5010 - 834 - Companion for AZ

5010 - 834 - Companion for AZ

DELTA DENTAL COMPANION GUIDE

______

Delta Dental of Arizona

HIPAA Transaction

Standard Companion Guide

Refers to the X12N Implementation Guide

005010X220: 834 – Benefit Enrollment and Maintenance

Companion Guide Version Number: 5.3

EDITOR’S NOTE:

This Companion Guide is a work in-progress. Information found here may change over time. Delta Dental of Arizona reserves the right to make changes to this Companion Guide.

Table of Contents

Introduction

General EDI Terminology

ASC X12 Nomenclature

Header Segments

Trailer Segments

Data Clarifications for the 834 Transaction Set

Preferred Values for Elements

Segments Not Used by Delta Dental

Introduction

This document is the property of Delta Dental of Arizona and is intended to provide guidance in implementing the ANSI ASC X12N Version 5010 Benefit Enrollment and Maintenance – 834 transaction. This ASC X12N 834 format is mandated by the Health Insurance Portability and Accountability Act (HIPAA). This transaction is used to transfer enrollment information electronically from the sponsor of the insurance coverage to a healthcare payer. Use of the 5010 version of the X12 standard is required by federal law. The compliance date for use of this standard is January 1, 2012.

There are required, as well as situational loops that each user must take into consideration in determining the appropriate use for their transactions. It is recommended that each user develop relevant business scenarios for their business uses of the 834, as the use of this transaction can vary from user to user. As guidance, please refer to the Business Scenarios developed by ASC X12N Insurance Subcommittee for the 834 transaction. These are located at:

This document is based on the implementation standard of the ASC X12N Benefit Enrollment and Maintenance – 834. It is meant to be a companion document and not a replacement for the ASC X12 834 implementation guide. Specific instructions contained in this document are provided for clarification purposes only and should be used in conjunction with the applicable HIPAA Implementation Guides published by Washington Publishing Company.

If you would like to view the implementation guide and the ASC X12 standards, please refer to the documents published by the Washington Publishing Company for the ASC X12N Insurance Subcommittee. The website for purchasing these documents is:

Store.x12.org

HIPAA regulations allow users to submit changes to the electronic transactions formats. To request changes for consideration to the ASC X12 standards, please contact the HIPAA Designated Standards Maintenance Organizations website at:

General EDI Terminology

A listing of terms commonly used throughout the HIPAA regulations and the EDI transactions is available from WEDI. The website is:

Go to the Resources, Select HIPAA Resources and it will be found under the other HIPAA resources section.

ANSI X12 834 v5010 – HIPAA standardized ANSI X12 transaction format for benefit enrollment and maintenance.

Basic Character Set – The basic character set includes those characters selected from the uppercase letters, digits, space, and specified characters such as: A…Z | 0…9 | ! | “ | & | ‘ | ( | ) | * | + | , | - | . | / | : |; | ? | = | space.

Data Segment – Corresponds to a record in data processing terminology. Consists of logically related data elements in a defined sequence (defined by X12). Each segment begins with a segment identifier, which is not a data element and one or more related data elements, which are preceded by a data element separator. Each segment ends with a segment terminator.

Data Element – Corresponds to a field in data processing. They are assigned a unique reference number. Each element has a name, description, type, minimum length and maximum length. The length of an element is the number of character positions used.

EDI – An acronym for Electronic Data Interchange.

Electronic Data Interchange – the application-to-application transfer of key business information transacted in a standard format using a computer-to-computer communications link.

Implementation guides – Documents that provide standardized data requirements and content as the specifications for consistent implementation of a standard transaction set. HIPAA implementation guides are published by the Washington Publishing Company on their website:

Interface – The point at which two systems connect to pass data.

Loops – Loops are groups of semantically related segments. Data segment loops may be unbounded or bounded.

Trading partners – Entities that exchange electronic data files. Agreements are sometimes made between the partners to define the parameters of the data exchange and simplify the implementation process.

X12 Transaction Set – A transaction set is considered one business document which is composed of a transaction set header control segment, one or more data segments, and a transaction set trailer control segment.

X12N – An Accredited Standards Committee (ASC) commissioned by the American National Standards Institute (ANSI) to develop standards for Electronic Data Interchange (EDI). While X12 indicates EDI, the N identifies the Insurance Subcommittee that is responsible for developing EDI standards for the insurance industry.

ASC X12 Nomenclature

The ASC X12 Nomenclature guide is a useful reference in understanding the details of the ASC X12 transactions. This includes hierarchical structure of the ASC X12 transactions, general definitions and concepts, relations among control segments, functional groups, and HL structures. The ASC X12 Nomenclature guide is the same for all transactions. To review this guide, please refer to the website:

Header Segments

Interchange Control Header

The ISA segment is the Interchange Header Segment. This segment identifies the sender and receiver for each transaction. This segment also identifies the delimiters used throughout the file.

Please use these values when sending the ISA segment:

Page # / Loop Id / Reference / Name / Length / Value
C.4 / n/a / ISA01 / Authorization Information Qualifier / 2/2 / 00
C.4 / n/a / ISA02 / Authorization Information / 10/10 / Fill with 10 Spaces
C.4 / n/a / ISA03 / Security Information Qualifier / 2/2 / 00
C.4 / n/a / ISA04 / Security Information / 10/10 / Fill with 10 Spaces
C.4 / n/a / ISA05 / Interchange ID Qualifier / 2/2 / Groups ID qualifier
C.4 / n/a / ISA06 / Interchange Sender ID / 15/15 / Group’s Tax ID or similar number (For TPA’s, this must be a unique number for each group that you send)
C.4 / n/a / ISA07 / Interchange ID Qualifier / 2/2 / 30
C.4 / n/a / ISA08 / Interchange Receiver ID / 15/15 / 860274899
C.6 / n/a / ISA15 / Interchange Usage Indicator / 1/1 / T = Test for all test files
P = Production for all production files

For all other ISA elements, please refer to the HIPAA-AS implementation Guides for specific instructions.

Functional Group Header

The GS segment indicates the beginning of a functional group and provides control information.

Please use these values when sending the GS segment:

Page # / Loop Id / Reference / Name / Length / Value
C.7 / n/a / GS02 / Application Sender’s Code / 2/15 / Use your Sender Id or the same value as ISA06
C.7 / n/a / GS03 / Application Receiver’s Code / 2/15 / DDAZ

For all other GS elements please refer to the HIPAA-AS implementation Guides for specific instructions.

Transaction Set Header

The ST segment indicates the start of a transaction set and assigns a control number.

For all ST elements please refer to the HIPAA-AS implementation Guides for specific instructions.

Sponsor Name - This segment identifies the sponsor.

Please use these values when sending the N1 segment in the 1000A loop:

Page # / Loop Id / Reference / Name / Length / Value
39 / 1000A / N101 / Entity Identifier Code / 2/3 / P5
39 / 1000A / N102 / Name / 1/60 / Group or Employer’s Name
40 / 1000A / N103 / Identification Code Qualifier / 1/2 / 24 or FI
40 / 1000A / N104 / Identification Code / 2/80 / Employer’s ID Number or Federal Tax ID

Payer - This segment identifies the payer.

Please use these values when sending the N1 segment in the 1000B loop:

Page # / Loop Id / Reference / Name / Length / Value
41 / 1000B / N101 / Entity Identifier Code / 2/3 / IN
41 / 1000B / N102 / Name / 1/60 / DELTA DENTAL OF ARIZONA
42 / 1000B / N103 / Identification Code Qualifier / 1/2 / FI
42 / 1000B / N104 / Identification Code / 2/80 / 860274899

TPA/Broker Name - This segment identifies the TPA/Broker if involved.

Please use these values when sending the N1 segment in the 1000C loop:

Page # / Loop Id / Reference / Name / Length / Value
43 / 1000C / N101 / Entity Identifier Code / 2/3 / BO for Broker, TV for TPA
43 / 1000C / N102 / Name / 1/60 / Broker or TPA Name
44 / 1000C / N103 / Identification Code Qualifier / 1/2 / FI
44 / 1000C / N104 / Identification Code / 2/80 / Broker or TPA Federal Tax ID

Trailer Segments

Interchange Control Trailer

The IEA segment identifies the end of an interchange of zero or more functional groups and interchange-related control segments and is the last segment within the transaction set.

For all IEA elements please refer to the HIPAA-AS Implementation Guides for specific instructions.

Functional Group Trailer

The GE segment indicates the end of a functional group and provides control information.

For all GE elements please refer to the HIPAA-AS implementation Guides for specific instructions.

Transaction Set Trailer

The SE segment indicates the end of a transaction set and provides the count of transmitted segments.

For all SE elements please refer to the HIPAA-AS implementation Guides for specific instructions.

1

October 1, 2010. 005010.5.3

DELTA DENTAL COMPANION GUIDE

Data Clarifications for the 834 Transaction Set

Delta Dental would prefer to receive the basic character set

Preferred Values for Elements

Page # / Loop Id / Reference / Name / Codes / Length / Notes/Comments
48 / 2000 / INS01 / Yes/No Condition Response Code – Insured Indicator / Y – Subscriber
N - Dependent / 1/1
48 / 2000 / INS02 / Individual Relationship Code / The preferred values for this are:
01 – Spouse
09 – Adopted Child
10 – Foster Child
15 – Ward
17 – Stepson or Stepdaughter
18 – Self (Subscriber)
19 – Child
23 – Sponsored Dependent
25 – Ex-Spouse
53 – Life Partner / 2/2
49 / 2000 / INS03 / Maintenance Type Code / 001 – Change
021 – Addition
024 – Cancellation or termination
025 – Reinstatement
030 – Audit or Compare / 3/3
49 / 2000 / INS05 / Benefit Status Code / The preferred values for this are:
A – Active
C – COBRA / 1/1
Page # / Loop Id / Reference / Name / Codes / Length / Notes/Comments
52 / 2000 / INS07 / COBRA Qualifying Event Code / 1 – Termination
2 – Reduction of work hours
3 – Medicare
4 – Death
5 – Divorce
6 – Separation
7 – Ineligible Child
8 – Bankruptcy of Retired Employee’s former employer
9 – Layoff
10 – Leave of Absence / 1/2 / Required if member is enrolled in COBRA
52 / 2000 / INS08 / Employment Status Code / AO – Active Military – Overseas
AU – Active Military – USA
FT – Full-time active employee
L1 – Leave of Absence
PT – Part-time Active Employee
RT – Retired
TE – Terminated / 2/2 / Required for subscriber
53 / 2000 / INS09 / Student Status Code / The preferred values for this are:
F – Full-time
N – Not a Student
P – Part-time will be treated as “Not a Student” / 1/1
53 / 2000 / INS10 / Yes/No Condition or Response – Handicap Indicator / N – No individual is not handicapped
Y – Yes individual is handicapped / 1/1
54 / 2000 / INS12 / Date Time Period / 1/35 / Date of death of the subscriber/dependent
55 / 2000 / REF01 / Reference Identification Qualifier / 0F – Subscriber Number / 2/3 / Required field for all members.
55 / 2000 / REF02 / Reference Identification / 1/50 / The Social Security number of the subscriber or the Employee ID number supplied by the employer. If both are required, use NM109 for the SSN. If SSN is required but EIN is optional, use REF01 = DX for the EIN. Numeric values only.
Page # / Loop Id / Reference / Name / Codes / Length / Notes/Comments
56 / 2000 / REF01 / Reference Identification Qualifier / 1L – Group Number / 2/3 / This should only be used for Dental only or Vision only groups. Groups with both should send in the 2300 loop.
56 / 2000 / REF02 / Reference Identification / 1/50 / The 18 digit Group Number assigned by Delta Dental
59 / 2000 / DTP01 / Date/Time Qualifier / 336 – Employment Begin (Hire Date)
350 – Education Begin (Student Start Date)
357 – Eligibility End (Termination Date/Last Day of Coverage) / 3/3
60 / 2000 / DTP03 / Date Time Period / 1/35 / Status Information Effective Date
62 / 2100A / NM101 / Entity Identifier Code / 74 – If sending corrected identifier information on already enrolled member
IL - If enrolling new member or updating member with no change in identifying
information / 2/3
63 / 2100A / NM102 / Entity Type Qualifier / 1 – Person / 1/1
63 / 2100A / NM103 / Name Last or Organization Name / 1/60 / Member Last Name
63 / 2100A / NM104 / Name First / 1/35 / Member First Name
63 / 2100A / NM105 / Name Middle / 1/25 / Send if supplied
Member Middle Name
63 / 2100A / NM107 / Name Suffix / 1/10 / Send if supplied
Member Name Suffix
64 / 2100A / NM108 / Identification Code Qualifier / 34 – Social Security Number / 1/2 / Send when required by X12 syntax
64 / 2100A / NM109 / Identification Code / 2/80 / Subscriber’s Social Security Number
65 / 2100A / PER01 / Contact Function Code / IP – Insured Party / 2/2 / Send if supplied
65 / 2100A / PER03/05/07 / Communication Number Qualifier / EM – Electronic Mail (Email)
HP – Home Phone Number
TE – Telephone
WP – Work Phone Number / 2.2 / Send if supplied
65 / 2100A / PER04/06/08 / Communication Number / Insert the email or phone number here. Please do not include any formatting in the phone number. i.e. Send the phone number as 5554443333 / Send if supplied
Page # / Loop Id / Reference / Name / Codes / Length / Notes/Comments
68 / 2100A / N301 / Address Information / 1/55 / Required when enrolling subscriber, when enrolling a dependent and the dependent’s address is different from the subscriber’s and when changing a member’s address.
Member Address Line 1
Please note that Delta Dental only stores the first 30 characters of this field.
68 / 2100A / N302 / Address Information / 1/55 / Required if second address line exists
Member Address Line 2
Please note that Delta Dental only stores the first 30 characters of this field.
69 / 2100A / N401 / City Name / 2/30 / Member City Name
69 / 2100A / N402 / State or Province Code / 2/2 / Member State Code
70 / 2100A / N403 / Postal Code / 3/15 / Member Postal Zone or Zip Code
70 / 2100A / N404 / Country Code / 2/3 / Required if country is not USA
71 / 2100A / DMG02 / Date Time Period / 1/35 / Required element. If not available, use Delta Dental’s default - 19010101
Member Birth Date
72 / 2100A / DMG03 / Gender Code / F – Female
M – Male
U – Unknown / 1/1
86 / 2100B / NM101 / Entity Identifier Code / 70 – Prior Incorrect Insured / 2/3
87 / 2100B / NM102 / Entity Type Qualifier / 1 – Person / 1/1
87 / 2100B / NM103 / Name Last or Organization Name / 1/60 / Incorrect Member Last Name
87 / 2100B / NM104 / Name First / 1/35 / Incorrect Member First Name
87 / 2100B / NM105 / Name Middle / 1/25 / Send if supplied
Incorrect Member Middle Name
87 / 2100B / NM107 / Name Suffix / 1/10 / Send if supplied
Incorrect Insured’s Name Suffix
87 / 2100B / NM108 / Identification Code Qualifier / 34 – Social Security Number / 1/2 / Send when required by X12 syntax
88 / 2100B / NM109 / Identification Code / 2/80 / Incorrect Subscriber’s Social Security Number
90 / 2100B / DMG02 / Date Time Period / 1/35 / Required when there is a change to previous demographic information
Incorrect Member Birth Date
Page # / Loop Id / Reference / Name / Codes / Length / Notes/Comments
90 / 2100B / DMG03 / Gender Code / F – Female
M – Male
U – Unknown / 1/1 / Incorrect Member Gender Code
92 / 2100C / NM101 / Entity Identifier Code / 31 – Postal Mailing Address / 2/3 / Send if mailing address is different from residence address, dependent’s address is different from the subscriber’s, or changing member’s address
92 / 2100C / NM102 / Entity Type Qualifier / 1 – Person / 1/1
94 / 2100C / N301 / Address Information / 1/55 / Member Address Line 1
94 / 2100C / N302 / Address Information / 1/55 / Required if second address line exist
Member Address Line 2
95 / 2100C / N401 / City Name / 2/30 / Member City Name
95 / 2100C / N402 / State or Province Code / 2/2 / Member State Code
96 / 2100C / N403 / Postal Code / 3/15 / Member Postal Zone or Zip Code
96 / 2100C / N404 / Country Code / 2/3 / Required if country is not USA
106 / 2100E / NM101 / Entity Identifier Code / M8 – Educational Institution / 2/3
106 / 2100E / NM102 / Entity Type Qualifier / 2 – Non-Person Entity / 1/1
107 / 2100E / NM103 / Name Last or Organization Name / 1/60 / School Name
140 / 2300 / HD01 / Maintenance Type Code / 001 – Change
002 – Delete (incorrect coverage record)
021 – Addition
024 – Cancellation/Termination
025 – Reinstatement
026 – Correction
030 – Audit or Compare
032 – Employee Information Not Applicable / 3/3 / Required when enrolling a new member or when adding, updating or removing coverage
141 / 2300 / HD03 / Insurance Line Code / DEN – Dental
VIS – Vision / 2/3 / Include a 2300 loop for each line of insurance present.
Page # / Loop Id / Reference / Name / Codes / Length / Notes/Comments
142 / 2300 / HD05 / Coverage Level Code / For 2 Tier:
EMP – Employee Only (S)
FAM – Family (F)
For 3 Tier:
EMP – Employee Only (S)
E1D – Employee and One Dependent (Child) (D)
ESP – Employee and Spouse (D)
E6D – Employee and Two or More Dependents (M)
For 4 Tier:
EMP – Employee Only (S)
ECH – Employee and Children (K)
ESP – Employee and Spouse (P)
FAM – Family (F)
For Composite:
FAM – Composite (T) / 3/3 / The preferred values are based on the group contract.
143 / 2300 / DTP01 / Date/Time Qualifier / 303 – Maintenance Effective (Change Date)
348 – Benefit Begin (Effective Date)
349 – Benefit End (Termination Date/Last Day of Coverage) / 3/3 / Required when enrolling a member or when there is a change to the dates.
144 / 2300 / DTP03 / Date Time Period / 1/35 / Coverage Period
146 / 2300 / REF01 / Reference Identification Qualifier / 1L – Group Number / 2/3 / This should only be used for groups with both Dental and Vision Groups with only Dental or Only vision should send in the 2000 loop.
147 / 2300 / REF02 / Reference Identification / 1/50 / The 18 digit Group Number assigned by Delta Dental
164 / 2320 / COB01 / Payer Responsibility Sequence Number Code / P – Primary
S – Secondary
T – Tertiary / 1/1 / Provide if available
164 / 2320 / COB02 / Reference Identification / 1/50 / Insured Group or Policy Number
164 / 2320 / COB03 / Coordination of Benefits Code / 1 – Coordination of Benefits
6 – No Coordination Of Benefits / 1/1
Page # / Loop Id / Reference / Name / Codes / Length / Notes/Comments
N/A / 2500 / FSA01 / Maintenance Type Code / 030 – Audit or Compare / 3/3 / Loop 2500 is for Flexible Spending Plans only. If FSA does not apply for a subscriber, omit this loop. If the loop is present, FSA is present.
N/A / 2500 / FSA02 / Flexible Spending Account Selection Code / H – Healthcare / 1/1

For all other elements, please refer to the HIPAA-AS implementation Guides for specific instructions.

Segments Not Used by Delta Dental

Loop / Segment ID / Name / Page / Loop / Segment ID / Name / Page
2100A / EC / Employment Class / 76 / 2330 / N3 / Coordination of Benefits Related Entity Address / 171
2100A / ICM / Member Income / 79 / 2330 / N4 / Coordination of Benefits City, State, Zip / 172
2100A / AMT / Member Policy Amounts / 81 / 2330 / PER / Administrative Communications Contact / 174
2100A / HLH / Member Health Information / 82 / 2330 / LS / Additional Reporting Categories / 176
2100A / LUI / Member Language / 84 / 2710 / LX / Member Reporting Categories / 177
2100D / NM1 / Member Employer / 97 / 2750 / N1 / Reporting Category / 178
2100D / PER / Member Employer Communications Numbers / 100 / 2750 / REF / Reporting Category Reference / 179
2100D / N3 / Member Employer Street Address / 103 / 2750 / DTP / Reporting Category Date / 181
2100D / N4 / MemberEmployerCity, State, Zip / 104 / 2750 / LE / Additional Reporting Categories Loop Termination / 183
2100E / PER / MemberSchool Communications Numbers / 108
2100E / N3 / Member School Street Address / 111
2100E / N4 / MemberSchoolCity, State, Zip / 112
2100F / NM1 / Custodial Parent / 114
2100F / PER / Custodial Parent Communications Numbers / 117
2100F / N3 / Custodial Parent Street Address / 120
2100F / N4 / Custodial ParentCity, State, Zip / 121
2100G / NM1 / Responsible Person / 123
2100G / PER / Responsible Person Communications Numbers / 126
2100G / N3 / Responsible Person Street Address / 129
2100G / N4 / Responsible PersonCity, State, Zip / 130
2200 / DSB / Disability Information / 137
2200 / DTP / Disability Eligibility Dates / 139
2300 / AMT / Health Coverage Policy / 145
2300 / IDC / Identification Card / 150
2310 / LX / Provider Information / 152
2310 / NM1 / Provider Name / 153
2310 / N3 / Provider Address / 156
2310 / N4 / ProviderCity, State, Zip Code / 157
2310 / PER / Provider Communications Numbers / 159
2310 / PLA / PCP Change Reason / 162
2320 / REF / Additional Coordination of Benefits Identifiers / 166
2320 / DTP / Coordination of Benefits Eligibility Dates / 168
2330 / NM1 / Coordination of Benefits Related Entity / 169

1

January 1, 2011. 005010.5.3