LifeMap

834 Benefit Enrollment & Maintenance

Companion Document


Table of Contents

Intended Use of this Companion Guide

File Communication:

Terms used in this Guide

New Trading Partners

834 Transaction File Methods/Types

LifeMap Group Number, Employee Class, Subgroup and Plan ID Requirement

Subscriber Number

General Information

Types of Maintenance – Adds, Changes, Terminations, Reinstates (Change files only)

Adds – Enrollments

Changes – Updating Existing Information (2100B Loop)

Terminations – Terminating benefits for Subscribers and/or Dependents

Reinstatement of Coverage

COBRA

834 Transaction File – Specific Loop/Segment/Data Element Information

Names (All Name Fields):

Communication Numbers:

Addresses:

Country Codes:

Country Subdivision Codes:

Gender:

Marital Status:

Maintenance Type Codes:

Insurance Line Codes:

Member Income:

Coverage Level Codes:

Identification Cards (ID Cards):

Member Level dates and Health Coverage dates Requirement:

Open Enrollment:

Header Information:

Example of Header:

APPENDIX 834 LifeMap Specific Detail

Intended Use of this Companion Guide

The LifeMap group companion guide is built with the intention of assisting our trading partners in creating and submitting ANSI X12 5010 834files thatare HIPAA complaint. This companion guide provides guidelines and clarifications of the HIPAA requirementsfor the 5010 834 transaction as theyapply torequirements of the LifeMap processing system. The details in this document are supplemental and should be used in conjunction with the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3) as published by Washington Publishing Company.

Uppercase Letters, Special Characters and Delimiters:

As specified in the TR3, the basic character set includes uppercase letters, digits, space and other special characters. Recommended delimiters are below

Inbound Delimiters

Data Element Separator / * / Asterisk
Sub-Element Separator / : / Colon
Segment Terminator / ~ / Tilde
Repetition Separator / ^ / Caret

Suggested delimiters for the transaction are assigned as part of the trading partner setup and should not be changed without notification

To avoid syntax errors, hyphens, parentheses, asterisks, colons and spaces are not recommended to be used within the transaction data.

File Communication:

A secure FTP site will be created for trading partners to submit their files to LifeMap. File summary reports with discrepancies will be communicated back to the trading partner.

All sections of thisguide relate to both audit and change files unless the header of the section specifically states it pertains to a certain type of 834 file.

Terms used in this Guide

Subscriber: Subscriber is the Employee requesting Health Care Coverage

Member: Subscriber and any covered dependent

Spouse: Husband or Wife

Dependent:Child or Children eligible to be covered on the Subscriber’s InsurancePolicy

Trading Partner: The Insured Group, Sponsor or Third Party Administrator

Changes 834 File: Also known as an A/C/D file. An 834 file containing only records with changes.

Full 834 File: An 834 full file containing all employee and dependent records regardless if there is a change or not.

New Trading Partners

A new Trading Partner Agreement must be submitted to LifeMap for each new Trading Partner and for each new Group the Trading Partner will be submitting. A one to two month testing period can be expected for a new Trading Partner. Please note that data accuracy and regular test files are vital to ensuring the one to two month testing period, otherwise, testing could follow a longer timeline.This is to ensure we receive the data correctly; the data meets ANSI requirements, as well as LifeMap system specific requirements.

834 Transaction File Methods/Types

A Trading partner can submit different types of 834 transaction files to change,verify or replace enrollment data in our system.

  1. Changes834 File:

LifeMap accepts Changes Only files. Change files contain INS03 = Add (021), Reinstate (025), Terminate (024) and Change (001) requests. Change 834 files list only change records. Change files must be sent with a BGN08 = 2 in the Header.

  1. Full Changes 834 File:

LifeMap accepts Full Changes 834 files. Change files contain INS03 = Add (021), Reinstate (025), Terminate (024) and Change (001) requests. Full Changes 834 files list all current membership whether or not involved in change. This is ONLY accepted for the first file sent to be used as a baseline. Change files must be sent with a BGN08 = 2 in the Header.

  1. Audit 834 File maintenance:

LifeMap does not currently accept INS03 = Audit (030) files.

LifeMapGroup Number, Employee Class, Subgroupand Plan ID Requirement

LifeMap requires Group Number, Subgroup, Employee Class and Plan IDs submitted for each Employee, requesting health coverage.

Group Number:

LifeMap’s system requires a Group number (Loop 1000, REF02) for each member. Group number is identified with REF01 (Loop 1000) =’38’. This is a LifeMap provided ten digit alphanumeric code.

Subgroup Number:

LifeMap’s system requires an Subgroup number (Loop 2000, REF02) for each Subscriber. The Subgroup is identified with REF01 (Loop 2000) =’1L’ submitted only at Subscriber level.

This is a LifeMap provided 4 digit numeric code – starting 0s MUST be included.

Employee Class:

LifeMap’s system requires anEmployee Class Reference Identifier (Loop 2000, REF02) for each SubscriberEmployee class is identified with REF01 (Loop 2000) =’17’ submitted only at Subscriber level.

This is a LifeMap provided 2 digit numeric code.

When the Employee Class is changed, the DTP01 (Loop 2000) 356(Eligibility Begin) date must be updated to reflect the Subscriber’s new employee Class Effective Date. Do not send Class Identifiers for Dependents.

The DTP01 (Loop 2000)356 date must be updated to reflect the Subscriber’s Subgroup Effective Date. Do not send Subgroup Identifiers for Dependents.

Plan ID:

LifeMap's system requires a Plan ID in the Plan Coverage Description (HD04) and Benefit Begin Date (DTP01 348) for each Employee and Dependent in the 2300 HD Loop.

Subscriber Number

For the Subscriber, the SSN needs to be sent in both the Subscriber ID segment (Loop 2000, REF02 identified with REF01=’0F’) and the SSN segment (Loop 2100A, NM109). For Spouse or Dependents, the Subscriber’s SSN must be sent in the Subscriber ID segment (Loop 2000, REF02 identified with REF01=’0F’) and the Spouse or Dependents own SSN in the SSN segment (Loop 2100A, NM109).

General Information

  • We recommend use of the Standard Delimiters –

* (asterisk) for Data Element Separator

: (colon) for Component Element Separator

~ (tilde) for Segment Delimiter

  • We only accept files with new line characters at the end of each segment.
  • Unlimited numbers of Members are allowed per ST - SE Transaction Set. All family members (Subscriber and spouse and/or Dependents) must be in the same transaction.
  • The schedule for transmissions will be determined in discussions between the affiliatedLifeMap Plan and the external Trading Partner.
  • The Subscriber must be listed first on all 834 Transactions. Spouse or Dependent(s) records must follow the Subscriber’s information.
  • The Date of Hire (Loop 2000, DTP 336) is essential in calculation of Probationary Periods.If a Date of Hire is not present, the Probationary Period is calculated from the Effective Date.
  • It is extremely important that the Coverage Level Code (Loop 2300, HD05) reflect the true Level of Coverage for the Subscriber and their family members (if any).Do not default to “FAM – Family” Coverage Level if the Subscriber’s coverage does not include the Subscriber, Spouse and at least oneDependent.
  • LifeMap prefers all data in Upper Case if possible.
  • LifeMap prefers to have no punctuation in any Member data fields including Name, Address, and City. Please do not send Periods, Commas, Percent Signs, and Parenthesis. Apostrophes and Hyphens are accepted. The “@” is mandatory for an email address.
  • Maintenance Reason Codes (Loop 2000, INS04) are necessary for LifeMapLetter Generation i.e. 03 (Death) or 09 (COBRA) etc. Failure to use these codes will result in an inappropriate letter being sent to the Member.
  • For End Dates,LifeMap’s system uses ‘Through Dates’, not ‘To Dates’. For example, a Termination Date of 03-31-2011 would extend coverage through that date with coverage ending at midnight on 03-31-2011.

Types of Maintenance – Adds, Changes, Terminations, Reinstates (Change files only)

The LifeMap System can handle Past, Present and Future dates when Adding, Changing, Terminating orReinstating a Subscriber and/or Spouse orDependent(s). Submitters must follow LifeMapEnrollment guidelines.

Adds – Enrollments

For New Member Enrollment, an add event must be submitted with maintenance type code 021 for both INS03 and HD01 for Changes Files.

For New Member Enrollment, the Member’sOriginal Effective Date of Coverage isloaded to the LifeMap system based on the Loop 2000 DTP01 356 date submitted in the file.

For New Member Enrollment the Loop 2000 DTP01 356 Original Effective Date must = the Loop 2300 DTP01348 Benefit Begin Date.

When the addition of spouse or dependent(s) changes the Family Coverage level(Loop 2300, HD05) of the Subscriber, a change event must be submitted to modify the Coverage Level of the Subscriber and all members’Loop 2300 DTP01 348 Benefit Begin Date must be updated as well.

Example: Subscriber had coverage for the Subscriber and two Dependents and the
Coverage Level was “E2D” or “ECH”. If the Spouse’s coverage is being added, the Subscriber would
need to have a Change event submitted with a new Coverage Level of “FAM – Employee, spouse and Dependents”.

Changes – Updating Existing Information (2100B Loop)

AChange event (INS03 = ‘001’) must be submitted with NM101 (Loop 2100A) = ‘74’ and NM101 (Loop 2100B) =‘70’ to change Last Name, First Name, SSN and Date of Birth, Gender, Marital Status and Address information . Relationship Code changes such as Son to Daughter, or Domestic Partner to Spouse cannot be changed using the 834 and must be submitted to LifeMapby email or other form agreed to by the LifeMap Membership Unit.

When the addition or termination of spouse or dependent(s) changes the Family Coverage level(Loop 2300, HD05) of the Subscriber, a change event must be submitted to modify the Coverage Level of the Subscriber and all members’Loop 2300 DTP01 348 Benefit Begin Date must be updated as well.

Terminations – Terminating benefits for Subscribers and/orDependents

The Termination Date submitted on the 834 Transaction File should be the Last Date of Coverage for a Subscriber and/or Spouse orDependent.

The Benefit End Date (2300 Health Coverage Loop, DTP 349) should be submitted with the associated Termination Date (Last Date the Subscriber/Dependent is Eligible for Coverage).

If the entire Subscriber’s Plan IDs are to be terminated, the termination information must be submitted in the INS level using maintenance type code 024 for INS03 and the termination date must be sent in Loop 2000 DTP01 337 information on Changes Files.

If one or more, but not all, of a Subscriber’s Plan ID’s are to be Terminated, the Termination information must be submitted in each Health Coverage Loop (2300) using the Maintenance Type Code 024 (Cancellation or Termination – Ref Des HD01) on Changes Files.

When terminating all Coverage for a Subscriber, spouse and dependent(s) associated with that Subscriber will be automaticallyterminated. When terminatinga specific Coverage (Plan ID) for a Subscriber, spouse and dependents associated with that Plan ID will also be terminated.When Terminating a Spouse or Dependent(s) only, that specificSpouse’s or Dependent’s Coverage will be affected.

If the Termination of Coverage for Spouse or Dependent(s) causes the Coverage Level (HD05) for the Subscriber to change, a Change event must be sent to update the new Coverage Level. The date that the new Coverage Level becomes effective must be sent in the Subscriber and Spouse or Dependents Loop 2300DTP01 348 date information

Example: Subscriber had coverage for the Subscriber, Spouse and two Dependents and the
Coverage Level was“Family”. If the Spouse’s coverage is beingterminated, the Subscriber would
need to have a Change event submitted with a new Coverage Level of “E2D – Employee and Two Dependents” or “ECH – Employee and Children”.

Reinstatement of Coverage

Reinstatement is defined as making the Coverage Active in a Group Number for a Subscriber or Spouse or Dependent(s) whopreviously had Coverage on the same Group Number. Coverage can be reinstated either with or without a Lapse in Coverage. All Reinstatements should be sent with the INS03 and HD01 as 025 on a Changes File.

If a Subscriber is to be reinstated with No Lapse in Coverage, send the Reinstatement Date as the day following the Termination Date.

Example: Subscriber was terminated effective 12/31/2010, the Reinstatement Date would be submitted as 01/01/2011. Spouse or any Dependent(s) to be reinstated with No Lapse in Coverage should be submitted in the same manner. When Reinstating with No Lapse in Coverage: Send the Reinstatement Date in the HD Loop 2300DTP 348.

If a Subscriber is to be reinstated with a Lapse in Coverage, send the Reinstatement Date as the Date Coverage is to resume.

Example: Subscriber was terminated 12/31/2010 and Coverage is to reinstate effective
04/01/2011, the Reinstatement Date would be sent as 04/01/2011. This would result in the
Subscriber having a Period of Time when they were Not Eligible for Coverage. Spouse or any Dependent(s)to be reinstated with a Lapse in Coverage should be submitted in the same manner. When Reinstating with a Lapse in Coverage: Send the Reinstatement Date in the HD DTP 348.

When a Subscriber is reinstated either with or without a Lapse in Coverage, special attention must be paid to the Reinstatement of Spouse or Dependent(s). Spouse and all Dependents that were terminated by the Subscriber’s most recent Termination event (12/31/2010 in the example above) will be reinstated by the Subscriber’s new Reinstatement event by the use of the correct Coverage Level Code (HD05). Use of the incorrect Coverage Level Code could Reinstate ineligible Spouse or Dependent(s).

Example 1: Subscriber was terminated on 12/31/2010.The covered Members included the
Subscriber, Spouse and 3 Children with a Coverage Level Code of Fam. When the Reinstatement
occurs, the Family makeup is to be the Subscriber, Spouse and 2 Children and the Coverage Level
Codeis Fam. All 3 Children will be reinstated by this event. In addition to the Reinstatement, a
Termination event should be sent for the Child who is not to be reinstated using the Date of
the Original Termination (12/31/2010).

Example 2: Subscriber was Terminated on 12/31/2010.The covered Members included the
Subscriber, Spouse and 3 Children and the Coverage Level Code was Fam. When the
Reinstatement occurs, the Family makeup is to be the Subscriber and Spouse and the Coverage
Level Code is ESP. The Reinstatement should be sent with Reinstatement (INS03 and HD01=025 on the Changes File) events for the Subscriber and Spouse with Coverage Level Code of ESP. Termination events should be sent for the Children using the Date of the Original Termination (12/31/2010).

The Reinstatement will not affect Spouse or Dependent(s) that were terminated prior to the most recent Termination.

When a Subscriber is Reinstated either with or without a Lapse in Coverage, Spouse or any Dependent(s) that were not previously covered should be sent with Add events (INS03 and HD01=021 on the Changes File). Those Family members being reinstated are sent as Reinstatements and the New Spouse or Dependents are sent as Adds.

COBRA

FAMILY IS ENROLLED AND ACTIVE - MOVE ENTIRE FAMILY TO COBRA

If an Active Subscriber and Spouse or all of the Dependents associated with the Subscriber elect COBRA coverage:

  • The Change transaction (INS03 = 001) must be submitted with Maintenance Reason Code
    (INS04 = 09 on a Changes File), Benefit Status Code (INS05= C) and an appropriate Reason (INS07) for COBRA eligibility.
  • Each Member enrolling in COBRA must have a COBRA Begin Date (2000 Loop DTP 340). The
    COBRA End Date (2000 Loop DTP 341) needs to include the appropriate COBRA Termination Date.
  • The 2300 Loop HD segments of the Subscriber must contain two Loops for each Plan ID. The first line will reflect the Termination of Active Coverage (HD01 = 024 in a Changes File). The second line will reflect the Change to COBRA coverage (HD01 = 001) with appropriate HD05 segments.

FAMILY IS ENROLLED AND ACTIVE – NOT ALL MEMBERS ENROLL IN COBRA

If an Active Subscriber elects COBRA coverage and not all Dependents or Spouse elect COBRA:

  • A Change transaction (INS03 = 001) must be submitted with a COBRA Maintenance Reason Code
    (INS04 = 09), COBRA Benefit Status Code (INS05=C) and an appropriate Reason (INS07) for COBRA eligibility.
  • The Subscriber 2300 Loop HD05 segment must reflect the Tier Level that will result from the Termination of Spouse or Dependent(s). (If the Subscriber was enrolled in Family Level coverage and Spouse or all Dependents are Terminating as the Subscriber enrolls in COBRA, the HD05 must be EMP.) Each Member enrolling in COBRA must have a COBRA Begin Date (2000 Loop DTP 340). The COBRA End Date (2000 Loop DTP 341) needs to include the appropriate COBRA Termination Date.
  • The 2300 Loop HD segments of the Subscriber electing COBRA coverage must contain two Loops for each Benefit. The first will be Termination (HD01 = 024) and the second must be a Change(HD01 = 001). This reflects the Termination of Active coverage and the Change to COBRA coverage.

Spouse or Dependent not going on COBRA:

  • Spouse or Dependent(s) who are not enrolling in COBRA must be submitted with Termination transaction (INS03 = 024) and Maintenance Reason Code of Termination (INS04 = 07), Benefit Status Code (INS05=A)
  • Spouse or Dependent will only have Maintenance Type Code (HD01) = 024 (Termination) segments.

CONTRACT IS ALREADY TERMINATED - REINSTATE CONTRACT TO COBRA

  • If a Contract which was previously sent as a Termination is to be Reinstated to COBRA coverage,then a Reinstatement transaction (INS03 = 025) must be submitted with COBRA Maintenance Reason Code (INS04 = 09), COBRA Benefit Status Code (INS05=C), and an appropriate COBRA Qualifying Reason in the INS07.
  • Each Member enrolling in COBRA must have a 2000 Loop DTP 340 reflecting the COBRA Begin Date and a DTP 341 reflecting the COBRA END Date. The 2300 Loop HD segments of the Subscriberand spouse or each Dependent electing COBRA coverage must contain Reinstatement (HD01 = 025). Spouse or any Dependent(s) not enrolling in COBRA are not included.
  • The Subscriber Coverage Level Code (2300 Loop HD05) must reflect the Family composition that will result from the Reinstatement

TERMINATE COBRA COVERAGE BEFORE COBRA END DATE AND MOVE TO ACTIVE COVERAGE

  • If a Subscriber Terminates their COBRA coverage prior to the allowed amount of coverage, and returns to Active coverage, a Change transaction (INS03 = 001) must be submitted with Maintenance Reason Code (INS04 = AI), Active Benefit Status Code (INS05 = A)and noCOBRA Qualifying Reason (INS07 = blank).
  • The actual COBRA End Date (2000 LoopDTP 341) for the Subscriber and/or Spouse or Dependent(s) in the 2000 Loop.
  • The 2300 Loop HD segments: Subscriber and Spouse or Dependent(s) electing Active coverage must contain two Loops for each Benefit. The first will be a Termination (HD01 = 024) and the second must be a Change (HD01 = 001). This reflects the Termination of COBRA coverage and the change to Active coverage.

Spouse or Dependent not moving to Active Coverage: