ASC X12 834 Benefit Enrollment and Maintenance Implementation Guidelines

STANDARD

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ASC X12 834 Benefit Enrollment and Maintenance Implementation Guidelines

(Version 4010 )

(004010X095 A1)

Purpose of This Document 3

Relationship to the Guide Mandated Under HIPAA 3

Types of Production Files to Send/Receive 3

Interchange Control Structures 4

Roles and Responsibilities 5

FTJ/FSL’s Roles 5

Trading Partner’s Roles 5

Start-up and Testing Process 5

Trading Partner Start-Up Process 5

FTJ/FSL’s Responsibility 5

834 Benefit Enrollment and Maintenance 6

General Check List 53

Frequency of Exchange 54

FTP Site Information 55

Purpose of This Document

The purpose of this Trading Partner Guide is to assist Trading Partners to FTJ/FSL in implementing version 4010 of the ASC X12N 834 (004010X095 A1) Benefit Enrollment and Maintenances Transaction Set. This document outlines various processes with regard to the implementation as well as how various business scenarios will be handled in the data.

This document is to be considered a supplement to the ASC X12N 834 (004010X095 A1) Benefit Enrollment and Maintenance implementation guidelines. This guide is intended to provide clarification only. The implementation guidelines should be used as the final rule for transactions and code sets.

Relationship to the Guide Mandated Under HIPAA

The Federal Register is the official daily publication for Rules, Proposed Rules, and Notices of Federal agencies and organizations, as well as Executive Orders and other Presidential Documents. The Transactions and Code Sets Final Rule, published in the Federal Register on August 17, 2000, named the ASC X12N 834 Implementation Guide 004010X095 Health Benefit Enrollment and Maintenance as the national standard for electronic enrollment and maintenance in a Health Plan. The rule mandates Health Plans, Health Care Clearinghouses, and Health Care Providers who transmit benefit enrollment and maintenance data electronically must accept this transaction. The rule recommends that employers and other sponsors use the named standard. All covered entities must meet a compliance date for the initial implementation of the code sets and transaction standards by October 16, 2002. These entities may request delayed compliance until October 16, 2003. However, they must be ready to test transactions by April 16, 2003.

Types of Production Files to Send/Receive

Each trading Partner needs to communicate to FTJ/FSL how they will transmit their information. The frequency of the transmission should be one of the following: daily, weekly, bi-monthly, or monthly. Files may be sent to FTJ/FSL 7 days a week, 24 hours a day, but will be processed Monday through Friday between 8:30 a.m. and 5:00 p.m. each day (this does not include holidays).

FTJ/FSL prefers to receive and send full files. (Note: You should use the control numbers in your transactions to ensure that we do not miss any files. The control number can be found in the ISA13 and should increment by one for each file you send us).

When the file is received by FTJ/FSL: At the trading partner’s request, a 997 Functional Acknowledgement can be returned for every 834 file that is sent to FTJ/FSL. This should be communicated to the technical contacts for additional information.

When the file is sent by FTJ/FSL: A 997 Functional Acknowledgement will be required for every 834 file received by the trading partner. An email notification can also be sent to an individual if requested by the trading partner. This email notification will let the trading partner know that a file has been sent or placed on the server for processing.

The member detail records within the 834 file should be sorted by subscriber ID number (ie. The entire family should be sent together). Within a family, children member detail records should be sorted in descending order by birth date.

Interchange Control Structures

Depending on if FTJ/FSL is the sender or receiver of the file, ISA05 through ISA08 will change accordingly. FTJ/FSL will be using their U.S. Federal Tax Identification Number to uniquely identify themselves. The trading partners can choose to use any HIPAA designated identifier to identify themselves.

Field / Value
ISA01 / 00
ISA02 / Spaces
ISA03 / 00
ISA04 / Spaces
ISA05 / (30 for FTJ/FSL)
ISA06 / Sender’s unique code (430949844 for FTJ/FSL)
ISA07 / (30 for FTJ/FSL)
ISA08 / Receiver’s unique code (430949844 for FTJ/FSL)
ISA09 / Date
ISA10 / Time
ISA11 / U
ISA12 / 00200
ISA13 / Interchange Control Number – Sequentially Generated Number (same as IEA segment)
ISA14 / 0 (zero)
ISA15 / T for Test
P for Production
GS01 / BE
GS02 / Same as ISA06
GS03 / Same as ISA08
GS04 / Date
GS05 / Time
GS06 / Interchange Control Number – Sequentially Generated Number (same as GE segment)
GS07 / X
GS08 / 004010X095

Roles and Responsibilities

FTJ/FSL’s Roles

·  A test plan and schedule are established and communicated with the trading partner

·  Milestones are agreed to, met, and documented

·  Test files are reviewed and verified by both FSL/FTJ and the trading partner

·  Issues are addressed promptly

·  “Show Stopper” problems are accelerated to appropriate management personnel

·  Ensure that the Trading Partner is ready to move to production status on schedule.

·  Designate a dedicated developer, to work solely on production, testing, and issue resolution for the EDI project, and support the EDI team. A technical contact will be provided (name, email address, and phone number).

Trading Partner’s Roles

It is assumed that a resource will be designated, by the trading partner, as the EDI contact and will also act as direct liaison for the start up process.

The Trading Partner will be responsible for:

·  Participating in initial, as well as follow up meetings

·  Adhering to the Trading Partner Guide which includes testing, and issue reporting

·  Designate a dedicated developer, to work solely on production, testing, and issue resolution for the EDI project, and support the EDI team. A technical contact will be provided (name, email address, and phone number) to the FTJ/FSL Edi contact person.

·  Provide a process approval (sign-off)

·  Participate in an ongoing procedural implementation

Start-up and Testing Process

Trading Partner Start-Up Process

·  Create a transmission process using:

o  FTP process to a non-secure location. PGP encryption is required using this method. PGP keys will need to be exchanged before test files can be sent.

o  Place file on FTJ/FSL’s secure website. PGP encryption is not required.

·  Develop a HIPAA compliant 834 transaction

·  Test the transmission connection used

·  Test the translation process at the Trading Partner Site

FTJ/FSL’s Responsibility

·  Verify data format is compliant to the 834 standard version 4010 (004010X095 A1)

·  Verify the Trading Partner transmission

·  Contact the Trading Partner of any problems with the test data on a timely basis

·  Complete assigned issue resolution tasks and system testing by the agreed target dates.

1

834 Benefit Enrollment and Maintenance

Functional Group ID=BE

Introduction:

This Draft Standard for Trial Use contains the format and establishes the data contents of the Benefit Enrollment and Maintenance Transaction Set (834) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to establish communication between the sponsor of the insurance product and the payer. Such transaction(s) may or may not take place through a third party administrator (TPA). For the purpose of this standard, the sponsor is the party or entity that ultimately pays for the coverage, benefit or product. A sponsor can be an employer, union, government agency, association, or insurance agency. The payer refers to an entity that pays claims, administers the insurance product or benefit, or both. A payer can be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Champus, etc.), or an entity that may be contracted by one of these former groups. For the purpose of the 834 transaction set, a third party administrator (TPA) can be contracted by a sponsor to handle data gathering from those covered by the sponsor if the sponsor does not elect to perform this function itself.

Table 1 - Header:

Pos. Seg. Req. Loop Notes and

No. ID Name Des. Max.Use Repeat Comments

Must Use / 010 / ST / Transaction Set Header / M / 1
Must Use / 020 / BGN / Beginning Segment / M / 1
030 / REF / Transaction Set Policy Number / O / 1
040 / DTP / File Effective Date / O / >1
LOOP ID - 1000A / 1
Must Use / 070 / N1 / Sponsor Name / M / 1 / n1
LOOP ID - 1000B / 1
Must Use / 070 / N1 / Payer / M / 1 / n2
LOOP ID - 1000C / 2
070 / N1 / TPA/Broker Name / X / 1 / n3
LOOP ID - 1100C / 1
Not Used / 120 / ACT / TPA/Broker Account Information / X / 1

Table 2 - Detail:

Pos. Seg. Req. Loop Notes and

No. ID Name Des. Max.Use Repeat Comments

LOOP ID - 2000 / >1
Must Use / 010 / INS / Member Level Detail / M / 1 / n4
Must Use / 020 / REF / Subscriber Number / M / 1 / n5
Must Use / 020 / REF / Member Policy Number / X / 1 / n6
Must Use / 020 / REF / Member Identification Number / O / 6 / n7
Not Used / 020 / REF / Prior Coverage Months / X / 1 / n8
025 / DTP / Member Level Dates / O / 20
LOOP ID - 2100A / 1
Must Use / 030 / NM1 / Member Name / M / 1
040 / PER / Member Communications Numbers / O / 1
050 / N3 / Member Residence Street Address / O / 1
060 / N4 / Member Residence City, State, Zip Code / O / 1
Must Use / 080 / DMG / Member Demographics / M / 1
110 / ICM / Member Income / O / 1
Not Used / 120 / AMT / Member Policy Amounts / X / 4
Not Used / 130 / HLH / Member Health Information / X / 1
Not Used / 150 / LUI / Member Language / X / 5
LOOP ID - 2100B / 1
030 / NM1 / Incorrect Member Name / O / 1
Not Used / 080 / DMG / Incorrect Member Demographics / X / 1
LOOP ID - 2100C / 1
Not Used / 030 / NM1 / Member Mailing Address / X / 1
Not Used / 050 / N3 / Member Mail Street Address / X / 1
Not Used / 060 / N4 / Member Mail City, State, Zip / X / 1
LOOP ID - 2100D / 3
Not Used / 030 / NM1 / Member Employer / X / 1
Not Used / 040 / PER / Member Employer Communications Numbers / X / 1
Not Used / 050 / N3 / Member Employer Street Address / X / 1
Not Used / 060 / N4 / Member Employer City, State, Zip / X / 1
LOOP ID - 2100E / 3
Not Used / 030 / NM1 / Member School / X / 1
Not Used / 040 / PER / Member School Communications Numbers / X / 1
Not Used / 050 / N3 / Member School Street Address / X / 1
Not Used / 060 / N4 / Member School City, State, Zip / X / 1
LOOP ID - 2100F / 1
030 / NM1 / Custodial Parent / O / 1
Not Used / 040 / PER / Custodial Parent Communications Numbers / X / 1
050 / N3 / Custodial Parent Street Address / O / 1
060 / N4 / Custodial Parent City, State, Zip / O / 1
LOOP ID - 2100G / 1
Not Used / 030 / NM1 / Responsible Person / X / 1
Not Used / 040 / PER / Responsible Person Communications Numbers / X / 1
Not Used / 050 / N3 / Responsible Person Street Address / X / 1
Not Used / 060 / N4 / Responsible Person City, State, Zip / X / 1
LOOP ID - 2200 / 1
Not Used / 200 / DSB / Disability Information / X / 1 / n9
Not Used / 210 / DTP / Disability Eligibility Dates / X / 2
LOOP ID - 2300 / 99
Must Use / 260 / HD / Health Coverage / M / 1
Must Use / 270 / DTP / Health Coverage Dates / M / 4
Not Used / 280 / AMT / Health Coverage Policy / X / 4
290 / REF / Health Coverage Policy Number / O / 3
Not Used / 300 / IDC / Identification Card / X / 10
LOOP ID - 2310 / 30
310 / LX / Provider Information / O / 1 / n10
Must Use / 320 / NM1 / Provider Name / M / 1 / n11
Not Used / 360 / N4 / Provider City, State, Zip Code / X / 1
Not Used / 370 / PER / Provider Communications Numbers / X / 2
Not Used / 395 / PLA / PCP Change Reason / X / 1
LOOP ID - 2320 / 5
400 / COB / Coordination of Benefits / O / 1
405 / REF / Additional Coordination of Benefits Identifiers / O / 5
Not Used / 410 / N1 / Other Insurance Company Name / X / 1
450 / DTP / Coordination of Benefits Eligibility Dates / O / 2
Must Use / 690 / SE / Transaction Set Trailer / M / 1

Transaction Set Notes

1. At least one iteration of loop 1000 is required to identify the sender or receiver.

2. A Subscriber is a person who elects the benefits and is affiliated with the employer or the insurer. A Dependent is a person who is affiliated with the subscriber, such as a spouse, child, etc., and is therefore entitled to benefits. Subscriber information must come before dependent information. The INS segment is used to note if information being submitted is subscriber information or dependent information.