Designator/Name REF01 Reference Identification Qualifier REF02 Subscriber Identifier REF01 Reference Identification Qualifier REF02 Insured Group or Policy Number DTP01 Date Time Qualifier DTP03 Status Information Effective Date Value 0F Subscriber Number (Employee s Social Security Number) 1L Group or Policy Number (Group Number) (See 834 IG) (See 834 IG) Definitions and Notes Specific to Anthem Copy this value from page ii, or ask your Marketing Representative. For Anthem medical benefits, the group number value is 8 characters in length. For Anthem dental benefits, the value is 10 characters in length. Be careful to accurately enter the group number. If this value changes, then: - 2300 (Health Coverage Date) DTP01 value equals 348 (Benefit Begin), and - DTP03 date value will reflect the date of the group number change. The chart below applies to DTP01 and DTP03. If INS06 (Medicare Plan Code) equals: and DTP01 equals: A (Medicare Part A) 338 (Medicare Begin) then DTP03 equals: Medicare A Effective Date A (Medicare Part A) 339 (Medicare End) Medicare A Cancel Date B (Medicare Part B) 338 (Medicare Begin) Medicare B Effective Date B (Medicare Part B) 339 (Medicare End) Medicare B Cancel Date C (Medicare Part A and B) C (Medicare Part A and B) 338 (Medicare Begin) Both Medicare Part A and B Effective Date 339 (Medicare End) Both Medicare Part A and B Cancel Date 301 (COBRA Qualifying Event) 336 (Employment Begin) 356 (Eligibility Begin) Qualifying Event Date Hire Date Eligibility Date IG Version 004010X095A1 Anthem Blue Cross and Blue Shield CG Release 1.0 (September 2003) Southeast Region 17

(Continued) Detail Level 834 Benefit Enrollment and Maintenance This chart includes only data elements requiring specific information for Anthem processing. Segment Reference Designator/Name Loop 2100A Member Name NM1 Member Name (834 IG Page 61) PER Member Communications Numbers (834 IG Page 64) N3 Member Residence Street Address (834 IG Page67) N4 Member Residence City, State, Zip Code (834 IG Page 68) NM106 Subscriber Name Prefix NM108 ID Code Qualifier NM109 Subscriber Identifier PER04 Communication Number PER06 Communication Number N301-N302 Address Information N404 Country Code Loop 2300 Health Coverage HD Health Coverage (834 IG Page 128) HD03 Insurance Line Code Value (See 834 IG) 34 Social Security Number (Member s Social Security Number) (Employee s primary daytime phone number) (Employee s secondary/ nighttime phone number) (See 834 IG) (See 834 IG) For Anthem, select the code for your line of business: DEN HMO POS PPO Dental Health Maintenance Organization Point of Service Preferred Provider Organization Definitions and Notes Specific to Anthem This data element is not required for HMO, POS, or Dental policies. Anthem s membership systems accept address lengths of 36 characters for HMO and 24 characters for PPO, PAR, and POS policies. If the address is greater than 36 or 24 characters, it is truncated at the appropriate position. Exception: The report will provide the address before truncation (up to 55 characters). For HMO, PPO, PAR and POS policies, Anthem will manually key it into the membership system. Use Code Source 5: Countries, Currencies and Funds, referred to in the 834 IG, to identify the country. If the country code does not match the chart, then the subscriber s record is displayed on the Exception Report for reconciliation between Membership and the group or vendor. The values shown on the left indicate the lines of coverage offered by Anthem. Do not enter any other codes. To change the Insurance Line, send two 834 transactions one to cancel the existing policy and the next to add the new one. For instructions see Section 4.1 Basic Instructions found at the beginning of this chapter. HD04 Plan Coverage Description HD05 Coverage Level Code (Plan Coverage Description) (See 834 IG) Copy this value from page ii, or ask your Marketing Representative. Copy this value from page ii, or ask your Marketing Representative. Anthem Blue Cross Blue Shield IG Version 004010X095A1 18 Southeast Region CG Release 1.0 (September 2003)

(Continued) Detail Level 834 Benefit Enrollment and Maintenance This chart includes only data elements requiring specific information for Anthem processing. Segment (Continued) Loop 2300 Health Coverage DTP Health Coverage Dates (834 IG Page 132) Reference Designator/Name DTP01 Date/Time Qualifier DTP02 Date/Time Period Format Qualifier DTP03 Coverage Period Value For Anthem, enter one of the following codes: 303 Maintenance Effective 348 Benefit Begin 349 Benefit End (See 834 IG) If applicable, enter one of the following dates: (PCP Effective Date) (Policy Effective Date) (Member Effective Date) (Member Cancel Date) (Policy Cancel Date) Definitions and Notes Specific to Anthem See the DTP Date Element Interaction Chart that follows. Be sure to always enter a date into this data element. Enter a new Policy Effective Date for any of the following changes: Group Number 2000 (Member Level Detail), Reference ID (Member Policy Number), REF02 (Insured Group or Policy Number) Insurance Line Code 2300 HD03 Plan Coverage Description (Also called Package ID by Anthem) 2300 HD04 Coverage Level Code (Also called Type of Membership by Anthem) 2300 HD05 Keep the existing Policy Effective Date when adding a new member or changing an address. Exceptions: If you add a member and change the coverage level, then do enter a new Policy Effective Date. If changing an address causes a change in the Group Number or the Plan Coverage Description (also called Package ID), then do enter a new Policy Effective Date. This situation often occurs when group numbers are based on location or service area. See the DTP Date Element Interaction Chart that follows. DTP Data Element Interaction Chart If 2300 DTP01 is: and the value in: then enter the following date into2300 DTP03: 348 Benefit Begin 2310 NM109 (Provider Identifier) is not blank, PCP Effective Date for the subscriber or dependent 348 Benefit Begin 2000 INS01 (Insured Indicator) = Y for Employee, 348 Benefit Begin 2000 INS01 (Insured Indicator) is N for Dependent, 349 Benefit End 2000 INS01 (Insured Indicator) is N for Dependent, 349 Benefit End 2000 INS04 (used by Anthem for Policy Cancel Reason) is not blank and INS01 = Y for Employee, Policy Effective Date Member Effective Date for the particular member Member Cancel Date for the particular member Note: INS04 is blank for a dependent cancel. Policy Cancel Date Note: Policy Cancel Date will not transmit without a Policy Cancel reason. Therefore, if DTP01 is 349 and INS04 is blank, the transaction will error. IG Version 004010X095A1 Anthem Blue Cross and Blue Shield CG Release 1.0 (September 2003) Southeast Region 19

(Continued) Detail Level 834 Benefit Enrollment and Maintenance This chart includes only data elements requiring specific information for Anthem processing. Segment Reference Designator/Name Loop 2310 Provider Information NM1 Provider Name (834 IG Page 140) Value NM103-NM107 Not needed Not needed NM109 Provider Identifier If the 834 transaction is adding a member to a POS or HMO policy, then enter the following value: PCP ID Definitions and Notes Specific to Anthem For HMO or POS, if the 834 transaction is adding a member, then you must enter PCP ID in NM109. If 2300 DTP01 (Date/Time Qualifier) is 348 and NM109 is not blank, then a date entered into 2300 DTP03 (Date/Time Period) signifies the PCP Effective Date. PLA PCP Change Reason (834 IG Page 148) PLA01-PLA05 (See 834 IG) The Electronic Enrollment System does not accept PCP changes. To change the PCP, the employee should call Anthem Customer Service. 4.4 834 Trailer The 834 trailer identifies the number of included segments and the transaction set control number. There is no specific information required for Anthem processing. For information, see the 834 IG, page 158. Anthem Blue Cross Blue Shield IG Version 004010X095A1 20 Southeast Region CG Release 1.0 (September 2003)

Chapter 5 Common Errors and FAQs Anthem and group/vendor trading partners must work together to efficiently maintain accurate group enrollment files. The group/vendor s role is to send 834 transactions in the most accurate and efficient ma nner. Delays in processing enrollment files are usually avoidable and caused by a few common errors. This chapter identifies and provides solutions to the most common errors. In addition, this chapter cites the most frequently asked questions and provides answers to those questions. This chapter is divided into the following sections: Section 5.1 Common Errors...22 5.2 Frequently Asked Questions (FAQs)...25 Page IG Version 004010X095A1 Anthem Blue Cross and Blue Shield CG Release 1.0 (September 2003) Southeast Region 21

5.1 Common Errors Anthem receives and processes most 834 enrollment transactions with no delays. However, as in all systems sometimes transactions are not accepted or processed as efficiently as possible. In most cases, the group or vendor can avoid unnecessary delays by carefully following the instructions in the 834 Implementation Guide (IG) and in this Companion Guide. Most delays are caused by a few common errors. The instructions in this section can help you to avoid many common errors and enable Anthem to efficiently accept and process your transactions. 5.1.1 Full 834 Transactions Always send full 834 enrollment transactions. Do not send transaction files with only change information. If there are additions, terminations, or changes to the current enrollment, send the entire enrollment file updated with the changes. If you are not able to send full files, please discuss alternatives with your Marketing Representative. To indicate the full transaction, always enter the value 4 in the 834 header, BGN Segment (Beginning Segment) BGN08 (Action Code); and in the Functional Group Header, GS03 (Application Receiver s Code), enter 058916206MEMEES. 5.1.2 Accurate Group Number Accurately enter the group number in the following data element. Segment REF Member Policy Number Loop 2000 Member Level Detail Reference Designator/Name REF01 (834 IG Page 53) REF02 Reference Identification Qualifier Insured Group or Policy Number Value 1L Group or Policy Number (Group Number) Copy this value from page ii, or ask your Marketing Representative. 5.1.3 Always Enter a Health Coverage Date Always enter a Health Coverage Date in the following data element. 2300...Health Coverage DTP...Health Coverage Dates DTP03...Coverage Period Anthem Blue Cross Blue Shield IG Version 004010X095A1 22 Southeast Region CG Release 1.0 (September 2003)

5.1.4 New Policy Effective Date to Change: Coverage Level Plan Coverage Description Group Number Insurance Line Code Enter a new Policy Effective Date in 2300 DTP03 for any of the following changes: Group Number Group Number...2000 (Member Level Detail) Ref (Member Policy Number) REF02 (Insured Group or Policy Number) Insurance Line Code Insurance Line Code...2300 HD03 Note: To change the insurance line, send a transmission with two 834 transactions one to cancel the existing policy and one to add the new one. For complete instructions, see Common Error #5.1.6. Plan Coverage Description (also called Package ID by Anthem) Plan Coverage Description...2300 HD04 Coverage Level (also called Type of Membership by Anthem) Coverage Level Code...2300 HD05 5.1.5 Keep Existing Policy Effective Date when: Adding a Member Changing an Address 5.1.6 To Change Insurance Line, Send Two 834 Transactions Keep the existing Policy Effective Date (2300 DTP03) when you add a new member or change an address. Exceptions: If you add a member and change the coverage level, then do enter a new Policy Effective Date. If changing an address causes the Group Number or the Plan Coverage Description (also called Package ID) to change, then enter a new Policy Effective Date. This situation often occurs when group numbers are based on location or service area. To change the insurance line, send a transmission with two 834 transactions one to cancel the existing policy and one to add the new one. 1. Create an 834 transaction to cancel the existing or previous policy. Include information from the following chart: Key Data Elements to Cancel Existing Insurance Line Segment Reference Designator/Name Value Loop 2000 Member Level Detail INS Member Level Detail (834 IG Page 43) INS04 Loop 2300 Health Coverage HD Health Coverage Maintenance Reason Code HD01 (834 IG Page 128) HD03 DTP Health Coverage Dates Maintenance Type Code Insurance Line Code DTP01 (834 IG Page 132) DTP03 Date/Time Qualifier Coverage Period (Policy Cancel Reason Code) 024 Cancellation or Termination (Existing Insurance Line) Example: To change from PPO to HMO, enter PPO. 349 Benefit End (Policy Cancel Date) IG Version 004010X095A1 Anthem Blue Cross and Blue Shield CG Release 1.0 (September 2003) Southeast Region 23