COMPANION GUIDE. Eligible Benefit Inquiry & Response. to the. ASC X12N 270/271 (Version X092A1) Implementation Guide

Transcription

1 COMPANION GUIDE to the Eligible Benefit Inquiry & Response ASC X12N 270/271 (Version X092A1) Implementation Guide May 1, 2008

2 270/271 Eligibility Benefit Inquiry & Response Table of Contents Introduction...2 Establishing Connectivity...3 Confidentiality, Privacy, and Security...3 Setup and Testing...4 Responses...5 Production...5 Data Requirements...8 Member Information...8 Request Type...9 National Provider Identifier...9 Attachment A: Helpful Hints...10 Attachment B: Frequently Asked Questions...11 Attachment C: 271 Response File...12 Attachment D: 270 Benefit Inquiry Specifications...16 Attachment E: 271 Benefit Response Specifications...33 Harvard Pilgrim Health Care 1 05/01/08

3 270/271 Eligibility Benefit Inquiry & Response Introduction The Health Insurance Portability and Accountability Act Administration Simplification (HIPAA-AS) requires Harvard Pilgrim Health Care and all other covered entities to comply with the electronic data interchange standards for health care as established by the Secretary of Health and Human Services. The ASC X12N 270/271 (version X092A1) Implementation Guide for Health Care Eligibility Benefit Inquiry and Response has been established as the standard for eligibility transactions and is available at This guide has been prepared to help those responsible for testing and setting up electronic eligibility transactions. Specifically, it documents and clarifies when situational data elements and segments must be used for reporting and identifies codes and data elements that do not apply to Harvard Pilgrim. This guide supplements (but does not contradict) any requirements in the ASC X12N 270/271 (version X092A1) implementation. The information here should be given to the provider s business area to ensure that eligibility responses are interpreted correctly. Harvard Pilgrim Health Care 2 05/01/08

4 270/271 Eligibility Benefit Inquiry & Response Establishing Connectivity You can submit HIPAA-compliant, 270 Eligibility Inquiries directly to Harvard Pilgrim using one of our preferred e-channels. Sending these transactions directly to Harvard Pilgrim eliminates the need for an intermediary and is offered to providers at no cost per transaction. Providers who submit eligibility inquiries directly to Harvard Pilgrim are supported with the highest levels of customer service and reporting information. Our preferred e-channels are: File Transfer Agent (FTA) through HPHConnect New England Healthcare EDI Network (NEHEN) NEHENNet Software system and transaction services vendors may also submit both real time and batch eligibility transactions via a secure internet connection, Harvard Pilgrim s Healthcare Transaction Services (HTS). For more information call Provider e-business at (press option 1, then 3, then 4). Confidentiality, Privacy and Security Maintaining the confidentiality of personal health information continues to be one of Harvard Pilgrim s guiding principles. Harvard Pilgrim has a strict confidentiality policy for safeguarding patient, employee, and health plan information. All staff is required to be familiar with, and comply with, Harvard Pilgrim s policy on the confidentiality of member personal and clinical information to ensure that it is treated in a confidential and respectful manner. The policy permits use or disclosure of members medical or personal information only as necessary to conduct required business, care management, approved research or quality assurance or measurement activities, or when authorized to do so by a member or as required by law. To comply with internal policies as well as the provisions of the Health Insurance Portability and Accountability Act (HIPAA), Harvard Pilgrim has outlined specific requirements applicable to the electronic exchange of protected health information (PHI), including provisions for: Maintaining confidentiality of protected information Confidentiality safeguards Security standards Return or destruction of protected information Compliance with state and federal regulatory and statutory requirements Required disclosure Use of business associates These requirements are detailed in the privacy and security agreement presented to Harvard Pilgrim s electronic trading partners during our initial discussions. Harvard Pilgrim offers a variety of solutions to transmit protected health information (PHI) using a public network. In accordance with Harvard Pilgrim Policy and the HIPAA Security Rule, any PHI that is transmitted using a public network must be encrypted. Web-based applications are configured to use secure socket layer security software capabilities, and only a browser with support for 128-bit high encryption is acceptable under this policy. In addition, Harvard Pilgrim Health Care 3 05/01/08

5 270/271 Eligibility Benefit Inquiry & Response Harvard Pilgrim s policy requires the use of any encryption technology to be approved by the Harvard Pilgrim information security officer prior to its implementation. NEHEN trading partners transmit transactions using private network frame relay connections, Virtual Private Networks (VPN) or X.509 digital certificates for Web Services connections. Technical Requirements Harvard Pilgrim supports both real-time and batch ASC X12N X092A1 eligibility benefit inquiry and response transactions. The transactions are fully HIPAA-compliant in structure and content. Real-time Real-time files are defined by Harvard Pilgrim as a single inquiry. A real-time 270 transaction must have all of the following characteristics: For NEHEN, last character of GS02 is set to R One and only one ST/SE segment One and only one information source (loop 2000A) One and only one information receiver (loop 2000B) One and only one subscriber (loop 2000C) Zero or one dependent (loop 2000D) Batch Batch files are all files that do not conform to the real-time characteristics. Batch files may not be processed immediately but are scheduled for processing. Responses to all the inquiries in the incoming 270 file will be collected and returned in one 271 response file. Harvard Pilgrim will usually respond within 24 hours to a batch inquiry. For NEHEN trading partners, the last character of GS02 must be set to B. Required File Attributes Harvard Pilgrim requires the following file attributes for both real-time and batch transactions: Each eligibility inquiry file should contain one and only one ISA segment and one and only one GS segment. For eligibility inquiry files sent to Harvard Pilgrim, the file name should be as follows: <ISA06>_<GS02>_<CCYYMMDD>_<HHMM>.270 The ISA06 and GS02 are your submitter and sender IDs provided by the EDI Team. These are followed by the full year, month and date, then by the hour and minutes the file was generated. The extension of.270 indicates eligibility inquiry. The file name must not include blank spaces. A correct naming convention is important, otherwise the EDI program will not recognize the file for pickup. You should take care to ensure that the file is named as specified above. Responses returned to you are also named in a specific way: Harvard Pilgrim returns a 997 file acknowledgement for all batch files. <ISA06>_<GS02>_<CCYYMMDD>_<HHMM>.997 Harvard Pilgrim Health Care 4 05/01/08

6 270/271 Eligibility Benefit Inquiry & Response Response (271) file returned by Harvard Pilgrim <ISA06>_<GS02>_<CCYYMMDD>_<HHMM>.271 Your system will be able to identify the files by the change in the date and time and by the extension. Setup and Testing Setup and testing of eligibility inquiries for the preferred e-channel of your choice: File Transfer Agent (FTA) through HPHConnect To send eligibility inquiries using the FTA of HPHConnect, you must be a registered user with a password and access to the FTA feature. If you haven t registered for HPHConnect, you may do so from the Register Here link at New England Healthcare EDI Network (NEHEN) To send eligibility inquiries via the NEHEN Gateway, you must be a member. For more information, call or e- mail scormier@csc.com. NEHENNet To send eligibility inquiries via NEHENNet, you must subscribe to NEHENNet. For more information, call , nehensales@nehennet.org, or visit Harvard Pilgrim requires submitters to test eligibility inquiries and retrieval of the 997 File Acknowledgement and the 271 Response prior to submitting production inquiries. Once in production, Harvard Pilgrim reserves the right to require re-testing if it is determined that the submitter is receiving an unacceptable volume of errors or for particular types of error. The following guidelines are provided for the testing of eligibility inquiries: Harvard Pilgrim encourages all submitters to use third-party verification utilities to test files for HIPAA compliance before submitting them to Harvard Pilgrim. For more information call Provider e-business at (press option 1, then 3, then 4). Before testing, Harvard Pilgrim will provide the submitter with a test plan specific to his or her organization. A password and user ID will also be provided, as required. Harvard Pilgrim will provide support for testing Mon. Fri., 8:30 a.m. 5:00 p.m. EST. Test files should be a reasonable representation of normal eligibility inquiries and must contain a reasonable variety of individual inquiries. Harvard Pilgrim strongly recommends that prior eligibility inquiries be used for the test file. Harvard Pilgrim expects that all test files are HIPAA-compliant in format and content. If files are known to contain errors, they should be corrected prior to submission. Harvard Pilgrim requires ISA15 contain T for test, any other value will fail the file. In general, turnaround time for test files is 48 hours, but could vary based on the quality of the data. Once testing is complete, Harvard Pilgrim will notify the submitter and review the results with the submitter, if necessary. Responses Harvard Pilgrim issues the following reports to indicate the acceptance or rejection of files: 270 Real-time Expect to receive a 271 response within seconds. For this transaction, no 997 will be sent. If a problem arises with the transaction, an error message will be sent back in the 271. Harvard Pilgrim Health Care 5 05/01/08

7 270/271 Eligibility Benefit Inquiry & Response 270 Batch 997 File Acknowledgement Harvard Pilgrim supports the functional acknowledgment transaction set (997) and uses it as an acknowledgement of the incoming batch 270 file. The submitter should review the 997 to verify that the file has been accepted. If, for some reason, a subsequent problem arises with the file, Harvard Pilgrim will contact the submitter. 270 TA1 Interchange Acknowledgement Request Harvard Pilgrim supports the acknowledgement request (TA1) when requested by submitter within the ISA14. If submitter elects not to receive a TA1, the 997 file acknowledgement will be the only electronic notification that Harvard Pilgrim has accepted or rejected a file. 271 Response By definition, the real time 270 is a synchronous transaction and the 271 is part of the whole transaction. Harvard Pilgrim supports the HIPAA-compliant 271 eligibility benefit response transaction. If the request is successful, the response will contain the member and PCP information that is stored in Harvard Pilgrim s claims processing system, even if that differs from the information in the original inquiry. The 271 response will indicate whether the patient is (as of the requested date of service): Not found Inactive Eligible If a date of service is not indicated in the 270, the current date is used. If a date span is indicated, the first date in the span will be used. If the patient is eligible, the response will include: Member demographics PCP s name and address, if applicable to the Member s product Plan type Termination date, if any Co-pay information Co-insurance percentage, if applicable Deductible, if applicable Out-of-pocket maximums, if applicable In-plan benefits Out-of-plan benefits, Choice Plus and Options PPO plans only Certain service codes referencing specific service types for which the member is eligible. Harvard Pilgrim s 271 response does not contain a complete list of all member benefits. See Attachment C for a list of the service type codes that may be returned in the response. If one of the service type codes is not returned, the member may not be covered for that service. (Benefit information is subject to change.) Production Upon successful completion of testing, the submitter will be approved to submit eligibility inquiries to production. Harvard Pilgrim requires ISA15 contain P for production, any other value will fail the file. Retesting may be required if it is determined that a submitter is receiving/ generating an unacceptable volume of errors or type of error. Harvard Pilgrim Health Care 6 05/01/08

8 270/271 Eligibility Benefit Inquiry & Response The attached spreadsheet (Attachment D) indicates segments and fields that can be sent to Harvard Pilgrim. In order for a 270 to be considered format and content compliant, all HIPAA-required segments and fields must be sent, regardless of Harvard Pilgrim s internal processing requirements. If you have questions, please contact the Harvard Pilgrim EDI team: Phone: (option 1, then option 3) Fax: edi_team@hphc.org Harvard Pilgrim Health Care 7 05/01/08

9 270/271 Eligibility Benefit Inquiry & Response Data Requirements Below are Harvard Pilgrim s data requirements for (and examples of) a 270 eligibility inquiry. Member Information Harvard Pilgrim requires one of the following sets of information: Complete Harvard Pilgrim member ID including suffix (11-character alphanumeric; for example, HP ). The last two digits represent the member suffix. Harvard Pilgrim member ID without suffix (nine-character alphanumeric), exact last name 1, partial first name 2, and exact date of birth. Exact last name 1, exact first name 3, exact date of birth, and gender. For Choice Plus Joint Offering and Options Joint Offering products (sold jointly by Harvard Pilgrim and United Healthcare), supply the nine-character subscriber ID, sixcharacter group number, exact date of birth, exact last name 1 and partial first name 2. Harvard Pilgrim recommends trading partners comply with the Eligibility Benefit Inquiry & Response Implementation Guide rules when a subscriber ID and a group number are required to identify members, i.e., loop 2000C NM109 would contain the nine-character subscriber ID and REF segment would contain six-character group number. To accommodate any trading partner system limitations in submitting subscriber and group number as required, Harvard Pilgrim will accept concatenated (linked) subscriber ID and group number without spaces or special characters in NM109 during the transition phase. Set the NM108 segment in the 2000C (or 2000D) loop to MI (member identification number). When responding to a 270 eligibility inquiry, Harvard Pilgrim will return 271 subscriber/member loops which mirror the structure of the associated inbound transaction. Received Member Identifier HP HP , exact last name, partial first name, and exact date of birth Subscriber ID and Group number Concatenated subscriber ID and group number Patient last name, patient first name, date of birth and gender Returned Member Identifier HP HP Subscriber ID and group number Concatenated subscriber ID and group number HP or Subscriber ID and group number The last name must match exactly, including any suffix, hyphen, or apostrophe. For example, Tellington Jones will not match Tellington-Jones and Jones will not match Jones III. 2 For example, a partial first name of An will match Ann, Andrew, or Anthony. 3 For example, an exact first name of Ann will not match a first name of Anne or a combined first name and middle initial of Ann S. Harvard Pilgrim Health Care 8 05/01/08

10 270/271 Eligibility Benefit Inquiry & Response If only demographic information is received in the 270 Harvard Pilgrim will return the following: Legacy products 11-character alphanumeric Harvard Pilgrim member ID in NM109 Joint offering products nine-character subscriber ID in NM109 and six-character group number in REF02. Request Type Set the EQ01 segment in the 2110C (or 2110D) loop to 30. At this time, Harvard Pilgrim responds to all eligibility inquiries with general benefit and eligibility information. National Provider Identifier Effective May 23, 2008, the National Provider Identifier is required in NM109 of any provider loop in a 270 eligibility transaction submitted to Harvard Pilgrim. A Harvard Pilgrim-issued provider identifier may be submitted only as a secondary identifier. EXAMPLE A USE OF NPI AND SUBSCRIBER ID AND GROUP NUMBER Here is a sample 270 eligibility inquiry that meets joint offerings requirements. ISA*00*00 *00*00 *ZZ*NEHENxxx *ZZ*NEHEN003 *030728*0959*U*00401* *0*P*: GS*HS*00044*NEHEN003* *0959* *X*004010X092A1 ST*270* BHT*0022*13* * *0959 HL*1**20*1 NM1*PR*2*Harvard Pilgrim Health Care*****PI*NEHEN003 HL*2*1*21*1 NM1*1P*2*ABC COMPANY*****XX*NATIONALPROVIDERIDENTIFIER HL*3*2*22*0 TRN*1*571445*99NEHENxxx NM1*IL*1*DOE*JOHN****MI* REF*6P* DMG*D8* *M DTP*307*D8* EQ*30 SE*13* GE*000001* IEA*00001* EXAMPLE B NPI AND LEGACY NUMBER Here is a sample 270 eligibility inquiry that meets Harvard Pilgrim legacy product requirements: ISA*00*00 *00*00 *ZZ*NEHENxxx *ZZ*NEHEN003 *030728*0959*U*00401* *0*P*: GS*HS*00044*NEHEN003* *0959* *X*004010X092A1 ST*270* BHT*0022*13* * *0959 HL*1**20*1 NM1*PR*2*Harvard Pilgrim Health Care*****PI*NEHEN003 HL*2*1*21*1 NM1*1P*2*ABC COMPANY*****XX*NATIONALPROVIDERIDENTIFIER Harvard Pilgrim Health Care 9 05/01/08

11 270/271 Eligibility Benefit Inquiry & Response REF*TJ*PROVIDERTAXID HL*3*2*22*0 TRN*1*571445*99NEHENxxx NM1*IL*1*DOE*JOHN****MI*HP DMG*D8* *M DTP*307*D8* EQ*30 SE*13* GE*000001* IEA*00001* Harvard Pilgrim Health Care 10 05/01/08

12 270/271 Eligibility Benefit Inquiry & Response Attachment A Helpful Hints In accordance with the Implementation Guide, section 1.3.2: The subscriber is a person who can be uniquely identified to an information source, traditionally referred to as a member. Transactions will be accepted with subscriber information in loop 2000C and patient information in loop 2000D. The Harvard Pilgrim system performs only one search. For example, if the complete member ID is provided and the search fails, the system does not search again on partial member ID, name, and date of birth. Similarly, if a partial member ID is provided and the search fails, the system does not search again on name, date of birth, and gender. If more than one member meets the search criteria, Harvard Pilgrim interprets HIPAA privacy and security recommendations and returns Duplicate Subscriber/Insured ID Number message, instead of multiple records. Please refine your eligibility inquiry with complete member demographics (last name, first name, gender and date of birth) and resubmit the request. If a date span is entered in an eligibility inquiry, Harvard Pilgrim uses only the first date of the span to determine eligibility. Member and provider information submitted on an eligibility inquiry does not update the member and provider information stored in Harvard Pilgrim s claims processing system. If the member is found and eligible, Harvard Pilgrim will return the member and provider information that is stored in the Harvard Pilgrim claims processing system. Harvard Pilgrim Health Care 10 05/01/08

13 270/271 Eligibility Benefit Inquiry & Response Attachment B Frequently Asked Questions Q: I have already certified/tested with Claredi (or another third party). Why do I need to test again with Harvard Pilgrim? A: Harvard Pilgrim tests with all electronic submitters in order to verify Harvard Pilgrim business rules are implemented. The goal is to eliminate errors and rejects. If a provider has already tested with a third party, testing should be relatively straightforward. Q: Can special characters still be used in surnames? A: Yes. Hyphens (Tellington-Jones) and apostrophes (O Donnell) are acceptable. If the member s name in Harvard Pilgrim s system contains a hyphen or apostrophe, and the search request does not, the member will not be found. Likewise, if the member s name in Harvard Pilgrim s system does not contain a hyphen or apostrophe, and the search request does contain one or more, the member will not be found. Q: Why is the member ID number returned in HPHConnect different than the member ID number in the 271 transaction response? A: While Harvard Pilgrim transitions claims processing activities from existing to new systems, some member identification numbers (e.g., Choice Plus Joint Offering and Options Joint Offering ) will be displayed on the HPHConnect portal differently than on standard EDI HIPAA transactions. The HPHConnect display will concatenate (link) the subscriber identification number and group number into one number, while attaching a unique suffix for each member. For example: = Subscriber # Group # Member Suffix The use of the unique member suffix for joint offering products is limited to the HPHConnect portal and if used in a 270 transaction will cause the transaction to fail. Use of linked subscriber and group numbers only may be used in a 270 transaction if the trading partner system is unable to submit the group number in the recommended segment. Harvard Pilgrim Health Care` 11 05/01/08

14 270/271 Eligibility Benefit Inquiry & Response Attachment C 271 Response File Primary Care Physician Harvard Pilgrim does not include the PCP loop when the member s product states a PCP is not required (i.e., preferred provider organization). If the national provider identifier is unavailable for a member s PCP, Harvard Pilgrim will return the PCP s full name and address, and phone number when known Out-of-Network Benefits. Out-of-network benefits are reported only for Choice Plus Joint Offering and Options Joint Offering products. Out-of-network benefits include any co-pay, co-insurance, deductible, or out-of-pocket maximum. Service Type Codes Harvard Pilgrim s 271 response does not contain a complete list of all member benefits. If one or more of the service type codes listed in the table below is not returned, the member may not be covered for those services. Harvard Pilgrim s implementation of the 271 response may include modifiers to provide more detail about the service, or to distinguish different contexts, such as preferred or non-preferred network, and specialist or primary care provider. This data is provided in the EB13 segment, with EB-1 set to ZZ. Service type codes and possible modifiers are shown below. Service Type (EB03) Service Type Description 11 Used Durable Medical Equipment 12 Durable Medical Equipment Purchase 18 Durable Medical Equipment Rental Description (EB13-2) Preferred Network Non-preferred Preferred Network Non-preferred Preferred Network Non-preferred 22 Social Work Early Intervention Early Intervention, Preferred Network Early Intervention, Non-preferred 33 Chiropractic Preferred Network Non-preferred 42 Home Health Care Specialist Primary Care Provider Preferred Network Non-preferred 48 Hospital Inpatient Preferred Network Non-preferred Modifier (EB13-3) T1 T2 T1 T2 T1 T2 EI T1 T2 T1 T2 SP PC T1 T2 T1 T2 Modifier (EB13-4) EI EI Harvard Pilgrim Health Care` 12 05/01/08

15 270/271 Eligibility Benefit Inquiry & Response Attachment C Service Type (EB03) Service Type Description Description (EB13-2) 53 Ambulatory Surgery Surgical Day Care Surgical Day Care, Preferred Network Surgical Day Care, Non-preferred 80 Immunization Allergy Injection Allergy Injection, Preferred Network Allergy Injection, Non-preferred 86 Emergency Services Preferred Network Non-preferred 91 Brand Name Prescription Tier 3 Copay Drug 91 Brand Name Prescription Tier 2 Copay Drug 92 Generic Prescription Drug Tier 1 Copay 98 Professional (Physician) Specialist Visit Office Primary Care Provider Preferred Network Non-preferred PCP Select Specialist Other Specialist Tier 1 Tier 2 Tier 3 Select Preventive AB Rehabilitation Inpatient Preferred Network Non-preferred AD Occupational Therapy Preferred Network Non-preferred AE Physical Medicine Preferred Network Non-preferred AF Speech Therapy Preferred Network Non-preferred AG Skilled Nursing Care Preferred Network Non-preferred BG Cardiac Rehabilitation Specialist Primary Care Provider Preferred Network Non-preferred PCP Select Specialist Other Specialist Tier 1 Tier 2 Tier 3 Modifier (EB13-3) SD T1 T2 AL T1 T2 T1 T2 SP PC T1 T2 PS OS G1 G2 G3 PV T1 T2 T1 T2 T1 T2 T1 T2 T1 T2 SP PC T1 T2 PS OS G1 G2 G3 Modifier (EB13-4) SD SD AL AL Harvard Pilgrim Health Care 13 05/01/08

16 270/271 Eligibility Benefit Inquiry & Response Attachment C Service Type (EB03) Service Type Description Description (EB13-2) BR Eye Specialist Primary Care Provider Preferred Network Non-preferred Modifier (EB13-3) SP PC T1 T2 Modifier (EB13-4) Pharmacy Formularies Harvard Pilgrim will now identify the applicable formulary for a member with prescription drug coverage. REF01 REF02 REF03 IF HPHC01 Harvard Pilgrim Formulary IF HPHC03 Joint Offerings Formulary EXAMPLE A A sample 271 response is shown below. ISA*00* *00* *ZZ*NEHEN003 *ZZ*NEHENxxx *030728*1524*U*00401* *0*P*: GS*HB*NEHEN003* R* *1524*1*X*004010X092A1 ST*271*1234 BHT*0022*11*EB * *1524 HL*1**20*1 NM1*PR*2*Harvard Pilgrim Health Care*****PI*NEHEN003 HL*2*1*21*1 NM1*1P*2*ABC COMPANY*****XX* HL*3*2*22*0 TRN*2*EB * NM1*IL*1*DOE*JOHN****MI*HP REF*IF*HPHC01*HARVARD PILGRIM FORMULARY N3*123 SOME STREET N4*REVERE*MA*02151 DMG*D8* *F DTP*307*RD8* EB*1***HM*INTEGRATED HMO PRODUCT EB*L LS*2120 NM1*P3*1*BROWN*TOM D****XX* N3*BOSTON NEIGHBORHOOD HLTH CENTER*10 GOVE ST N4*BOSTON*MA* PER*IC**TE* PRV*PC*ZZ*GR LE*2120 EB*B**42***27*0 EB*B**48***27*50 EB*B**78***27*10 EB*B**91***27*20 EB*B**91***27*15 EB*B**92***27*10 Harvard Pilgrim Health Care 14 05/01/08

17 270/271 Eligibility Benefit Inquiry & Response Attachment C EB*B**98***27*10 EB*B**AB***27*200 EB*B**AD***27*10 EB*B**AE***27*10 EB*B**AF***27*10 EB*B**AG***27*50 EB*B**BG***27*10 EB*B**BR***27*10 SE*34*1234 GE*1*1 IEA*1* EXAMPLE B A sample of joint offering 271 response is shown below. ISA*00* *00* *ZZ*NEHEN003 *ZZ*NEHENxxx *030728*1524*U*00401* *0*P*: GS*HB*NEHEN003* R* *1524*1*X*004010X092A1 ST*271*1234 BHT*0022*11*EB * *1524 HL*1**20*1 NM1*PR*2*Harvard Pilgrim Health Care*****PI*NEHEN003 HL*2*1*21*1 NM1*1P*2*ABC COMPANY*****XX* HL*3*2*22*0 TRN*2*EB * NM1*IL*1*DOE*JOHN****MI* REF*6P* REF*IF*HPHC03*JOINT OFFERINGS FORMULARY N3*123 SOME STREET N4*REVERE*MA*02151 DMG*D8* *F DTP*307*RD8* EB*1*** PR*CHOICE PLUS JOINT OFFERING EB*L LE*2120 EB*B**42***27*0 EB*B**48***27*50 EB*B**52***27*50 EB*B**78***27*10 EB*B**98***27*10 EB*B**AB***27*200 EB*B**AD***27*10 EB*B**AE***27*10 EB*B**AF***27*10 EB*B**AG***27*50 EB*B**BG***27*10 EB*B**BR***27*10 SE*34*1234 GE*1*1 IEA*1* Harvard Pilgrim Health Care 15 05/01/08

18 Attachment D 270 Eligibility, Coverage or Benefit Inquiry ID Page ment Description Loop ID Req Max Use Valid Values ISA Interchange control header R 1 ISA01 Auth info qualifier R "00" ISA02 -Auth information R bb ISA03- Security info qual R "'00" ISA04 security info R bb ISA05 Interchange ID qual R ZZ ISA06 Interchange sender ID R Sender's identification, as per trading partner agreement. ISA07 Interchange ID qual R ZZ ISA08 Interchange Receiver ID R HPHC0001 (non-nehen submitter) or HPHC's identification, as per NEHEN0003 (NEHEN submitter) trading partner agreement. ISA09 Envelope creation date R YYMMDD date ISA10 Envelope creation time R time ISA11 Interchange control std R U HIPAA version ISA12 Interchange Version R ISA13 Interchange control Number R EDI Compliance value ISA14 Ack requested R 0/1 ISA15 Usage Indicator R P/T A file sent to HPHC's production mailbox must contain P and if sent to the HPHC test mailbox must contain T. ISA16 Component Element Separator R : 105th byte of ISA ment terminator R ~ Tilde ~ or other value as specified by sender GS Functional Group header R 1 GS01 Functional ID Code R HS GS02 Application Sender's Code R Sender's ID based on trading partner agreement. Refer to Companion Guide GS03 Appl. Receiver's Code R HPHC's identification, as per trading partner agreement. Refer to Companion Guide. GS04 Data Interchange Date R CCYYMMDD Date GS05 Data Interchange Time R Time GS06 Group Ctl No. R Assigned by Sender GS07 Responsible Agency code R X GS08 Version R 00410X092A1 ST Transaction set header R 1 36 ST01 Transaction set id code R 270 Eligibility, Coverage or Benefit Inquiry ST02 Transaction Set control number R BHT Beginning of Hierarchical Transaction R 1 38 BHT01 Hierarchical Structure Code R 0022 Information Source, Information Receiver, Subscriber, dependent BHT02 Transaction Set Purpose Code R 01 Cancellation 13 Request 36 Authority to Deduct (Reply) BHT03 Reference ID S BHT04 Date R BHT05 Time R BHT061 Transaction Type Code S RT- Spend Down RU Medical Services Reservation LOOP ID 2000A INFORMATION SOURCE R 1 LEVEL HL Information Source Level 2000A R 1 42 HL01 Hierarchical ID Number 2000A R HL03 Hierarchical Level Code 2000A R 20 Information Source HL04 Hierarchical Child Code 2000A R 1 Additional Subordinate HL date ment in This Hierarchical Structure Must be 270: Eligibility, coverage or Benefit Inquiry LOOP ID 2100A INFORMATION SOURCE R 1 NAME NM1 Information Source Name 2100A R 1 44 NM101 Entity Identifier Code 2100A R 2B Third-Party Administer 36 Employer GP Gateway provider P5 Plan Sponsor PR Payer PR Payer NM102 Entity Type Qualifier 2100A R 1 Person 2 Non person 2 Non Person Entity NM103 Name Last or Organization Name 2100A S Harvard Pilgrim Health Care Harvard Pilgrim Health Care 16 May 1, 2008

19 Attachment D 270 Eligibility, Coverage or Benefit Inquiry ID Page ment Description Loop ID Req Max Use Valid Values NM104 Name First 2100A S NM105 Name Middle 2100A S NM107 Name Suffix 2100A S A7 NM108 Identification Code Qualifier 2100A R 24 Employer's Identification Number 46 Electronic Transmitter identification Number (ETIN) FI Federal taxpayer's Identification Number NI National Association of Insurance Commission (NAIC) Identification PI Payor Identification XV Health Care Financing Administration National PlanID (Required if National PlanID is mandated for use) XX Health Care Financing Administration National Provider Identifier (Requires value if National Provider is mandated for use) PI NM109 Identification Code 2100A R Harvard Pilgrim identifier LOOP ID 2000B INFORMATION RECEIVER R 1 LEVEL HL Information Receiver Level 2000B R 1 48 HL01 Hierarchical ID Number 2000B R HL02 Parent ID Number 2000B R HL03 Hierarchical Level Code 2000B R 21 Information Receiver 21 information receiver HL04 Hierarchical Child Code 2000B R 1 Additional Subordinate HL data ment in This Hierarchical Structure. LOOP ID 2100B INFORMATION RECEIVER R 1 NAME NM1 Information Receiver Name 2100B R 1 50 NM101 Entity Identifier Code 2100B R 1P Provider 2B Third-Party Administer 36 Employer 80 Hospital FA Facility GP Gateway provider P5 Plan Sponsor PR Payer 1P Provider 80 Hospital FA Facility NM102 Entity Type Qualifier 2100B R 1 Person 2 Non person 2 Non-person Entity NM103 Name Last or Organization Name 2100B S NM104 Name First 2100B S NM105 Name Middle 2100B S NM107 Name Suffix 2100B S NM108 Identification Code Qualifier 2100B R 24 Employer's Identification Number 34 Social Security Number FI Federal taxpayer's Identification Number PI Payor Identification PP Pharmacy Process Number SV Service Provider Number XV Health Care Financing Admin. Nat'l Plan ID (Required if Nat'l Plan ID is mandated for use) XX Health Care Financing Admin. Nat'l Provider Identifier (Requires value if Nat'l Provider is mandated for use) XX-National Provider Identifier NM109 Identification Code 2100B R National Provider Identifier REF Information Receiver Additional Information 2100B S 9 Harvard Pilgrim Health Care 17 May 1, 2008

20 Attachment D 270 Eligibility, Coverage or Benefit Inquiry ID Page ment Description Loop ID Req Max Use Valid Values 55 REF01 Reference ID Qualifier 2100B R 0B State License Number If present, must be syntactically 1C Medicare Provider Number (Only correct but not processed by HPHC. to be used when the information source is "not" Medicare) 1D Medicaid Provider Number (Only to be used when the information source is "not" Medicare) 1J Facility ID Number 4A Personal Identification Number (PIN) CT Contract Number (Only to be used once the Nat'l Provider has been mandated) EL Electronic device pin number EO Submitter Identification Number HPI Health Care Financing Administration Na'l Provider Identifier JD User Identification N5 Provider Plan network Identification Number N7 Facility Network Identification Number Q4 Prior Identifier Number SY Social Security Number TJ Federal Taxpayer's Identification Number REF02 Reference ID 2100B R REF03 Description 2100B S N3 Information Receiver Address 2100B S 1 57 N301 Address Information 2100B R N302 Address Information 2100B S N4 Information Receiver City/State/ZIP Code 2100B S 1 58 N401 City Name 2100B R N402 State or Province Code 2100B R N403 Postal Code 2100B R N404 Country Code 2100B S PER Information Receiver Contact Information 2100B S 3 If present, must be syntactically correct but not processed by HPHC. 60 PER01 Contact Function Code 2100B R PER02 Name 2100B S PER03 Communication Number Qualifier 2100B S ED Electronic Data Interchange access Number EM Electronic Mail FX Facsimile TE Telephone PER04 Communication Number 2100B S PER05 Communication Number Qualifier 2100B S ED Electronic Data Interchange access Number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER06 Communication Number 2100B S PER07 Communication Number Qualifier 2100B S ED Electronic Data Interchange access Number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER08 Communication Number 2100B S PRV Information Receiver Provider Information 2100B S 1 If present, must be syntactically correct but not processed by HPHC. Harvard Pilgrim Health Care 18 May 1, 2008

21 Attachment D 270 Eligibility, Coverage or Benefit Inquiry ID Page ment Description Loop ID Req Max Use Valid Values 64 PRV01 Provider Code 2100B R AD Admitting AT Attending BI Billing CO Consulting CV Covering H Hospital HH Home Health Care LA Laboratory OT Other Physician P1 Pharmacist P2 Pharmacy PC Primary care Physician PE Performing R Rural Health Clinic RF Referring SB Submitting SK Skilled Nursing Facility SU Supervising F123 PRV02 Reference Identification Qualifier 2100B R ZZ Mutually Defined PRV03 Reference Identification 2100B R LOOP ID 2000C SUBSCRIBER LEVEL R 1 HL Hierarchical Level 2000C R 1 67 HL01 Hierarchical ID Number 2000C R HL02 Hierarchical Parent ID Number 2000C R HL03 Hierarchical Level Code 2000C R 22 Subscriber HL04 Hierarchical Child Code 2000C R 0 No Subordinate HL ment in This Hierarchical Structure 1 Additional Subordinate HL Data ment in This Hierarchical Structure TRN Subscriber Trace Number 2000C S 2 69 TRN01 Trace Type Code 2000C R 1 Current Transaction Trace Number TRN02 Reference Identification 2000C R TRN03 Originating Company Identifier 2000C R TRN04 Reference Identification 2000C S LOOP ID 2100C SUBSCRIBER NAME R 1 NM1 Subscriber Name 2100C R 1 71 NM101 Entity Identifier Code 2100C R IL Insured or subscriber NM102 Entity Type Qualifier 2100C R 1 Person NM103 Name Last or Organization Name 2100C S NM104 Name First 2100C S NM105 Name Middle 2100C S NM107 Name Suffix 2100C S NM108 Identification Code Qualifier 2100C S MI Member Identification Number ZZ Mutually Defined MI member identification number NM109 Identification Code 2100C S Alpha-numeric Harvard Pilgrim Member ID (11 characters) Or Numeric Subscriber ID (up to 9 numbers) Or Concatenated Subscriber and Group ID (up to 15 characters) REF Subscriber Additional Identification 2100C S 9 Refer to Companion Guide for Search Criteria. Harvard Pilgrim Health Care 19 May 1, 2008

22 Attachment D 270 Eligibility, Coverage or Benefit Inquiry ID Page ment Description Loop ID Req Max Use Valid Values 75 REF01 Reference Identification Qualifier 2100C R 18 Plan Number 1L Group or Policy Number. ( If it cannot be determined / use code "IG" or "6P" when they can be determined. ) 1W Member identification Number 49 Family Unit Number 6P Group Number A6 Employee Identification Number CT Contract Number EA Medical Record Identification Number EJ Patient Account Number F6 Health Insurance Claim (HIC) Number GH Identification Card Serial Number HJ Identity Card Number IG Insurance Policy Number N6 Plan Network Identification Number NQ Medicaid Recipient Identification Number SY Social Security Number 6P - Group Number Refer to Companion Guide for Search Criteria. REF02 Reference Identification 2100C R Group Number N3 Subscriber Address 2100C S 1 77 N301 Address Information 2100C R N302 Address Information 2100C S N4 Subscriber City/State/ZIP Code 2100C S 1 78 N401 City Name 2100C S N402 State or Province Code 2100C S N403 Postal Code 2100C S N404 Country Code 2100C S PRV Provider Information 2100C S 1 If present, must be syntactically correct but not processed by HPHC C R AD Admitting AT Attending BI Billing CO Consulting CV Covering H Hospital HH Home Health Care LA Laboratory OT Other Physician P1 Pharmacist P2 Pharmacy PC Primary care Physician PE Performing R Rural Health Clinic RF Referring SB Submitting SK Skilled Nursing Facility SU Supervising PRV02 Reference Identification Qualifier 2100C R 9K Servicer D3 National Association Board of Pharmacy Number EI Employer Identification Number HPI Health Care Financing Administration National Provider identifier SY Social Security Number TJ Federal Taxpayer's Identification Number ZZ Mutually Defined (Health Care Provider Taxonomy Code list) PRV03 Reference Identification 2100C R DMG Subscriber Demographic Information 2100C S 1 Refer to Search Criteria in Companion Guide. Harvard Pilgrim Health Care 20 May 1, 2008

23 Attachment D 270 Eligibility, Coverage or Benefit Inquiry ID Page ment Description Loop ID Req Max Use Valid Values 83 DMG01 Date Time Period Format Qualifier 2100C S D8 Date Express "CCYYMMDD" DMG02 Date Time Period 2100C S Subscriber date of birth DMG03 Gender Code 2100C S F Female Subscriber gender code M Male INS Subscriber Relation 2100C S 1 85 INS01 Yes/No Condition or Response Code 2100C R Y Yes INS02 Individual Relationship Code 2100C R 18 Self INS017 Number 2100C R DTP Subscriber Date 2100C S 9 87 DTP01 Date/Time Qualifier 2100C R 102 Issue 307 Eligibility 435 Admission 472 Service 307 eligibility DTP02 Date Time Period Format Qualifier 2100C R D8 Date Express "CCYYMMDD" RD8 Range of Date Express as "CCYYMMDD CCYYMMDD" DTP03 Date Time Period 2100C R Date of service If Date range is submitted, eligibility is checked for the First Date. 89 LOOP ID 2110C SUBSCRIBER ELIGIBILITY or BENEFIT INQUIRY INFORMATION S 10 EQ Subscriber Eligibility or Benefit Inquiry Information 2110C S 1 89 EQ01 Service Type Code 2110C S 1 Medical Care 2 Surgical 3 Consultation 4 Diagnostic X-Ray 5 Diagnostic Lab 6 Radiation Therapy 7 Anesthesia 8 Surgical Assistance 9 Other Medical 10 Blood Charges 11 Used Durable Med. Equip't 12 Durable Med. Equip't Purchase 13 Ambulatory Svc. Ctr. Facility 14 Renal Supplies in the Home 15 Alternate method Dialysis 16 Chronic Renal Disease Equip't 17 Pre-Admission Testing 18 Durable Medical Equip't Rental 19 Pneumonia Vaccine 20 Second Surgical Opinion 21 Third Surgical Opinion 22 Social Worker 23 Diagnostic Dental 24 Periodontics 25 Restorative HPHC treats all inquiries as Service Type Code 30. Harvard Pilgrim Health Care 21 May 1, 2008

24 Attachment D 270 Eligibility, Coverage or Benefit Inquiry ID Page ment Description Loop ID Req Max Use Valid Values 26 Endodontics 27 Maxillofacial Prosthetics 28 Adjunctive Dental Services Health Benefit Plan Cvge Plan Waiting Period 33 Chiropractic 34 Chiropractic Office Visits 35 Dental Care 36 Dental Crowns 37 Dental Accident 38 Orthodontics 39 Prosthodontics 40 Oral Surgery 41 Routine (Preventive) Dental 42 Home Health Care 43 Home Health Prescriptions 44 Home Health Visits 45 Hospice 46 Respite Care 47 Hospital 48 Hospital Inpatient 49 Hospital Room & Board 50 Hospital Outpatient 51 Hospital Emergency Accident 52 Hospital Emergency Medical 53 Hospital Ambulatory Surgical 54 Long Term Care 55 Major Medical 56 Medical Related Transp. 57 Air Transportation 58 Cabulance 59 Licensed Ambulance 60 General Benefits 61 In-vitro fertilization 62 MR/CAT Scan 63 Donor Procedures 64 Acupuncture 65 Newborn Care 66 Pathology 67 Smoking Cessation 68 Well Baby Care 69 Maternity 70 Transplants 71 Audiology Exam 72 Inhalation Therapy 73 Diagnostic Medical 74 Private Duty Nursing 75 Prosthetic Device Harvard Pilgrim Health Care 22 May 1, 2008

25 Attachment D 270 Eligibility, Coverage or Benefit Inquiry ID Page ment Description Loop ID Req Max Use Valid Values 76 Dialysis 77 Otological Exam 78 Chemotherapy 79 Allergy Testing 80 Immunizations 81 Routine Physical 82 Family Planning 83 Infertility 84 Abortion 85 AIDS 86 Emergency Services 87 Cancer 88 Pharmacy 89 Tree Standing Prescription Drug 90 Mail Order Prescription Drug 91 Brand Name prescription Drug 92 Generic Prescription Drug 93- Podiatry 94 Podiatry Office Visits 95 Podiatry Nursing Home Visits 96 Professional (Physician) 97 Anesthesiologist 98 Professional (Physician) Visits Office 99 Professional (Physician) Visits Inpatient A0 Professional (Physician) Visits Outpatient A1 Professional (Physician) Visits Nursing Home A2 Professional (Physician) Visits Skilled Nursing Facility A3 Professional (Physician) Visits Home A4 Psychiatric A5 Psychiatric Room & Board A6 Psychotherapy A7 Psychiatric Inpatient A8 Psychiatric Outpatient A9 Rehabilitation AA Rehabilitation Room & Board AB Rehabilitation Inpatient AC Rehabilitation Outpatient AD Occupational Therapy AE Physical Therapy AF Speech Therapy AG Skilled Nursing Care Room & Board AI Substance Abuse AJ Alcoholism AK Drug Addition AL Vision (Optometry) AM Frames AN Routine Exam AO Lenses Harvard Pilgrim Health Care 23 May 1, 2008

26 Attachment D 270 Eligibility, Coverage or Benefit Inquiry ID Page ment Description Loop ID Req Max Use Valid Values AQ Nonmedically Necessary Physical AR Experimental Drug Therapy BA Independent Drug Therapy BB Partial Hospitalization (Psychiatric) BC Day Care (Psychiatric) BD Cognitive Therapy BE Massage Therapy BF Pulmonary Rehabilitation BG Cardiac Rehabilitation BH Pediatric BI Nursery I143 BJ Skin BK Orthopedic BL Cardiac BM Lymphatic BN Gastrointestinal BP Endocrine BQ Neurology BR Eye BS Invasive Procedures EQ02 Composite Medical Procedure Identifier 2110C S If present must be syntactically correct but not processed by HPHC. A8 EQ02-1 Product/Service ID Qualifier 2110C R AD American Dental Association Code CJ Current Procedural terminology(cpt) Code HC Health Care Financing Administration Common Proceduarl Coding System(HCPCS) Codes ID International Classification Of Diseases Clinical Modification(ICD-9- CM) Procedure IV Home Infusion EDI Coalition(HIEC) Product / Service Code N4 National Drug Code (NDC) ZZ Mutually Defined ( NOT ADVISED) EQ02-2 Product/Service ID 2110C R EQ02-3 Procedure Modifier 2110C S EQ02-4 Procedure Modifier 2110C S EQ02-5 Procedure Modifier 2110C S EQ02-6 Procedure Modifier 2110C S EQ03 Coverage Level Code 2110C S CHD Children Only DEP Dependents Only ECH Employee & Children EMP Employee Only ESP Employee & Spouse FAM Family IND Individual SPC Spouse & Children SPO Spouse Only If present must be syntactically correct but not processed by HPHC. EQ04 Insurance Type Code 2110C S AP Auto Insurance policy C1 Commercial CO Consolidated Omnibus Budget Reconciliation Act (COBRA) GP Group Policy HM Health Maint. Org. (HMO) HN Health Maint. Org. (HMO) Medicare IP Individual Policy MA Medicare Part A MB Medicare Part B MC Medicaid PR Preferred Provider Org. (PPO) PS Point of Service (POS) SP Supplemental Policy WC Workers Compensation If present must be syntactically correct but not processed by HPHC. Harvard Pilgrim Health Care 24 May 1, 2008

27 Attachment D 270 Eligibility, Coverage or Benefit Inquiry ID Page ment Description Loop ID Req Max Use Valid Values AMT Subscriber Spend Down Amount 2110C S 1 If present must be syntactically correct but not processed by HPHC. 99 AMT01 Amount Code Qualifier 2110C R R Spend Down AMT02 Monetary Amount 2110C R III Subscriber Eligibility or Benefit Additional Inquiry Information 2110C S 10 If present must be syntactically correct but not processed by HPHC. 101 III01 Code List Qualifier Code 2110C R BF Diagnosis BK Principal Diagnosis ZZ Mutually Defined III02 Industry Code 2110C R 11 Office 12 Home 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room Hospital 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Facility 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 41 Ambulance Land 42 Ambulance Air or Water 50 Federally Qualified health care 51 Impatient Psych.Facility 52 Psych. Facility Partial Hospitalization 53 Community Mental Health Center 54 Intermed. Care Facility/ Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psych.Residential Treatment Center 60 Mass Immunization Center 61 Compr.Inpatient Rehab.Facility 62 Compr.e Outpatient Rehab. Facility 65 End-Stage Renal Disease Treatment Facility 71 State or Local Public Health Clinic 72 Rural Health Clinic 81 Independent Laboratory 99 Other Unlisted Facility REF Subscriber Additional Information 2110C S 1 If present must be syntactically correct but not processed by HPHC. 104 REF01 Reference Identification Qualifier 2110C R 9F Referral Number G1 Prior Authorization Number 104 REF02 Reference Identification 2110C R DTP Subscriber Eligibility/Benefit Date 2110C S DTP01 Date/Time Qualifier 2100C R 102 Issue 307 Eligibility 435 Admission 472 Service DTP02 Date Time Period Format Qualifier 2110C R D8 Date Express "CCYYMMDD" RD8 Range of Date Express as "CCYYMMDD CCYYMMDD" DTP03 Date Time Period 2110C R 307 eligibility If Date range is submitted, eligibility is checked for the First Date. 108 LOOP ID 2000D Dependent Level S 1 HL Hierarchical Level 2000D R HL01 Hierarchical ID Number 2000D R HL02 Hierarchical Parent ID Number 2000D R HL03 Hierarchical Level Code 2000D R 23 Dependant Harvard Pilgrim Health Care 25 May 1, 2008

28 Attachment D 270 Eligibility, Coverage or Benefit Inquiry ID Page ment Description Loop ID Req Max Use Valid Values HL04 Hierarchical Child Code 2000D R 0 No Subordinate HL segment in This Hierarchical Structure TRN Dependent Trace Number 2000D S TRN01 Trace Type Code 2000D R 1 Current Transaction Trace Number TRN02 Reference Identification 2000D R TRN03 Originating Company Identifier 2000D R TRN04 Reference Identification 2000D S LOOP ID 2100D DEPENDENT NAME R NM101 Entity Identifier Code 2100D R 03 Dependent NM102 Entity Type Qualifier 2100D R 1 Person NM103 Name Last or Organization Name 2100D S NM104-First Name 2100D S NM105 Name Middle 2100D S NM107 Name Suffix 2100D S REF Dependent Additional Identification 2100D S REF01 Reference Identification Qualifier 2100D R 18 Plan Number 1L Group or Policy Number. (If it cannot be determined/ use code "IG" or "6P" when they can be determined.) 6P Group Number A6 Employee Identification Number CT Contract Number EA Medical Record Identification Number EJ Patient Account Number F6 Health Insurance Claim (HIC) Number GH Identification Card Serial Number HJ Identity Card Number IF Issue Number IG Insurance Policy Number N6 Plan Network Identification Number SY Social Security Number REF02 Reference Identification 2100D R N3 Dependent Address 2100D S N301 Address Information 2100D R N302 Address Information 2100D S N4 Dependent City/State/ZIP Code 2100D S N401 City Name 2100D S N402 State or Province Code 2100D S N403 Postal Code 2100D S N404 Country Code 2100D S PRV Provider Information 2100D S 1 If present must be syntactically correct but not processed by HPHC. 121 PRV01 Provider Code 2100D R AD Admitting AT Attending BI Billing CO Consulting CV Covering H Hospital HH Home Health Care LA Laboratory OT Other Physician P1 Pharmacist P2 Pharmacy PC Primary care Physician PE Performing R Rural Health Clinic RF Referring SB Submitting SK Skilled Nursing Facility SU Supervising Harvard Pilgrim Health Care 26 May 1, 2008

29 Attachment D 270 Eligibility, Coverage or Benefit Inquiry ID Page ment Description Loop ID Req Max Use Valid Values PRV02 Reference Identification Qualifier 2100D R 9K Servicer D3 National Association Board of Pharmacy Number EI Employer Identification Number HPI Health Care Financing Administration National Provider identifier SY Social Security Number TJ Federal Taxpayer's Identification Number ZZ Mutually Defined (Health Care Provider Taxonomy Code list) PRV03 Reference Identification 2100D R DMG Dependent Demographic Information 2100D S DMG01 Date Time Period Format Qualifier 2100D S D8 Date Express as "CCYYMMDD" DMG02 Date Time Period 2100D S Dependent Date of Birth DMG03 Gender Code 2100D S F Female M Male INS Dependent Relationship 2100D S 1 If present, must be syntactically correct but not processed by HPHC. 126 INS01 Yes/No Condition or Response Code 2100D R N No INS02 Individual Relationship Code 2100D R 01 Spouse 19 Child 34 Other Adult INS017 Number 2100D S DTP Dependent Date 2100D S 2 If present, must be syntactically correct but not processed by HPHC. 129 DTP01 Date/Time Qualifier 2100D R 102 ISSUE 307 Eligibility 435 Admission 472 Service DTP02 Date Time Period Format Qualifier 2100D R D8 RD8 D8 Date Express "CCYYMMDD" RD8 Range of Date Express as "CCYYMMDD CCYYMMDD" 129 DTP03 Date Time Period 2100D R EQ LOOP ID 2110D DEPENDENT ELIGIBILITY or BENEFIT INQUIRY INFORMATION Dependent Eligibility or Benefit Inquiry Information R D S 1 Harvard Pilgrim Health Care 27 May 1, 2008