834 Enrollments - Inbound Translation

Transcription

1 R = Required, = ituational Loop R or egment ANI 834 Request Field Name Allowable Data Values IG Page INTERCHANGE CONTROL HEADER (R) Field ize Min Max Business Rule R IA01 Authorization Information 00 No auth info present 03 Additional data information B3 2 2 R IA02 Authorization Information B R IA03 ecurity Info 00 No info present 01 Password B4 2 2 R IA04 ecurity Information B R IA05 Interchange ID ZZ Mutually Defined B4 2 2 R IA06 Interchange ender ID B R IA07 Interchange ID ZZ Mutually Defined B4 2 2 R IA08 Interchange Receiver ID B R IA09 Interchange Date YYMMDD B5 6 6 R IA10 Interchange Time HHMM B5 4 4 R IA11 Interchange Control tds. U B5 1 1 Identifier R IA12 Interchange Control Version B5 5 5 No. R IA13 Interchange Control No. B5 9 9 R IA14 Acknowledgment Requested 0 No Acknowledgement Requested 1 Acknowledgement Requested B6 1 1 R IA15 Usage Indicator P Production Data T Test Data B6 1 1 R IA16 Component Element eparator FUNCTIONAL GROUP HEADER (R) R G01 Functional ID Code BE Benefit Enrollment and Maintenance (834) B6 1 1 B8 2 2 NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 1 of 20 Published August 2003

2 Loop R or egment ANI 834 Request Field Name Allowable Data Values IG Page Field ize Min Max R G02 Application ender's Code B Business Rule R G03 Application Receiver's Code B R G04 Date CCYYMMDD B8 8 8 R G05 Time HHMM B8 4 8 R G06 Group Control Number Numeric B9 1 9 R G07 Responsible Agency Code X Accredited tandards Committee B9 1 2 X12 R G08 Version/Release/ Industry ID Code X095A1 B Transaction et Header (R) R T01 Transaction et Identifier Code 834 Benefit Enrollment and Maintenance R T02 Transaction et Control Number Beginning egment (R) R BGN01 Transaction et Purpose Code 00 ORIGINAL UBMIION RE-UBMIION 22 INFORMATION R BGN02 Reference Identification R BGN03 Date CCYYMMDD R BGN04 Time HHMM R BGN05 Time Code R BGN06 Reference Identification R BGN07 Transaction Type Code R BGN08 Action Code 2 CHANGE (UPDATE) VERIFY PAYER/PONOR YTEM R BGN09 ecurity Level Code Transaction et Policy Number (R) REF01 Reference Identification 38 Master Policy Number REF02 Reference Identification File Effective Date () DTP01 Date/Time 7 EFECTIVE DATE MAINTENANCE EFFECTIVE DATE 382 ENROLLMENT DATE 388 PAYMENT COMMENCEMENT DATE 1000A 1000A 1000A DTP02 Date/Time Period Format D8 CCYYMMDD DTP03 Date/Time Period ponser Name (R) R N101 Entity Identifier Code P5 Plan ponser N102 Name NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 2 of 20 Published August 2003

3 Loop R or egment ANI 834 Request Field Name Allowable Data Values IG Page Field ize Min Max Business Rule R N103 Identifier Code FI Federal Taxpayer's Identifiction number A ZZ Mutually Defined 1000A R N104 Identifier Code B Payer P 1000C() TPA/Broker Name TPA/Broker Account Information 1000C Member Level Detail (R) R IN01 Yes/No Condition Response Code R IN02 Individual Relationship Code 18 ELF 1 POUE 19 CHILD R IN03 Maintenance Type Code 001 CHANGE (UPDATE) 021 ADDITION 024 CANCEL/TERMINATE 025 REINTATEMENT 030 AUDIT/COMPARE R R IN04 IN05 Maintenance Reason Code Benefit tatus Code Y INURED UBCRIBER N NOT THE INURED 01 Divorce 02 Birth 03 Death 04 Retirement 05 Adoption 06 trike 07 Termination of Benefits 08 Termination of Employment 09 Consolidation Omnibus Budget Act (COBRA) 10 Consolidation Omnibus Budget Act (COBRA) Premium Paid 11 urviving pouse 14 Voluntary Withdrawal 15 Primary Care Provider (PCP) Change 16 Quit 17 Fired 18 uspended 20 Active 21 Disability 22 Plan Change 25 Change in Identifying Data Elements 26 Declined Coverage 27 Pre Enrollment 28 Initial Enrollment 29 Benefit election 31 Legal eperation 32 Marriage 33 Personnel Data 37 Leave of Absence with Benefits 38 Leave of Absence without Benefits 39 Lay Off with Benefits 40 Lay Off without Benefits 41 Re-enrollment 43 Change of Location AI No Reaon Given XN Notification Only XT Transfer A ACTIVE NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 3 of 20 Published August 2003

4 Loop R or egment ANI 834 Request Field Name Allowable Data Values IG Page C COBRA urving Insured T TEFRA IN06 Medicare Plan Code A Medicare Part A B Medicare Part B C Part A and B D Medicare Part Unk Field ize Min Max IN07 Consolidated Omnibus Budget 1 Termination of Employment Reconcilation Act (COBRA) 2 Reduction of Work Hours Qualifying 3 Medicare 4 Death 5 Divorce 6 eparation 7 Ineligible Child 8 Bankruptcy of a retired employee IN08 Employment tatus Code FT Full Time Active Medicaid TE Loss of Eligibility/disenrollment IN09 tudent tatus Code IN10 Yes/No Condition Response Y or N HANDICAP INDICATOR Code IN11 Date Time Period Format D8 CCYYMMDD IN12 Date Time Period IN17 Number ubscriber Number (R) R REF01 Reference Identification 0F UBCRIBER NUMBER R REF02 Reference Identification Member Policy Number () R REF01 Reference Identification 1L POLICY NUMBER R REF02 Reference Identification Member Identification Number () R REF01 Reference Identification 17 Client reporting Category Client Number 3H Case Number DX Department Agency Number F6 HIC Number Q4 Prior ID Number ZZ Mutually Defined Number 60 Cross Reference Number REF02 Reference Identification Prior Coverage Months () R REF01 Reference Identification QQ Unit Number R REF02 Reference Identification Member Level Dates () R DTP01 Date/Time 336 EMPLOYMENT BEGIN ELIGIBILITY BEGIN 357 ELIGIBILITY END 473 MEDICIAD BEGIN 474 MEDICIAD END R DTP02 Date Time Period Format D8 CCYYMMDD Business Rule NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 4 of 20 Published August 2003

5 Loop R or egment ANI 834 Request Field Name Allowable Data Values IG Page Field ize Min Max R DTP03 Date Time Period Member Name(R) R NM101 Entity Identifier Code 74 CORRECTION L INURED R NM102 Entity Type 1 Person R NM103 Name Last or Organization Name R NM104 Name First NM105 Name Middle NM106 Name Prefix NM107 Name uffix NM108 Identification Code 34 ocial ecurity Number ZZ Mutually Defined r NM109 Identification Code Member Communication Numbers () R PER01 Contact Function Code IP INURED PARTY R PER03 Communication Number HP Home Phone R PER04 Communicaiton Number PER05 Communication Number WP Work Phone PER06 Communication Number PER07 Communication Number PER08 Communication Number Member Resident treet Address () R N301 Address Information N302 Address Information Member Resident City, tate, Zip Code () N401 City Name N402 tate or Province Code N403 Postal Code N404 Country Code N405 Location N406 Location Identifier Member Demographics () R DMG01 Date Time Period Format D8 CCYYMMDD R DMG02 Date Time Period R DMG03 Gender Code F Female M Male U Unknown DMG04 Marital tatus Code DMG05 Race or Ethnicity Code DMG06 Citizenship tatus Code Member Income Member Policy Amounts Member Health Information Member Language () Business Rule NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 5 of 20 Published August 2003

6 Loop 2100B R or egment ANI 834 Request Field Name Allowable Data Values IG Page Field ize Min Max LUI01 Identification Code LE IO 639 Language Codes LUI02 Identification Code LUI03 Description LUI04 Use of Language Indicatator Incorrect Member Name () 5 Reading 7 peaking 8 Native Business Rule 2100B R NM101 Entity Identifier Code 70 PRIOR INCORRECT INURED B R NM102 Entity Type 1PERON R NM103 Name Last or Organization B Name 2100B R NM104 Name First B NM105 Name Middle B NM106 Name Prefix B NM107 Name uffix B NM108 Identification Code 34 ocial ecurity Number NM109 Identification Code B 2100B Incorrect Member Demographics () R DMG01 Date Time Period Format D8 CCYYMMDD B 2100B R DMG02 Date Time Period B R DMG03 Gender Code C Member Mailing Address Member Mail City, tate, Zip 2100C Member Employer () R NM101 ENTITY IDENTIFIER CODE E Employer Name R NM102 Entity Type 1 Person Non Person Entity NM103 Name Last or Organization Name NM104 Name First NM105 Name Middle NM107 Name uffix NM108 Identification Code ZZ Mutually Defined NM109 Identification Code Member Employer Communication Numbers () PER01 Contact Function Code EP Employer Contact PER02 Name PER03 Communication Number TE Telephone PER04 Communication Number PER05 Communication Number PER06 Communication Number PER07 Communication Number PER08 Communication Number Member Employer treet Address () N301 Address Information NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 6 of 20 Published August 2003

7 Loop R or egment ANI 834 Request Field Name Allowable Data Values IG Page Field ize Min Max N302 Address Information Member Employer City tate Zip () N401 City Name N402 tate or Province Code N403 Postal Code N404 Country Code E Member chool () 2100E R NM101 Entity Identifier Code M8 Educational Institution E R NM102 Entity Type R NM103 Name Last or Organization E Name 2100E chool Communication Numbers () 2100E R PER01 Contact Function Code K chool Clerk R PER03 Communication Number TE Telephone E R PER04 Communication Number E 2100E 2100E 2100E 2100E PER05 Communication Number TE Telephone PER06 Communication Number PER07 Communication Number TE Telephone PER08 Communication Number Business Rule 2100E Member chool treet Address () 2100E N301 Address Information E N302 Address Information E Member chool City tate Zip () 2100E N401 City Name E N402 tate or Province Code E N403 Postal Code F Custodial Parent Custodial Parent Communication Numbers 2100F Custodial Parent treet Address 2100F Custodial Parent City, tate, Zip 2100F 2100G Responsible Person () NM101 Entity Identifier Code QD REPONIBLE PARTY E1 Person or Other Entitiy Responsible EL Executor of Estate EX Ex-pouse GD Gaurdian G J6 Power of Attorney 2100G NM102 Entity Type 1 PERON NM103 Name Last or Organization G Name 2100G NM104 Name First G NM105 Name Middle G NM106 Name Prefix G NM107 Name uffix G NM108 Identification Code 34 ocial ecurity Number NM109 Identification Code G 2100G Responsible Person Communication Numbers () NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 7 of 20 Published August 2003

8 Loop R or egment ANI 834 Request Field Name Allowable Data Values IG Page Field ize Min Max Business Rule 2100G PER01 Contact Function Code RP REPONIBLE PERON PER03 Communication Number HP Home Phone G 2100G PER04 Communication Number PER05 Communication Number WP Work Phone G PER06 Communication Number PER07 Communication Number G PER08 Communication Number Responsible Person treet Address 2100G Responsible Person City,tate, Zip 2100G 2200 Disability Information Disability Eligibity Dates Health Coverage () HD01 Maintenance Type Code Health Coverage Maintenance Code: 001 Change 002 Delete 021 Addition Cancellation or Termination HD03 Insurance Line Code: AK Mental Health HD04 Plan Coverage Description HD05 Coverage Level Code Health Coverage Dates (R) R DTP01 Date/Time 303 MAINTENANCE EFFECTIVE BENEFIT BEGIN 349 BENEFIT END LAT PREMIUM PAID R DTP02 Date Time Period Format D8 CCYYMMDD R DTP03 Date Time Period Health Coverage Policy 2300 Health Coverage Policy Number 2300 Identification Card 2300 Provider Number 2300 Provider Name (R) R NM101 Entity Identifier Code P3 Primary Care Provider R NM102 Entity Type 1 Person Non Person Entity NM103 Name Last or Organization Name NM104 Name First NM105 Name Middle NM106 Name Prefix NM107 Name uffix R NM108 Identification Code 34 ocial ecurity Number FI Federal Taxpayer Identification Number XX Health Care Financing Administration National Provider Identifier NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 8 of 20 Published August 2003

9 Loop R or egment ANI 834 Request Field Name Allowable Data Values IG Page Field ize Min Max R NM109 Identification Code R NM110 Entity Relationship Code 25 ETABLIHED PATIENT NOT ETABLIHED PATIENT 72 UNKNOWN Provider City tate Zip () R N401 City Name R N402 tate or Provence Code R N403 Postal Code N404 Country Code N405 Location N406 Location Identifier Provider Communication Numbers () R PER01 Contact Function Code R PER03 Communication Number WP Work Phone PER04 Communication Number PER05 Communication Number PER06 Communication Number PER07 Communication Number R PER08 Communication Number PCP Change Reason () R PLA01 Action Code 2 CHANGE R PLA02 Entity Identifier Code 1P PROVIDER R PLA03 Date DATE CCYYMMDD R PLA05 Maintenance Reason Code 14 VOLUNTARY WITHDRAWAL PLAN CHANGE 46 CURRENT CUTOMER INFORMATION FILE IN ERROR AA DIATIFACTION WITH OFFICE TAFF AB DIATIFACTION WITH MEDICAL CARE/ERVICE RENDERED AC INCONVENIENT OFFICE LOCATION AD DIATIFACTION WITH OFFICE HOUR AE RUNABLE TO CHEDULE APPOINTMENT IN A TIMELY MANNER AF DIATIFACTION WITH PHYICIAN' REFERRAL POLICY AG LE REPECT AND ATTENTION TIME GIVEN THAN OTHER PATIENT AH PATIENT MOVED TO A NEW LOCATION AI NO REAON GIVEN AJ APPOINTMENT TIME NOT MET IN A TIMELY MANNER Business Rule Coordination of Benefits () R COB01 Payer Responsibility equence Number Code P PRIMARY COVERAGE POLICY NUMBER ECONDARY COVERAGE POLICY COB02 Reference Identification NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 9 of 20 Published August 2003

10 Loop R or egment ANI 834 Request Field Name Allowable Data Values IG Page Field ize Min Max 1 1 Transaction et Trailer (R) R E01 Number of Included egments R E02 Transaction et Control Number FUNCTIONAL GROUP TRAILER (R) R GE01 Number of Transactions ent B R GE02 Group Control No. B R IEA01 Number of Functional Groups B7 1 5 R IEA02 Interchange Control No. B7 9 9 Business Rule R COB03 Coordination of Benefits Code 1 COB UNKNOWN NO COB Additional Coordination of Benefits Identifiers Other Insurance Company Name () 2320 R N101 Entity Identifier Code IN INURER N102 Name N103 Identifier Code FI Federal Taxpayer Identification Number NI National Association of Insurance Commissioners (NAIC)Identification XV Health Care Financing Administration National PlanID 2320 N104 Identification Code Coordination of Benefits Eligibility Dates () DTP01 Date/Time 344 COB BEGIN COB END DTP02 Date Time Period Format D8 CCYYMMDD DTP03 Date Time Period INTERCHANGE CONTROL TRAILER (R) NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 10 of 20 Published August 2003

11 Comment The following group of segments is found in Appendix B3 of the Implementation Guide. NHP uses ZZ Mutually Defined as the Default. (Appendix B4 - IA05) The Trading Partner Agreement determines the Interchange ender ID number. ender number will be mutually defined as indicated in IA05 (IA06) NHP uses ZZ Mutually Defined as the Default. (Appendix B4 - IA05) This is the NHP number that the sender assigned (IA08). NHP will accept the 4010 Addenda Version. This numeric field must be the same as IEA02, Change Control Trailer, Interchange Control No. NHP will always acknowledge the receipt of a file with a 997 Response and will not validate this field for a code "0 - No Acknowledgement Requested". The Trading Partner Agreement specifies that NHP will determine when a file is put in production. NHP will notify the sender via phone. (IA15). NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 11 of 20 Published August 2003

12 Comment Application ender's Code and other Functional Group Header information is coded as agreed to in the Trading Partner Agreement. (G02) Code agreed to in Trading Partner Agreement. (G03) G06 must match GE02 (Functional Group Trailer). ender Assigns the number. Returned on the 997 Response (G06) REFERENCE NUMBER File Transaction processed date the File's transaction process time TIME ZONE NOT UED BY NHP Master Policy Number DATE NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 12 of 20 Published August 2003

13 Comment ponsor Identifier RELATIONHIP TRANACTION TYPE DIENROLLMENT REAON NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 13 of 20 Published August 2003

14 Comment CONVERION TO COBRA NOT UED BY NHP DEATH DATE Birth equence Number UBCRIBER NUMBER NUMBER NUMBER NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 14 of 20 Published August 2003

15 Comment DATE ubscriber Identifier HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER ADDRE LINE 1 ADDRE LINE 2 DATE OF BIRTH GENDER NOT UED BY NHP NOT UED BY NHP NOT UED BY NHP NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 15 of 20 Published August 2003

16 Comment OCIAL ECURITY NUMBER DOB EX Telephone Number Insured Employee Address Line NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 16 of 20 Published August 2003

17 Comment Insured Employee City Insured Employee tate Insured Employee Postal Not used by NHP. chool Name CHOOL PHONE NUMBER ADDITIONAL CHOOL CONTACT NUMBER ADDITIONAL CHOOL CONTACT NUMBER OCIAL ECURITY NUMBER NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 17 of 20 Published August 2003

18 Comment PHONE NUMBER PHONE NUMBER DATE ocial ecurity Number or Federal Taxpayer's Identification Id NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 18 of 20 Published August 2003

19 Comment NHP PROVIDER ID Work Phone Number NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 19 of 20 Published August 2003

20 Comment NAME Federal Tax Number or National Association of Insurance Commissioner's Identification Number NUMBER DATE Must match Functional Group Header (G06) Must match Interchange Control Header (IA13) NHP Companion Guide 834 Appendix F Rel 1V0.xls Page 20 of 20 Published August 2003