HIPAA 834
Benefit Enrollment and Maintenance
Companion Guide
Version 1.0
September 30, 2013
This is not meant to replace the 834 X12 guide. This information only highlights the segments used in standard data exchange.
Table of Contents
1.Introduction
1.1Scope
1.2References
2.Connectivity1
2.1Direct Submission1
2.2FTP 1
2.3Frequency of Files1
2.4Testing2
2.5Clearinghouse/Trade Partner2
2.6How To Get Started2
3.File Format2
3.1Key Segments2
3.2Functional Group Header 3
3.3 ANSI 834 File Information 3
3.4Business Scenarios6
3.5Examples7
1. Introduction
Please recognize that the X12 standards as adopted by HIPAA were created by volunteers from many different organizations from across the country. As such, there will be mandatory information that Priority Health does not need (but, you must include to be compliant) and there will be situational information that will be required for proper claim processing. This companion guide was designed and is intended to be used in conjunction with the HIPAA Implementation Guide. The companion guide will outline the specifications required by Priority Health for the 834 Benefit enrollment and maintenance transaction. The companion guide is not intended to replace the X12N implementation guides. The implementation guides for X12N 834 version 4010A1, 5010A1 and all other HIPAA transactions are available electronically at
.
1.1Scope
Priority Health will use the 834 Benefit and Enrollment Maintenance to transfer Enrollment information from the group to the plan. Eligibility and benefits can also be obtained via our website
1.2References
- 834 Benefit Enrollment and Maintenance
- Priority Health Proprietary format
2.Connectivity
2.1FTP
File transfer protocol- this allows you to transfer files directly to PH through the Internet. In order to use this option the files must be encrypted.
2.2Frequency of Files
Transactional files can be accepted as frequently as 1 per day. Full audit files may be received on a weekly basis. If you require an exception to this policy, you will need to have this approved during testing.
2.3Testing
Priority Health will participate in testing activities with each trading partner upon request of direct submission. Testing is a requirement on behalf of Priority Health to assure quality. Notification will be given upon completion of testing.
2.4Clearinghouses/Trade Partners
If your system is not capable of sending the 834direct you may need to work with your vendor to determine what clearinghouse your transactions will be routed through.
2.5How to Get Started
This document is intended for established Priority Health Trading Partners only. If you are not already an established Trading Partner, then please contact the Priority Health EDI team for setup instructions.
Phone:Fax:
Email: / (800) 942-0954
(616) 464-8686
(616) 942-9932
3.File Format
3.1Key segments items in yellow are for the 4010 version. Items in green are for the 5010 version. All other segments share the same values if not highlighted.
Envelope/Segment Information
Element Description / Segment / Element / Required / Expected DataInterchange Control Header / ISA
Authorization Information Qualifier / ISA01 / Recommended value “00”
Authorization Information / ISA02 / Fill with spaces 10/10
Security Information Qualifier / ISA03 / Recommended value “00”
Security Information / ISA04 / Fill Spaces with 10/10
Interchange ID Qualifier / ISA05 / Recommended value ZZ or 30
Interchange Sender ID / ISA06 / Sender’s identification – please send their tax id
Interchange ID Qualifier / ISA07 / Recommended value ZZ or 30
Interchange Receiver ID / ISA08 / Receiver identification - 382715520
Interchange Date / ISA09 / Date - YYMMDD
Interchange Time / ISA10 / Time - HHMM
Interchange Control Standards Identifier / ISA11 / Recommended value U version 4010
Repetition Separator / ISA11 / This is a delimiter and not a data element
Interchange Control Version Number / ISA12 / Recommended value “00401”
Interchange Control Version Number / ISA12 / 00501
Interchange Control Number / ISA13 / Sender assigned control number
Interchange Control Number / ISA13 / ISA13 must equal value in IEA02
Acknowledgement Requested / ISA14 / Recommended value 0 or 1
Acknowledgement Requested / ISA14 / Recommended value 0 or 1
Usage Indicator / ISA15 / P or T will determine if this is a Test or Production
Usage Indicator / ISA15 / P or T will determine if this is a Test or Production
Component Element Separator / ISA16 / :
Component Element Separator / ISA16
Segment Terminator / ~ Or other value as specified by sender
3.2Functional Group Header
Element Description / Segment / Element / Required / Expected DataGS / Functional Group Header
GS01 / Recommended value BE
GS02 / Sender’s id. Should = ISA06
GS03 / Receiver’s code. Should = ISA08
GS04 / Date
GS05 / Time HHMM
GS06
GS07 / Recommended value X
GS08 / Version – values may be 005010X220A1 or you may use 004010X095A1
BGN / Beginning of Hierarchical Transaction
BGNT01 / Recommended value 00
BGN02 / Reference Identification
BBN03 / Date
BGN04 / Time
BGN05 / Time Code
BGN06 / Reference Identification
BGN07 / Transaction type Code
BGN08 / 2= CHANGE 4=VERIFY
REF / Transmission Type ID
REF01 / Recommended value 38 You may only use this segment if there is one master policy number submitted in the file. This value must be consistent throughout the file.
REF02
3.3ANSI 834 File Information
Loop / Segment / Element / Required / Expected Data1000A / N / Sponsor Name
N101 / Recommended value P5
N102 / Plan Sponsor name
N103 / FI – Federal tax id
ZZ – HIPAA employer id
N104 / Identification code
1000B / N / Payer
N101 / IN
N102 / Insurer name
N103 / FI
N104 / 382715520
2000 / REF / Subscriber Number
INS / Member Level Detail
INS01 / Y = Subscriber
N = Dependent
INS02 / Refer to HIPAA guide for codes
INS03 / 001 – Change
021 – Addition
024 – Cancellation or Termination
025 – Reinstatement
030 – Audit or Compare
INS04 / Refer to HIPAA guide for codes
INS05 / A – Active
C – Cobra
S – Surviving Insured
INS06 / A – Medicare A only
B – Medicare B only
C – Medicare A and B
D – Medicare Part unknown
E – No Medicare coverage
INS07 / 1 – Termination of Employment
2 – Reduction of work hours
3 – Medicare
4 – Death
5 – Divorce
6 – Separation
7 – Ineligible child
8 – Bankruptcy of a retired employee
INS08 / FT – full-time
PT – part-time
RT – retired
TE - terminated
INS09 / Situational Field
F – full-time student
N – not a student
P – part-time student
INS10 / Y – Handicapped
N – Not handicapped
INS11 / D8
INS12 / CCYYMMDD
REF01 / OF
REF02 / Subscriber Number (SS number, PH defined number, or group defined number)
REF01 / 1L
REF02 / Priority Health provides group number. This number is required is required on all members.
2100A / NM / Member Name
NM101 / 74
IL
NM102 / 1
NM103 / Last Name
NM104 / First Name
NM105 / Middle Name
NM106 / Prefix
NM107 / Suffix
NM108 / 34 – Social Security Number
ZZ – Mutually defined
NM109 / Subscriber Identifier or Social Security Number
PER / Member Communication Numbers
PER01 / IP – Insured Party
PER03 / EM – email
EX – telephone extension
FX – fax
HP – home phone
TE – telephone
WP – work phone
PER04 / Communication number
PER05-09 / Repeat segments above
N4 / Member Residence Street Address
N301 / Subscriber address line 1. (required)
N302 / Subscriber Street address 2
N401 / City Name (required)
N402 / State or Province Code
N403 / Postal Code
N404 / Country Code (only required when address is outside the United States of America. If not required, do not send)
N405 / 60 – indicates that N406 will contain an out of area indicator for this member
CY - County
DMG / Member Demographics
DMG01 / D8
DMG02 / Member Date of Birth (required)
DMG03 / F – Female (required)
M – Male (required)
DMG04 / Situational Field
S – Single
M – Married
R - Unreported
2300 / HD / Health Coverage
HD01 / This segment is required when enrolling a new member or when adding, updating or removing coverage from an existing member.
001 – Change
002 – Delete
021 – Addition
024 – Cancellation/Termination
025 – Reinstatement
026 – Correction – correct an incorrect record
030 – Audit or compare
032 – Employee information not applicable
HD03 / Insurance line code. See HIPAA guidelines for valid HIPAA codes
HD04 / Plan coverage description. Required by Priority Health. Priority Health assigned code to identify the benefit package the member has elected
HD05 / Coverage level code. See HIPAA guidelines for valid HIPAA codes.
DTP01 / Health coverage dates.
303 – Maintenance effective. This is the effective date of a change where a member’s coverage is not being added or removed.
348 – Benefits begin date. Effective date of coverage should always be sent when adding coverage.
349 – Benefits end date. This is the date coverage is being terminated. If this date is submitted for an employee, all members (spouse and/or dependents) associated with the employee (contract) will be cancelled.
543 – Last premium paid date.
DTP02 / D8 – indicates CCYYMMDD format
DTP03 / CCYYMMDD
2310 / NM / Provider Name
NM101 / Required Field (if submitting PCP)
NM102 / Required Field (if submitting PCP)
1 – Person
2 – Non Person Entity
NM108 / Number to identify the provider ID code.
34 – Social Security Number
FI – Federal taxpayer’s id number
SV – Service provider number
XX – HCFA National Provider Identifier
NM109 / The provider number is required if submitting PCP date
NM110 / This element indicates whether the member is an existing patient of the provider.
25 – established patient
26 – Not established patient
72 - unknown
3.4Business Scenarios
The following business rules will be applied to the processing of your file:
All new enrollments and cobra reinstatements with an effective over 120 days will not automatically process. They will be edited from the file for manual review and authorization.
All termination transactions with an effective date 120 days in the past will not process automatically. They will be edited from the file for manual review and authorization.
All new enrollments will require the a employee identifier number, effective date of enrollment, date of birth, first and last name, gender, and address in order to be processed.
Priority Health will process transactions by the rule that benefits will follow the subscribers. Our EDI process does not currently support cafeteria style benefit transactions.
If your plan design allows for split family elections, separate transactions should be submitted for each member as the subscriber. For example a subscriber and spouse are changing coverage due to the subscriber turning 65. The subscriber will be changing to a plan for retirees only and the spouse is remaining on a plan design for under 65 populations. Both members should be transmitted to PH as subscribers on their own plan. The spouse can not be transmitted under the previous SS# that indicates joint coverage with the spouse.
If your group offers Medicare or ancillary (i.e. dental or vision) products then an HD segment must be sent for each benefit. However if your group only has medical and prescription coverage any prescription drug coverage can be automatically assigned with the medical plan indicated in the file. Therefore, only one HD segment per member would be required
For the following business scenarios, substitute the following numbers where indicated
for : <- AUTOCAM CORPORATION
REF*1L*~ - 789340Group Number.
REF*DX* ~ <-Class ID FOR EXAMPLE S001CA01 would be sent.
HD*021*HMO*MED00001 * ~ <-. Indicates type of medical plan
Class codes for REF (DX) 03 and HD04 are summarized below:
Group Number = REF1L / Sub Group = REF*DX / Class=REF*DX / Name of Class / MEDICAL PLAN = (HD04)789340 / S001 / CA01 / TRANS CORP – HSA / SMED0001 = HSA INDIVIDUAL
SMED0002 = HSA FAMILY
789340 / S001 / CA02 / TRANS CORP – PPO / SMED0003 = PPO INDIVIDUAL
SMED0004 = PPO FAMILY
789340 / S001 / CA03 / TRANS CORP – OUT OF STATE / SMED0100 = HSA INDIVIDUAL
SMED0101 = HSA FAMILY
SMED0102 = PPO INDIVIDUAL
SMED0103 = PPO FAMILY
789340 / S002 / CA04 / TRANS KENTWOOD – HSA / SMED0001 = HSA INDIVIDUAL
SMED0002 = HSA FAMILY
789340 / S002 / CA05 / TRANS KENTWOOD – PPO / SMED0003 = PPO INDIVIDUAL
SMED0004 = PPO FAMILY
789340 / S002 / CC02 / TRANS KENTWOOD – COBRA / SMED0001 = HSA INDIVIDUAL
SMED0002 = HSA FAMILY
SMED0003 = PPO INDIVIDUAL
SMED0004 = PPO FAMILY
789340 / S003 / CA06 / TRANS MARSHALL – HSA / SMED0001 = HSA INDIVIDUAL
SMED0002 = HSA FAMILY
789340 / S003 / CA07 / TRANS MARSHALL - PPO / SMED0003 = PPO INDIVIDUAL
SMED0004 = PPO FAMILY
789340 / S003 / CC03 / TRANS MARSHALL – COBRA / SMED0001 = HSA INDIVIDUAL
SMED0002 = HSA FAMILY
SMED0003 = PPO INDIVIDUAL
SMED0004 = PPO FAMILY
789340 / S004 / CA08 / TRANS DOWAGIAC – HSA / SMED0001 = HSA INDIVIDUAL
SMED0002 = HSA FAMILY
789340 / S004 / CA09 / TRANS DOWAGIAC - PPO / SMED0003 = PPO INDIVIDUAL
SMED0004 = PPO FAMILY
789340 / S004 / CC04 / TRANS DOWAGIAC – COBRA / SMED0001 = HSA INDIVIDUAL
SMED0002 = HSA FAMILY
SMED0003 = PPO INDIVIDUAL
SMED0004 = PPO FAMILY
789340 / S005 / CA10 / MED KENTWOOD– HSA / SMED0001 = HSA INDIVIDUAL
SMED0002 = HSA FAMILY
789340 / S005 / CA11 / MED KENTWOOD- PPO / SMED0003 = PPO INDIVIDUAL
SMED0004 = PPO FAMILY
789340 / S005 / CC05 / MED KENTWOOD – COBRA / SMED0001 = HSA INDIVIDUAL
SMED0002 = HSA FAMILY
SMED0003 = PPO INDIVIDUAL
SMED0004 = PPO FAMILY
789340 / S006 / CA12 / MED PLYMOUTH – HSA / SMED0100 = HSA INDIVIDUAL
SMED0101 = HSA FAMILY
789340 / S006 / CA13 / MED PLYMOUTH - PPO / SMED0102 = PPO INDIVIDUAL
SMED0103 = PPO FAMILY
789340 / S006 / CC06 / MED PLYMOUTH – COBRA / SMED0100 = HSA INDIVIDUAL
SMED0101 = HSA FAMILY
SMED0102 = PPO INDIVIDUAL
SMED0103 = PPO FAMILY
789340 / S007 / CA14 / MED HAYWARD – HSA / SMED0100 = HSA INDIVIDUAL
SMED0101 = HSA FAMILY
789340 / S007 / CA15 / MED HAYWARD - PPO / SMED0102 = PPO INDIVIDUAL
SMED0103 = PPO FAMILY
789340 / S007 / CC07 / MED HAYWARD – COBRA / SMED0100 = HSA INDIVIDUAL
SMED0101 = HSA FAMILY
SMED0102 = PPO INDIVIDUAL
SMED0103 = PPO FAMILY
**********This group has medical plans assigned by individual and family. Please ensure there is a coverage level code submitted in the HD05 for this group************
Notes:
- HD segment(s) are required for all enrollments, terminations of individual benefits, and when a change in benefits is made.
- If you want to send PCP information, contact Priority Health for specifics on how to send the necessary PCP identification numbers.
- ID Cards will be automatically generated for new enrollments, name changes, and any change to the number of members covered in a contract a contract. For this reason, the IDC segment is not required.
- EDI service receipt will be generated and sent to your group contact with the completion of each file.
- Do not send a DTP date qualifier in the header of the file. The date qualifiers submitted on the member transaction will be used to drive eligibility
- The master policy number sent in the REF*38 segment must be the same throughout the file. If you are sending multiple group numbers in the file, then REF*38 segment must be excluded from the header of the file.
- You may send a QTY segment in the file only if you are using version 005010X220A1
3.5Examples:
The following scenarios show new lines after the tilde character (segment delimiter). This is for readability of the examples. In the actual X12 transmission, there should be no new line or carriage return characters after the segment terminator.
Each benefit will require a separate HD segment
Enroll an active employee with HMO, RX and Dental
INS*Y*18*021*28*A***FT~
REF*0F*123456789~
REF*1L*789340~ <- group number
REF*DX*CA01S001~ <- sub group and / or class
NM1*IL*1*SMITH*JOHN*Q***34*123456789~
PER*IP**HP*6161234567*WP*6161234568~
N3*1234 PRIORITY DRIVE~
N4*PRIORITYVILLE*MI*49525~
DMG*D8*19600101*M~
HD*021**POS*MED0001~ <- HD04 = PLAN ID
DTP*348*D8*20020101~
HD*021**DEN*SDEN0001~ <- HD04 = PLAN ID
DTP*348*D8*20020101~
Enroll an active employee with Flex and Dental
INS*Y*18*021*28*A***FT~
REF*0F*123456789~
REF*1L*789340~ <- group number
REF*DX*CA01S001~ <- sub group and / or class
NM1*IL*1*SMITH*JOHN*Q***34*123456789~
PER*IP**HP*6161234567*WP*6161234568~
N3*1234 PRIORITY DRIVE~
N4*PRIORITYVILLE*MI*49525~
DMG*D8*19600101*M~
HD*021**HLT*SFLEX001~ <- HD04 = PLAN ID
DTP*348*D8*20020101~
HD*021**DEN*SDEN0001~ <- HD04 = PLAN ID
DTP*348*D8*20020101~
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