BlueCross BlueShield of VT. Vermont

BlueCross BlueShield of Vermont 834 Benefit Enrollment and Maintenance Companion Guide HIPAA/V4010X095A1 Version: 1.0 Company: BlueCross BlueShield of VT Publication: 12/19/2012 Blue Cross & Blue Shield of Vermont Version: 1.0

Table of Contents 1. Introduction... 2 2. Change versus Full File Audits... 2 3. Coverage Levels and Dependents... 2 4. Dates... 3 5. Connectivity... 3 6. Testing and Certification... 4 7. Production Processing... 4 8. Trading Partners... 4 9. BCBSVT Business Rules and Edits... 5 9.1 ISA & IEA: Interchange Control Header & Trailer... 5 9.2 GS & GE: Functional Group Header & Trailer... 6 9.3 ST & SE: Transaction Set Header & Trailer... 6 9.4 Header (BGN/REF/DTF)... 7 9.5 Sponsor, Payer and TPA... 8 9.6 Member Level Details Loop 2000... 8 9.7 Member Name Loop 2100A...12 9.8 Incorrect Member Name Loop 2100B...13 9.9 Health Coverage Loop 2300...14 9.10 Provider Information Loop 2310...15 9.11 Miscellaneous...15 10. Examples...17 Appendix A (Testing/Certification Scenarios)...25 Document Revision History:...26 Benefit Enrollment and Maintenance - 834 i X12V4010X095A1

1. Introduction This document is the property of Blue Cross Blue Shield of Vermont (BCBSVT) and is for use solely in your capacity as a Trading Partner of health care transactions with BCBSVT. This information is intended to serve only as a companion guide to the HIPAA ANSI X12N 834A1 and should be used in conjunction with the HIPAA Implementation Guide. The specifications contained within this Companion Guide define current functions and provide supplemental information specific to Blue Cross & Blue Shield of Vermont (BCBSVT). The implementation guides are available at Washington Publishing Company website at www.wpc-edi.com. This Companion Guide is subject to change as new information is available. Please check the BCBSVT Web site, at www.bcbsvt.com, for updated documents. Note: BCBSVT accepts 4010A1 version of 834 Benefit Enrollment and Maintenance. All Alpha Characters in the file must be Upper Case. 2. Change versus Full File Audits The 834 transaction set can be used to provide either updates to the membership database or full file audits against the membership database. An update is either a new add, termination or change request. This transaction only contains information about changed members. A full file audit lists all current members. This facilitates keeping the sponsor s and payer s systems synchronized. It is not intended to contain a history of all previous enrollments. BGN08 is used to indicate whether the transaction is a full file audit (4) or an update (2). When sending a full file audit, Loop 2000, INS03 must be 030. INS04 must be XN and Loop 2300, HD01 must be 030. When submitting full files, a single transaction set (ST/SE) must contain all of the enrollment transactions that belong to the BCBSVT group number that is specified in REF02 segment in the header, they cannot be submitted in multiple transaction sets. Separate full file must be submitted for each of the groups, if an employer has multiple group numbers with BCBSVT. For example, if an employer ABC has two group numbers 12345 and 98765 with BCBSVT, two full files must be submitted one for group number 12345 and one for 98765. 3. Coverage Levels and Dependents Reporting of the coverage level code (e.g., individual, family, etc.) and benefit package information is reported at the employee level. Changes for the employee may need to be submitted with the addition or termination of a dependent or coverage level. Subscriber numbers are reported in the Loop 2000 REF (0F Identification Qualifier) Segment. BCBSVT requires the Subscriber s Social Security Number be sent in REF02. If the member is currently enrolled in a VT Blue 65 program, the one to two position suffix code must follow the Social Security Number with no spaces or hyphens. The Subscriber s group number is reported in Loop 2000 REF (1L Identification Qualifier) Segment. REF02 must be populated with the Subscriber s 5 or 6 position BCBSVT Group number which will be provided to you prior to testing. The Subscriber s Account Number is reported in Loop 2000 REF (DX Identification Qualifier) Segment. REF02 Benefit Enrollment and Maintenance - 834 2 X12V4010X095A1

must be populated with the Subscriber s 8 or 9 position BCBSVT Account number which will be provided to you prior to testing. Loop 2300 HD- Health Coverage, HD04 requires a concatenation of BCBSVT 4 position tier code plus a 4 position benefit package code. Prior to testing, a spreadsheet/grid will be provided defining the group number, account number, tier and benefit package that will need to be used. Student information should be sent when describing a non-employee/non-spouse dependent whose age requires a qualifying condition for enrollment (e.g., being a full time active student). Please contact your BCBSVT Account Manager for your student age requirements. Disability information should only be sent when enrolling a disabled member or when disability information about an existing member is added or changed. This information is reported in Loop 2000, INS10. Certain change/update transactions (BGN08 code value 2 ) must be submitted in a specific sequence in order for the membership database to be updated properly. Examples of these transactions, as well as others, are provided under the Examples section of this document. Change/update files can be transmitted as needed (daily, weekly). BCBSVT recommends that change/update files be transmitted not more than once a day, but should be sent daily if activity has been performed to ensure that all enrollment and maintenance activity is processed in the appropriate order. 4. Dates File effective date is required in full files only with 303 qualifier, and this date is used to cancel the members in BCBSVT system that are not present in full files for that master policy number identified in REF segment. Member level dates in loop 2000 are required to submit for member cancellation transactions with 357 qualifier in both change and full files. It is also required to submit member add and change transactions with 356 qualifier in full files. Health Coverage dates in loop 2300 is required with 348 qualifier for new member add transactions and with 303 for member change transactions in both change and full files as well. 5. Connectivity Trading Partners can access the BCBSVT secure FTP site in one of two ways, to submit x12 files. You will be provided HostName, UserName and Password upon receipt of completed Trading Partner Agreement. If you are logging in for the first time you will need to change your password and Method 1 will be the only way to do this. Once you have changed your password you can use either method. The SFTP User Guide is available on BCBSVT website that will provide more information. Our Secure FTP site requires password change every 90 days. Contact BCBSVT helpdesk at (800) 334-3441 option 1 or email helpdesk@bcbsvt.com if password reset is needed. Method 1 Via the web interface Submitters will browse to and login to https://moveit.bcbsvt.com Method 2 Via FTP Client using FTP over SSL or FTP over SSH. Configure your ftp client to use one of the above protocols along with the hostname, username and password. After it is configured simply login to see your Home and Distribution folders. SFTP User Guide the Online Manual link from the website provides more information about supported clients. Benefit Enrollment and Maintenance - 834 3 X12V4010X095A1

6. Testing and Certification Upon receipt of completed Trading Partner agreement and EDI enrollment forms, BCBSVT will provide the necessary information for you to start sending test files. It is required to submit a minimum of two test files that pass EDI validation and load into BCBSVT membership system successfully. Test files must be submitted with a usage indicator of T in ISA15. Test files received with usage indicator of P or Production files received with usage indicator of T will be rejected, and it will require resubmission of the files with correct usage indicator. We recommend you to submit the transactions for the scenarios that are outlined in Appendix A section. Upon successful completion of testing BCBSVT will communicate a plan for production processing of your files. 7. Production Processing Schedule: BCBSVT accepts transmissions 24 hours a day, 7 days a week. All 834 transactions received on a business day prior to 6:30PM will be processed in a batch mode that evening. Any transactions received after 6:30PM will be processed the following business day. Notifications regarding system upgrades and/or downtimes will be provided on our SFTP log in site. BCBSVT suggests separate transmissions for multiple clients (or employer). Any errors detected in a transaction set will result in the entire transmission being rejected. Interchange Control number (ISA13) must be unique within the sender/receiver relationship for each submission, not for each client when a clearinghouse is submitting for multiple clients. We highly suggest the use of the TA1 & 997 functional acknowledgement files. BCBSVT does not use the ISA14 element to identify the request of an acknowledgement. To request TA1 s & 997 s please request this option on the EDI Enrollment form and we will flag our system to provide TA1 s and 997 functional acknowledgements 8. Trading Partners A BCBSVT EDI trading partner is any business partner (provider, clearinghouse, billing service, software vendor, employer, etc.) who transmits to or receives electronic data from BCBSVT. In order to establish a trading partner relationship with BCBSVT, it is necessary to complete a Trading Partner Agreement. In addition, trading partners must also complete a copy of EDI enrollment form for certain EDI transaction types. Both documents are located on the BCBSVT Web site: Both documents must be completed and returned to: Blue Cross and Blue Shield of Vermont (BCBSVT) Attn: Channel Services (EDI Department) P.O. BOX 186 Montpelier, VT 05601-0186 BCBSVT will only accept transactions from valid trading partners whose submitter/sender IDs are on file. It will reject transmissions if the submitter ID cannot be validated. Contact Information For more information or questions regarding this or other EDI transactions, you may contact us at: EDI Tech Support: Phone: (800) 334-3441, select option 2 Email: editechsupport@bcbsvt.com Fax: (802) 225-7696 Benefit Enrollment and Maintenance - 834 4 X12V4010X095A1

9. BCBSVT Business Rules and Edits This companion guide only addresses the business rules specific to BCBSVT, and do not send the information if it is not required by Implementation guide. The following are specific BCBSVT rules applicable to benefit enrollment and maintenance transactions: 9.1 ISA & IEA: Interchange Control Header & Trailer Interchange Control Header (ISA) Authorization Information Qualifier ISA01 BCBSVT require 00 Authorization Information ISA02 BCBSVT requires 10 spaces Security Information Qualifier ISA03 BCBSVT require 00 Security Information ISA04 BCBSVT requires 10 spaces Interchange ID Qualifier ISA05 BCBSVT require ZZ Interchange Sender ID ISA06 BCBSVT assigned 4 digit Sender ID followed by 11 spaces Interchange ID Qualifier ISA07 BCBSVT require ZZ Interchange Receiver ID ISA08 Must be BCBSVT followed by 6 spaces Interchange Date ISA09 Yymmdd Interchange Time ISA10 Hhmm Interchange Control Standards ISA11 U Identifier Interchange Control Version Number ISA12 00401 Interchange Control Number ISA13 9 digit unique control number must match with IEA02 Acknowledgment Requested ISA14 0 BCBSVT do not use this value to generate Acknowledgement. Contact EDI department with your request for Acknowledgements. Usage Indicator ISA15 P for Production Files T for Test Files Component Element Separator ISA16 Use a valid HIPAA element separator Interchange Control Trailer (IEA) Number of Included Functional IEA01 Number of functional groups (GS/GE) Groups Interchange Control Number IEA02 9 digit unique control number must match with ISA13 Benefit Enrollment and Maintenance - 834 5 X12V4010X095A1

9.2 GS & GE: Functional Group Header & Trailer Functional Group Header (GS) Functional Identifier Code GS01 BE Application Sender's Code GS02 BCBSVT assigned 4 digit Sender ID Application Receiver's Code GS03 Must be BCBSVT Date GS04 Ccyymmdd Time GS05 Hhmm Group Control Number GS06 1 to 9 digit control number must match with GE02 Responsible Agency Code GS07 X Version / Release / Industry Identifier Code GS08 004010X095A1 Functional Group Trailer (GE) Number of Transaction Sets Included GE01 Number of Transaction sets (ST/SE) included. Group Control Number GE02 1 to 9 digit control number must match with GS06 9.3 ST & SE: Transaction Set Header & Trailer Transaction Set Header (ST) Transaction Set Identifier Code ST01 834 Transaction Set Control Number ST02 4 to 9 digit control number must match with SE02 Transaction Set Trailer (SE) Number of Included Segments SE01 Number of segments included in the transaction set. Transaction Set Control Number SE02 4 to 9 digit control number must match with ST02 Benefit Enrollment and Maintenance - 834 6 X12V4010X095A1

9.4 Header (BGN/REF/DTF) Specify the type of file that is being sent in BGN08, and send the REF and DTP segments appropriately for full files only. Do not send REF and DTP segments for change files. BGN - Beginning Segment Transaction Set Control Number BGN01 00 Original BCBSVT requires this code should be used for the first transmission, corrected transmission, and resending of a transmission that has been lost and never received by the Payer. Action Code BGN08 2 - Change/Update Must be 2 for change files. 15 - Resubmission BCBSVT require this code should only be submitted when the sender has contacted BCBSVT and the usage was agreed upon by the two entities. When using this option a new Interchange control number (ISA13) will need to be provided. 4 Verify Must be 4 for Verify/Full files. REF - Transaction Set Policy Number BCBSVT require this segment for full files (BNG08 = 4) only. Do not send this segment on change files. Reference Identification Qualifier REF01 38 Master Policy Number Reference Identification REF02 Must be five or six position BCBSVT Group Number and only in a verifying audit file. This Group Number will be provided to you after the Trading Partner Agreement is signed prior to begin testing. DTP - File Effective Date BCBSVT require this segment for full files (BNG08 = 4) only. Do not send this segment on change files. Date/Time Qualifier DTP01 303 Maintenance Effective Must be 303 Date Time Period DTP03 ccyymmdd DTP03 date must be the last day of the month (20121130, 20121231 etc).this date will be used to terminate all active members in the BCBSVT system but not present in this full file, for the group identified in REF02. Benefit Enrollment and Maintenance - 834 7 X12V4010X095A1

9.5 Sponsor, Payer and TPA Sponsor Name Loop 1000A Identification Code Qualifier N103 FI Federal Taxpayer s Identification Number Identification Code N104 BCBSVT require your Federal Taxpayer s Identification Number using the format 123456789. Do not use spaces, hyphens or special characters. Failure to provide the Federal Taxpayer s ID in the prescribed format will result in the rejection of the transmission. Payer Loop 1000B Identification Code Qualifier N103 FI Federal Taxpayer s Identification Number Identification Code N104 Must use 030277307. TPA/Broker Name Loop 1000C Use this loop only when a Third Party Administrator (TPA)/Broker are involved. Do not send this loop when TPA/Broker is not involved. Entity Identifier Code N101 BO Broker or Sales office TV Third Party Administrator Identification Code Qualifier N103 FI Federal Taxpayer s Identification Number Identification Code N104 BCBSVT require TPA/Broker s Federal Taxpayer s Identification Number using the format 123456789. Do not use spaces, hyphens or special characters 9.6 Member Level Details Loop 2000 Loop 2000 Member Level Details (INS) Individual Relationship Code INS02 Relationship Codes that are used by BCBSVT: 01 - Spouse Should also use this code for Partner/Party of a Civil Union. 09 - Adopted Child 17 - Stepson or Stepdaughter 18 - Self Benefit Enrollment and Maintenance - 834 8 X12V4010X095A1

19 - Child 38 - Collateral Dependent Valid only for specific group contracts. To verify the qualifications for your group policy contact your BCBSVT Account Manager. 53 - Life Partner Use for Domestic Partner: This code should only be transmitted when this type of dependent coverage is applicable to your group coverage. Maintenance Type Code INS03 Valid Maintenance type codes for BCBSVT are: 001 - Change 021 - Addition 024 - Cancellation or Termination Do not send a cancellation or termination transaction when changing TIER/BENEFIT PACKAGE (HD04). Send a change transaction with a new TIER/BENEFIT PACKAGE (HD04) with new effective date in loop 2300. Our system will cancel/terminate the previous Tier/Benefit package with the date prior to the effective date of the new Tier/Benefit Package. 025 - Reinstatement All of the above codes must only be used in change files. 030 - Audit or Compare This code should only be used when the contract between the sponsor and the payer has agreed upon its usage. This code is required on full file processing (for add, change and cancellation transactions). Maintenance Reason Code INS04 A valid maintenance Reason Code from the below list is required to process transaction successfully into BCBSVT system. 01 - Divorce 02 - Birth 03 - Death 04 - Retirement 05 - Adoption 07 - Termination of Benefits 08 - Termination of Employment 09 - Consolidation Omnibus Budget Reconciliation Act (COBRA) 14 - Voluntary Withdrawal 15 - Primary Care Provider (PCP) Change 22 - Plan Change Use this when the changing the Account, Tier Code or Benefit Package. 25 - Change in Identifying Data Elements Benefit Enrollment and Maintenance - 834 9 X12V4010X095A1

Should be sent when a change to the Members First Name, Last Name, Date of Birth, or Gender is being made. If a change to the SSN is required, a termination transaction for the incorrect number should be sent, followed by an add transaction with the correct number. 28 - Initial Enrollment 31 - Legal Separation 32 - Marriage 41 - Re-enrollment 43 - Change of Location AI - No Reason Given This code is not used unless agreed upon by both Trading Partners. XN - Notification Only This code should only be used when the contract between the sponsor and the payer has agreed upon its usage. This code must be submitted on full files. XT - Transfer A transfer is when a change to the BCBSVT Group Number is required. A termination transaction of the old Group must be sent, followed by an Add transaction with all of the new BCBSVT information. Benefit Status Code INS05 A - Active C - Consolidated Omnibus Budget Reconciliation Act (COBRA) Employment Status Code INS08 This is required for Subscriber Add and Change transactions only. Valid Employment Status Codes for BCBSVT are: AO - Active Military - Overseas AU - Active Military - USA FT - Full-time L1 - Leave of Absence PT - Part-time RT - Retired TE Terminated Loop 2000 Subscriber Number (REF) Reference Identification Qualifier REF01 0F Subscriber Number Reference Identification REF02 The Subscriber s Social Security Number must be sent (in REF02). If the member is currently enrolled/enrolling in VT Blue65, send the Subscribers Social Security Number with the one to two position Medicare assigned Suffix code(s) immediately following it (No spaces, hyphens or special characters should be sent). Benefit Enrollment and Maintenance - 834 10 X12V4010X095A1

Loop 2000 Member Policy Number (REF) This segment must be sent at member level with each transaction. Reference Identification Qualifier REF01 1L - Group or Policy Number Reference Identification REF02 REF02 must be sent with the Subscribers five or six position BCBSVT Group Number. Loop 2000 Member Identification Number (REF) This segment must be sent at member level with each transaction. Reference Identification Qualifier REF01 6O - Cross Reference Number DX - Department/Agency Number DX is the required minimum qualifier for this segment. Other qualifiers may be used in addition to the DX qualifier. F6 - Health Insurance Claim (HIC) Number Q4 - Prior Identifier Number Reference Identification REF02 REF02 must be a minimum of eight or nine position BCBSVT Account Number when REF01 equals DX. Loop 2000 Member Level Dates (DTP) Change File - Member Cancellation must be submitted with DTP01 = 357. Full file Member Add and Change transactions must be submitted with DTP01 = 356. Member Cancellation from a full file must be submitted with two DTP segments, DTP01 = 356 and DTP01 = 357 unless Term By Absence is requested. Date/Time Qualifier DTP01 Valid Date/Time qualifiers for BCBEVT are: 356 Eligibility Begin Required for Add and Change transactions in a full file only with member s eligibility start date. 357 - Eligibility End Required for Cancellation Transactions. Send the last day that the member will have coverage in DTP03. If the Subscriber is sent, all members under the policy will be cancelled. If only a dependent is sent, only the individual dependent will be cancelled. Benefit Enrollment and Maintenance - 834 11 X12V4010X095A1

9.7 Member Name Loop 2100A Loop 2100A Member Name (NM1) Entity Identifier Code NM101 IL - Insured or Subscriber Entity Type Qualifier NM102 1 Person 74 Corrected Insured. Must only be submitted this code when Name, Date of Birth, Gender or Marital Status change is submitted along with the incorrect information in loop 2100B. Member Last Name NM103 BCBSVT allows 35 Characters. Member First Name NM104 BCBSVT allows 25 Characters. Member Middle Name NM105 BCBSVT allows 25 Characters. Name Suffix NM107 BCBSVT allows 10 Characters. Identification Code Qualifier NM108 34 - Social Security Number Identification Code NM109 Nine digit member s Social Security Number. Loop 2100A - Member Demographics (DMG) Gender Code DMG03 Valid Gender Codes for BCBSVT are: F - Female M Male Marital Status Code DMG04 Marital Status Code must only be sent on Subscriber Transactions. Do not submit on dependent enrollment transactions. Valid Marital Status Codes for BCBSVT are: B - Registered Domestic Partner D - Divorced I - Single M - Married R - Unreported S - Separated U - Unmarried (Single or Divorced or Widowed) W - Widowed X - Legally Separated Benefit Enrollment and Maintenance - 834 12 X12V4010X095A1

9.8 Incorrect Member Name Loop 2100B This loop must be submitted only when there is a Name, Date of Birth, Gender or Marital Status change/correction is being requested in Loop 2100A with NM101 = 74. Loop 2100B Member Name (NM1) Submit with prior incorrect information. Entity Identifier Code NM101 70 Prior Incorrect Insured. Required only when Name, Date of Birth, Gender or Marital Status change is submitted along with the corrected information in loop 2100A. Entity Type Qualifier NM102 1 Person Member Last Name NM103 BCBSVT allows 35 Characters. Member First Name NM104 BCBSVT allows 25 Characters. Member Middle Name NM105 BCBSVT allows 25 Characters. Name Suffix NM107 BCBSVT allows 10 Characters. Identification Code Qualifier NM108 34 - Social Security Number Identification Code NM109 Nine digit member s Social Security Number. Loop 2100B - Member Demographics (DMG) Submit with prior incorrect information. Gender Code DMG03 Valid Gender Codes by BCBSVT are: F - Female M Male Marital Status Code DMG04 Marital Status Code must only be sent on Subscriber Transactions. Do not submit on dependent enrollment transactions. Valid Marital Status Codes by BCBSVT are: B - Registered Domestic Partner D - Divorced I - Single M - Married R - Unreported S - Separated U - Unmarried (Single or Divorced or Widowed) W - Widowed X - Legally Separated Benefit Enrollment and Maintenance - 834 13 X12V4010X095A1

9.9 Health Coverage Loop 2300 Loop 2300 Health Coverage (HD) Maintenance Type Code HD01 Valid Maintenance Type codes for BCBSVT are: 001 Change 021 Addition 025 Reinstatement Can use to reinstate same TIER/BENEFIT PACKAGE (HD04) without a break in coverage. Send new TIER/BENEFIT PACKAGE (HD04) with original effective date of the TIER/BENEFIT PACKAGE. 030 - Audit or Compare This code must be used for full files only. Insurance Line Code HD03 HLT Plan Coverage Description HD04 Send concatenated TIER/BENEFIT PACKAGE value. Value should be a fixed length: TIER CODE = 4; BENEFIT PACKAGE = 4. Example: 2001AB01 This information will be provided by BCBSVT Account Manager upon submission of Trading Partner Agreement. Coverage Level Code HD05 It is required for Subscriber transactions only, do not submit on dependent member transactions. Valid Coverage Level Codes for BCBSVT are: EMP - Employee Only ESP - Employee and Spouse ECH - Employee and Children FAM - Family E1D - Employee and One Dependent E2D - Employee and Two Dependents E3D - Employee and Three Dependents E5D - Employee and One or More Dependents E6D - Employee and Two or More Dependents E7D - Employee and Three or More Dependents E8D - Employee and Four or More Dependents E9D - Employee and Five or More Dependents Loop 2300 - Health Coverage Dates (DTP) Date/Time Qualifier DTP01 Valid Date/Time qualifiers for BCBSVT are: 303 - Maintenance Effective Use this code for changes to an existing policy. Example: Account and/or Benefit Package or Tier has been changed. 348 - Benefit Begin Benefit Enrollment and Maintenance - 834 14 X12V4010X095A1

Use this code for Add transactions. Loop 2300 Identification Card (IDC) Plan Coverage Description IDC01 BCBSVT requires use a single zero Identification Card Type Code IDC02 H - Health Insurance Action Code IDC04 Valid Action Codes for BCBSVT are: RX Replace 9.10 Provider Information Loop 2310 Loop 2310 Provider Name (NM1) Entity Identifier Code NM101 Valid Entity Identifier Codes for BCBSVT are: P3 - Primary Care Provider Physician that is selected by the insured to provide medical care. Entity Type Qualifier NM102 1 Person Identification Code Qualifier NM108 Valid Entity Identification Code qualifiers for BCBSVT are: XX - Health Care Financing Administration National Provider Identifier Identification Code NM109 Must be the Provider s 10 position PCP NPI Number. Entity Relationship Code NM110 Valid Entity Relationship Codes for BCBSVT are: 25 - Established Patient 26 - Not Established Patient 9.11 Miscellaneous Below are some additional segments that are used by BCBSVT for processing but not listed above. Member Communication Numbers (Loop 2100A) Member Mailing Address (Loop 2100C) PER NM1, N3 & N4 Use PER segment for submitting member communication phone number and or email address. Member mailing address is required to process enrollment transactions into BCBSVT system. Use NM1, N3 & N4 segments to submit member Benefit Enrollment and Maintenance - 834 15 X12V4010X095A1

Custodial Parent (Loop 2100F) NM1, PER, N3 & N4 mailing address information Use this segment to submit custodial parent information. Valid Communication Number Qualifier in PER segment for Custodial Parent are: HP - Home Phone Number WP - Work Phone Number EX - Telephone Extension PCP Change Reason (Loop 2310) PLA Use this segment to report the reason and the effective date that a member changes primary care provider. Coordination of Benefits (Loop 2320) COB, REF, N1 & DTP Use COB, REF, N1 & DTP segments to submit Coordination of Benefits information. Benefit Enrollment and Maintenance - 834 16 X12V4010X095A1

10. Examples Subscriber Add INS*Y*18*021*28*A***FT*N*N~ REF*DX*12345000~ NM1*IL*1*LAST*FIRST*M**SR~ DMG*D8*19550101*M*I~ HD*021**HLT*1001ABCD*EMP~ DTP*348*D8*20130101~ LX*1~ NM1*P3*1******XX*0001234567*25~ PLA*2*1P*20130101**AI~ Benefit Enrollment and Maintenance - 834 17 X12V4010X095A1

Dependent Add Spouse INS*N*01*021*28*A***FT*N*N~ REF*DX*12345000~ NM1*IL*1*LAST*FIRST*M~ DMG*D8*19600101*F~ HD*021**HLT*2001ABCD~ DTP*348*D8*20130101~ LX*1~ NM1*P3*1******XX*0001234567*25~ PLA*2*1P*20130101**AI~ Child INS*N*19*021*28*A***FT*N*N~ REF*DX*12345000~ NM1*IL*1*LAST*FIRST*M**JR~ DMG*D8*19980101*M~ HD*021**HLT*3001ABCD~ DTP*348*D8*20130101~ LX*1~ NM1*P3*1******XX*0001234567*25~ PLA*2*1P*20130101**AI~ Benefit Enrollment and Maintenance - 834 18 X12V4010X095A1

PCP Change Send the new PCP provider number and the effective date. The benefit effective on the HD segment should be the current effective date for the member. INS*N*01*001*15*A***FT*N*N~ REF*DX*12345000~ NM1*IL*1*LAST*FIRST*M~ DMG*D8*19600101*F~ HD*021**HLT*2001ABCD~ DTP*303*D8*20120101~ LX*1~ NM1*P3*1******XX*0001234567*25~ PLA*2*1P*20121215**AI~ Address Change INS*Y*18*001*43*A***FT*N*N~ REF*DX*12345000~ NM1*IL*1*LAST*FIRST*M**SR~ DMG*D8*19550101*M*I~ N3*110 MAIN STREET*APARTMENT A~ N4*CENTER CITY*VT*12345001~ HD*021**HLT*1001ABCD*EMP~ DTP*348*D8*20120101~ Benefit Enrollment and Maintenance - 834 19 X12V4010X095A1

Cancel Dependent No Downgrade Send the cancel date on the DTP 2000 loop. Normally the cancel date is the last day of the month. INS*N*19*024*14*A***FT*N*N~ REF*DX*12345000~ DTP*357*D8*20121231~ NM1*IL*1*LAST*FIRST*M**JR~ DMG*D8*19980101*M~ Cancel Dependent with Downgrade The first transaction actually cancels the member. The second transaction will downgrade the subscriber s (or entire family s) tier. INS*N*01*024*01*A***FT*N*N~ REF*DX*12345000~ DTP*357*D8*20121231~ NM1*IL*1*LAST*FIRST*M~ DMG*D8*19600101*F~ INS*Y*18*001*01*A***FT*N*N~ REF*DX*12345000~ NM1*IL*1*LAST*FIRST*M**SR~ DMG*D8*19550101*M*I~ HD*001**HLT*1001ABCD*EMP~ DTP*303*D8*20130101~ Benefit Enrollment and Maintenance - 834 20 X12V4010X095A1

Add Dependent with Upgrade The first transaction upgrades the subscriber s (and family s) tier. The second transaction adds the new family member. INS*Y*18*001*32*A***FT*N*N~ REF*DX*12345000~ NM1*IL*1*LAST*FIRST*M**SR~ DMG*D8*19550101*M*M~ HD*001**HLT*2001ABCD*ESP~ DTP*303*D8*20130101~ INS*N*01*021*32*A***FT*N*N~ REF*DX*12345000~ NM1*IL*1*LAST*FIRST*M~ DMG*D8*19600101*F~ HD*021**HLT*2001ABCD~ DTP*348*D8*20130101~ LX*1~ NM1*P3*1******XX*0001234567*25~ PLA*2*1P*20130101**AI~ Benefit Enrollment and Maintenance - 834 21 X12V4010X095A1

Account # Change (plan change) Only the account number and HD segment information will be changed, the new benefit effective date is reflected on the DTP segment. INS*Y*18*001*22*A***FT*N*N~ REF*DX*12345001~ NM1*IL*1*LAST*FIRST*M**SR~ DMG*D8*19550101*M*M~ HD*001**HLT*2002ABCD*ESP~ DTP*303*D8*20130101~ INS*N*01*001*22*A***FT*N*N~ REF*DX*12345001~ NM1*IL*1*LAST*FIRST*M~ DMG*D8*19600101*F~ HD*001**HLT*2002ABCD ~ DTP*303*D8*20130101~ Benefit Enrollment and Maintenance - 834 22 X12V4010X095A1

Group # Change/Plan Change If the group number changes, the family must be cancelled from the old group and each family member added to the new group. INS*Y*18*024*22*A***FT*N*N~ REF*DX*12345000~ DTP*357*D8*20121231~ NM1*IL*1*LAST*FIRST*M**SR~ DMG*D8*19550101*M*M~ INS*Y*18*021*22*A***FT*N*N~ REF*1L*67890~ REF*DX*67890000~ NM1*IL*1*LAST*FIRST*M**SR~ DMG*D8*19550101*M*M~ HD*021**HLT*2002ABCD~ DTP*348*D8*20130101~ LX*1~ NM1*P3*1******XX*0001234567*25~ PLA*2*1P*20130101**AI~ INS*N*01*021*22*A***FT*N*N~ REF*1L*67890~ REF*DX*67890000~ NM1*IL*1*LAST*FIRST*M~ DMG*D8*19600101*F~ HD*021**HLT*2002ABCD~ DTP*348*D8*20130101~ LX*1~ NM1*P3*1******XX*0001234567*25~ PLA*2*1P*20130101**AI~ Benefit Enrollment and Maintenance - 834 23 X12V4010X095A1

Name and Birth Date Correction Always include the old demographics information when there is a change. INS*Y*18*001*25*A***FT*N*N~ REF*DX*12345000~ NM1*74*1*NEW LAST*NEW FIRST*M**SR~ DMG*D8*19550101*M*I~ NM1*70*1*OLD LAST*OLD FIRST*M**SR~ DMG*D8*19650101*M*I~ N3*110 MAIN STREET*APARTMENT A~ N4*CENTER CITY*VT*12345001~ HD*001**HLT*1001ABCD*EMP~ DTP*303*D8*20130101~ Benefit Enrollment and Maintenance - 834 24 X12V4010X095A1

Appendix A (Testing/Certification Scenarios) BCBSVT recommends that you include the enrollment transactions but not limited to the scenarios that are outlined in this section below, to complete successful testing as a new trading partner submitting enrollment transactions. BCBSVT will work with you on how to submit test files and status of the test files validation and loading into BCBSVT membership system. Upon completion of successful testing we will start processing your production files. Membership Adds: 1. Enrolling a new subscriber only policy. 2. Enrolling subscriber and spouse policy. 3. Enrolling a new family (subscriber, spouse and child dependents) policy. 4. Enrolling a new family (subscriber, and dependent children) policy. 5. Adding a new dependent member to a family policy, without a benefit or tier change to the policy. 6. Enrolling subscriber and a domestic partner policy. 7. Enrolling a new family policy with one of the children as a student status. 8. Enrolling a new family policy with twins. 9. Enrolling a new member with phone number and email address. 10. Enrolling a new member with a Primary Care Physician. 11. Enrolling a new subscriber with COB. Membership Cancels: 12. Cancel subscriber only policy. 13. Cancel subscriber and spouse policy. 14. Cancel a family policy. 15. Cancel a dependent member of a family remaining at a family policy. Subscriber Upgrades with dependent member add. 16. Subscriber upgrade from a single to two people by adding a spouse 17. Subscriber upgrade from a single to two people by adding a dependent child 18. Subscriber upgrade from a single to family by adding spouse and dependent child 19. Subscriber upgrade from a single to family by adding dependent children 20. Subscriber upgrade from two people (subscriber & spouse) to a family by adding and dependent child 21. Subscriber upgrade from two people (subscriber & child) to family by adding spouse. Subscriber Downgrades with dependent member cancel. 22. Subscriber downgrade from two people (subscriber & spouse) to a single by cancelling spouse. 23. Subscriber downgrade from two people (subscriber & child) to single by cancelling dependent child. 24. Subscriber downgrade from family to a single by cancelling spouse and dependent children. 25. Subscriber downgrade from family (subscriber & children) to single by cancelling dependent children. 26. Subscriber downgrade from family to two people by cancelling dependent children. 27. Subscriber downgrade from family to two people (subscriber & child) by cancelling spouse. Membership Changes. 28. Subscriber s Address change 29. Subscriber s Last name change 30. Subscriber s phone number change 31. Subscriber s email address change 32. Subscriber s PCP change 33. Dependent member s PCP change 34. Subscriber s DOB correction Benefit Enrollment and Maintenance - 834 25 X12V4010X095A1

Document Revision History: Version Number Date Modified By Comments/Revision Details 1.0 12/19/2012 Anantha Boppana Initial version Benefit Enrollment and Maintenance - 834 26 X12V4010X095A1