Subject: Changes for the 834 Benefit Enrollment and Maintenance Companion Document

Transcription

1 December 2013 Subject: Changes for the 834 Benefit Enrollment and Maintenance Companion Document The table below summarizes recent changes to the ANSI ASC X12N 834 (005010X220A1) Benefit Enrollment and Maintenance BCBSM EDI 834 Companion Document. Section Description of Change Pages Appendix F: BCBSM MEDICARE ADVANTAGE GROUP ENROLLMENT DOCUMENT Appendix G: CDH MAPPING DOCUMENT Reordered Appendices CDH mapping document was moved to end of guide as Appendix G; BCBSM Medicare Advantage Enrollment Document is now Appendix F Appedices B, C, D and E Revised instruction for Loop 2300 HD04 to reference CDH Mapping Document (Appendix G) If you have any questions regarding this information, please call our Electronic Data Interchange department at Sincerely, 13, 18, 23 and 28 John Bialowicz, Manager Electronic Business Interchange Group

2 Blue Cross Blue Shield of Michigan HIPAA EDI Companion Document American National Standards Institute (ANSI) ASC X12N 834 (005010X220A1) Benefit Enrollment and Maintenance Published March 2011 Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

3 Table of Contents Table of Contents... 1 Introduction... 2 Testing Overview and Transmission Method... 3 ANSI ASC X12N Benefit Enrollment and Maintenance 834 (005010X220A1) Reporting Instruction Clarifications... 4 General Overview... 4 Change File, Full File Update or Full Audit File... 4 Consumer Driven Health Plans (CDHP)... 5 Maximums/Limitations... 5 Additional Information... 5 TA1 Interchange Acknowledgements Functional Acknowledgements... 5 Enrollment 834 Interchange Envelope and Functional Group Structure... 6 Global Data Requirements for the 834 Transaction Set... 6 APPENDIX A: BLUE CARE NETWORK GROUP ENROLLMENT DOCUMENT... 8 APPENDIX B: BCBSM MOS (METAVANCE) GROUP ENROLLMENT DOCUMENT... 9 APPENDIX C: BCBSM LOCAL GROUP ENROLLMENT DOCUMENT APPENDIX D: BCBSM NATIONAL GROUP ENROLLMENT DOCUMENT APPENDIX E: BCBSM HYBRID/ METAVANCE GROUP ENROLLMENT DOCUMENT APPENDIX F: BCBSM MEDICARE ADVANTAGE GROUP ENROLLMENT DOCUMENT APPENDIX G: BCBSM CDH MAPPING DOCUMENT Page 1 of 33

4 Introduction This document is the property of Blue Cross Blue Shield of Michigan (BCBSM) and is for use solely in your capacity as a Trading Partner of health care transactions with BCBSM, Blue Care Network (BCN) and National Account Services Corporation (NASCO). NASCO is referred to in this document as BCBSM National. This document is intended for use as a companion to the HIPAA-mandated ANSI ASC X12N 834 version X220 and the modifications implemented with the adopted Type 1 Errata (X12N/5010X220A1) transaction set Technical Reports Type 3 (TR3). Specific payer instructions contained in this document are provided for clarification purposes only and should be used in conjunction with the applicable HIPAA TR3s and the adopted Type 1 Errata published by the Washington Publishing Company. TR3s can be downloaded from the Washington Publishing Company web site at Copyright (c) 2006, Data Interchange Standards Association on behalf of ASC X12.Format (c) 2006, Washington Publishing Company. All Rights Reserved. This document provides information related to specific elements within the ANSI ASC X12N 834 version X220A1 transaction, but does not change the definition, data condition, or use of a data element or segment in a standard, add data elements or segments to the maximum defined data set, use any code or data elements that are either marked not used in the standard s implementation specification or are not in the standard s implementation specification(s), or change the meaning or intent of the HIPAA standards implementation specifications. 1 For group specific reporting requirements refer to the BCN, BCBSM and Medicare Advantage group enrollment documents located in back of this EDI Companion Document: APPENDIX A: BLUE CARE NETWORK GROUP ENROLLMENT DOCUMENT (INCLUDES BCN ADVANTAGE) APPENDIX B: BCBSM MOS (METAVANCE) GROUP ENROLLMENT DOCUMENT APPENDIX C: BCBSM LOCAL GROUP ENROLLMENT DOCUMENT APPENDIX D: BCBSM NATIONAL GROUP ENROLLMENT DOCUMENT APPENDIX E: BCBSM HYBRID/ METAVANCE GROUP ENROLLMENT DOCUMENT APPENDIX F: BCBSM MEDICARE ADVANTAGE GROUP ENROLLMENT DOCUMENT (NOTE: THIS INFORMATION IS NOT INTENDED FOR USE BY BCN ADVANTAGE GROUPS) APPENDIX G: BCBSM CDH MAPPING DOCUMENT All instructions were written as known at the time of publication and are subject to change based on mutually agreed-upon conditions between BCBSM/National, BCN, and their customers. Changes will be communicated in future letters and on the BCBSM web site: 1 Standards for Electronic Transactions, Federal Register, Vol. 65, No. 160, August 17, 2000 pg Page 2 of 33

5 Testing Overview and Transmission Method 1: Download a Validator User Guide. Visit the How to learn about electronic enrollment site: Select Enrollment Login Page at the bottom of the webpage At the bottom of the login screen, select nonclaims testing user guide (PDF) #2: Request a Validator login ID and password. On the same login screen noted above, select Step 1: To log in, you'll need to request a user ID and password. Via the request, provide your personal company name and tax id (not the employer group s information). If you do not receive your login id and password within a two days, please contact the EDI Helpdesk , Opt#2 or our EDI Support Specialist submitteridrequests@bcbsm.com. #3: Log in and begin Validator self-testing. NOTE: When testing with the Validator Self-Test Tool, do not send PHI data in the test file. Be sure to send test data and not the actual enrollment data. Keep the test file small limiting it to about 15 or so samplings of your data. For example, if you will be sending Medicare, COB, etc. be sure to include them in your Validator test. #4: Complete Validator self-testing. You must receive a green check to complete testing successfully. Once testing is complete, contact our EDI Analyst via for a review and sign-off. EDICustMgmt@bcbsm.com Please include the following in your at the above address: Validator Id Group tested Date of File BCBSM/BCN Business Analyst Version (5010) Page 3 of 33

6 #5: Obtain final approval. Once the Validator testing review is complete, you and your BCBSM/BCN Business Analyst will receive notification from EDI. Your BCBSM/BCN Business Analyst will submit a request for you to receive Secured File Transfer Protocol (SFTP) connection. You will use this SFTP connection to send file(s) into BCBSM. You will continue working with your BCBSM/BCN Business Analyst for subsystem and production testing: o o o You will be instructed on submitting your first subsystem test file with an ISA15 indicator of T. Once you pass subsystem and are approved for production, you will be instructed to change ISA15 from T to P. Files containing P in ISA15 will then be recognized and processed as a production file; however, you cannot submit a production file until approved by the Business Analyst. ANSI ASC X12N Benefit Enrollment and Maintenance 834 (005010X220A1) Reporting Instruction Clarifications General Overview The Health Insurance Portability and Accountability Act (HIPAA) require that all health insurance payers in the United States comply with the version EDI standards for health care as established by the Secretary of Health and Human Services. Change File, Full File Update or Full Audit File The 834 transaction set can be used to: provide updates to the membership database via change files; provide updates to the membership database via full files; or request an audit against the membership database via full audit files. Please note, full audit files are used for informational purposes and updates/changes contained in a full audit file are not applied. A change file contains add, terminate or update requests. A change file should only contain information about the changed members. A full file can be used to apply updates. Submitters should send terminations on full files that are being used to apply updates. Page 4 of 33

7 A full audit file lists all current members. A full audit file facilitates keeping the sponsor s and payer s systems synchronized. A full audit file is not intended to contain a history of all previous enrollments. When sending a full file audit, Loop 2000, INS03 must be 030. INS04 must be XN and Loop 2300, HD01 must be 030. It will do a compare only. Updates will not be applied. In all three instances, BGN08 must be reported and identify whether the transaction is: an update (2); a full file to apply changes (RX); or a full file audit (4). Consumer Driven Health Plans (CDHP) Refer to the Data Requirements section for details to report information related to Health Savings Account (HSA), Health Reimbursement Account (HRA) and Flexible Spending Account (FSA) benefits. Maximums/Limitations To ensure proper routing when possible, lines of business should be submitted in separate transactions. Additional Information TA1 Interchange Acknowledgements Interchange Acknowledgements (TA1) are used to reply to an interchange or transmission, notify the sending trading partner of problems that were encountered in the interchange control structure, and verify the envelope information. TA1 acknowledgements are only provided when requested in the Interchange Control Header. Refer to Appendix B (B Interchange Acknowledgment,TA1) of the ANSI ASC X12N 834 version X220 TR3 for additional terminology, and information for the TA1 Interchange Acknowledgement. 999 Functional Acknowledgements Functional Acknowledgements (999) are used to facilitate control of EDI. Segments within the 999 are used to identify the acceptance or rejection of functional groups, transaction sets or segments. Data elements in error can also be identified. BCBSM will return 999 acknowledgements on a daily basis to verify receipt of files from trading partners. Refer to Section Implementation Acknowledgment of the ANSI ASC X12N 834 version X220 TR3 for additional terminology and information for the 999 Functional Acknowledgement. Page 5 of 33

8 Enrollment 834 Interchange Envelope and Functional Group Structure Trading partners should follow the Interchange Control Structure (ICS) and Functional Group Structure (GS) guidelines for HIPAA that are located in the HIPAA implementation guides. The following sections address specific information needed by BCBSM in order to process the ASC X12N/005010X220A1-834 Benefit Enrollment and Maintenance Transaction. This information should be used in conjunction with the ASC X12N/005010X220 Benefit Enrollment and Maintenance TR3. Element Name Element Instruction Pg# Authorization Information Qualifier ISA01 Report 00. C.4 Security Information Qualifier ISA03 Report 00. C.4 Interchange Sender ID ISA06 Report the Federal Tax ID of the Submitter. C.4 Interchange ID Qualifier ISA07 Report ZZ or 30. Reporting ZZ is recommended. C.5 Interchange Receiver ID ISA08 Report C.5 Functional Identifier Code GS01 Report BE C.7 Application Sender s Code GS02 Report the Federal Tax ID of the Submitter. C.7 Application Receiver s Code GS03 Report C.7 Global Data Requirements for the 834 Transaction Set Loop Segment/Element Instruction Industry/Element Name Pg# Header Required for all 834 transactions. For reporting requirements refer to the BCN or specific BCBSM group enrollment documents located in the back of this EDI Companion Document. Header DTP01 For reporting requirements refer to the BCN or specific BCBSM group enrollment documents 1000B N103 N104 located in the back of this EDI Companion Document. All groups: Report FI. Report C N103 N104 For reporting requirements refer to the BCN or specific BCBSM group enrollment documents located in the back of this EDI Companion Document All groups: To facilitate processing of your enrollment files, we strongly encourage you to report the group number. For reporting requirements refer to the BCN or specific BCBSM group enrollment documents located in the back of this EDI Companion Document For reporting requirements refer to the BCN or specific BCBSM group enrollment documents located in the back of this EDI Companion Document. Master Policy Number 36 Date/Time Qualifier 37 Indicator Insurer Tax ID Qualifier and TPA or Broker Identification Code Reference Identification Member Policy Number Reference Identification Member Supplemental Identifier Page 6 of 33

9 Loop Segment/Element Instruction Industry/Element Name Pg# 2100A NM108 & NM109 All groups: Report qualifier 34 and the SSN for all subscribers and all dependents age 45 or older Insured Identifier A DMG03 All groups: To facilitate processing of your enrollment files, we strongly encourage you limit usage Member Gender Code 72 to codes M or F HD Segment All groups: To facilitate processing of your enrollment files, report at least one HD loop. Health Coverage 140 For reporting requirements refer to the BCN or specific BCBSM group enrollment documents located in the back of this EDI Companion Document HD03 For reporting requirements refer to the BCN or specific BCBSM group enrollment documents Insurance Line Code 141 located in the back of this EDI Companion Document HD04 To facilitate processing of your enrollment files, we strongly encourage you to report the Plan Coverage Description 141 information if requested. For reporting requirements refer to the BCN or specific BCBSM group enrollment documents located in the back of this EDI Companion Document DTP01 For reporting requirements refer to the BCN or specific BCBSM group enrollment documents Benefit Begin and Benefit End 144 located in the back of this EDI Companion Document. Date 2300 For reporting requirements refer to the BCN or specific BCBSM group enrollment documents Reference Identification 146 located in the back of this EDI Companion Document. Health Coverage Policy Number 2320 For reporting requirements refer to the BCN or specific BCBSM group enrollment documents Coordination of Benefits 164 located in the back of this EDI Companion Document NM103 For reporting requirements refer to the BCN or specific BCBSM group enrollment documents located in the back of this EDI Companion Document. Coordination of Benefits Insurer Name 170 Page 7 of 33

10 Appendix A: BLUE CARE NETWORK GROUP ENROLLMENT DOCUMENT Loop Segment/Element Instruction Industry/Element Name Header REF01 & Required for all 834 transactions. Master Policy Number BCN HMO: Report 38 in REF01 and report HMO in. 1000A N101 & N102 BCN HMO: Report P5 in REF01 and report constant name of the employer group. Plan Sponsor Name Append BCN at the beginning of the employer group name. 1000B N101 & N102 BCN HMO: Report IN in REF01 and Blue Care Network in. Payer / Insurer Name 1000C N101 & N102 BCN HMO: Report TV in REF01 and TPA Name in. TPA/Identification Code 2000 INS02 BCN HMO: When enrolling a Sponsored Dependent, INS02 must contain a value of 38. BCN s Individual Relationship Code business rule for Sponsored Dependents: Dependent is over the age of 26 (not disabled), supported by the subscriber and living in the subscriber s household. Typically it is a parent of the subscriber or parent of the subscriber s spouse INS04 BCN HMO: When enrolling a surviving spouse, report 11 in INS04 and S in INS05. Maintenance Reason Code 2000 INS06 BCN HMO: BCN assigns Medicare plans only if the member has both Medicare Parts A & B. Medicare Status Code Send C if member has both Parts A & B. Do not send a value if member does not have both Parts A & B BCN HMO: Report 1L in REF01 and report the insured s group number in (8 digit number includes leading zeros). Group number is supplied by BCN in the Group Structure document. Reference Identification Member Policy Number 2000 BCN HMO: Report DX in REF01 and report the insured s 4 digit Sub-Group I.D. in (4 digit Reference Identification number includes leading zeros). Member Supplemental Identifier 2000 BCN HMO: Report 17 in REF01 and report the insured s 4 digit Class I.D. in (4 digit number includes leading zeros). Reference Identification Member Supplemental Identifier 2300 HD Segment To facilitate processing of your enrollment files, report at least one HD loop. Health Coverage BCN HMO: Report only one HD Loop 2300 HD03 BCN HMO: Report HMO. Insurance Line Code 2300 HD04 BCN HMO: Do not report as this data is internally generated by BCN. Plan Coverage Description 2300 DTP01 BCN HMO: Use only codes 348 (Benefit Begin) and 349 (Benefit End). Benefit Begin and Benefit End Date Use only code 349 on term transactions; HD01 must be 024 on term transactions 2300 BCN HMO: Do not report the group number information in this Loop Reference Identification Health Coverage Policy Number 2310 NM1 Segment BCN HMO: This segment is used to report information related to the Primary Care Provider. The Primary Care Provider NPI of the Primary Care Provider should be reported when available. Otherwise, report either their identifier from the hardcopy provider directory or their physician number from NM103 BCN HMO: Preferred reporting is MEDA, MEDB with respective 344 & 345 dates in the Coordination of Benefits Insurer Name Page 8 of 33

11 Appendix B: BCBSM MOS (METAVANCE) GROUP ENROLLMENT DOCUMENT Loop Segment/El ement Instruction Header BGN08 The BGN08 action code identifies whether the file should be used to update a membership database or to verify that the payer s and employer group s systems are synchronized. Industry/Element Name Action Code BGN08 - Report 2 for Update or Update file with changed members only. BGN08 - Report RX for Replace file with current members and current terminations. REF01 - Report Report MOS. Header REF01 & Master Policy Number Header DTP01 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the File Effective Date. Date/Time Qualifier DTP01 - Report 007 for Effective Date. Any members removed from a Replace file without a termination date may be terminated at midnight of the Effective Date. 1000A N101 & N102 N101 - Report P5. N102 Report constant name of the employer group. Plan Sponsor Name 1000C N103 & N104 N103 - Report 94. N104 - Report the BCBSM Agent Code when applicable. Qualifier and TPA or Broker Identification Code 2000 INS03 INS03 Report 001 change elements for Update file. INS03 Report 021 add coverage for Update file. INS03 Report 025 reinstate coverage for Update file. INS03 Report 024 terminate coverage for Update file. INS03 Report 030 for Replace file INS04 INS04 Report XN for active members on a Replace file. INS04 Report appropriate code for terminations on an Update file. INS04 Report appropriate code for all members on an Update file INS05 INS05 - Report A if member is active in the plan. INS05 - Report C if member has COBRA. COBRA Begin and End dates are required when enrolled in COBRA. INS05 - Report S if member is the Surviving Insured Maintenance Type Code Maintenance Reason Code Benefit Status Code Page 9 of 33

12 Loop Segment/El ement Instruction 2000 INS06 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the Medicare Plan Code when a member is 65 years old or older, or permanently handicapped. Claims may not be adjudicated appropriately if the data is not available on the file. Industry/Element Name Medicare Plan Code INS Report A, B, C or D when member is Medicare eligible. INS Report E when member is not Medicare eligible. INS Report 0 when member is Medicare Eligible because of Age. INS Report 1 when member is Medicare Eligible because of Disability. INS Report 2 when member is Medicare Eligible because of ESRD INS07 INS07 - Report a valid Qualifying Event when INS05 = C for COBRA. COBRA Qualifying Event 2000 INS09 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the Student Status Code for Family Continuation Riders. Student Status Code INS09 - Report F when the dependents are covered under the plan contract as a student 2000 INS10 INS10 - Report Y when member is permanently handicapped. Yes/No Condition or Response Code 2000 INS17 INS17 Report Birth Sequence Number only when multiple dependents have the same birth date. Number 2000 REF01 & 2000 REF01 & 2000 REF01 & 2000 REF01 & REF01 - Report 0F. - Report the contract number (e.g., SSN) of the subscriber. For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the Group and Division numbers supplied by BCBSM. Errors may be returned if the data is not available on the file. The Policy or Group Number must be reported in the 2000 Loop or the 2300 Loop. REF01 - Report 1L - Report the member s Group Number followed by a space and then the Division Number. (e.g. xxxxxxxxx xxxx). REF01 - Report 17 - Report Other Reporting Category. REF01 - Report 23 - Report the Servicing Plan Code for Claims Paid in other States. Subscriber Number Qualifier and Group or Policy Number Client Reporting Category Client Number Page 10 of 33

13 Loop Segment/El ement Instruction 2000 REF01 & REF01 - Report DX - Report the Payroll or Department Number only if validated by BCBSM. Industry/Element Name Payroll or Department Number 2000 REF01 & 2000 REF01 & REF01 - Report 6O - Report the Surviving Insured s prior contract number. REF01 - Report F6. - Report the member s health insurance claim (HIB/HIC) number when the member is Medicare eligible. Any member who is age 65 or older is Medicare eligible or permanently handicapped. If the HIB number is reported in COB02, then is not required in a REF*F6. Cross Reference Number Medicare HIC Number 2000 DTP01 DTP01 - Report 336 for Employment Begin Date. DTP01 - Report 356 for Eligibility Begin Date. This date is not the date coverage begins. DTP01 - Report 340 for COBRA Begin Date. Report 340 when INS05 = C for COBRA. DTP01 - Report 341 for COBRA End Date. Report 341 when INS05 = C for COBRA. Member Level Date Qualifier 2100A NM108 & NM109 NM108 - Report 34. NM109 - Report the member s social security number. When reported, report the social security number of the member identified in NM103-NM107 of this segment. Identification Code 2100A PER03 PER05 PER07 Report up to three of the communication numbers below in the PER segment. Report EM for Electronic Mail. Report HP for Home Phone Number. Report TE for Telephone. Report WP for Work Phone Number. Communication Number Qualifier 2100A DMG03 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the appropriate Gender Code. Errors will be returned if the data is spaces or U on the file. Member Gender Code DMG03 - Report F for female. DMG03 - Report M for male. DMG03 - U is not advised. Page 11 of 33

14 Loop Segment/El Instruction ement 2100A HLH01 Health related code may be required for specific employer groups. Industry/Element Name Health Information HLH01 - Report valid HLH01 from the 834 Implementation Guide. 2100G NM101 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report QMSCO for dependents in the 2100G Loop. Errors may be returned if the data is not submitted on the file. Responsible Person NM101 - Report E1 for QMSCO dependents and 19 for Child in INS02. Supporting court documentation must be sent to BCBSM DSB08 BCBSM recommends the 2200 Loop be sent for ESRD members, if not already indicated in INS06-2. Medical Code Value 2300 HD Segment DSB08 - Report 585 for ESRD For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report at least one HD or 2300 Loop. Report additional HD Loops if HD03 is different. The exception is the CDHP products where HD03 is the same. Health Coverage 2300 HD01 HD01 Report 001 Change data on Update file. HD01 Report 021 Add coverage on Update file. HD01 Report 024 Terminate coverage on Update or Replace file. HD01 Report 030 for Replace member other than a termination of the coverage. Maintenance Type Code Page 12 of 33

15 Loop Segment/El Instruction Industry/Element Name ement 2300 HD04 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the 8 character Benefit Package ID supplied by BCBSM. Errors may be returned if the data is not submitted on the file. Plan Coverage Description HD04 - Report the 8 character Benefit Package ID on every member of the contract. Example: HD*030**PPO*XXXXXXXX*EMP~ (Subscriber record) HD04 - For HSA, HRA, RRA or FSA benefits complete this data element as follows: Position Value 1 3 constant CDH (to identify subsequent data) 4 blank or space 5 12 Product Identifier (refer to Appendix G for a list of valid product identifier codes) 13 blank or space Goal Amount for FSA Products (formatted as or leave blank). Do not report a Goal Amount for HSA or HRA. Note: Reporting of HSA, HRA, RRA or FSA benefits requires submission of an additional HD segment to provide the CDH related information. Each product selected by the member requires a separate HD Loop HD05 HD05 - Report the Coverage Level code from those listed in the 834 implementation guide for subscribers only. Coverage Level Code 2300 DTP Report one of the following dates: Health Coverage Dates 2300 REF01 & DTP01 - Report 348 Benefit Begin Date for Replace or Update files. DTP01 - Report 349 Benefit End Date for Replace or Update files. HD01 must be 024 if DTP 349 is sent. DTP01 - Report 303 Maintenance Effective Date for Update files only. DTP03 - Benefit End Date is the coverage end date. The member will have coverage through the date submitted as the Benefit End Date. For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the Group and Division numbers supplied by BCBSM. Errors may be returned if the data is not available on the file. If the member has several coverage levels, report each Group and Division number associated with each coverage level in separate 2300 Loops. REF01 - Report 1L - Report the member s Group Number followed by a space and then the Division Number. Example: xxxxxxxxx xxxx Qualifier and Group or Policy Number Page 13 of 33

16 Loop Segment/El ement Instruction 2320 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the HIB/HIC Number and the Medicare Part Dates in the 2320 Loops. Repeat 2320 Loop up to 2 times. Claims may not be adjudicated appropriately if the data is not available on the file. Industry/Element Name Coordination of Benefits 2320 COB01 COB01 - Report P for Primary (Retired) COB01 - Report S for Secondary (Employed) Payer Responsibility Sequence Number Code 2320 COB02 COB02 - Report HIB/HIC number when indicating Medicare coverage. Reference Identification Insured Group or Policy Number 2320 COB03 COB03 - Report 1 for Coordination of Benefits. Coordination of Benefits Code 2320 DTP Report a DTP segment with each Medicare Part sent. DTP COB Begin Date. DTP COB End Date NM1 NM103 Report MEDICARE PART A for Medicare Part A NM103 Report MEDICARE PART B for Medicare Part B Coordination of Benefit Eligibility Dates Coordination of Benefit Related Entity Page 14 of 33

17 Appendix C: BCBSM LOCAL GROUP ENROLLMENT DOCUMENT Loop Segment/Element Instruction Industry/Element Name Header BGN08 The BGN08 action code identifies whether the file should be used to update a membership database or to verify that the payer s and employer group s systems are synchronized. BGN08 - Report 2 for Update or Update file with changed members only. BGN08 - Report RX for Replace file with current members and current terminations. Header REF01 & REF01 - Report Report PPO. Header DTP01 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the File Effective Date. Action Code Master Policy Number Date/Time Qualifier DTP01 - Report 007 for Effective Date. Any members removed from an Replace file without a termination date may be terminated at midnight of the Effective Date. 1000A N101 & N102 N101 - Report P5. N102 Report constant name of the employer group. 1000C N103 & N104 N103 - Report 94. N104 - Report the BCBSM Agent Code when applicable INS03 INS03 Report 001 change elements for Update file. INS03 Report 021 add coverage for Update file. INS03 Report 025 reinstate coverage for Update file. INS03 Report 024 terminate coverage for Update file. INS03 Report 030 for Replace file INS04 INS04 Report XN for active members on a Replace file. INS04 Report appropriate code for terminations on an Update file. INS04 Report appropriate code for all members on an Update file INS05 INS05 - Report A if member is active in the plan. INS05 - Report C if member has COBRA. COBRA Begin and End dates are required when enrolled in COBRA. INS05 - Report S if member is the Surviving Insured Plan Sponsor Name Qualifier and TPA or Broker Identification Code Maintenance Type Code Maintenance Reason Code Benefit Status Code Page 15 of 33

18 Loop Segment/Element Instruction Industry/Element Name 2000 INS06 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the Medicare Plan Code when a member is 65 years old or older, or permanently handicapped. Claims may not be adjudicated appropriately if the data is not available on the file. Medicare Plan Code INS Report A, B, C or D when member is Medicare eligible. INS Report E when member is not Medicare eligible. INS Report 0 when member is Medicare Eligible because of Age. INS Report 1 when member is Medicare Eligible because of Disability. INS Report 2 when member is Medicare Eligible because of ESRD INS07 INS07 - Report a valid Qualifying Event when INS05 = C for COBRA. COBRA Qualifying Event 2000 INS09 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the Student Status Code for Family Continuation Riders. Student Status Code INS09 - Report F when the dependents are covered under the plan contract as a student 2000 INS10 INS10 - Report Y when member is permanently handicapped. Yes/No Condition or Response Code 2000 INS17 INS17 Report Birth Sequence Number only when multiple dependents have the same birth date. Number 2000 REF01 & REF01 - Report 0F. - Report the contract number (e.g., SSN) of the subscriber REF01 & For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the Group and Division numbers supplied by BCBSM. Errors may be returned if the data is not available on the file. The Policy or Group Number must be reported in the 2000 Loop or the 2300 Loop. REF01 - Report 1L - Report the member s Group Number followed by a hyphen and then the Suffix Number. (e.g. xxxxx-xxx) REF01 & REF01 - Report DX - Report the Payroll or Department Number 2000 REF01 & REF01 - Report 6O - Report the Surviving Insured s prior contract number. Subscriber Number Qualifier and Group or Policy Number Payroll or Department Number Cross Reference Number Page 16 of 33

19 Loop Segment/Element Instruction Industry/Element Name 2000 REF01 & REF01 - Report F6. - Report the member s health insurance claim (HIB/HIC) number when the member is Medicare eligible. Any member who is age 65 or older is Medicare eligible or permanently handicapped. If the HIB number is reported in COB02, then it is not required in a REF*F6. Medicare HIC Number 2000 DTP01 DTP01 - Report 336 for Employment Begin Date. DTP01 - Report 356 for Eligibility Begin Date. This date is not the date coverage begins. DTP01 - Report 340 for COBRA Begin Date. Report 340 when INS05 = C for COBRA. DTP01 - Report 341 for COBRA End Date. Report 341 when INS05 = C for COBRA. DTP01 - Report 357 for Eligibility End Date. This will terminate all coverage for member. 2100A NM108 & NM109 NM108 - Report 34. NM109 - Report the member s social security number. When reported, report the social security number of the member identified in NM103-NM107 of this segment. 2100A PER03 PER05 PER07 Report up to three of the communication numbers below in the PER segment. Report EM for Electronic Mail. Report HP for Home Phone Number. Report TE for Telephone. Report WP for Work Phone Number. 2100A DMG03 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the appropriate Gender Code. Errors will be returned if the data is spaces or U on the file. Member Level Date Qualifier Identification Code Communication Number Qualifier Member Gender Code DMG03 - Report F for female. DMG03 - Report M for male. DMG03 - U is not advised. 2100A HLH01 Health related code may be required for specific employer groups. Health Information HLH01 - Report valid HLH01 from the 834 Implementation Guide. 2100G NM101 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report QMSCO for dependents in the 2100G Loop. Errors may be returned if the data is not submitted on the file. Responsible Person NM101 - Report E1 for QMSCO dependents and 19 for Child in INS02. Supporting court documentation must be sent to BCBSM. Page 17 of 33

20 Loop Segment/Element Instruction Industry/Element Name 2200 DSB08 BCBSM recommends the 2200 Loop be sent for ESRD members, if not already indicated in INS06-2. Medical Code Value DSB08 - Report 585 for ESRD 2300 HD Segment For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report at least one HD or 2300 Loop. Report additional HD Loops if HD03 is different. The exception is the CDHP products where HD03 is the same HD01 HD01 Report 001 Change data on Update file. HD01 Report 021 Add coverage on Update file. HD01 Report 024 Terminate coverage on Update or Replace file. HD01 Report 030 for Replace member other than a termination of the coverage HD04 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the 12 character Service Code supplied by BCBSM. Errors may be returned if the data is not submitted on the file. Health Coverage Maintenance Type Code Plan Coverage Description HD04 - Report the 8 character Benefit Package ID on every member of the contract. Example: HD*030**PPO*XXXXXXXXXXXX*EMP~ (Subscriber record) HD04 - For HSA, HRA or FSA benefits complete this data element as follows: Position Value 1 3 constant CDH (to identify subsequent data) 4 blank or space 5 12 Product Identifier (refer to Appendix G for a list of valid product identifier codes) 13 blank or space Goal Amount for FSA Products (formatted as or leave blank) Note: Reporting of HSA, HRA, RRA or FSA benefits requires submission of an additional HD segment to provide the CDH related information. Each product selected by the member requires a separate HD Loop HD05 HD05 - Report the Coverage Level code from those listed in the 834 implementation guide for subscribers only. Coverage Level Code Page 18 of 33

21 Loop Segment/Element Instruction Industry/Element Name 2300 DTP Report one of the following dates: Health Coverage Dates DTP01 - Report 348 Benefit Begin Date for Replace or Update files. DTP01 - Report 349 Benefit End Date for Replace or Update files. HD01 must be 024 if DTP 349 is sent. DTP01 - Report 303 Maintenance Effective Date for Update file only. DTP03 - Benefit End Date is the coverage end date. The member will have coverage until midnight of the day before the date submitted as the Benefit End Date REF01 & For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the Group and Division numbers supplied by BCBSM. Errors may be returned if the data is not available on the file. If the member has several coverage levels, report each Group and Division number associated with each coverage level in separate 2300 Loops. Qualifier and Group or Policy Number REF01 - Report 1L - Report the member s Group Number followed by a hyphen and then the Suffix Number. Example: xxxxx-xxx 2320 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the HIB/HIC Number and the Medicare Part Dates in the 2320 Loops. Repeat 2320 Loop up to 2 times. Claims may not be adjudicated appropriately if the data is not available on the file. Coordination of Benefits 2320 COB01 COB01 - Report P for Primary (Retired) COB01 - Report S for Secondary (Employed) Payer Responsibility Sequence Number Code 2320 COB02 COB02 - Report HIB/HIC number when indicating Medicare coverage. Reference Identification Insured Group or Policy Number 2320 COB03 COB03 - Report 1 for Coordination of Benefits. Coordination of Benefits Code 2320 DTP Report a DTP segment with each Medicare Part sent. DTP COB Begin Date. DTP COB End Date NM1 NM103 Report MEDICARE PART A for Medicare Part A NM103 Report MEDICARE PART B for Medicare Part B Coordination of Benefit Eligibility Dates Coordination of Benefit Related Entity Page 19 of 33

22 Appendix D: BCBSM NATIONAL GROUP ENROLLMENT DOCUMENT Loop Segment/Element Instruction Industry/Element Name Header REF01 38 Transaction Set Policy Number/ Reference Identification Qualifier Master Policy Number Qualifier Header BCBSM National (NASCO) report: HLT Transaction Set Policy Number/ Reference Identification Header DTP DTP File Effective Date / Date Time DTP03 - Date the 834 Outbound Interchange File is created <CCYYMMDD> 100A N101 P5 Sponsor Name / Entity Identifier Code 1000A N102 Plan Sponsor: Sponsor Name TPA or Account should send the Group's unique name for which the Transmission is being created. 1000A N103 FI - Federal Taxpayer's Identification Number, 24 - Employer's Identification Number (EIN) issued by the IRS Sponsor Name / Identification Code Qualifier 1000A N104 Federal Tax Id or EIN of Plan Sponsor Sponsor Name / Identification Code 1000B N101 IN Payer / Entity Identifier Code Insurer 1000B N102 Should send the Insurer Name to whom the Transmission is being sent: Payer / Name BCBS MI (NASCO) 1000B N103 FI - Federal Tax Identification Number 94 - Code assigned by the organization that is the ultimate destination of the transaction set XV - Centers for Medicare and Medicaid Services PlanID. Payer / Identification Code Qualifier 1000B N104 Federal Tax Id of Payer/Insurer (BCBSM) Payer / Identification Code 1000C N101 TV = Third Party Administrator (TPA). This loop is not needed if group sends their own files. BO - Broker or TPA Name / Entity Identifier Code Sales Office 1000C N102 TPA/BO Name TPA Name / Name 1000C N103 FI - Federal Tax Identification Number 94 - Code assigned by the organization that is the ultimate destination of the transaction set XV - Centers for Medicare and Medicaid Services PlanID. TPA Name / Identification Code Qualifier 1000C N104 Federal Tax Id of Third Party Administrator TPA Name / Identification Code 2000 INS01 Y = Subscriber (Employee) or N = Non-Subscriber (Dependent) Member Level Detail / Yes/No Condition or Response Code 2000 INS02 If a group does not need any special backend reports for its membership, the group does not need to send numerous relationships on files. Member Level Detail / Individual Relationship Code Effective 1/1/11, groups should not send code 23 = Sponsored Dependent; which is family continuation for age 19 to 26. Page 20 of 33

23 Loop Segment/Element Instruction Industry/Element Name INS03 BCBSM preferred groups to utilize code 030 which can add, update, and terminate members/contracts when the file is an Audit or Replace file. 001=Change (Changes File), 021 = Add, 024 = Terminate, 025 = Reinstatement 030=Audit/ Compare (Full File). Member Level Detail / Maintenance Type Code INS12 NASCO does not store this value Member Level Detail / Date Time Period - Death Date of Subscriber or Dependent REF01 0F Subscriber Identifier / Reference Identification Qualifier 2000 SSN of Subscriber Subscriber Identifier / Reference Identification 2000 REF01 1L Member Policy Number / Reference Identifier Qualifier 2000 Report Member Group or Policy Number Member Policy Number / Reference Identifier 2000 REF01 3H Member Supplemental ID/ Reference Identification Qualifier 2000 Value needed to indicate what line of business a dependent has selected not to be enrolled in. Member Supplement ID/ Reference Identification -Case Number (Split Level Benefits) 2000 REF01 6O Member Supplemental ID / Reference Identification Qualifier 2000 Used when further Identification of a member is required for reporting, indexing, or other purpose as mutually agreed upon between the sender and receiver of the transaction set. Member Supplemental ID / Reference Identification Cross Reference Number REF01 DX Member Supplemental ID / 2000 Department Codes, if applicable (reference group structure). Need a 9 alphanumeric value, left justify and zero fill to obtain 9 positions Reference Identification Qualifier Member Supplemental ID / Reference Identification Department Number 2000 REF01 F6 Member Supplemental ID / Reference Identification Qualifier 2000 HIC # (HIC# is identical to HIB#) Member Supplemental ID / Reference Identification Medicare Health Insurance Claim (HIC) Number Page 21 of 33

24 Loop Segment/Element Instruction Industry/Element Name 2000 REF01 Q4 Member Supplemental ID / Reference Identification Qualifier 2000 Use to pass the Identification Number under which the member had previous coverage with the payer. Member Supplemental ID / Reference Identification Prior Identification Number 2000 REF01 QQ Member Supplemental ID / Reference Identification Qualifier 2000 Used when members in a coverage group are set up as different units under the terms of the insurance policy. This may exist within another grouping such as division or department. Member Supplemental ID / Reference Identification Unit Number 2000 REF01 ZZ Member Supplemental ID / Reference Identification Qualifier 2000 Can be used to send group specific additional data, as needed. Member Supplemental ID / Reference Identification Mutually Defined 2000 DTP01 BCBSM NASCO requires this segment: Used to send the effective date of a change to an existing member's information, excluding changes made in Loop 2300, Used to send the Employment Begin/Hire Date for Subscriber only, not for Dependents, 356 and/or Used to send the Eligibility Begin and/or End date for dependents with split level benefits Member Level Dates / Date/Time Qualifier 2100A PER03 NASCO can only store one phone number. Member communication numbers / Communication Number qualifier. 2100A PER05 NASCO can only store one phone number. Member communication numbers / Communication Number qualifier 2100A PER07 NASCO can only store one phone number. Member communication numbers / Communication Number qualifier 2100A N407 Required when address is not in the United States Member Residence City, State, Zip code / Country Subdivision Code 2100A N401 Country Name should go in this position if provided or mapped Member Residence City, State, Zip code Foreign Address / City Name 2100A N402 Constant 'XX' for foreign addresses Member Residence City, State, Zip code Foreign Address / State of Province code 2100A N403 Constant zero's for foreign address (00000) Member Residence City, State, Zip code Foreign Address / Postal Code 2100A N404 If Country Code Not Equal to USA, we could populate this Country code to map a Country Name and store the name in the City Name field above. Member Residence City, State, Zip code Foreign Address / Country Code Page 22 of 33

25 Loop Segment/Element Instruction Industry/Element Name 2100A N407 Required when address is not in the United States Member Residence City, State, Zip code Foreign Address / Country Subdivision Code 2100F PER03 NASCO can only store one phone number. Custodial Parent Communications Numbers / Communication Number Qualifier 2100F PER05 NASCO can only store one phone number. Custodial Parent Communications Numbers / Communication Number Qualifier 2100F PER07 NASCO can only store one phone number. Custodial Parent Communications Numbers / Communication Number Qualifier 2100F N407 Required when address is not in the United States Custodial Parent / Country Subdivision Code 2100F N401 Country Name should go in this position if provided or mapped Custodial Parent Foreign Address / City Name 2100F N402 Constant 'XX' for foreign addresses Custodial Parent Foreign Address /State of Province Code 2100F N403 Constant zero's for foreign address (00000) Custodial Parent Foreign Address /Postal Code 2100F N404 If Country Code Not Equal to USA, we could populate this Country code to map a Country Name and store the name in the City Name field above. Custodial Parent Foreign Address / Country Code 2100F N407 Required when address is not in the United States Custodial Parent Foreign Address 2100G NM101 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report QMSCO for dependents in the 2100G Loop. Errors may be returned if the data is not submitted on the file. / Country Subdivision Code Responsible Person / Entity Identifier Code NM101 - Report E1 for QMSCO dependents and 19 for Child in INS02. Supporting court documentation must be sent to BCBSM HD03 Benefit Type Code; HLT for NASCO membership Health Coverage / Insurance Line Code 2300 HD04 Plan Coverage Description defined by Client/Carrier - see group structure. Health Coverage / Plan Coverage There should be a space between the group number the section number and the package code. Description Example: XXXXX XXXX XXX 2300 HD03 Benefit Type Code; HLT for NASCO membership HD CDH Product/ Insurance Line 2300 HD04 Consumer Driver Health (CDH) product information the contract is enrolled in. Can be duplicated to enable you to report all products needed. A listing is available in Appendix G. Code HD CDH Product/ Plan Coverage Description Page 23 of 33

26 Loop Segment/Element Instruction Industry/Element Name 2320 DTP = Begin Date for Medicare A or B. It can also be the Begin Date for when Medicare became Primary or Secondary. 345 = End Date for Medicare A or B. It can also be the End Date for when Medicare stopped being Primary or Secondary. Coordination of Benefits Eligibility Dates / Date Time Qualifier 2330 NM101 IN Coordination of Benefits Related Entity / Entity Identifier Code 2330 NM102 2=Non-Person Entity Coordination of Benefits Related Entity / Entity Type Qualifier 2330 NM103 Organization Name used for Medicare data. Report: MEDA= Medicare Part A, MEDB = Medicare Part B, MEDD =Medicare Part D Coordination of Benefits Related Entity / Last Name or Organization Name Page 24 of 33

27 Appendix E: BCBSM HYBRID/ METAVANCE GROUP ENROLLMENT DOCUMENT Loop Segment/El Instruction Industry/Element Name ement Header BGN08 BGN08 - Report RX (the file should always be a full file containing adds, changes and terminations) Action Code Header REF01 & REF01 - Report Report NTL. Master Policy Number 1000A N101, N102, N103 & N C N101, N102, N103 & N104 N101 - Report P5. N102 Report NTL834 + constant name of the employer group. For example if the employer group name is AEES report NTL834 AEES. N103 Report FI N104 Report the Federal Tax ID of the employer Group N101 Report TV N102 Report TPA/Broker name N103 - Report FI N104 - Report the taxpayer ID of the TPA/Broker Plan Sponsor Name Qualifier and TPA or Broker Identification Code 2000 INS03 INS03 Report 030 Maintenance Type Code 2000 INS04 INS04 Report XN Maintenance Reason Code 2000 INS05 INS05 - Report A if member is active in the plan. INS05 - Report C if member has COBRA INS06 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the Medicare Plan Code when a member is 65 years old or older, or permanently handicapped. Claims may not be adjudicated appropriately if the data is not available on the file. Benefit Status Code Medicare Plan Code INS Report A, B, C or D when member is Medicare eligible. INS Report E when member is not Medicare eligible. INS Report 0 when member is Medicare Eligible because of Age. INS Report 1 when member is Medicare Eligible because of Disability. INS Report 2 when member is Medicare Eligible because of ESRD INS07 INS07 - Report a valid Qualifying Event when INS05 = C for COBRA. COBRA Qualifying Event 2000 INS09 INS09 Do NOT send F even if the member is a student. Since the dependant age limit has been increased to 26, a student dependant can be sent a dependant. Therefore this element is optional and need not be sent. Student Status Code Page 25 of 33

28 Loop Segment/El Instruction Industry/Element Name ement 2000 INS10 INS10 - Report Y when member is permanently handicapped. Yes/No Condition or Response Code 2000 INS17 INS17 Report Birth Sequence Number only when multiple dependents have the same birth date. Number 2000 REF01 & 2000 REF01 & 2000 REF01 & 2000 REF01 & 2000 REF01 & REF01 - Report 0F. - Report the contract number (e.g., SSN) of the subscriber. For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the Group and Division numbers supplied by BCBSM. Errors may be returned if the data is not available on the file. The Policy or Group Number must be reported in the 2000 Loop or the 2300 Loop. REF01 - Report 1L - Report the member s Group Number followed by a space and then the Division Number. (e.g. xxxxxxxxx xxxx). REF01 - Report DX - Report the Payroll or Department Number if validated by BCBSM. REF01 - Report 6O - Report the Surviving Insured s prior contract number. REF01 - Report F6. - Report the member s health insurance claim (HIB/HIC) number when the member is Medicare eligible. Any member who is age 65 or older is Medicare eligible or permanently handicapped. If the HIB number is reported in COB02, then is not required in a REF*F6. Subscriber Number Qualifier and Group or Policy Number Payroll or Department Number Cross Reference Number Medicare HIC Number 2000 DTP01 DTP01 - Report 336 for Employment Begin Date. DTP01 - Report 340 for COBRA Begin Date. Report 340 when INS05 = C for COBRA. DTP01 - Report 341 for COBRA End Date. Report 341 when INS05 = C for COBRA. Member Level Date Qualifier 2100A NM108 & NM109 NM108 - Report 34. NM109 - Report the member s social security number. When reported, report the social security number of the member identified in NM103-NM107 of this segment. Identification Code Page 26 of 33

29 Loop 2100A Segment/El Instruction ement PER03 Report up to three of the communication numbers below in the PER segment. PER05 PER07 Report EM for Electronic Mail. Report HP for Home Phone Number. Report TE for Telephone. Report WP for Work Phone Number. Industry/Element Name Communication Number Qualifier 2100A DMG03 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the appropriate Gender Code. Errors will be returned if the data is spaces or U on the file. Member Gender Code DMG03 - Report F for female. DMG03 - Report M for male. DMG03 - U should NOT be sent. 2100A HLH01 Health related code may be required for specific employer groups. Health Information HLH01 - Report valid HLH01 from the 834 Implementation Guide. 2100G NM101 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report QMSCO for dependents in the 2100G Loop. Errors may be returned if the data is not submitted on the file. Responsible Person NM101 - Report E1 for QMSCO dependents and 19 for Child in INS02. Supporting court documentation must be sent to BCBSM DSB08 BCBSM recommends the 2200 Loop be sent for ESRD members, if not already indicated in INS06-2. Medical Code Value 2300 HD Segment DSB08 - Report 585 for ESRD For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report at least one HD or 2300 Loop. Report additional HD Loops if HD03 is different. The exception is the CDHP products where HD03 is the same. Health Coverage 2300 HD01 HD01 Report 024 Terminate coverage on Replace file. HD01 Report 030 for all other transaction types. Maintenance Type Code Page 27 of 33

30 Loop Segment/El Instruction Industry/Element Name ement 2300 HD04 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the 8 character Benefit Package ID supplied by BCBSM. Errors may be returned if the data is not submitted on the file. Plan Coverage Description HD04 - Report the 8 character Benefit Package ID on every member of the contract. Example: HD*030**PPO*XXXXXXXX*EMP~ (Subscriber record) HD04 - For HSA, HRA, RRA or FSA benefits complete this data element as follows: Position Value 1 3 constant CDH (to identify subsequent data) 4 blank or space 5 12 Product Identifier (refer to Appendix G for a list of valid product identifier codes) 13 blank or space Goal Amount for FSA Products (formatted as or leave blank) Note: Reporting of HSA, HRA, RRA or FSA benefits requires submission of an additional HD segment to provide the CDH related information. Each product selected by the member requires a separate HD Loop HD05 HD05 - Report the Coverage Level code from those listed in the 834 implementation guide for subscribers only. Coverage Level Code 2300 DTP Report one of the following dates: Health Coverage Date DTP01 - Report 348 Benefit Begin Date. DTP01 - Report 349 Benefit End Date. HD01 must be 024 if DTP 349 is sent. DTP01 - Report 303 Maintenance Effective Date. DTP03 - Benefit End Date is the coverage end date. The member will have coverage through the date submitted as the Benefit End Date For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the HIB/HIC Number and the Medicare Part Dates in the 2320 Loops. Repeat 2320 Loop up to 2 times. Claims may not be adjudicated appropriately if the data is not available on the file COB01 COB01 - Report P for Primary (Retired) COB01 - Report S for Secondary (Employed) COB01 - Report T for Tertiary (Employed) COB01 - Report U if unknown Coordination of Benefits Payer Responsibility Sequence Number Code 2320 COB02 COB02 - Report HIB/HIC number when indicating Medicare coverage. Reference Identification Insured Group or Policy Number Page 28 of 33

31 Loop Segment/El ement Instruction 2320 COB03 COB03 - Report 1 for Coordination of Benefits COB03 Report 5 for unknown Industry/Element Name Coordination of Benefits Code 2320 DTP Report a DTP segment with each Medicare Part sent. Coordination of Benefit Eligibility Dates DTP COB Begin Date. DTP COB End Date NM1 NM101 Report IN Coordination of Benefit Related Entity 2330 NM1 NM103 Report MEDICARE PART A for Medicare Part A NM103 Report MEDICARE PART B for Medicare Part B Coordination of Benefit Related Entity 2330 N4 N401 Report the City Name of the COB company Other Insurance City Name Page 29 of 33

32 APPENDIX F: BCBSM MEDICARE ADVANTAGE GROUP ENROLLMENT DOCUMENT Loop Segment/ Instructions Industry/Element Name Element Header BGN08 The BGN08 action code identifies whether the file should be used to update a membership database or to verify Action Code that the payer's and employer group's systems are synchronized. BGN - Report RX for Replace file with current members and current terminations. Header REF01 & REF01 - Report 38 Master Policy Number - Report MAGP 1000A N101 & N101 - Report P5 Plan Sponsor Name N102 N102 - Report constant name of the employer group 2000 INS03 INS03 - Report 001 change elements for Update file. Maintenance Type Code INS03 - Report 021 add coverage for Update file. INS03 - Report 025 reinstate coverage for Update file. INS03 - Report 024 terminate coverage for Update file. INS03 - Report 030 for Replace file INS08 INS08 - Report Employment Status Code Benefit Status Code FT - Full time PT - Part time RT Retired TE- Terminated 2000 INS06-1 INS Report C for Medicare Part A and B Medicare Status Code INS06-2 INS06-2 Report 1 for Disability INS06-2 Report 2 for ESRD 2000 INS10 INS10 - Report Y when member is permanently handicapped Yes/No Condition or Response Code 2000 REF01 & REF01 - Report 0F Subscriber Number 2000 REF01 & 2000 REF01 & 2000 REF01 & - Report the contract number (e.g., SSN) of the subscriber For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the GROUP and Suffix numbers supplied by BCBSM. Errors may be returned if the data is not available on the file. The Group and Suffix Number must be reported in the 2000 loop or the 2300 loop. REF01-1L - Group Number (5bytes)/Suffix (3bytes) ie REF01 - Report F6 - Report the member's health insurance claim (HIB/HI) number when the member is Medicare eligible. Any member who is age 65 or older is Medicare eligible or permanently handicapped. REF01 - Q4 - Prior Identifier Number Member Group or Policy Number Medicare HIC Number Prior Identification Number Page 30 of 33

33 Loop Segment/ Element 2000 REF01 & Instructions REF01 6O Report the Medicare A and B effective dates as follows: REF*6O*MED PART A CCYYMMDD MED PART B CCYYMMDD~ 2000 DTP01 DTP01 - Report 338 for Medicare Begin DTP01 - Report 339 for Medicare End Date DTP01 - Report 300 the Enrollment Signature Date Industry/Element Name Reference Identification Qualifier Member Level Date Qualifier 2000 DTP03 Report the appropriate date associated with the qualifiers in DTP 01 Member Level Date Period 2100A NM108 & NM109 NM108 - Report 34 NM109 - Report the member's social security number. When reported, report the social security number of the Identification Code 2100A PER03 PER05 PER07 member identified in NM103-NM107 of this segment. Report up to three of the communication numbers below in the PER segment. Report EM for Electronic Mail. Report HP for Home Phone Number. Report WP for Work Phone Number. 2100A DMG03 For proper adjudication of your enrollment files, BCBSM strongly encourages the sponsor, TPA or vendor to report the appropriate Gender Code. Errors will be returned if the data is spaces or U on the file. DMG03 - Report F for female. DMG03 - Report M for male. DMG03 - U is not advised. 2100G 2100G 2100G 2100G NM101 thru NM107 PER03 PER05 PER07 N301 N302 N401 thru N404 NM101 - Report QD responsible party NM102 - Report 1 Person NM103 - Report last name or Organization name NM104 - Report First name NM105 - Report Middle name NM106 - Report Name Prefix NM107 - Report Name Suffix Report up to three of the communication numbers below in the PER segment for the responsible party. Report EM for Electronic Mail. Report HP for Home Phone Number. Report WP for Work Phone Number. N301 - Report responsible party address line 1 N302 - Report responsible party address line 2 N401 - Report responsible party City N402 - Report responsible party State N403 - Report responsible party Zip Code (no dashes or spaces) N404 - Report responsible party County if not in United States 2200 DSB08 BCBSM recommends the 2200 loop to be sent for ESRD members, if not already indicated in INS06-2 DSB08 - Report 585 for ESRD 2200 DTP01 DTP01 - Report 360 Initial Disability Period Start DTP02 - Report 361 Initial Disability Period End Communication Number Qualifier Member Gender Code Entity ID Code Communication Number Qualifier Address Information City, State or Province Code, Postal Code, Country Code Medical Code Value Disability Eligibility Dates Page 31 of 33

34 Loop Segment/ Element 2300 HD Segment Instructions HD01 - Report 001 Change data on Update file. HD01 - Report 021 Add coverage for Update file. HD01 - Report 024 Terminate coverage on Update or Replace file. HD01 - Report 030 for Replace member other than a termination of coverage. HD03 - Report PPO Industry/Element Name Maintenance Type code 2300 DTP01 DTP01 - Report 348 for Subscriber effective date DTP01 - Report 349 for Benefit End Date Health Coverage Date Qualifier 2300 DTP02 DTP02 D8 Health Coverage Date 2320 COB02 COB02 - Report policy number Coordination of Benefits 2320 REF01 & REF01 - Report 6P - Report Group Number Reference Identification Qualifier 2330 NM103 NM103 - Report name of the insurance company Coordination of Benefits Related Entity 2750 REF01 REF01 - Report 6M Application Number Reporting Category - Report Application Number 2750 DTP02 DTP03 DTP02 D8 DTP03- Report Application Date CCYYMMDD Reporting Category Date Page 32 of 33

35 Appendix G: BCBSM CDH MAPPING DOCUMENT The HD segment is repeated multiple times to identify the CDH Product election(s) followed by the DTP segment(s). The CDH Product(s) indicator is reported in the 2300 Loop as shown below. Repeat to identify the HSA product indicator and if applicable, repeat for additional CDH products with the goal amounts. General guidelines: Loop 2300 HD Segment breakdown: 1 st loop report the BPID segment 2 nd loop report the HSA product 3 rd loop report the CDH products w/ goal amount (Goal Amount for FSA Products start at 14-22) Product Identifiers Full Product Description Product Identifiers Full Product Description FSA Flexible Spending Account HRALPDEN HRA Limited Purpose Dental FSADEPCA FSA Dependent Care HRALPDV HRA Limited Purpose Dental Vision FSALPDEN FSA Limited Purpose Dental HRALPVIS HRA Limited Purpose Vision FSALPDV FSA Limited Purpose Dental Vision HRAPDED HRA Post Deductible FSALPVIS FSA Limited Purpose Vision HRARET HRA Retiree only FSAPARK FSA Parking HSA Health Savings Account FSAPDED FSA Post Deductible FSATRANS FSA Transportation HRA Health Reimbursement Account contribution or allocation based Page 33 of 33