West Virginia HMO Rosters Companion Guide 834

West Virginia HMO Rosters Companion Guide 834 Version 1.8 Created Modified March 09, 2015 March 09, 2015 I

TABLE OF CONTENTS Record of change... 3 Companion Guide Purpose... 3 Overview... 3 Scope... 4 Requirements... 4 Mapping Descriptions... 4 Appendix A Crosswalk for Add/Drop Indicator... 12 Appendix B Crosswalk between MMIS codes and IG codes... 13 March 09, 2015 II

Record of change DATE DESCRIPTION OF CHANGE ORIGINATOR DMS APPROVED 06/22/11 Created to reflect 5010 WVEDI 02/10/13 Updated X12 values to include ESRD and comments WVEDI 03/07/13 Updated X12 comments WVEDI Loop 2300 - DTP - Health Coverage Dates - DTP03 - Date Time Period Loop 2750 Reporting Category Reference - REF02 Reference Identification 03/11/13 Updated X12 Comments WVEDI Loop 2100 A - N4 - Member Residence City, State, Zip Code Loop 2310 - NM1 - Provider Name 03/21/13 Updated X12 Comments WVEDI BGN08 Loop 2310 - NM1 - Provider Name 07/01/13 Updated DMG segment WVEDI 10/24/13 Added MAGI Loop/Segment Information WVEDI 10/19/14 Updated INS04 and Appendix B WVEDI 02/11/15 Added Home Health to Loop 2750 and HLT qualifier WVEDI added to 2300 HD03 when Health Home provider provided. 03/09/15 Corrected wording from Home Health to Health Home WVEDI Companion Guide Purpose This companion guide document further defines situational and required data elements for the following transaction type that are used for processing eligibility requests for programs administered by West Virginia Bureau for Medical Services. This document is not the complete EDI transaction format specifications. Minimal functionality is detailed in this companion guide. Premium Payment ASC X12N 820 (005010X218) February 2007 Overview This is a companion guide for the 834 X12 transaction for sending eligibility rosters to our HMO trading partners. March 09, 2015 3

Scope This document will serve as reference to all mappings of the previous file format to the 834 X12 transaction. Requirements Processing Frequency Interface Delivery Method Customer Point of Contact Twice a month (One full file, one supplemental/adds file) Export FTP edihelpdesk@molinahealthcare.com Mapping Descriptions Current HMO Roster Layout with corresponding 834 field locations: Position Description 834 Position 1-3 HMO County part of 2300 HD04 4-13 HMO ID Replaced by ISA08/GS03 14-20 HMO Plan Replaced by ISA08/GS03 21-31 Recipient Number 2000 REF02 (qual 0F) 32-33 Enroll Approach 2000 INS04 34-35 Disenroll Reason not used 36-37 Exemption Reason not used 38-45 Beginning Date 2300 DTP(qual 348) 46-53 Ending Date 2300 DTP(qual 349) March 09, 2015 4

54-54 Enrollment Status not used 55-55 Disenrollment Status not used 56-75 Recipient Last Name 2100A NM103 76-90 Recipient First Name 2100A NM104 91-91 Recipient Middle Initial 2100A NM105 92-92 Recipient Sex Code 2100A DMG03 93-100 Recipient Date of Birth 2100A DMG02 101-130 Recipient Address Line 1 2100A N301 131-175 Recipient Address Line 2 2100A N302 176-190 Recipient City 2100A N401 191-192 Recipient State 2100A N402 193-201 Recipient Zip Code 2100A N403 202-211 Recipient Phone Number 2100A PER04 212-220 Recipient SSN 2100A NM109 221-222 Rate Cell not used 223-233 Recipient Member ID not used 234-235 Aid Category part of 2300 HD04 236-237 Deprivation Code not used 238-240 Relationship Code not used March 09, 2015 5

241-241 Current PCP not used 242-266 PCP Name 2310 NM1 267-274 Report Date ISA09 275-284 Case Number 2000 REF 285-285 Add/Drop Indicator 2000 INS03 286-286 Type of Run ISA15 287-297 Conversion ID 2000 REF Member Policy Number (T99) 298-367 Comment not used 368-368 MCCA Code not used 369-369 Aid Sort Field not used 370-377 Redetermination Date part of 2300 HD04 378-379 Benefit Package Code part of 2300 HD04 380-380 Ethnicity Code 2100A DMG05 381-400 Rate Code part of 2300 HD04 401-408 Original Basic Plan Eff Date 2000 DTP (300 qual) 409-416 Current Eligibility Eff Date 2000 DTP (303 qual) 417-424 Mailing Date part of 2300 HD04 425-450 Filler Not Used March 09, 2015 6

EDI Data Element Definition Reference Description Number-Name Usage Sample Data Sample ISA Segment: ISA - Interchange Control Header Required ISA*00* *00* *ZZ*WV_MMIS_4MOLINA*ZZ*THP *080219*1331*^*00501*000000020*0*P*:~ ISA01 - Author Info Qualifier 00 ISA02 - Author Information ten spaces ISA03 - Security Info Qualifier 00 ISA04 - Security Information ten spaces ISA05 - Interchange ID Qualifier ZZ ISA06 - Interchange Sender ID WV_MMIS_4MOLINA ISA07 - Interchange ID Qualifier ZZ ISA08 - Interchange Receiver ID THP or UNICARE5010 or CARELINK or WVFHP5010 ISA09 - Interchange Date yymmdd ISA10 - Interchange Time hhmm ISA11 Repetition Separators ^ ISA12 - Inter Ctrl Version Num 00501 ISA13 - Inter Ctrl Number unique # 9 digits long ISA14 Acknowledgement Requested 0 ISA15 - Usage Indicator T (test) or P (production) ISA16 - Component Element Separator ~ GS - Functional Group Header Required GS01 - Functional ID Code BE GS02 - Application Sender's Code WV_MMIS_4MOLINA Sample GS Segment: GS*BE*WV_MMIS_4MOLINA*THP*20080219*1331*933*X*005010X220A1~ GS03 - Application Receiver's Code THP or UNICARE5010 or CARELINK or WVFHP5010 GS04 - Date ccyymmdd GS05 - Time hhmm GS06 - Group Ctrl Number unique # GS07 - Responsible Agency Code X GS08 - Version/Release ID Code 005010X220A1 ST - Transaction Set Header Required ST01 - Transaction Set Identifier Code 834 Sample ST Segment: ST*834*000000001*005010X220A1~ ST02 - Transaction Set Control Number unique # starting at 1 and incrementing by 1 each ST segment ST03 Implementation Convention Reference 005010X220A1 BGN - Beginning Segment Required Sample BGN Segment: BGN*00*WXENR0000481497*20080219*1331*LT***2~ BGN01 -Transaction Set Purpose code 00 BGN02 - Reference Identification Internal Molina Enrollment ID BGN03 - Date ccyymmdd BGN04 - Time hhmm BGN05 - Time Code not used BGN06 - Reference Identification not used BGN07 - Transaction Type Code NOT USED not used BGN08 - Action Code 4 for a full file, 2 for a supplemental file BGN09 - Security Level Code NOT USED not used March 09, 2015 7

DTP - File Effective Date Sample DTP Segment: DTP*303*D8*20080219~ DTP01 - Date/Time Qualifier 303 DTP02 - Date Time Period Format Qualifier D8 DTP03 - Date Time Period ccyymmdd (file creation date) Loop 1000A - N1 - Sponsor Name N101 - Entity Identifier code P5 N102 Name MEDICAID N103 - Identification Code Qualifier FI N104 - Identification Code 89-1234567 Sample 1000A N1 Segment: N1*P5*MEDICAID*ZZ*89-1234567~ Loop 1000B - N1 - Payer Name N101 - Entity Identifier code IN N102 - Name MEDICAID N103 - Identification Code Qualifier XV N104 - Identification Code 89-1234567 Sample 1000B N1 Segment: N1*IN*MEDICAID*FI*89-1234567~ Loop 2000 - INS - Member Level Detail Sample 2000 INS Segment: INS*Y*18*030*20*A*E**FT~ INS01 - Yes/No Condition or Response Code Y INS02 - Individual Relationship code 18 INS03 - Maintenance Type Code 021 for Addition or 024 for Cancellation/Termination or 025 for Reinstatement or 030 for Audit or compare. INS04 - Maintenance Reason Code / RECOMMENDED INS05 - Benefit Status Code A INS06-1 - Medicare Status Code E 07 - or 20 Active or XN - Notification Only or AL - Algorithm Assigned Benefit Selection or EC - Member Benefit Selection or 14 - Voluntary Withdrawal INS06-2 - Medicare Status Code 2 for End Stage Renal Disease (ESRD) INS07 - COBRA Qualifying not used INS08 - Employment Status Code, must be populated for Subscribers (INS01=Y) INS09 - Student Status Code not used INS10 - Yes/No Condition or Response code not used INS11 - Date Time Period Format Qualifier not used INS12 - Date Time Period not used INS13 - Confidentiality Code NOT USED not used INS14 - City Name NOT USED not used INS15 - State or Province code NOT USED not used INS16 - Country Code NOT USED not used INS17 - Number not used FT Loop 2000 - REF - Subscriber Identifier Sample 2000 REF Segment: Subscriber Identifier REF*0F*00701049114~ March 09, 2015 8

REF01 - Reference Identification Qualifier 0F REF02 - Reference Identification Medicaid ID for Subscriber Loop 2000 - REF - Member Policy Number REF01 - Reference Identification Qualifier 1L Sample 2000 REF Segment : Member Policy Number REF*1L*7~ REF02 - Reference Identification Internal Molina Policy Number (T99 Value) Loop 2000 - REF Member Supplemental Identifier REF01 - Reference Identification Qualifier 3H REF02 - Reference Identification Case Number Sample 2000 REF Segment : Member Supplemental Identifier REF*3H*123456789~ Loop 2000 - DTP - Eligibility Dates Sample 2000 DTP Segment: Member Level Dates DTP*300*D8*20050501~ DTP*303*D8*20071130~ DTP01 - Date/Time Qualifier 300 for Enrollment Signature Date or 303 for Maintenance Effective DTP02 - Date Time Period Format Qualifier D8 DTP03 - Date Time Period Original Basic Plan Effective Date or Current Eligibility Effective Date Loop 2100 A - NM1 - Member Name NM101 - Entity Identifier Code IL NM102 - Entity Type Qualifier 1 Sample 2100A NM1 Segment: NM1*IL*1*DOE*JOHN*R***34*123456789~ NM103 - Name Last or Organization Name Subscriber Last Name NM104 - Name First Subscriber First Name NM105 - Name Middle Subscriber Middle Initial NM106 - Name Prefix not used NM107 - Name Suffix not used NM108 - Identification Code Qualifier 34 NM109 - Identification Code Subscriber SSN Loop 2100 A - PER - Member Communications Numbers PER01 - Contact Function Code IP PER02 - Name NOT USED not used Sample 2100A PER Segment: PER*IP**HP*3041234567~ PER03 - Communication Number Qualifier EM or HP or WP or FX or TE PER04 - Communication Number Subscriber Email or Phone or Secondary Phone or Fax or Emer Phone PER05 - Communication Number Qualifier EM or HP or WP or FX or TE PER06 - Communication Number Subscriber Email or Phone or Secondary Phone or Fax or Emer Phone PER07 - Communication Number Qualifier EM or HP or WP or FX or TE PER08 - Communication Number Subscriber Email or Phone or Secondary Phone or Fax or Emer Phone Loop 2100 A - N3 - Member Residence Street Address Sample 2100A N3 Segment: N3*1479 DAYBROOK RD~ N301 - Address Information Subscriber Physical Address Line 1 N302 - Address Information Subscriber Physical Address Line 2 March 09, 2015 9

Loop 2100 A - N4 - Member Residence City, State, Zip Code Sample 2100A N4 Segment: N4*FAIRVIEW*WV*26570~ N401 - City Name Subscriber Physical City N402 - State or Province Code Subscriber Physical State N403 - Postal Code Subscriber Physical Zip (5 digit zip only) N404 - Country Code not used N405 - Location Qualifier not used N406 - Location Identifier not used Loop 2100A - DMG - Member Demographics Sample 2100A DMG Segment: DMG*D8*19740305*F**C~ DMG01 - Date Time Period Format Qualifier D8 DMG02 - Date Time Period Subscriber Date of Birth DMG03 - Gender Code Subscriber Gender DMG04 - Marital Status Code not used DMG05 - Race or Ethnicity Code Subscriber Ethnic ID DMG05-02 Qualifier Code If DMG05 = E populate RET DMG05-03 Industry Code If DMG05 = E populate the proper Ethnic Code DMG06 - Citizenship Status Code not used Loop 2300 - HD - Health Coverage HD01 - Maintenance Type Code 021 for Addition or 024 for Termination or 025 for Reinstatement or 030 for Audit HD02 - Maintenance Reason Code NOT USED not used Sample 2300 Segment: HD Health Coverage: HD*030**POS*001 FCMQCA FC BA 20100101 20091002*IND~ HD03 - Insurance Line Code POS or HLT when Health Home provider provided in 2750 REF Concatenate: HD04 - Plan Coverage Description HD05 - Coverage Level Code IND HMO County Rate Code Aid Category Benefit Package Code Redetermination Date Mailing Date Note: 1. is the field delimiter 2. Loop 2300 HD04 filed length must not exceed 50 characters Loop 2300 - DTP - Health Coverage Dates Sample 2300 DTP Segment: Health Coverage Dates DTP*348*D8*20060201~ DTP01 - Date/Time Qualifier 348 for start and 349 for stop DTP*349*D8*20071130~ DTP02 - Date Time Period Format Qualifier D8 DTP03 - Date Time Period start or stop date of coverage When DTP01 = 379. 20781231 will be used as a default for 99999999 from the proprietary file on active members with no defined termination date. Loop 2000 - REF Health Coverage Policy Number REF01 - Reference Identification Qualifier 1L REF02 - Reference Identification Recipient Number Sample 2000 REF Segment: Prior Coverage REF*QQ*0~ Loop 2310 - LX - Provider Information LX01 - Assigned Number 1 Sample 2310 LX Segment: LX*1~ March 09, 2015 10

Loop 2310 - NM1 - Provider Name NM101 - Entity Identifier Code P3 NM102 - Entity Type Qualifier 1 NM103 - Name Last or Organization Name not used NM104 - Name First not used NM105 - Name Middle not used NM106 - Name Prefix not used NM107 - Name Suffix not used NM108 - Identification Code Qualifier SV Sample 2310 NM1 Segment: NM1*P3*1******SV*550585592*25~ NM109 - Identification Code Provider Last Name PCP Name NM110 - Entity Relationship Code 25 Loop 2310 - N4 - Provider City, State, Zip Code Sample 2310 N4 Segment: N4*Saint Clairsville*OH*439500000~ N401 - City Name Provider City N402 - State or Province Code Provider State N403 - Postal Code Provider Zip N404 - Country Code not used N405 - Location Qualifier not used N406 - Location Identifier not used Loop 2310 - PER - Provider Communications Number Sample 2310 PER Segment: PER*IC**WP*8006246961~ PER01 - Contact Funct Code IC PER02 - Name NOT USED not used PER03 - Communication Number Qualifier WP PER04 Communication Number Provider Phone Number Loop 2700 LS Additional Reporting Categories Sample LS Segment: LS*2700~ LS01 Loop Identifier Code 2700 Loop 2710 Member Reporting Categories Sample LX Segment: LX*1~ LX01 Assign Number 1 Loop 2750 Reporting Category Sample N1 Segment: N1*75*MAGI~ N101 Identifier Code 75 N102 Name MAGI Loop 2750 Reporting Category Reference Sample REF Segment: REF*ZZ*4 27500 1~ REF01 Identification Qualifier ZZ Concatenate: REF02 Reference Identification House Hold Size House Hold Income Tier Level Note: 1. is the field delimiter 2. Tier Level will be 1, 2, or 3 March 09, 2015 11

Loop 2710 Member Reporting Categories LX01 Assign Number 2 Sample LX Segment: LX*2~ Loop 2750 Reporting Category Sample N1 Segment: N1*75* HEALTH HOME ~ N101 Identifier Code 75 N102 Name HEALTH HOME Loop 2750 Reporting Category Reference REF01 Identification Qualifier XX1 REF02 Reference Identification Health Home Name Sample REF Segment: REF*XX1*Name of Health Home Loop 2750 Additional Reporting Categories Loop LE01 Loop Identification Code 2700 Sample LE Segment: LE*2700~ SE - Transaction Set Trailer Sample SE Segment: SE*18021*000000007~ SE01 - Number of Included Segments # of segments SE02 - Transaction Set Control Number Unique # matching ST02 element GE - Functional Group Trailer GE01 - Number of Transaction Sets Included Sample GE Segment: GE*1*933~ # of transactions GE02 - Group Control Number Unique # matching GS06 IEA - Interchange Control Trailer Sample IEA Segment: IEA*1*000000020~ IEA01 - Number of Included Functional Groups 1 IEA02 - Interchange Control Number Unique # matching ISA13 Appendix A Crosswalk for Add/Drop Indicator The following table contains the crosswalk between the Roster codes and the IGs Maintenance Type Code Roster IG Code Description Code Description A Add/Enroll 021 Addition D Drop/Disenroll 024 Cancellation or Termination R Reinstatement 025 Reinstatement E Ongoing enrollment 030 Audit or Compare March 09, 2015 12

Appendix B Crosswalk between MMIS codes and IG codes The following table contains the crosswalk between the MMIS codes and the IGs Maintenance Reason Code Medicaid Management Information System Code (MMIS) Actionid Action Description Reasonid Reason Description Code March 09, 2015 13 IG Maintenance Reason Code Description 110 Terminate Enrollment QXUNS0001316 Death 03 Death 110 Terminate Enrollment QXUNS0001317 Loss of WV Residence 07 110 Terminate Enrollment QXUNS0001318 110 Terminate Enrollment QXUNS0001319 110 Terminate Enrollment QXUNS0001320 Does not meet eligibility requirements for A B 07 Does not meet eligibility requirements for APTD 07 Does not meet eligibility requirements for AFDC 07 110 Terminate Enrollment QXUNS0001321 Unable to locate 07 110 Terminate Enrollment QXUNS0001322 Does not meet State Title XIX Financial Standards 07 110 Terminate Enrollment QXUNS0001323 Case of recipient added in error 07 110 Terminate Enrollment QXUNS0001324 Dependent reached age 21 07 110 Terminate Enrollment QXUNS0001325 Automatic cancel for type 3 eligibility 07 110 Terminate Enrollment QXUNS0001326 Expiration of type 2 eligibility 07 110 Terminate Enrollment QXUNS0001327 DHS unable to locate 07 110 Terminate Enrollment QXUNS0001328 Mandatory review (medically needy) 07 110 Terminate Enrollment QXUNS0001329 Miscellaneous 07 113 New Provider for Enrollment QXUNSWV00000162 C - Choice HMO selected by recipient C Member Benefit Selection 113 New Provider for Enrollment QXUNSWV00000163 D - HMO Designated by broker 20 Active 113 New Provider for Enrollment QXUNSWV00000164 X - HMO Special Exemption 20 Active 113 New Provider for Enrollment QXUNSWV00000165 AD - HMO Auto Enrolled AL Algorithm Assigned Benefit Selection 113 New Provider for Enrollment QXUNSWV00000166 P - PAAS Provider Choice 20 Active 113 New Provider for Enrollment QXUNSWV00000167 C - PAAS Member Choice 20 Active 113 New Provider for Enrollment QXUNSWV00000168 S - PAAS State Choice 20 Active 115 Terminate Provider for Enrollment QXUNS0001334 Medicaid Ineligible 07 115 Terminate Provider for Enrollment QXUNS0001335 Medicare Ineligible 07 115 Terminate Provider for Enrollment QXUNS0001336 Relocation 07 115 Terminate Provider for Enrollment QXUNS0001337 Plan Switch 22 Plan Change 115 Terminate Provider for Enrollment QXUNS0001338 Special Exemption 07 115 Terminate Provider for Enrollment QXUNS0001339 Spendown 07

115 Terminate Provider for Enrollment QXUNS0001340 System County Ineligible 07 115 Terminate Provider for Enrollment QXUNS0001341 System Medicaid Ineligible 07 115 Terminate Provider for Enrollment QXUNS0001342 System Aid Ineligible 07 115 Terminate Provider for Enrollment QXUNS0001343 System MRDD Ineligible 07 115 Terminate Provider for Enrollment QXUNS0001344 System LTC Ineligible 07 115 Terminate Provider for Enrollment QXUNS0001345 System LTC Ineligible 07 115 Terminate Provider for Enrollment QXUNS0001346 System Aged Ineligible 07 115 Terminate Provider for Enrollment QXUNS0001347 System Relocation 07 115 Terminate Provider for Enrollment QXUNS0001348 System RAPIDS RNUM 07 Enroll Different Eligible 115 Terminate Provider for Enrollment QXUNS0001349 Number 07 115 Terminate Provider for Enrollment QXUNS0001350 Other 07 115 Terminate Provider for Enrollment QXUNS0001351 069 Foster Ineligible 07 SSI Member Voluntary 115 Terminate Provider for Enrollment WVM0000715027 Termination 14 Foster Care Voluntary 115 Terminate Provider for Enrollment WVM0001139592 Termination 14 Voluntary Withdrawal Voluntary Withdrawal March 09, 2015 14