HealthNow NY. Standard Companion Guide Transaction Information

Transcription

1 HealthNow NY Standard Companion Guide Transaction Information Instructions related to Transactions based on ASC X12 Implementation Guides, version X220A1 Companion Guide Version Number: [1.0] July 15 th

2 This template is Copyright 2010 by The Workgroup for Electronic Data Interchange (WEDI) and the Data Interchange Standards Association (DISA), on behalf of the Accredited Standards Committee (ASC) X12. All rights reserved. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided as is without any express or implied warranty. Note that the copyright on the underlying ASC X12 Standards is held by DISA on behalf of ASC X Companion Guide copyright by HealthNow NY dba Blue Cross Blue Shield of Western NY and Blue Shield of Northeastern NY. Preface Companion Guides (CG) may contain two types of data, instructions for electronic communications with the publishing entity (Communications/Connectivity Instructions) and supplemental information for creating transactions for the publishing entity while ensuring compliance with the associated ASC X12 IG (Transaction Instructions). Either the Communications/Connectivity component or the Transaction Instruction component must be included in every CG. The components may be published as separate documents or as a single document. The Communications/Connectivity component is included in the CG when the publishing entity wants to convey the information needed to commence and maintain communication exchange. The Transaction Instruction component is included in the CG when the publishing entity wants to clarify the IG instructions for submission of specific electronic transactions. The Transaction Instruction component content is limited by ASCX12 s copyrights and Fair Use statement. 2

3 Table of Contents 1 Introduction Background Overview of HIPAA Legislation Compliance according to HIPAA Compliance according to ASC X Intended Use Included ASC X12 Implementation Guides Instruction Tables Additional Information Business Scenarios Payer Specific Business Rules and Limitations Frequently Asked Questions Other Resources Change Summary

4 Transaction Instruction 1 Introduction 1.1 Background Overview of HIPAA Legislation The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carries provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard HIPAA serves to: Create better access to health insurance Limit fraud and abuse Reduce administrative costs Compliance according to HIPAA The HIPAA regulations at 45 CFR require that covered entities not enter into a trading partner agreement that would do any of the following: Change the definition, data condition, or use of a data element or segment in a standard. Add any data elements or segments to the maximum defined data set. Use any code or data elements that are marked not used in the standard s implementation specifications or are not in the standard s implementation specification(s). Change the meaning or intent of the standard s implementation specification(s). 4

5 1.1.3 Compliance according to ASC X12 ASC X12 requirements include specific restrictions that prohibit trading partners from: Modifying any defining, explanatory, or clarifying content contained in the implementation guide. Modifying any requirement contained in the implementation guide. 1.2 Intended Use The Transaction Instruction component of this companion guide must be used in conjunction with an associated ASC X12 Implementation Guide. The instructions in this companion guide are not intended to be stand-alone requirements documents. This companion guide conforms to all the requirements of any associated ASC X12 Implementation Guides and is in conformance with ASC X12 s Fair Use and Copyright statements. 2 Included ASC X12 Implementation Guides This table lists the X12N Implementation Guides for which specific transaction Instructions apply and which are included in Section 3 of this document. Unique ID Name X220A1 Benefit Enrollment and Maintenance (834) 5

6 3 Instruction Tables These tables contain one or more rows for each segment for which a supplemental instruction is needed. Legend SHADED rows represent segments in the X12N implementation guide. NON-SHADED rows represent data elements in the X12N implementation guide X220A1 Benefit Enrollment and Maintenance (834) Loop ID Reference Name Notes/Comments N/A ISA Interchange Control Header N/A ISA05 Interchange ID Qualifier 30 N/A ISA06 Interchange Sender ID Sender's U.S. Federal Tax Identification Number N/A ISA07 Interchange Receiver ID 30 N/A ISA08 Interchange Receiver ID HealthNow NY U.S. Federal Tax Identification Number N/A ISA11 Repetition Separator ^ N/A GS02 Application Sender s Code Sender s U.S. Federal Tax Identification Number N/A GS03 Application Sender s Code Facets N/A BGN01 Transaction Set Purpose Code HealthNow NY only supports 00 - Original. N/A BGN08 Beginning Segment Action Code HealthNow NY would prefer all files be submitted as 2 Change (Update) however we can process 4 Verify files. We do not support RX Replace. N/A QTY Transaction Set Control Totals Required when specified in your Trading Partner Agreement. N/A REF Transaction Set Policy Number This segment is required. REF02 Master Policy Number 8 Digit Group ID assigned by HealthNow NY. 1000A N1 Sponsor Name 1000A N103 Identification Code Qualifier FI 1000A N104 Identification Code Sender s U.S. Federal Tax Identification Number 1000B N1 Payer 1000B N102 Name BCBSWNY, BSNENY or HealthNow NY 1000B N103 Interchange ID Qualifier FI 6

7 Loop ID Reference Name Notes/Comments 1000B N104 Identification Code HealthNow NY U.S. Federal Tax Identification Number C N1 TPA/Broker Name 1000C N101 TPA/Broker Name HealthNow NY would prefer use of TV INS Member Level Detail 2000 INS02 Individual Relationship Code HealthNow NY Supports the following: 01 Spouse 15 Ward 17 -Stepson/ Stepdaughter 18 - Self 19 - Child 23 - Sponsored Dependent 26 -Legal Guardian 31 - Court Appointed Guardian 53 Life Partner INS03 Maintenance Type Code HealthNow NY Supports the following Change 021 Addition (use for Reinstatements also) Cancellation or Termination 2000 INS04 Maintenance Reason Code HealthNow NY Requires INS06 Medicare Status Code HealthNow NY Requires if member has Medicare INS10 Handicapped Yes/No Condition or Response Code 2000 REF Subscriber Identifier HealthNow NY Requires REF02 Reference Identification Subscriber SSN 2000 REF Member Policy Number 2000 REF02 Reference Identification 8 Digit Group ID assigned by HealthNow NY REF Member Supplemental Identifier 2000 REF02 Reference Identification 3H Case Number. If unknown use Use Class ID assigned by HEALTHNOW NY DX Use Subgroup assigned by HEALTHNOW NY F6 Medicare HIC if available ZZ Use to report an employee s personal ID with their employer. 2100A NM1 Member Name 2100A NM103 Name Last or Organization Name Include Suffix. Should not be reported in NM A NM107 Suffix Do not use. Include Suffix in NM A PER Member Communications Numbers 7

8 Loop ID Reference Name Notes/Comments 2100A PER03 Communication Number Qualifier HealthNow NY supports TE - Telephone EM Electronic Mail 2100A PER04 Communication Number Do not include leading 1 when reporting phone number 2200 DSB Disability Information HealthNow NY only requires when member has Permanent or Total Disability 2300 HD Health Coverage 2300 HD01 Maintenance Type Code HealthNow NY Supports the following Change 021 Addition (use for Reinstatements also) Cancellation or Termination 2300 HD03 Insurance Line Code HealthNow NY Supports the following: AG Preventative Care/Wellness DEN Dental EPO Exclusive Provider Organization HLT Health HMO Health Maintenance Organization PDG Prescription Drug POS Point of Service PPO Preferred Provider Organization VIS Vision 2300 HD04 Plan Coverage Description Use Plan ID assigned by HealthNow NY 2300 HD05 Coverage Level Code HealthNow NY Supports the following: IND Individual FAM Family ESP Employee and Spouse ECH Employee and Children E1D Employee and One Dependent TWO Two Party 2300 DTP Health Coverage Dates 2300 DTP01 Date/Time Qualifier HealthNow NY Supports the following: 303 Maintenance Effective 348 Benefit Begin 349 Benefit End 2300 IDC Identification Card 2300 IDC04 Action Code HealthNow NY Does not support RX - Replace requests. Member should contact Customer Service NM1 Provider Name 2310 NM101 Entity Identifier Code HealthNow NY supports: P3 Primary Care Provider 2310 NM108 Identification Code Qualifier SV Use the 12 digit Provider ID available on our company website. 8

9 4 Additional Information 4.1 Business Samples Simple Enrollment ST*834*0001*005010X220A1~ BGN*00*1* *0128****2~ REF*38*963852~ QTY*TO*1~ 1000A Sponsor Name Entity ID P5 N1*P5*GROUP EMPLOYERS INC*FI* ~ Plan Sponsor Qualifier Group Employers Inc. Sponsor ID B Payer FI Entity Identifier IN N1*IN*HealthNow NY*FI* ~ Insurer Name Qualifier HealthNow NY Insurer Identification Code Member Level Detail FI INS01 Insured Indicator Y INS*Y*18*021*28*A*E**FT~ INS02 Relationship Code 18 REF*0F* ~ INS03 Maintenance Type 021 (Addition) REF*1L* ~ INS04 Maintenance Reason 28 (Initial Enrollment) REF*3H*0000~ INS05 Benefit Status A REF*DX*0001~ INS06 Medicare Plan Code E (No Medicare) REF*17*0T01~ INS08 Employment Status FT DTP*356** ~ INS11 Date/Time Qualifier INS12 Date of Death REF01 Subscriber Number Qual 0F (Subscriber Number) REF02 Subscriber SSN REF01 Group Number Qualifer REF02 Group Number REF01 Case Number Qualifier IL 3H REF02 Suffix 0000 REF01 ID Qualifier DX REF02 Subgroup 0001 REF01 ID Qualifier 17 REF02 Class ID DTP01 Date/Time Qualifier 0T (Eligibility Begin) 9

10 DTP02 Date Time Period DTP03 Status Information Eff Dt A Member Name NM101 Entity Identifier IL NM1*IL*1*BUSH JR*JOAN*W***34* ~ NM102 Entity Qualifier 1 PER*IP**TE* ~ NM103 Last Name BUSH JR N3*2 N FIRTH ST*APT 101~ NM104 First Name JOAN N4*BUFFALO*NY*14202~ NM105 Middle Name W DMG** *F~ NM108 ID Qualifier 34 NM109 SSN PER01 Contact Function Code PER03 Comm Number Qual IP (Insured Party) TE (Telephone) PER04 Residence Ph Num N301 Member Residence 2 N. FIFTH ST N302 Residence Line 2 APT 101 N401 Member Residence City BUFFALO NY N403 ZIP DMG01 Date Format DMG02 Member DOB DMG03 Gender 2300 Health Coverage F HD01 Maintenance Type Code 021 HD*021**PPO*PPO5N0S0*EMP~ HD03 Ins Line Cd PPO DTP*348** ~ HD04 Plan ID HD05 Coverage Level Code DTP01 Date/TimeQualifier DTP02 Date/Time Format DTP03 Coverage Period PPO5N0S0 EMP 348 (Benefits Begin) (Enroll From Dt) SE*21*0001~ 10

11 Newborn 1000A Sponsor Name ST*834*0001*005010X220A1~ BGN*00*1* *0128****2~ REF*38*963852~ QTY*TO*1~ Entity ID P5 N1*P5*GROUP EMPLOYERS INC*FI* ~ Plan Sponsor Group Employers Inc. Qualifier FI Sponsor ID B Payer Entity Identifier IN N1*IN*HealthNow NY*FI* ~ Insurer Name Qualifier HealthNow NY Insurer Identification Code FI 2000 Member Level Detail INS01 Insured Indicator Y INS*Y*18*001*02*A*E**FT~ INS02 Relationship Code 18 REF*0F* ~ INS03 Maintenance Type 001 (Change) REF*1L* ~ INS04 Maintenance Reason 02 (Birth) REF*3H*0000~ INS05 Benefit Status A REF*DX*0001~ INS06 Medicare Plan Code E (No Medicare) REF*17*0T01~ INS08 Employment Status FT DTP*356** ~ INS11 Date/Time Qualifier INS12 Date of Death REF01 Subscriber Number Qual 0F (Subscriber Number) REF02 Subscriber SSN REF01 Group Number Qualifer 1L REF02 Group Number REF01 Case Number Qualifier 3H REF02 Suffix 0000 REF01 ID Qualifier Qual DX DX REF02 Subgroup 0001 REF01 ID Qualifier 17 REF02 Class ID DTP01 Date/Time Qualifier DTP02 Date Time Period 0T (Eligibility Begin) DTP03 Status Information Eff Dt

12 2100A Member Name NM101 Entity Identifier IL NM1*IL*1*BUSH*JOAN*W~ NM102 Entity Qualifier 1 PER*IP**TE* ~ NM103 Last Name BUSH N3*2 N FIRTH ST*APT 101~ NM104 First Name JOAN N4*BUFFALO*NY*14202~ NM105 Middle Name W DMG** *F~ PER01 Contact Function Code PER03 Comm Number Qual IP (Insured Party) TE (Telephone) PER04 Residence Ph Num N301 Member Residence 2 N. FIFTH ST N302 Residence Line 2 APT 101 N401 Member Residence City BUFFALO NY N403 ZIP DMG01 Date Format DMG02 Member DOB DMG03 Gender 2100C Member Mailing Address Only present if different from residential address F NM1*31*1~ NM101 Entity Identifier Code 31 N3*P.O. BOX 123~ NM102 Entity Type Qualifier 1 N4*BUFFALO*NY*14202~ N301 Member Mail Street P.O. Box 123 N302 2 nd Mbr Mail Street N401 Member Mail City Buffalo NY N403 ZIP Health Coverage HD01 Maintenance Type Code 021 HD*021**PPO*PPO5N0S0*EMP~ HD03 Ins Line Cd PPO DTP*348** ~ HD04 Plan ID HD05 Coverage Level Code DTP01 Date/TimeQualifier DTP02 Date/Time Format PPO5N0S0 EMP 348 (Benefits Begin) DTP03 Coverage Period (Enroll From dt) 2000 Member Level Detail INS01 Insured Indicator N INS*N*19*021*28*A*E~ INS02 Relationship Code 19 REF*0F* ~ INS03 Maintenance Type 021 (Addition) REF*1L* ~ INS04 Maintenance Reason 28 (Initial Enrollment) REF*3H*0000~ INS05 Benefit Status A REF*DX*0001~ INS06 Medicare Plan Code E (No Medicare) REF*17*0T01~ 12

13 INS11 Date/Time Qualifier DTP*356** ~ INS12 Date of Death REF01 Subscriber Number Qual 0F (Subscriber Number) REF02 Subscriber SSN REF01 Group Number Qualifer 1L REF02 Group Number REF01 Case Number Qualifier 3H REF02 Suffix 0000 REF01 ID Qualifier Qual DX REF02 Subgroup 0001 REF01 ID Qualifier 17 REF02 Class ID DTP01 Date/Time Qualifier DTP02 Date Time Period 0T (Eligibility Begin) DTP03 Status Information Eff Dt A Member Name NM101 Entity Identifier IL NM1*IL*1*BUSH*BABY GIRL*W~ NM102 Entity Qualifier 1 DMG** *F~ NM103 Last Name NM104 First Name NM105 Middle Name PER01 Contact Function Code PER03 Comm Number Qual BUSH BABY GIRL W IP (Insured Party) TE (Telephone) PER04 Residence Ph Num N301 Member Residence 2 N. FIFTH ST N302 Residence Line 2 APT 101 N401 Member Residence City BUFFALO NY N403 ZIP DMG01 Date Format DMG02 Member DOB DMG03 Gender 2100C Member Mailing Address Only present if different from residential address NM101 Entity Identifier Code 31 NM102 Entity Type Qualifier 1 N301 Member Mail Street N302 2 nd Mbr Mail Street N401 Member Mail City, F 13

14 N403 ZIP 2300 Health Coverage HD01 Maintenance Type Code 021 HD*021**PPO*PPO5N0S0~ HD03 Ins Line Cd PPO DTP*348** ~ HD04 Plan ID DTP01 Date/TimeQualifier DTP02 Date/Time Format DTP03 Coverage Period PPO5N0S0 348 (Benefits Begin) (Enroll From Dt) SE*35*0001~ 14

15 Domestic Partner ST*834*0001*005010X220A1~ BGN*00*1* *0128****2~ REF*38*963852~ QTY*TO*1~ 1000A Sponsor Name Entity ID P5 N1*P5*GROUP EMPLOYERS INC*FI* ~ Plan Sponsor Group Employers Inc. Qualifier FI Sponsor ID B Payer Entity Identifier IN N1*IN*HealthNow NY*FI* ~ Insurer Name HealthNow NY Qualifier FI Insurer Identification Code Member Level Detail INS01 Insured Indicator Y INS*Y*18*001*02*A*E**FT~ INS02 Relationship Code 18 REF*0F* ~ INS03 Maintenance Type 001 (Change) REF*1L* ~ INS04 Maintenance Reason 02 (Birth) REF*3H*0000~ INS05 Benefit Status A REF*DX*0001~ INS06 Medicare Plan Code E (No Medicare) REF*17*0T01~ INS08 Employment Status FT DTP*356** ~ INS11 Date/Time Qualifier INS12 Date of Death REF01 Subscriber Number Qual 0F (Subscriber Number) REF02 Subscriber SSN REF01 Group Number Qualifer 1L REF02 Group Number REF01 Case Number Qualifier 3H REF02 Suffix 0000 REF01 ID Qualifier Qual DX DX REF02 Subgroup 0001 REF01 ID Qualifier 17 REF02 Class ID 0T01 DTP01 Date/Time Qualifier 356 (Eligibility Begin) DTP02 Date Time Period DTP03 Status Information Eff Dt A Member Name 15

16 NM101 Entity Identifier IL NM1*IL*1*BUSH*JOAN*W~ NM102 Entity Qualifier 1 PER*IP**TE* ~ NM103 Last Name BUSH N3*2 N FIRTH ST*APT 101~ NM104 First Name JOAN N4*BUFFALO*NY*14202~ NM105 Middle Name W DMG** *F~ PER01 Contact Function Code PER03 Comm Number Qual IP (Insured Party) TE (Telephone) PER04 Residence Ph Num N301 Member Residence 2 N. FIFTH ST N302 Residence Line 2 APT 101 N401 Member Residence City BUFFALO NY N403 ZIP DMG01 Date Format DMG02 Member DOB DMG03 Gender 2100C Member Mailing Address Only present if different from residential address F NM1*31*1~ NM101 Entity Identifier Code 31 N3*P.O. BOX 123~ NM102 Entity Type Qualifier 1 N4*BUFFALO*NY*14202~ N301 Member Mail Street P.O. Box 123 N302 2 nd Mbr Mail Street N401 Member Mail City Buffalo NY N403 ZIP Health Coverage HD01 Maintenance Type Code 021 HD*021**PPO*PPO5N0S0*EMP~ HD03 Ins Line Cd PPO DTP*348** ~ HD04 Plan ID HD05 Coverage Level Code DTP01 Date/TimeQualifier DTP02 Date/Time Format PPO5N0S0 EMP 348 (Benefits Begin) DTP03 Coverage Period (Enroll From dt) 2000 Member Level Detail INS01 Insured Indicator N INS*N*53*021*28*A*E~ INS02 Relationship Code 53 REF*0F* ~ INS03 Maintenance Type 021 (Addition) REF*1L* ~ INS04 Maintenance Reason 28 (Initial Enrollment) REF*3H*0000~ INS05 Benefit Status A REF*DX*0001~ INS06 Medicare Plan Code E (No Medicare) REF*17*0T01~ INS11 Date/Time Qualifier DTP*356** ~ 16

17 INS12 Date of Death REF01 Subscriber Number Qual REF02 Subscriber SSN REF01 Group Number Qualifer REF02 Group Number REF01 Case Number Qualifier 0F (Subscriber Number) 1L 3H REF02 Suffix 0000 REF01 ID Qualifier Qual DX REF02 Subgroup 0001 REF01 ID Qualifier 17 REF02 Class ID DTP01 Date/Time Qualifier DTP02 Date Time Period 0T (Eligibility Begin) DTP03 Status Information Eff Dt A Member Name NM101 Entity Identifier IL NM1*IL*1*PARTNER*DOMESTIC*W~ NM102 Entity Qualifier 1 DMG** *F~ NM103 Last Name NM104 First Name NM105 Middle Name PER01 Contact Function Code PER03 Comm Number Qual PARTNER DOMESTIC W IP (Insured Party) TE (Telephone) PER04 Residence Ph Num N301 Member Residence 2 N. FIFTH ST N302 Residence Line 2 APT 101 N401 Member Residence City BUFFALO NY N403 ZIP DMG01 Date Format DMG02 Member DOB DMG03 Gender 2100C Member Mailing Address Only present if different from residential address NM101 Entity Identifier Code 31 NM102 Entity Type Qualifier 1 N301 Member Mail Street N302 2 nd Mbr Mail Street N401 Member Mail City, N403 ZIP 2300 Health Coverage F 17

18 HD01 Maintenance Type Code 021 HD*021**PPO*PPO5N0S0~ HD03 Ins Line Cd PPO DTP*348** ~ HD04 Plan ID DTP01 Date/TimeQualifier DTP02 Date/Time Format DTP03 Coverage Period PPO5N0S0 348 (Benefits Begin) (Enroll From Dt) SE*35*0001~ 18

19 COBRA ST*834*0001*005010X220A1~ BGN*00*1* *0128****2~ REF*38*963852~ QTY*TO*1~ 1000A Sponsor Name Entity ID P5 N1*P5*GROUP EMPLOYERS INC*FI* ~ Plan Sponsor Group Employers Inc. Qualifier FI Sponsor ID B Payer Entity Identifier IN N1*IN*HealthNow NY*FI* ~ Insurer Name HealthNow NY Qualifier FI Insurer Identification Code Member Level Detail INS01 Insured Indicator Y INS*Y*18*001*09*C*E*1*FT~ INS02 Relationship Code 18 REF*0F* ~ INS03 Maintenance Type 001 REF*1L* ~ INS04 Maintenance Reason 09 REF*3H*0000~ INS05 Benefit Status C REF*DX*0001~ INS06 Medicare Plan Code E REF*17*0T01~ INS08 Employment Status FT DTP*356** ~ INS11 Date/Time Qualifier INS12 Date of Death REF01 Subscriber Number Qual 0F REF02 Subscriber SSN REF01 Group Number Qualifer 1L REF02 Group Number REF01 Case Number Qualifier 3H REF02 Suffix 0000 REF01 ID Qualifier Qual DX DX REF02 Subgroup 0090 REF01 ID Qualifier 17 REF02 Class ID 0T01 DTP01 Date/Time Qualifier 356 DTP02 Date Time Period DTP03 Status Information Eff Dt A Member Name 19

20 NM101 Entity Identifier IL NM1*IL*1*BUSH*JOAN*W***34* ~ NM102 Entity Qualifier 1 PER*IP**TE* ~ NM103 Last Name BUSH N3*2 N FIRTH ST*APT 101~ NM104 First Name JOAN N4*BUFFALO*NY*14202~ NM105 Middle Name W DMG** *F~ NM108 ID Qualifier 34 NM109 SSN PER01 Contact Function Code PER03 Comm Number Qual IP (Insured Party) TE (Telephone) PER04 Residence Ph Num N301 Member Residence 2 N. FIFTH ST N302 Residence Line 2 APT 101 N401 Member Residence City BUFFALO NY N403 ZIP DMG01 Date Format DMG02 Member DOB DMG03 Gender 2300 Health Coverage F HD01 Maintenance Type Code 021 HD*021**PPO*PPO5N0S0*EMP~ HD03 Ins Line Cd PPO DTP*348** ~ HD04 Plan ID HD05 Coverage Level Code DTP01 Date/TimeQualifier DTP02 Date/Time Format DTP03 Coverage Period PPO5N0S0 EMP 348 (Benefits Begin) (Enroll From dt) SE*21*0001~ 20

21 Contract Termination ST*834*0001*005010X220A1~ BGN*00*1* *0128****2~ REF*38*963852~ QTY*TO*1~ 1000A Sponsor Name Entity ID P5 N1*P5*GROUP EMPLOYERS INC*FI* ~ Plan Sponsor Group Employers Inc. Qualifier FI Sponsor ID B Payer Entity Identifier IN N1*IN*HealthNow NY*FI* ~ Insurer Name HealthNow NY Qualifier FI Insurer Identification Code Member Level Detail INS01 Insured Indicator Y INS*Y*18*024*08*A*E**TE~ INS02 Relationship Code 18 REF*0F* ~ INS03 Maintenance Type 024 (Termination) REF*1L* ~ INS04 Maintenance Reason 08 REF*3H*0000~ INS05 Benefit Status A REF*DX*0001~ INS06 Medicare Plan Code E REF*17*0T01~ INS08 Employment Status TE INS11 Date/Time Qualifier INS12 Date of Death REF01 Subscriber Number Qual 0F REF02 Subscriber SSN REF01 Group Number Qualifer 1L REF02 Group Number REF01 Case Number Qualifier 3H REF02 Suffix 0000 REF01 ID Qualifier Qual DX DX REF02 Subgroup 0090 REF01 ID Qualifier 17 REF02 Class ID 0T A Member Name NM101 Entity Identifier IL NM1*IL*1*BUSH*JOAN*W***34* ~ NM102 Entity Qualifier 1 PER*IP**TE* ~ NM103 Last Name BUSH N3*2 N FIRTH ST*APT 101~ 21

22 NM104 First Name JOAN N4*BUFFALO*NY*14202~ NM105 Middle Name W DMG** *F~ NM108 ID Qualifier 34 NM109 SSN PER01 Contact Function Code PER03 Comm Number Qual IP (Insured Party) TE (Telephone) PER04 Residence Ph Num N301 Member Residence 2 N. FIFTH ST N302 Residence Line 2 APT 101 N401 Member Residence City BUFFALO NY N403 ZIP DMG01 Date Format DMG02 Member DOB DMG03 Gender 2300 Health Coverage F HD01 Maintenance Type Code 024 HD*024**PPO* PPO5N0S0*EMP~ HD03 Ins Line Cd PPO DTP*349** ~ HD04 Plan ID HD05 Coverage Level Code DTP01 Date/TimeQualifier DTP02 Date/Time Format DTP03 Coverage Period PPO5N0S0 EMP 349 (Benefits End) (Enroll From dt) SE*20*0001~ 22

23 Dependent Termination ST*834*0001*005010X220A1~ BGN*00*1* *0128****2~ REF*38*963852~ QTY*TO*1~ 1000A Sponsor Name Entity ID P5 N1*P5*GROUP EMPLOYERS INC*FI* ~ Plan Sponsor Group Employers Inc. Qualifier FI Sponsor ID B Payer Entity Identifier IN N1*IN*HealthNow NY*FI* ~ Insurer Name HealthNow NY Qualifier FI Insurer Identification Code Member Level Detail INS01 Insured Indicator Y INS*Y*18*001*AI*A*E**FT~ INS02 Relationship Code 18 REF*0F* ~ INS03 Maintenance Type 001 (Change) REF*1L* ~ INS04 Maintenance Reason AI REF*3H*0000~ INS05 Benefit Status A REF*DX*0001~ INS06 Medicare Plan Code E (No Medicare) REF*17*0T01~ INS08 Employment Status FT DTP*356** ~ INS11 Date/Time Qualifier INS12 Date of Death REF01 Subscriber Number Qual 0F (Subscriber Number) REF02 Subscriber SSN REF01 Group Number Qualifer 1L REF02 Group Number REF01 Case Number Qualifier 3H REF02 Suffix 0000 REF01 ID Qualifier Qual DX DX REF02 Subgroup 0001 REF01 ID Qualifier 17 REF02 Class ID 0T01 DTP01 Date/Time Qualifier 356 (Eligibility Begin) DTP02 Date Time Period DTP03 Status Information Eff Dt A Member Name 23

24 NM101 Entity Identifier IL NM1*IL*1*BUSH*JOAN*W~ NM102 Entity Qualifier 1 PER*IP**TE* ~ NM103 Last Name BUSH N3*2 N FIRTH ST*APT 101~ NM104 First Name JOAN N4*BUFFALO*NY*14202~ NM105 Middle Name W DMG** *F~ PER01 Contact Function Code PER03 Comm Number Qual IP (Insured Party) TE (Telephone) PER04 Residence Ph Num N301 Member Residence 2 N. FIFTH ST N302 Residence Line 2 APT 101 N401 Member Residence City BUFFALO NY N403 ZIP DMG01 Date Format DMG02 Member DOB DMG03 Gender 2100C Member Mailing Address Only present if different from residential address F NM1*31*1~ NM101 Entity Identifier Code 31 N3*P.O. BOX 123~ NM102 Entity Type Qualifier 1 N4*BUFFALO*NY*14202~ N301 Member Mail Street P.O. Box 123 N302 2 nd Mbr Mail Street N401 Member Mail City Buffalo NY N403 ZIP Health Coverage HD01 Maintenance Type Code 001 HD*001**PPO*PPO5N0S0*EMP~ HD03 Ins Line Cd PPO DTP*348** ~ HD04 Plan ID HD05 Coverage Level Code DTP01 Date/TimeQualifier DTP02 Date/Time Format PPO5N0S0 EMP 348 (Benefits Begin) DTP03 Coverage Period (Enroll From dt) 2000 Member Level Detail INS01 Insured Indicator N INS*N*19*024*28*A*E~ INS02 Relationship Code 01 REF*0F* ~ INS03 Maintenance Type 024 (Termination) REF*1L* ~ INS04 Maintenance Reason AI (No Reason Given) REF*3H*0000~ INS05 Benefit Status A REF*DX*0001~ INS06 Medicare Plan Code E (No Medicare) REF*17*0T01~ REF01 Subscriber Number Qual 0F (Subscriber Number) 24

25 REF02 Subscriber SSN REF01 Group Number Qualifer REF02 Group Number REF01 Case Number Qualifier 1L 3H REF02 Suffix 0000 REF01 ID Qualifier Qual DX REF02 Subgroup 0001 REF01 ID Qualifier 17 REF02 Class ID 2100A Member Name 0T01 NM101 Entity Identifier IL NM1*IL*1*BUSH*JERRY*W~ NM102 Entity Qualifier 1 DMG** *M~ NM103 Last Name NM104 First Name NM105 Middle Name PER01 Contact Function Code PER03 Comm Number Qual BUSH JERRY W IP (Insured Party) TE (Telephone) PER04 Residence Ph Num N301 Member Residence 2 N. FIFTH ST N302 Residence Line 2 APT 101 N401 Member Residence City BUFFALO NY N403 ZIP DMG01 Date Format DMG02 Member DOB DMG03 Gender M 2100C Member Mailing Address Only present if different from residential address NM101 Entity Identifier Code 31 NM102 Entity Type Qualifier 1 N301 Member Mail Street N302 2 nd Mbr Mail Street N401 Member Mail City, N403 ZIP 2300 Health Coverage HD01 Maintenance Type Code 024 HD*024**PPO*PPO5N0S0~ HD03 Ins Line Cd PPO DTP*349** ~ HD04 Plan ID DTP01 Date/TimeQualifier DTP02 Date/Time Format PPO5N0S0 349 (Benefits End) 25

26 DTP03 Coverage Period SE*34*0001~ Control Segments ISA - INTERCHANGE CONTROL HEADER ISA*00* *00* *30* *30* *110804*0920*^*00501* *0*P*:~ GS - FUNCTIONAL GROUP HEADER GS*BE* *FACETS* *0907*1*X*005010X220A1~ GE*1*1~ GE - FUNCTIONAL GROUP TRAILER IEA - INTERCHANGE CONTROL TRAILER IEA*1* ~ 4.2 Payer Specific Business Rules and Limitations Transfer of Files and Testing procedures. - Please refer to our New Group Implementation Guide available upon request. This guide contains information on setting up your file transfers as well as Testing Requirements. Automated file retrieval occurs at 11am, 2pm and 2am Mon Fri. Daily Batch process occurs at 8am, 1pm Mon Fri. (** Some Holidays may be excluded. ) Please contact your group representative for additional information). Files received after 2pm will not be processed until the next scheduled cycle. HealthNow NY would prefer Change Only files be submitted. If you require full file submissions please notify your enrollment representative. Weekly submissions are preferred. All files should be validated for HIPAA Compliance prior to submission. Processing time for compliant files is 24 hours from receipt. If errors are found, we will notify you within 48 hours with details of the issues and a recommended solution. HealthNow NY requests the following delimiters : 26

27 * Element Separator ; Composite Element Separator ~ Segment Terminator Scheduled Maintenance - You will be notified in advance of any scheduled maintenance. HealthNow NY utilizes the member dates reported in the 2300 loop for contract effective and termination dates. PCP s should only be submitted when you know the ID and the member is a current patient. If PCP is unknown, the loop should not be submitted. Medicare information should be submitted when known. Information to be included: o Medicare ID o Enrollment dates (Part A, Part B and/or Part D) Marital Status (DMG04) should be left blank if unknown. Domestic Partners should be reported INS02 = 53 Life Partner Plan ID s (HD04) HMO 100 Series PPO 6300 PPO5Y0S0 HMO 102 PPO 6340 HMO Y0S0 HMO 109 PPO 7200 Contact your Enrollment representative for further information HMO 200 Corp PPO HMO 202 EPO Y0S1 HMO 203 EPO 5006 EPO1Y Y0S2 HMO Y0S3 HMO 206 AQUA AQ11Y00S POS 150 & Y0S0 POS Y0F0 POS 7100 CP06Y0S0 Stand Alone RX DRG1Y000 PPO 800 PPO 803 PPO1Y0S0 Buffalo Traditional HMM1Y000 27

28 PPO 809 PPO 816 PPO 822 PPO Frequently Asked Questions Contacts at HealthNow NY are Primary Contact Technical Questions should be directed to 4.4 Other Resources For full implementation guides and other 5010 standards 5 Change Summary Document Version Number Change Date Page Numbers Updated Reason for Change Version 1.0 7/15/2011 Creation of Document. 28