834 Benefit Enrollment and Maintenance

Transcription

1 Companion Document Benefit Enrollment and Maintenance This Companion Document serves as supplementary material to the primary resources, ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3) version X220, August 2006, and the Errata version, June 2010, published by the Washington Publishing Company ( Since the TR3 explicitly states how the transaction is to be used for HIPAA compliance, this document provides only information about 834 segments and data elements that require specific instructions to efficiently process through Anthem systems in Virginia. It is imperative that all trading partners review this material in conjunction with the TR3. Section Benefit Enrollment and Maintenance: Basic Instructions Section Benefit Enrollment and Maintenance: Business Case Scenarios Section Benefit Enrollment and Maintenance: Enveloping Section Benefit Enrollment and Maintenance: Charts for Situational Rules Any questions? Contact EDI Solutions Desk EDI.ENT.Support@anthem.com LiveChat Page 1 of 14

2 Section 1 - Basic Instructions 1.1 X12 and HIPAA Compliance Checking, and Business Edits EDI interchanges submitted to Anthem for processing pass through compliance edits acknowledgments and reports for accepted/rejected files will be placed in the submitter s trading partner mailbox for pickup. TA1 Interchange Acknowledgment. Anthem returns TA1 X12 and proprietary reports to the submitter of inbound 834 files containing envelope errors in the ISA and GS segments. Level 1. Anthem returns a 999 Functional Acknowledgment (FA) to the submitter for every inbound transaction received. Each transaction passes through edits to ensure that it is X12 compliant. If the X12 syntax or any other aspect of the 834 is not X12 compliant, the 999 FA will also report the Level 1 errors in AK segments and indicate that the entire transaction set has been rejected. NOTE! If the four following segments and data elements are missing, the transaction will be delayed. 1. Header, Transaction Set Policy Number (REF) 2. Header, File Effective Date (DTP) 3. Loop 2100A, Identification Code (NM109) 4. Loop 2300, Health Coverage (HD) (except when requesting ID cards) Level 2. In addition to HIPAA TR3 edits, Anthem applies business edits to ensure that the necessary information is populated and complete for efficient processing. When encountering HIPAA compliance, code set or business errors, Anthem returns an 864 Level 2 Status Report to the submitter indicating the entire transaction set has been rejected. (An notification from file enrollment system will be returned to the submitter to indicate the file has been applied.) 1.2 Dates File Effective Date Effective date of actual file used if member level effective date is not present in Loop Effective Date Member level effective date. The file effective date will be utilized unless otherwise stated in Loop 2000-Member Level Detail, Member Level Dates. Override Date Member level date denoted in Loop 2000, DTP03 with values 303, 356, and 357. PCP Effective Date, Policy Effective Date, Member Effective Date, Member Cancel Date, Policy Cancel Date, COB Effective Date Populate these dates on the file whenever available. 1.3 Dependents Subscribers and dependents are sent as separate occurrences of Loop The initial enrollment for the subscriber must be sent before sending the initial enrollment for any of the subscriber s dependents. 1.4 Transfer of Coverage Transfer of coverage, often referred to as plan changes, can occur on two levels: 1) Firm Division and 2) Health Benefit Plan. Anthem recognizes specific plan change transactions that will automatically cancel the old plan and establish the new plan and new effective date. Page 2 of 14

3 1.5 Cancellations Future Cancellations When sending future termination records, the group must continue to send the member records up to the date of cancellation. Cancellation by Omission Anthem does not terminate policies if the policy is missing A cancel record with the cancellation/termination date must be communicated on the EDI file. 1.6 Primary Care Physician (PCP) New members a PCP ID must be supplied for any member whose health plan requires a PCP. Anthem will no longer select a PCP for a member when Loop 2300, NM109 is not populated on the file. Adding members to POS or HMO Policy If an 834 transaction adds a member to a POS or HMO policy, provide the PCP ID in Loop 2310, NM109. Updating PCP Anthem allows for PCP changes for those groups who require PCPs. To relay a PCP change, provide information in Loop The member s Effective Date will translate to the PCP s Effective Date. 1.7 Scheduling Receipt Time for Same-Day EDI Processing 834 File enrollment files are processed as they are received, usually fully processed within 48 business hours under normal operating conditions. If a group transmits two files, within the same week, the system will fully complete the process cycle on the first file, then proceed to the second. Please contact the Anthem File Enrollment Coordinator for specifics. 834 Submission Frequency Anthem encourages enrollment files to be submitted no more than once a week. Some groups elect to send files every two weeks or monthly, depending on the transaction volume. If there is an emergency, call your Membership Representative for manual keying. As long as you make the same changes on your system, when you send in your next file, the File Enrollment System will recognize and synchronize the files. Processing Times and Holiday Schedules Transactions may be submitted to the Enterprise EDI Gateway 24 hours a day, 7 days a week. During a typical business week, reports and acknowledgments are returned within 2-3 hours after EDI receives the transmission. If a holiday schedule necessitates a delivery time change, a notification is placed in the gateway mailbox. 1.8 Uppercase Letters, Special Characters, and Delimiters As specified in the TR3, the basic character set includes uppercase letters, digits, space, and other special characters. All HIPAA deemed values (segments, qualifiers) must be submitted in UPPERCASE letters only. Suggested delimiters for the transaction are assigned as part of the trading partner set up. EDI Representative will discuss options with trading partners, if applicable. Inbound Delimiters Suggested Value Data Element Separator * Asterisk Sub-Element Separator : Colon Segment Terminator ~ Tilde Repetition Separator ^ Caret Page 3 of 14

4 To avoid syntax errors, hyphens, parentheses and spaces are not recommended to be used in values for identifiers. Examples: Tax ID SSN Phone Since originally submitted values may be returned on outbound transactions, Anthem encourages trading partners to not use the following special characters as part of the value: asterisk (*), less than/greater than signs (<, >), colon (:), and slash (/). This minimizes the risk for a special character to be recognized as a delimiter. Example: Provider submits a Social Security Number Although a hyphen (-) is a valid special character, it adversely affects processing since the membership system is unable to process correctly. 1.9 Decimal R Data Elements R data elements are those that contain a decimal point; involving monetary amounts, units, visits, weights, and frequency. Anthem recommends using decimal points for monetary amounts, and whole numbers for other types of R data elements Updates Always send full 834 enrollment transactions. Do not send transactions with only change information. All transaction files transmitted need to be full files. If there are additions, terminations, or changes to the current enrollment, send the entire enrollment file updated with the changes. If you are not able to send full files, please discuss alternatives with your Marketing Representative. For full files, data element BGN08 must be submitted with action code 4 (Verify), or RX (Replace). Per 5010, action code 4 strictly indicates that the file is for verification only. To ensure that a full file is uploaded to the membership system, begin using action code RX instead Spouse/Dependent Coverage If the policy does not include a spouse and/or dependents, then the transmission must only include an 834 record for the employee. It must not include records for a spouse and/or dependents. If the policy does include a spouse and/or dependents, then the transmission must include an INS loop (Member Level Detail) for the employee, spouse and each dependent Separate Transactions for Each Insurance Line Anthem is unable to process multiple iterations of Loop 2300 HD for a member. A separate transaction set containing all the members for each line of business is required. Example: If members are enrolled in both PPO (health) and DEN (dental), Anthem expects separate transaction sets with all the members for PPO under one and all the members for DEN under another Maintenance In Loop 2000, Member Level Detail, data elements INS03 and INS04 identify a member s enrollment status. If the enrollment involves a change of addition (INS03 populated with 001 or 021 ), a reason must be given for qualification. Otherwise, the file will be rejected. Example: Member adding newborn to her insurance policy. In Loop 2000, INS03 is populated with value 021 (addition) followed by INS04 with value 020 (birth). Page 4 of 14

5 Section 2a - Business Case Scenarios 1. Adding a new member (Spouse or Child) to an existing policy. Scenario A: Adding the member results in a coverage change. If adding the member will cause a change to the coverage level of the policy, then you must also make some changes to the Membership Code and the Policy Effective Date. You must update Loop 2300, HD05 Coverage Level Code and DTP 348 Benefit Begin Date (Policy Effective Date). This equates to the Member Effective Date of the new member. Example: Employee Only (EMP) policy effective 1/1/02. He adds his spouse effective 10/15/02 to the policy. This will cause a change to the Membership Code from EMP to Employee + Spouse (ESP). The Effective Dates for the Spouse and the Policy is 10/15/02. *If the policy is for HMS Dental, then you must also update the Member Effective Dates of every member on the policy to be equal to the Policy Effective Date. Scenario B: Adding the member does not cause any change to the coverage level. If adding the member does not cause any change, then add the new member s information. No changes needed to other existing effective dates or to Membership Code. Example: Family policy effective 1/1/02. Child added effective 10/15/02 to the policy. To add the new member, include the new member s information with his/her effective date. All other dates remain the same. 2. Canceling a member (Spouse or Child) from a policy. When canceling a member, you must include a Member Cancel Date in DTP 349 Benefit End Date in that member s information. Continue to transmit canceled records until the date of the cancellation has passed and the termination date has been transmitted at least once. Scenario A: Canceling the member results in a coverage change. If canceling the member will cause a change to the coverage level of the policy, then you must also make some changes to the Membership Code (HD05 Coverage Level Code) and Policy Effective Date. The updated Policy Effective Date (DTP 348 Benefit Begin Date) should be equal to the Member s Cancel Date (DTP 349 Benefit End Date). Example: Cancellation of child from Employee + Child (E1D) policy effective 1/1/02, will result in change to Employee Only (EMP) policy. Cancel the Child by updating the Child s information with a Cancel Date effective 11/1/02 and update the policy with the new Membership Code and new Policy Effective Date 11/1/02. The updated Membership Code and Policy Effective Date must correspond to the Member s Cancel Date. ***If the policy is for HMS Dental, then you must also update the Member Effective Dates of every member on the policy, except the one(s) being canceled, to be equal to the Policy Effective Date. Page 5 of 14

6 Scenario B: Canceling the member does not cause any change to the coverage level. If canceling the member does not cause a change to the coverage level of the policy, then add the Member s Cancel Date to that member s information. It is unnecessary to make any changes to the Policy Effective Date and/or the Membership Code. Example: Cancellation of one child from Employee + Children policy effective 1/1/02, will result in no change to membership code and Policy Effective Date. Cancel the Child by adding the member cancel date of 11/1/02 to that member s information. No need to update the Policy Effective Date and/or any other member s information, and the membership code remains that same. 3. Canceling a policy. When canceling a policy, include a Policy Cancel Date in DTP 349 Benefit End Date and a Policy Cancel Reason in INS04 Maintenance Reason Code. There is no need to include the cancel date on each member s information. Continue to transmit canceled records until the date of the cancellation has passed and the termination date has been transmitted at least once. Example: Employee + Child (E1D) policy effective 1/1/02 to be cancelled 11/1/02. In order to cancel this entire policy, add the cancel date (11/1/02) and cancel reason. Please note that the Cancel Reason is required. It is an error to send a Policy Cancel Date without a Policy Cancel Reason. 4. Changing Group Numbers, Packages or Divisions within a single Carrier. **Division (alphanumeric) is another term for Group Number used by HMO. **Changes to Group Numbers (numeric), Package Codes or Divisions are only permitted during Open Enrollment or in special circumstances, such as COBRA elections or when moving to a new location within the company causes a change in the Group Number. When changing the group number, package code or division of a policy, you must provide the new group number in Loop 2000 REF segment with a value of 1L in REF01 and the group number in REF02 and/or the new package code in HD04. You must also update the Policy Effective Date in DTP 348 Benefit Begin Date. Example: Employee Only (EMP) policy in Division 0B During Open Enrollment, this member chose to switch to another benefit plan, resulting in a change of Division. To change the policy to be in the new division, 0B221001, change the Group Number and Policy Effective Date from 1/1/02 to 1/1/03. Please note that it is unnecessary to update any information for any of the members. It is also unnecessary to transmit a cancel from the old group number and add to the new group number as two separate transactions. The HIPAA 834 interprets this kind of change to include the cancel from the old group number. ***If the policy is for HMS Dental, then you must also update the Member Effective Dates of every member on the policy to be equal to the Policy Effective Date. Page 6 of 14

7 5. Changing Carriers (i.e. Changing from PPO to HMO, or vice-versa). **Changes to Carriers are only permitted during Open Enrollment or in special circumstances. Changing Carriers is complicated because it actually requires two separate transactions or records for the single policy. The first record must be a cancel from the original carrier. The second record is the add to the new carrier. Continue to transmit canceled records until the date of the cancellation has passed and the termination date has been transmitted at least once. Example: Employee + Spouse (ESP) policy is an HMO policy. At Open Enrollment, this policy will be moving to a PPO benefit package. In order to properly convey the change from HMO to PPO to the EES system, send two records; (1) cancel from HMO and (2) add to PPO. (1) The first record policy with the HMO group number (0B221000) with a Policy Effective Date of 1/1/01 and a Policy Cancel Date of 12/31/02 and a Cancel Reason. (2) The second record - policy with the PPO group number ( ) with a Policy Effective Date of 1/1/03. All Members on the policy have Member Effective Dates of 1/1/03. Please note that the Member Effective Dates on the new PPO record are equal to the PPO Policy Effective Date. 6. Terminating the Subscriber but Keeping the dependents active. **Applies to situation where the employee dies and the family is still eligible for coverage. **Applies to situation where the employee quits and elects to keep the children on COBRA. If the Subscriber (or Employee) cancels coverage (or is deceased) then all members on that policy are also canceled. To keep the Spouse or any of the Children active, you will need to create a new policy for those members, assigning the Spouse s SSN or the SSN of the youngest Child on the policy as the Policyholder or Subscriber. That member becomes the employee with relation code of INS02 = 18. Continue to transmit canceled records until the date of the cancellation has passed and the termination date has been transmitted at least once. Example: The employee on an Employee + Spouse (ESP) policy died. However, the Spouse is still eligible for coverage. The original policy is canceled with the appropriate Cancel Date, last day of coverage for HMO (10/28/02) and first day without coverage for PPO (10/29/02). Send a cancel date on the Employee s policy and also add a new policy for the Spouse. The new policy for the Spouse will have the same Policy Effective Date (10/29/02) for PPO as the cancel date of the deceased Employee; however, for HMO, the new Policy Effective Date will be the next day i.e. 10/29/02. Please note in the new policy, the Spouse is now the policyholder and both the Policy Effective Date and Member Effective Date are equal to the cancel date of the original policy for PPO so that there is no break in coverage. **For an HMO policy, the Effective Dates on the new policy would be the day after the Cancel Date on the original policy. This prevents an overlap in coverage. Page 7 of 14

8 Section 2b - Business Case Scenarios Common business case scenarios have been identified in 834 format below: Business Case Scenarios Loop Data Element [Value] 834 Translation: SEGMENT, Data Element Separator (*), Value/[Value], Segment Terminator (~) Name Change 2000 INS01[Y] + INS02[relationship code] + INS03[001] + INS04[25] 2100A NM101[74] + NM102[1] + NM103 + NM104 + NM105 NEW NAME 2100B NM101[70] + NM102[1] + NM103 + NM104 + NM105 OLD NAME INS*Y*[relationship code]*001*25~ NM1*74*1*[last name/org]*[first name]*[middle name]~ NM1*70*1*[last name/org]*[first name]*[middle name]~ Add Dependents 2000 INS01[N] + INS02[relationship code] + INS03[021] + INS04[no 28] INS*N*[relationship code]*021~ Terminate Dependents 2000 INS01[N] + INS02[relationship code] + INS03[024] INS*N*[relationship code]*024~ Terminate Contract 2000 INS01[Y] + INS02[18] + INS03[024] INS*Y*18*024~ Firm Division / Product Change 2000 INS01[Y] + INS02[18] + INS03[001] + INS04[22 OR XT] 2300 REF01[1L] + REF02 NEW FIRM DIVISION 2300 HD01[001] + HD04 NEW HEALTH BENEFIT PLAN (HBP) INS*Y*18*001*[22 OR XT]~ REF*1L*[group policy]~ HD*001***[plan coverage description]~ Primary Care Physician (PCP) Change 2000 INS01[Y] + INS02[relationship code] + INS03[001] + INS04[15] 2310 LX PLA01[2] + PLA02[1P] + PLA03 + PLA05 INS*Y*[relationship code]*001*15~ LX*[number] PLA*2*1P*[date CCYYMMDD]**[reason code]~ PLA01[2] + PLA02[1P] + PLA03 + PLA05 INS*Y*[relationship code]*001*15~ LX*[number] PLA*2*1P*[date CCYYMMDD]* *[reason code]~ According to the 834 TR3, data element PLA04 is not used. Account for PLA04 by using the asterisk (*) as the data element separator. Changing the Insurance Line (PPO, HMO, or POS) 2000 INS01[Y] + INS02[relationship code] + INS03[030] + INS04[XN] + INS05[A] 2300 HD01[024] + HD03[PPO] 2300 DTP01[349] + DTP02[D8] + DTP03[policy cancel date] CANCEL PPO POLICY 2000 INS01[Y] + INS02[relationship code] + INS03[030] + INS04[XN] + INS05[A] 2300 HD01[024] + HD03[HMO] 2300 DTP01[348] + DTP02[D8] + DTP03[policy effective date] ADD HMO POLICY INS*Y*[relationship code]*030*xn*a~ HD*024**PPO~ DTP*349*D8*[policy cancel date CCYYMMDD] INS*Y*[relationship code]*030*xn*a~ HD*030**HMO~ DTP*348*D8*[policy effective date CCYYMMDD] Page 8 of 14

9 Section 3 - Enveloping EDI envelopes control and track communications between you and Anthem. One envelope may contain many transaction sets grouped into the following: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) 834 Benefit Enrollment and Maintenance-Envelope Specific to Anthem VA (TR3, Appendix C) ISA Interchange Control Header GS Functional Group Header GE Functional Group Trailer IEA Interchange Control Trailer ISA01 00 GS01 BE GE01 refer to TR3 IEA01 refer to TR3 ISA02 refer to TR3 GS02 SENDER ID GE02 refer to TR3 IEA02 refer to TR3 ISA03 00 EDI assigned ISA04 refer to TR3 Left-justified followed by ISA05 ZZ no zeroes or spaces ISA06 SENDER ID EDI assigned Left-justified GS03 VAMEMFES BCCASTAR followed by spaces GS04 refer to TR3 GS05 refer to TR3 ISA07 ZZ GS06 refer to TR3 ISA08 VAMEMFES GS07 X BCCASTAR GS08 ISA09 refer to TR3 ISA10 refer to TR3 ISA11 ^ (5E) NOTE. Critical Batching and Editing Information ISA *Files must be submitted with ISA08=GS03. ISA13 refer to TR3 *Transactions must be batched in separate functional group by GS03. ISA14 refer to TR3 *Unique group control number (GS06) MUST NOT be duplicated within 365 days ISA15 1 by Trading Partner ID (GS02); files containing duplicate or previously received ISA16 : (3A) group control numbers will be rejected. Page 9 of 14

10 Section 4 - Charts for Situational Rules Listed below are loops, segments, and data elements required for proper adjudication by Anthem per the situational rules in the 834 TR3. TR3 Segment 834 Benefit Enrollment and Maintenance Reference Designator(s) Value Definitions and Notes Specific to Anthem VA P.31 ST Transaction Set Header ST03 Implementation Convention Ref P.32 BGN BGN08 Beginning Segment Action Code P.36 REF Transaction Set Policy Number - refer to TR3 P.37 DTP File Effective Date - refer to TR3 P.38 QTY Transaction Set Control Totals - refer to TR3 Loop ID 1000A Sponsor Name P.39 N1 Sponsor Name - refer to TR3 Loop ID 1000B Payer P.41 N1 N102 ANTHEM HEALTH PLANS OF VIRGINIA INC 2 4 RX Payer Name N Identification Code Loop ID 1000C TPA/Broker Name P.43 N1 TPA/Broker Name - refer to TR3 Loop ID 1100C TPA/Broker Account Information P.45 ACT TPA/Broker Account Information - refer to TR3 Loop ID 2000 Member Level Detail P.47 INS INS02 Member Level Detail Individual Relationship Code INS04 Maintenance Reason Code INS09 Student Stat Code INS10 Yes/No Condition or Response Code P.55 REF Subscriber Identifier REF02 Reference Identification P.56 REF REF02 Member Policy Number Reference Identification Child/Dependent; 53 - Life Partner Only 1 member record with Rel Code of Employee per contract allowed Only 1 member record with Rel Code of Spouse/domestic partner per contract. The Domestic Partner value can only be used for Groups that allow this benefit. If Cancel Reason is populated, must be a valid value for: Termination of coverage Employee request Use when switching from HMO to POS or from POS to HMO (no notifications will be sent to the Employee) Deceased Left organization under 65 Left organization over 65 If benefits specify a different maximum dependent age for full time students, identify which dependents are FT For handicapped children over the max dependent age to maintain coverage - Send Y if the dependent is handicapped. When the value is Y for a new Member, the record will pend. (Subscriber Identifier) - Benefit Enrollment and Maintenance 2 - Change (Update) 4 - Verify FILE IS NOT UPLOADED RX - Replace FILE IS UPLOADED Represents the Tax ID of Anthem Health Plans of Virginia Inc 01 - Spouse; 17 - Stepson/Stepdaugter; 18 - Self; 19 - Represents Social Security Number (9 digits) for each Subscriber. If HMO, the Group # (9 alphanumerics) must be valid for this node according to File Enrollment Node Setup. If PAR, the Group/Package combination (9 alphanumerics) must be valid for this node according to File Enrollment Node Setup. If ADV (DENTAL), the Group # must be 10 alphanumerics Page 10 of 14

11 TR3 Segment Reference Value Designator(s) Loop ID 2000 Member Level Detail (cont'd) P.57 REF Member Supplemental Identifier - refer to TR3 P.59 DTP DTP03 Member Level Date Time Period Dates Loop ID 2100A Member Name P.62 NM1 Member Name NM , 107 Name Last, First, Middle, Suffix NM106 Name Prefix NM109 Identification Code P.65 PER Member Comm PER04 Communic. No. Numbers P.68 N3 N301 Member Residence Address Street Address Information 834 Benefit Enrollment and Maintenance (Member Last, First, Middle Name, Suffix) (Member Name Prefix) (Subscriber Identifier) (Communic. Number) P.69 N4 Member City, N403 Postal Code State, ZIP Code P.71 DMG DMG03 Member Gender Code Demographics DMG04 Marital Status P.76 EC Employment Class - refer to TR3 P.79 ICM Member Income - refer to TR3 P.81 AMT Member Policy Amounts - refer to TR3 P.82 HLH Member Health Information - refer to TR3 P.84 LUI Member Language - refer to TR3 (Member Postal Zone or Zip Code) discrepancy. I M Definitions and Notes Specific to Anthem VA Medicare Part A Effective Date must member's birth date Medicare Part A Cancel Date must Med Part A Eff Date Medicare Part B Effective Date must member's birth date Medicare Part B Cancel Date must Med Part B Eff Date Hire Date (employee starts work) must Eff Date Eligibility Date (eligible for health benefits) must Eff Date Eligibility Date must Hire Date Name must contain only the following characters: 'a-z', 'A-Z', hyphen (-), single quote ('), period (.), comma (,) or space ( ). Should include the suffix, if applicable. If populated, Title must be one of the following and cannot contain any punctuation, including periods: MR, MS, MRS, DR, FR, SR, REV. Title must agree with Gender Code: Prefix MR or FR, DMG03=M Prefix MS, SR, MRS, DMG03=F Valid SSN (9 numeric digits) for each subscriber record needed to process the transaction successfully. If populated, SSN must be unique among members on the Customer policy. If the SSN of the Employee changes, this will cause an error. Format - <AAA><BBBCCCC> 3 digit area code and 7 digit phone number Address for enrolling subscriber, for a dependent when the subscriber's address differs from the dependent's, or for a change in member's address. Max 36 bytes for HMO Max 24 bytes for PPO, PAR, and POS policies Valid zip code - format contains full nine digits with no hyphens or spaces If U is passed, the record will error and be reported back as I - Single M - Married Page 11 of 14

12 TR3 Segment 834 Benefit Enrollment and Maintenance Reference Designator(s) Value Definitions and Notes Specific to Anthem VA Loop ID 2100B Incorrect Member Name P.86 NM1 Incorrect Member Name - refer to TR3 P.89 DMG Incorrect Member Demographics - refer to TR3 Loop ID 2100C Member Mailing Address P.92 NM1 Member Mailing Address - refer to TR3 P.94 N3 Member Mail Street Address - refer to TR3 P.95 N4 Member Mail City, State, ZIP Code - refer to TR3 Loop ID 2100D Member Employer P.97 NM1 Member Employer - refer to TR3 P.100 PER Member Employer Communications Numbers - refer to TR3 P.103 N3 Member Employer Street Address - refer to TR3 P.104 N4 Member Employer City, State, ZIP Code - refer to TR3 Loop ID 2100E Member School P.106 NM1 Member School - refer to TR3 P.108 PER Member School Communications Numbers - refer to TR3 P.111 N3 Member School Street Address - refer to TR3 P.112 N4 Member School City, State, ZIP Code - refer to TR3 Loop ID 2100F Custodial Parent P.114 NM1 Custodial Parent - refer to TR3 P.117 PER Custodial Parent Communications Numbers - refer to TR3 P.120 N3 Custodial Parent Street Address - refer to TR3 P.121 N4 Custodial Parent City, State, ZIP Code - refer to TR3 Loop ID 2100G Responsible Person P.123 NM1 Responsible Person - refer to TR3 P.126 PER Responsible Person Communications Numbers - refer to TR3 P.129 N3 Responsible Person Street Address - refer to TR3 P.130 N4 Responsible Person City, State, ZIP Code - refer to TR3 Loop ID 2100H Drop Off Location P.132 NM1 Drop Off Location - refer to TR3 P.134 N3 Drop Off Location Street Address - refer to TR3 P.135 N4 Drop Off Location City, State, ZIP Code - refer to TR3 Loop ID 2200 Disability Information P.137 DSB Disability Information - refer to TR3 P.139 DTP Disability Eligibility ibilit Dates - refer to TR3 Loop ID 2300 Health Coverage Segment needed for each member and dependent record to process the transaction successfully. P.141 HD HD Cancellation or Termination Health Coverage Maint Type Code Audit or Compare HD03 DEN DEN - Dental (ADV) Insurance Line HMO HMO - Health Maintenance Organization Code POS POS - Point of Service PPO PPO - Preferred Provider Org (Par/PPO) HD04 When changing to a Group Number and/or Package Code that Plan Coverage requires a PCP, the PCP fields must also be completed. All Description effective dates must be equal. HD05 E1D - Employee + 1; ECH - Employee and Children; ESP - Cov Level Code Employee and Spouse; FAM - Family; IND - Individual Page 12 of 14

13 TR3 Segment Reference Designator(s) Loop ID 2300 Health Coverage (cont'd) P.143 DTP DTP03 Health Coverage Date Time Period Dates Value later than 60 days from the file receipt date. When this field is populated, the Group Number and/or Package Code must remain unchanged. P.145 AMT Health Coverage Policy - refer to TR3 P.146 REF Health Coverage Policy Number - refer to TR3 P.148 REF Prior Coverage Months - refer to TR3 P.150 IDC Identification Card - refer to TR3 Loop ID 2310 Provider Information P.152 LX Provider Information - refer to TR3 P.153 NM1 NM109 Provider Name Identification Code NM110 Entity Relationship Code P.156 N3 Provider Address - refer to TR3 P.157 N4 Provider City, State, ZIP Code - refer to TR3 P.159 PER Provider Communications Numbers - refer to TR3 P.162 PLA Provider Change Reason - refer to TR3 Loop ID 2320 Coordination of Benefits P.164 COB Coordination of Benefits - refer to TR3 P.166 REF Additional Coordination of Benefits - refer to TR3 P.168 DTP Coordination of Benefits Eligibility Dates DTP03 Date Time Period 834 Benefit Enrollment and Maintenance Definitions and Notes Specific to Anthem VA Effective Date is the date that the most recent coverage change is to take effect. When adding a new policy, this date cannot be earlier than 60 days prior to the first of the current month. Cancel Date is the date that the policy is to be canceled. Enter the last day with coverage unless you ve made prior arrangements with Anthem. You should continue to transmit canceled records until the date of the cancellation has passed and the termination date has been transmitted at least once. When the group allows odd Cancel Date, this date can be any day of the month. When the group does not allow odd Cancel Dates, this date must be the last day of the month. Policy Cancel Date cannot be earlier than 60 days prior to the first of the month in which the file was received, and cannot be HMO PCP ID must be 6 numeric digits. Par/PPO - PCP ID must be 5 alphanumeric digits ADV (DENTAL) - PCP ID does not apply If Par and PCP is pediatrician, member's age must < 22 If PCP accepts only female patients, DMG03=F For members already enrolled, make PCP changes through the file or by calling Customer Service (but not both). Consult with your Sales/Business contact on options. If 72 is passed, the record will error and be reported back as discrepancy. Established Patient defined as one who has seen or has another family member who has seen that provider within the last 36 months and his/her patient Status Indicator denotes this. COB Other Policy Effective Date must member's birth date COB Other Policy Cancel Date must Eff Date Page 13 of 14

14 TR3 Segment 834 Benefit Enrollment and Maintenance Reference Designator(s) Value Definitions and Notes Specific to Anthem VA Loop ID 2330 Coordination of Benefits Related Entity P.169 NM1 Coordination of Benefits Related Entity - refer to TR3 P.171 N3 Coordination of Benefits Related Entity Address - refer to TR3 P.172 N4 Coordination of Benefits Other Insurance Company City, State, ZIP Code - refer to TR3 P.174 PER Administrative Communications Contact - refer to TR3 P.176 LS Additional Reporting Categories - refer to TR3 Loop ID 2710 Member Reporting Categories P.177 LX Member Reporting Categories - refer to TR3 Loop ID 2750 Reporting Category P.178 N1 Reporting Category - refer to TR3 P.179 REF Reporting Category Reference - refer to TR3 P.181 DTP Reporting Category Date - refer to TR3 P.183 LE Additional Reporting Categories Loop Termination - refer to TR3 P.184 SE Transaction Set Trailer - refer to TR3 Page 14 of 14