834:Benefit Enrollment and Maintenance

834:Benefit Enrollment and Maintenance

This document is intended to provide guidance in implementing the ANSI ASC X12N Version 5010 Benefit Enrollment and Maintenance - 834 transaction. It provides standardized data requirements and content for Delta’s 834 transaction trading partners. It is meant to be a companion document to, not a replacement for, the ASC X12 834 implementation guide.

1.1 Introduction to the 834

The Health Insurance Portability and Accountability Act (HIPAA) mandates this ASC X12N 834 format between certain trading partners (i.e., group health plans). This transaction is used to transfer enrollment information from the sponsor of the insurance coverage or benefits to a healthcare payer. This specification offers both “full file” and “changes only” reporting of enrollment information.

There are two types of loops that users must take into consideration to determine the appropriate use for their transactions — required loops and situational loops. Comments have been added to aid users in making decisions on the use and data content of this 834. In addition, it is recommended that users devise relevant business scenarios for their business uses of the 834, as the use of this transaction can vary from user to user. For guidance, please refer to the Business Scenarios developed by the ASC X12N Insurance Subcommittee for the 834 transaction. These are located at:

This handbook is based on the implementation standard of the ASC X12N 5010 Benefit Enrollment and Maintenance -834. 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 web site for these documents is:

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

Section 2 - EDI Set-up

2.1 Getting Started

To be able to participate in EDI to send enrollment (834) information to Delta, you must select or develop an Electronic Data Interchange system that is HIPAA compliant. You will need telecommunication hardware and software that will allow you to transmit electronically to your Delta Plan. If you already use an electronic commerce system you may need to have your system upgraded in order to submit documents electronically in the format required by Delta. Please discuss the File Transmission methods with your Delta Technical Analyst.

2.2 Sender ID

Each Trading Partner that performs the physical communications function of transmitting documents and/or receiving reports is assigned a Sender ID by Delta. This Sender ID allows the submitter entrance to the EDI facility. The sender ID is provided to the submitter after receipt of completed EDI Request form.

2.3 File Attributes

Each file should only contain one type of transaction – i.e. 820 or 834.

2.4 Transmission Enveloping

Each file transmitted to Delta must be enveloped with the X12 EDI control segments. These segments are used for identifying the sender and receiver, identifying the type of documents being sent, providing hash totals for the receiver to validate and for identifying the file sent with date, time and control number.

As shown below, there are three sets of enveloping required for each file sent to the Delta. Each envelope structure includes a header segment that opens the enveloping and a trailer segment that closes the envelope. The three sets of envelopes are:

Interchange Control

Functional Group

Transaction Set

The envelope structure, its relation to the file of documents constructed under the ASC X12 standard and the purpose of each segment of the envelope are presented in the following table.

EDI TRANSMISSION FILE STRUCTURE
Segment Id / Segment Name / Purpose
ISA
GS
ST
–
SE
GE
IEA / Interchange Control Header
Functional Group Header
Transaction Set Header
File of EDI Documents
Transaction Set Trailer
Functional Group Trailer
Interchange Control Trailer / Identifies the sender and receiver of the electronic data interchange. Provides for uniquely identifying the transmission.
Identifies the following group of transactions as health claims.
Identifies the transactions that follow as being 834 Health Enrollment
File formatted in the 834 format.
Ends the transaction set, provides a count of segments from ST/SE, inclusive
Ends the functional group, provides a count of the ST/SE sets in the file (normally 1)
Ends the submission, provides counts of GS/GE sets in the file (normally 1)

The Header Segments constructed below shows an example of formatting an Enrollment Header in ASC X12 834 Format.

2.5 Envelope Header Records

DDBENX00 is an Example of an assigned Sender ID for entry into the EDI Enterprise System. The other fields depicted are as described in the Traders Handbook.

EDI ISA INTERCHANGE CONTROL HEADER EXAMPLE
EDI Envelope Segments
ISA*00* *00* *ZZ*DDBENX00 *ZZ*942411167 *021011*2142*^*00501*000000021*0*P*>~
GS*BE*DDBENX00*942411167*20021011*2142*000000021*X*005010X220A1~
ST*834*000000021*005010X220A1~

Note: The shading in the above ISA header implies the spacing is to remain in the ISA

2.6 Envelope Trailer Records

EDI ISA INTERCHANGE TRAILER EXAMPLE
EDI Envelope Segments
SE*18508*000000021~
GE*1*000000021~
IEA*1*000000021~

2.7 Separators

Sub-element Separators, Elements Separators and Segment Terminator:

Separators are used between fields in a segment and between segments in the transmission file to allow for field compression and block transmission.

Once specified in the Interchange Header, the characters are not to be used in any data element (see HIPAA Guides Appendix A.1.2.7). Misuse of these fields will cause the file to be rejected.

EDI Sub-element, Element and Terminator
EDI Separators CHARACTER NAME
Sub-element Separator- ISA16: : (Colon or any other character not contained within file)
Element Separator....………....: * (Asterisk)
Segment Terminator..………...: ~ (Tilde)

2.8 Telecommunications

Files can be transmitted using FTP or some other mutually agreeable HIPAA compliant transmission method. HIPAA privacy regulations may require encryption of data. Please contact your Delta Technical Analyst to discuss options.

1

HEADER

Level
Loop
(Repeat) / Seg/Elem
ID / Seg/Elem/
Loop Name / X12
Req / Seg
Rpt / Data
Type / Min/ Max
Length / Comments/Purpose / Example/Values/
Delta Usage / Trading Partner Comments
Header / ISA / Interchange Control Header / REQUIRED – Fixed Length Record Segment that identifies key control components of the interchange. / ISA*00*……….*00*……….*ZZ* DDPPGGGGG*ZZ*94241167 *YYMMDD*HHMM*^*00501*234567234*1*T*:~
ISA01 / Authorization Information Qualifier / R / ID / 2/2 / Identifies the type of information in ISA02 – Authorization Information / 00 – No Auth Info Present
ISA02 / Authorization Information / R / AN / 10/10 / Additional identification or authorization information about the Sender. / Blanks
ISA03 / Security Information Qualifier / R / ID / 2/2 / Identifies the type of information in ISA04 – Security Information / 00 – No Sec Info Present
ISA04 / Security Information / R / AN / 10/10 / Additional security information about the Sender / Blanks
ISA05 / Interchange ID Qualifier / R / ID / 2/2 / Identifies the system/method of code structure used to designate the sender or receiver ID element being qualified / ZZ – Mutually Defined
ISA06 / Interchange Sender ID / R / AN / 15/15 / Sender ID code / DDPPGGGGG where PP is plan code and GGGGG is the group number
ISA07 / Interchange ID Qualifier / R / ID / 2/2 / Identifies the system/method of code structure used to designate the sender or receiver ID element being qualified / ZZ – Mutually Defined
ISA08 / Interchange Receiver ID / R / AN / 15/15 / Receiver ID code / 942411167
ISA09 / Interchange Date / R / DT / 6/6 / Date of interchange YYMMDD / Date file was created
ISA10 / Interchange Time / R / TM / 4/4 / Time of interchange HHMM / Time file was created
ISA11 / Interchange Control Standards Identifier / R / ID / 1/1 / Identifies agency responsible for control standard in headers/trailers / ^ – US EDI Community (ASC X12,TDCC,UCS)
ISA12 / Interchange Control Version Number / R / ID / 5/5 / Identifies the version number of the control standards / 00501 – Draft Publication for ASC X12
ISA13 / Interchange Control Number / R / N0 / 9/9 / Control number assigned by sender. Must be identical to the Interchange Trailer (IEA02) / Sender Defined - Unique control number assigned by originator. Begin submitting transactions using the number 0001 in this element and increment from here.
ISA14 / Acknowledgement Requested / R / ID / 1/1 / Code sent by sender to request interchange acknowledgement (TA1) / 0 – No acknowledgement requested
ISA15 / Usage Indicator / R / ID / 1/1 / Identifies whether interchange data is test (T) or production (P) data / T – Test Data
P – Production Data
ISA16 / Component Element Separator / R / 1/1 / Identifies the delimiter used to separate multiple component data elements within a composite data structure / :
Header / GS / Functional Group Header / REQUIRED – Identifies the beginning of the functional group and provides interchange control information. / GS*BE*SENDER CODE*RECEIVER CODE*19990101*0915*1*X*005010X220A1~
GS01 / Functional Identifier Code / R / ID / 2/2 / Identifies the a group of related translations sets / BE
GS02 / Applications Sender’s Code / R / AN / 2/15 / Identifies party sending transmission; agreed to by trading partners / Sender Code – Same as ISA06
GS03 / Applications Receivers Code / R / AN / 2/15 / Identifies party receiving transmission; agreed to by trading partners / Receiver Code – Same as ISA08
GS04 / Date / R / DT / 8/8 / Transmission creation date – format CCYYMMDD
GS05 / Time / R / TM / 4/8 / Transmission creation time – format HHMM
GS06 / Group Control Number / R / N0 / 1/9 / Assigned number originated and maintained by the sender. This number must be identical to GE02 / Sender Code- Same as GE02 suppressing leading zeroes
GS07 / Responsible Agency Code / R / ID / 1/2 / Code used to identify the issuer of the standard, used with GS08 below / X – Accredited Standards Committee X12
GS08 / Version/Release/ Industry ID Code / R / AN / 1/12 / Code indicating the version, release, sub-release, and industry identifier of the EDI standard being used, including GS and GE segments / 005010X220A1
Header / ST / Transaction Set Header / R / 1 / REQUIRED - Indicate start of a transaction set and to assign a control number / ST*834*0001*005010X220A1~
ST01 / Transaction Set ID Code / R / ID / 3/3 / Used by translation routines of the interchange partners to select the appropriate transaction set definition / 834 – Benefit Enrollment
ST02 / Transaction Set Control Number / R / AN / 4/9 / Unique control number assigned by originator. Begin submitting transactions using the number 0001 in this element and increment from here. ST02 and SE02 must be identical. / 0001
ST03 / Implementation Convention Reference / S / AN / 1/35 / Reference assigned to identify the implementation convention / Sender Code – Same as GS08

DETAIL

Level
Loop
(Repeat) / Seg/Elem ID / Seg/Elem
Loop Name / X12 Req / Seg Rpt / Data Type / Min/Max Length / Comments/Purpose / Example / Trading Partner Comments
Header / Beginning Segment / REQUIRED HEADER
BGN / Beginning Segment / R / 1 / Indicates the beginning of the transaction set. (BGN) / BGN*00*11227*19990101*1200*ES***4*~ / If sending multiple groups on one file, send each group within their own BGN segments
BGN01 / Transaction Set Purpose Code / R / ID / 2/2 / Identifies the purpose of the transactions. Initial submission, Re-submission or Correction (Data Change), or Informational / Lost / Copy (Same Data) / 00 - Original
BGN02 / Reference Identification / R / AN / 1/30 / Transaction set identifier code, Assigned by the sending application / Sender Define - Unique control number assigned by originator. Begin submitting transactions using the number 0001 in this element and increment from here.
BGN03 / Date / R / DT / 8/8 / Identifies the date the submitter created this file (CCYYMMDD) / CCYYMMDD
BGN04 / Time / R / TM / 4/8 / Identifies time of day that submitter created this file. Unique Time Stamp (HHMM) / HHMM
BGN05 / Time Code / S / ID / 2/2 / Utilized to identify time zone changes If needed. Identifies sender time zone / ET – Eastern Time
CT – Central Time
MT – Mountain Time
PT – Pacific Time
BGN06 / Reference Identification / S / AN / 1/50
BGN07 / Not Used / Place Holder Asterisk / *
BGN08 / Action Code / R / ID / 1/2 / Used to identify file action. Update records only file or audit / verify full enrollment file. / 2 - Update (Changes Only)
4 - Verify (Full File)
RX – Replacement File / Adding qualifier RX to signify replacement file.
BGN09 / Not Used / Place Holder Asterisk / *
REF / Transaction Set Policy Number / S / 1 / Utilized when a unique group ID number applies to the entire transaction set / REF*38*PA12345
REF01 / Reference Identification Qualifier / R / ID / 2/3 / Master policy number reference code - 38 / 38
REF02 / Reference Identification / R / AN / 1/50 / Master group number / Delta required values:
PPGGGGG / PP=Delta Assigned Plan Code
GGGGG = 5 Digit numeric Group number
DTP / File Effective Date / S / >1 / Identifies the start of the eligibility reporting for all transactions in the file. / DTP*007*D8*19990101~ / The start date of the eligibility reporting period. This date can vary by group or division. Separate files are to be sent for separate reporting periods. Please contact your Delta Enrollment representative for further information.
DTP01 / Date Time Qualifier / R / ID / 3/3 / 007 - Effective Date
DTP02 / Date Time Period Format Qualifier / R / ID / 2/3 / D8
DTP03 / Date Time Period / R / AN / 1/35 / CCYYMMDD
Header
1000A
(1) / Sponsor Name / REQUIRED LOOP - This loop identifies the group
N1 / Sponsor Name / R / 1 / Utilized to identify the plan sponsor (employer, union, etc) / N1*P5**FI*91042134~
N101 / Entity ID Code / R / ID / 2/3 / Plan Sponsor Entity Code = P5 / P5
N102 / Name / S / AN / 1/60 / Sender Name (Free Text) / Sender defined
N103 / Identification Code Qualifier / R / ID / 1/2 / Until HIPAA EIN finalized use Federal Tax Payers ID identifier (FI), Once HIPAA EIN finalized use (ZZ) / FI
N104 / Identification Code / R / AN / 2/80 / If N103 = FI then Fed. Taxpayer ID (9 AN) / Federal Taxpayer's Identification Number
Header
1000B
(1) / Payer / REQUIRED LOOP - This loop identifies Delta
N1 / Payer / R / 1 / Identifies the payer. Delta Dental Member Plans that pay claims or administer the services / N1*IN**FI*942411167~
N101 / Entity ID Code / R / ID / 2/3 / Insurer = IN / IN
N102 / Name / S / AN / 1/60 / Payer Name (Free Text) / Delta Dental of California
Delta Dental Insurance Company
Delta Dental of Pennsylvania
Delta Dental of New York
Delta Dental of West Virginia
Delta Dental of Delaware
Delta Dental of Washington DC
N103 / Identification Code Qualifier / R / ID / 1/2 / Until HIPAA National Plan ID finalized, use Federal Tax Payers ID identifier (FI), once HIPAA Plan ID finalized use (XV) / FI
N104 / Identification Code / R / AN / 2/80 / If N103 = FI then Fed. Taxpayer ID (9 AN)
If N103 = XV then HIPAA National Plan ID / 942411167
Header
1000C
(1) / TPA/Broker Name / SITUATIONAL LOOP - This loop is required if a TPA/broker is involved
N1 / TPA/Broker Name / S / 1 / If the loop is required, this segment is required / N1*TV**FI*123345456~
N101 / Entity ID Code / R / ID / 2/3 / If Broker utilize BO
If TPA utilize TV / BO – Broker or Sales Office
TV – Third Party Administrator
N102 / Name / S / AN / 1/60 / Payer Name (Free Text)
N103 / Identification Code Qualifier / R / ID / 1/2 / Until HIPAA National Plan ID finalized, use Federal Tax Payers ID identifier (FI), once HIPAA Plan ID finalized use (XV), or 94 for organization code / FI
N104 / Identification Code / R / AN / 2/80 / If N103 = FI then Fed. Taxpayer ID (9 AN)
If N103 = XV then HIPAA National Plan ID
If N103 = 94 then organization defined code / Federal Tax Payers ID
Header
1100C
(1) / TPA/Broker Account Information / SITUATIONAL LOOP - This loop is required if the account number of TPA or Broker is different than the plan sponsor
ACT / TPA/Broker Account Information / S / 1 / If the loop is required, this segment is required / ACT*1234*****45678~
ACT01 / Account Number / R / AN / 1/35 / TPA or Broker Account Number
ACT02 / Not Used / Place Holder Asterisk / *
ACT03 / Not Used / Place Holder Asterisk / *
ACT04 / Not Used / Place Holder Asterisk / *
ACT05 / Not Used / Place Holder Asterisk / *
ACT06 / Account Number / R / AN / 1/35 / Secondary TPA or Broker Account Number (If more than 1)
Detail
2000
/ Member Level Detail / SITUATIONAL LOOP - In this loop, subscriber information must precede dependent information or the subscriber information must have been submitted to the receiver in a previous transmission
INS / Member Level Detail / S / 1 / If the loop is required, this segment is required / INS*Y*18*030**A*E**FT~
INS01 / Yes/No Condition Response Code / R / ID / 1/1 / Insured Indicator. A "Y" value indicates insured is a subscriber / Y-Subscriber
N-Dependent
INS02 / Individual Relationship Code / R / ID / 2/2 / Code indicating the relationship between two individuals or entities / 18 -Self (subscriber)
01 -Spouse
19 - Child
53 - Life Partner
05 - Grandchild
07 - Nephew/Niece
09 - Adopted Child
10 - Foster Child
11 - Son/Daughter In law
15 - Ward
17 - Stepchild
23 - Sponsored Dependant
24 - Dependant of Dependant
25 - Ex Spouse
38 - Collateral Dependant
INS03 / Maintenance Type Code / R / ID / 3/3 / Code identifying the specific type of item maintenance / 021-Add subscriber or dependent
001-Change subscriber or dependent
024-Terminate Member
025-Reinstatement
030- Audit or compare
INS04 / Maintenance Reason Code / S / ID / 2/3 / Code identifying the reason for a maintenance change / Not Required
INS05 / Benefit Status Code / R / ID / 1/1 / The type of coverage under which benefits are paid / A - Active
C - COBRA
S - Surviving Insured
T - TEFRA
INS06 / Medicare Plan Code / S / ID / 1/1 / Code identifying the Medicare Plan (required if a member is being enrolled or disenrolled in Medicare or has terminated or changed their Medicare enrollment) / Not utilized in Delta processing
INS07 / Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying / S / ID / 1/2 / A qualifying event which results in a loss of coverage for a Qualified Beneficiary (required if a member is being or is enrolled for a benefit covered by COBRA) / Not utilized in Delta processing
INS08 / Employment Status Code / S / ID / 2/2 / Code showing the general employment status of an employee/claimant (required for a subscriber) / AO – Active Oversees
AU – Active Military
FT – Full Time
L1 – Leave of Absence
PT – Part Time
RT – Retired
TE – Terminated
INS09 / Student Status Code / S / ID / 1/1 / Note: Delta processes P – Part time student as equal to N – Not a Student. / F – Full-time Student
N – Not a Student
P – Part Time Student
INS10 / Handicapped Indicator / S / ID / 1/1 / Code indicating a Yes or No condition or response. A "Y" value indicates an individual is handicapped / Y – Yes
N - No
INS11 / Date Time Period Format Qualifier / S / ID / 2/3 / Not utilized in Delta processing.
INS12 / Date Time Period / S / AN / 1/35 / Not utilized in Delta processing.
INS13 / Not Used / Place Holder Asterisk / *
INS14 / Not Used / Place Holder Asterisk / *
INS15 / Not Used / Place Holder Asterisk / *
INS16 / Not Used / Place Holder Asterisk / *
INS17 / Number / S / NO / 1/9 / Birth Sequence Number. A generic number (required if reporting family members with the same birth date, when needed for proper reporting, tracking or response to benefits) / Birth Sequence Number
2000 / REF / Subscriber Number / R / 1 / This is the subscriber’s identification number (typically the SSN), used to link the subscriber with dependents. / REF*0F*NNNNNNNNN~
REF01 / Reference Identification Qualifier / R / ID / 2/3 / Code qualifying the Reference Identification / 0F-Subscriber Number
17 - Member Alternate ID
3H - Case ID / REF*17 to be used when REF*0F represents the subscriber SSN
REF*3H to be used for non-commercial (ie, children’s health) plans only
REF02 / Subscriber Identification / R / AN / 1/50 / Provide the subscriber’s SSN for all members (Subscriber & Dependants) / Subscriber’s SSN
2000 / REF / Member Policy Number / S / 1 / This segment should be used if the policy or group number applies to all coverage data that apply for this member (required unless the policy number is sent in the REF segment, loop 2300) / REF*1L*PPGGGGGDDDDD~ / Preference is always to have the Group and Division ID’s passed in the 2000 loop versus the 2300 loop
REF01 / Reference Identification Qualifier / R / ID / 2/3 / Code qualifying the Reference Identification / 1L
REF02 / Reference Identification / R / AN / 1/50 / Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier. Indicator identifying number of prior months insurance coverage that may apply under the portability provisions of HIPAA / Delta required values: