834 Benefit Enrollment and Maintenance

Transcription

1 Companion Document Benefit Enrollment and Maintenance Basic Instructions This section provides information to help you prepare for the ANSI ASC X12.84, Benefit Enrollment and Maintenance (834) transaction. The remaining sections of this appendix include tables that provide information about 834 segments and data elements that require specific instructions to efficiently process through Anthem West systems. Use the information in this appendix with the 834 Implementation Guide based on the October 1997 ASC X12 Standards, Version 4, Release 1, Sub- Release 0 (004010). 1 X12 and HIPAA Compliance Checking, and Business Edits 2 Dates Type 1. Anthem West returns a 997 Functional Acknowledgment to the submitter for every inbound 834 transaction received. Each transaction passes through edits to ensure that it is X12 compliant. If the X12 syntax or any other aspect of the 834 is not X12 compliant, the 997 Functional Acknowledgment will also report the Level 1 errors in AK segments and indicate that the entire transaction set has been rejected. Type 2. HIPAA Implementation Guide edits are strictly enforced. If an error is encountered, Anthem West will return an 864 Text Message Transaction (Code Set Error Report) to the submitter listing the Level 2 HIPAA compliance errors and indicating the entire transaction set has been rejected. Effective date Eligibility Date Enrollment Date

2 3 Dependents Plan Date Coverage Date Benefit Date Subscribers and dependents are sent as separate occurrences of Loop The initial enrollment for the subscriber must be sent before sending the initial enrollment for any of the subscriber s dependents. Anthem West links subscribers and dependents by the subscriber s social security number. 4 Termination Anthem West accepts either a termination date or an absent record in order to terminate a subscriber or dependent. 5 Transfer of Coverage 6 Updates In order to transfer from one coverage to another, it is necessary to terminate the old coverage and then add the new coverage. An add to a new coverage must never be assumed to result in the automatic termination of the prior coverage. Anthem West requests one transaction per member per file. An update is either an add, terminate or change request. The transaction only contains information about the changed members. Full file audits are not recommended, but will be accepted 834 Benefit Enrollment and Maintenance Header The 834 Header identifies the start of a transaction, the specific transaction set, and its business purpose to transfer enrollment information from the sponsor of the insurance coverage, benefits, or policy to a payer. The following table explains the header segments and data elements that require specific information for Anthem West processing. 2

3 834 Benefit Enrollment and Maintenance Detail The 834 Detail level contains all data relating to the requested transaction. Each loop encompasses the subscriber, the dependent, and the patient detail information including demographics and coverage and eligibility. 834 Benefit Enrollment and Maintenance Header and Detail Segment Reference Designator(s) Value Definitions and Notes Specific to Anthem West ST Transaction Set Header BGN Beginning Segment REF Transaction Set Policy Number ST01 Transaction Set BGN01 Transaction Set Purpose Code BGN02 Reference Identification BGN03 Date BGN08 Action Code REF02 Reference Identification Benefit Enrollment and Maintenance Page 28 (Transaction Set Identifier Code) (Transaction Set Creation Date) 2 4 (Master Policy Number) 2 - Change (Update) 4 - Verify DTP File Effective Date DTP01 Date/Time Qualifier DTP03 Date Time Period Loop ID 1000A - Sponsor Name N1 N102 Sponsor Name Name Loop ID 1000B - Payer N1 N102 Payer Name N104 N Page 34 (Plan Sponsor Name) (Sponsor Identifier) (Insurer Name) (Insurer ) Effective Maintenance Effective Enrollment Payment Commencement Loop ID 1000C - TPA/Broker Name N1 N102 TPA/Broker Name Name (TPA or Broker Name) 3

4 N104 (TPA or Broker ) Loop ID 1100C - TPA/Broker Account Information ACT Account Identification ACT01 Account Number (TPA or Broker Account Number) ACT06 Account Number Loop ID 2100A - Member Name NM1 NM103 Member Name Name Last or Organization Name PER Member Communications Numbers NM104 Name First NM105 Name Middle NM106 Name Prefix NM107 Name Suffix NM109 PER04, 06, 08 Communication Number (TPA or Borker Account Number) (Subscriber Last Name) (Subscriber First Name) (Subscriber Middle Name) (Subscriber Name Prefix) (Subscriber Name Suffix) (Subscriber Identifier) Page 65 Sent if multiple TPA or Broker Account Numbers apply to this transaction N3 Member Residence Street Address Situational N301 Address Information (Subscriber Address Line) Required by Anthem West N4 Member Residence N401 City Name (Subscriber City Name) Required by Anthem West City, State, Zip Code N402 State or Province Code (Subscriber State Code) Required by Anthem West N403 Postal Code N404 Country Code N406 Location Identifier (Subscriber Postal Zone or ZIP Code) (Location ) DMG Member Demographics Situational DMG02 Date Time Period DMG03 Gender Code (Member Birth Date) F M U F - Female M - Male U Unknown Required by Anthem West DMG04 Marital Status Code Page 71 4

5 DMG05 Race or Ethnicity Code DMG06 Citizenship Status Code Page 72 Page 72 Loop ID 2100A - Member Name cont'd ICM ICM01 Member Income Frequency Code ICM02 Monetary Amount ICM03 Quantity ICM04 Location Identifier (Wage Amount) (Work Hours Count) (Location ) 1 Weekly 2 Bi-Weekly 3 Semi-Monthly 4 Monthly 6 Daily 7 Annually 8 Two callendar months 9 Lump sum separation allowance AMT Member Policy Amounts HLH Health Information LUI Member Language ICM05 Salary Grade AMT01 Amount Qualifier Code AMT02 Monetary Amount HLH01 Health-Related Code HLH02 Height HLH03 Weight LUI01 Qualifier LUI02 LUI03 Description LUI04 Use of Language Indicator Loop ID 2100B - Incorrect Member Name NM1 NM103 Incorrect Member Name Name Last or Organization Name NM104 Name First NM105 Name Middle NM106 Name Prefix (Salary Grade Code) B9 C1 D2 P3 (Contract Amount) N S T U (Member Height) (Member Weight) LD LE (Language Code) (Language Description) (Prior Incorrect Insured Last Name) (Prior Incorrect Insured First Name) (Prior Incorrect Insured Middle Name) (Prior Incorrect Insured Name Prefix) B9 - Co-insurance - Actual C1 - Co-Payment Amount D2 - Deductible Amount P3 - Premium Amount N - None S - Substance Abuse T - Tobacco Use U - Unknown LD - Code Source 457 LE - Code Source Language Reading 7 - Language Speaking 8 - Native Language 5

6 NM107 Name Suffix (Prior Incorrect Insured Name Suffix) DMG Incorrect Member Demographics NM109 DMG02 Date Time Period (Prior Incorrect Insured Identifier) (Prior Incorrect Insured Birth Date) Loop ID 2100C - Member Mailing Address N3 N301 Member Mail Street Address Information Address (Subscriber Address Line) N4 Member Mail City, State, Zip N401 City Name N402 State or Province Code (Subscriber City Name) (Subscriber State Code) N403 Postal Code N404 Country Code Loop ID 2100D - Member Employer NM1 NM103 Member Employer Name Last or Organization Name PER Member Employer Communications Numbers NM109 PER04, 06, 08 Communication Number (Subscriber Postal Zone or ZIP Code) (Insured Employer Name) (Insured Employer Identifier) EM EX FX TE Required if outside USA EM Electronic Mail EX Telephone Extension FX Facsimile TE - Telephone N3 N301 Member Employer Street Address Information Address (Insured Employer Address Line) N4 Member Employer City, State, Zip N401 City Name N402 State or Province Code (Insured Employer City Name) (Insured Employer State Code) N403 Postal Code (Insured Employer Postal Zone or ZIP Code) Loop ID 2100E - Member School NM1 NM103 Member School Name Last or Organization Name (School Name) 6

7 PER Member School Communications Number PER04, 06, 08 Communication Number Page 101 Complete communications number including country or area code when applicable N3 Member School Street Address N4 Member School City, State, Zip N301 Address Information N401 City Name N402 State or Province Code (School Address Line) (School City Name) (School State Code) N403 Postal Code Loop ID 2100F - Custodial Parent NM1 Custodial Parent PER Custodial Parent Communications Number NM103 Name Last or Organization Name NM104 Name First NM109 PER04, 06, 08 Communication Number (School Postal Zone or ZIP Code) (Custodial Parent Last Name) (Custodial Parent First Name) (Custodial Parent Identifier) Page 110 N3 Custodial Parent Street Address N4 Custodial Parent City, State, Zip N301 Address Information N401 City Name N402 State or Province Code (Custodial Parent Address Line) (Custodial Parent City Name) (Custodial Parent State Code) N403 Postal Code (Custodial Parent Postal Zone or ZIP Code) Loop ID 2100G - Responsible Person NM1 Responsible Person NM101 Entity Identifier Code NM103 Name Last or Organization Name NM104 Name First E1 EI EXS GD J6 QD (Responsible Part Last or Organization Name) (Responsible Party First Name) E1 Person or other entity legally responsible for child EI Executor of Estate EXS- Ex Spouse GD Guardian J6 Power of Attorney QD Responsible Party 7

8 PER Responsible Person Communications Number NM109 PER04, 06, 08 Communication Number (Responsible Party Identifier) Page 119 N3 Responsible Person Street Address N4 Responsible Person City, State, Zip N301 Address Information N401 City Name N402 State or Province Code (Responsible Party Address Line) (Responsible Party City Name) (Responsible Party State Code) N403 Postal Code (Responsible Party Postal Zone or ZIP Code) Loop ID Disability Information DSB Disability Information DTP Disability Eligibility Dates DSB01 Disability Type Code DSB07 Product/Service ID Qualifier DSB08 Medical Code Value DTP03 Date Time Period DX (Diagnosis Code) (Disability Eligibility Date) 1 Short Term Disability 2 Long Term Disability 3 Permanent or total disability 4 No Disability DX - ICD-9-CM Diagnosis Loop ID Health Coverage HD Health Coverage DTP Health Coverage Dates HD01 Maintenance Type Code HD03 HLT Insurance line Code HD04 Plan Coverage Description HD05 Coverage Level Code DTP03 Date Time Period Page 130 Page 130 (Coverage Period) 001 Change 002 Delete 021 Addition 024 Cancellation or Termination HLT Health information AMT Health Coverage Policy AMT02 Monetary Amount (Contract Amount) 8

9 REF Health Coverage Policy Number REF02 Reference Identification (Insured Group or Policy Number) IDC Identification Card IDC01 Plan Coverage Description Page 137 IDC04 Action Code 1 2 RX 1 - Add 2 - Change (Update) RX - Replace Loop ID Provider Information LX Provider Information LX01 Assigned Number Page 139 NM1 Provider Name Required NM103 Name Last or Organization Name NM104 Name First (Provider Last or Organization Name) (Provider First Name) N4 Provider City, State, Zip Code NM109 N401 City Name N402 State or Province Code (Provider Identifier) (Member City Name) (Member State Code) N403 Postal Code N406 Location Identifier (Member Postal Zone or Zip Code) (Location ) PER Provider Communications Numbers PER04, 06, 08 Communication Number Page 146 PLA PCP Change Reason PLA03 Date PLA05 Maintenance Reason Code (Provider Effective Date) Page 149 Loop ID Coordination of Benefits COB Coordination of Benefits COB01 Payer Responsibility Sequence Number Code P S T U P Primary S Secondary T Tertiary U - Unknown COB02 Reference Identification (Insured Group or Policy Number) COB03 Coordination of Benefits Code Coordination of Benefits 5 - Unknown 6 - No Coordination of Benefits 9

10 REF Additional Coordination of Benefits Identifiers N1 Other Insurance Company Name DTP Coordination of Benefits Eligibility Dates REF01 Reference Identification Qualifier REF02 Reference Identification N102 Name N104 DTP03 Date Time Period 6P A6 (Insured Group or Policy Number) (Insurer Name) (Insured Group or Policy Number) (Coordination of Benefits Date) 6P Group Number A6 Employee ID number Enveloping This section explains EDI enveloping of the 834 transaction that will help you as you submit requests to Anthem West. EDI envelopes control and track communications between you and Anthem West. One envelope may contain many transaction sets grouped into functional groups. The envelope includes the following components: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) 834 Envelope Control Segments Inbound to Anthem West Benefit Enrollment and Maintenance Interchange Control Header (ISA) The ISA segment is the beginning, outermost envelope of the interchange control structure. It contains authorization and security information, and it identifies the sender, receiver, date, time, and interchange control number. Use the following table as a supplement to the 834 Implementation Guide. This table provides information that is specific to Anthem West. The information does not modify the 834 Implementation Guide. 10

11 2 834 Benefit Enrollment and Maintenance Functional Group Header (GS) The GS segment identifies the collection of transaction sets that are included within the functional group. More specifically, the GS segment identifies the functional control group, sender, receiver, date, time, group control number and version/release/industry code for the transaction sets. Use the following table as a supplement to the 834 Implementation Guide. This table provides information that is specific to Anthem West. The information does not modify the 834 Implementation Guide Benefit Enrollment and Maintenance Functional Group Trailer (GE) The GE segment indicates the end of the functional group and provides control information. Use the following table as a supplement to the 834 Implementation Guide. This table provides information that is specific to Anthem West. The information does not modify the 834 Implementation Guide Benefit Enrollment and Maintenance Interchange Control Trailer (IEA) The IEA segment is the ending, outermost level of the interchange control structure. It indicates and verifies the number of functional groups included within the interchange and the interchange control number (the same number indicated in the ISA segment). Use the following table as a supplement to the 834 Implementation Guide. This table provides information that is specific to Anthem West. The information does not modify the 834 Implementation Guide. 834 HIPAA Transaction - Enveloping information Segment Reference Designator(s) 834 Benefit Enrollment and Maintenance Interchange Control Header (ISA) Value Definitions and Notes Specific to Anthem West ISA Interchange Control ISA01 Authorization Information Qualifier No Authorization Information Present 11

12 Header ISA02 Authorization Information ISA03 Security Information Qualifier ISA04 Security Information ISA05 Interchange ID Qualifier ISA06 Interchange Sender ID (10 Spaces) Enter 10 positions No Security Information Present (10 Spaces) Enter 10 positions. ZZ Qualifier dependent on interchange sender ID selected. (Submitter ID) Example: CO12346E Position 1,2: alpha characters representing state (CO or NV) Position 3-7: incrementally sequenced number Position 8: alpha character representing type of submitter E = enrollment submitter ISA07 Interchange ID Qualifier ISA08 Interchange Receiver ID ISA09 Interchange Date ISA10 Interchange Time ISA11 Interchange Control Standards Identifier ISA12 Interchange Control Version Number ISA13 Interchange Control Number ISA14 Acknowledgment Requested ISA15 Usage Indicator ISA16 Component Element Separator ZZ ZZ - Mutually Defined ANTHEM ANTHEM - Anthem Blue Cross and Blue Shield, West Region (YYMMDD) (HHMM) U Value must be a valid date in YYMMDD format. Value must be a valid time in HHMM format. U - U.S. EDI Community of ASC X12, TDCC, and UCS Draft Standards for Trial Used Approved for Publication by ASC X12 Procedures Review Board through October 1997 (Assigned by the Sender) Format - 9 position numeric Value must be unique. Value must be greater than zero. 0 Anthem West will not respond with TA1 interchange acknowledgment when the interchange is received successfully. P, T Submitter ID must be approved to submit production data. P - Production Data T - Test Data (X) X - 1 character contained in Basic or Extended Character set. Value must not equal A-Z, a-z, 0-9, "space", and special characters which may appear in text data (i.e., hyphen, comma, period, apostrophe). Segment GS Functional Group Reference Designator(s) GS01 Functional Identifier Code 834 Benefit Enrollment and Maintenance Functional Group Header (GS) Value Definitions and Notes Specific to Anthem West BE BE - Benefit Enrollment and Maintenance (834) 12

13 Header GS02 Application Sender's Code (Submitter ID) Example: CO12346E Position 1,2: alpha characters representing state (CO or NV) Position 3-7: incrementally sequenced number Position 8: alpha character representing type of submitter E = enrollment submitter GS03 Application Receiver's Code ANTHEMCO Routing to: ANTHEMCO - CO Applications: BCBS AMISYS, FEP, NASCO ANTHEMNV ANTHEMNV - NV Applications: BCBS AMISYS, FEP, NASCO GS04 Date (CCYYMMDD) Value must be a valid date in CCYYMMDD format. GS05 Time (HHMM) Value must be a valid time in HHMM format. GS06 Group Control Number (Assigned by Sender) Format - 1 through 9 positions, numeric Value must be unique. Value must be greater than zero. GS07 Responsible Agency Code X X - Accredited Standards Committee X12 GS08 Version / Release / Industry Identifier Code X095 Operationally used to identify the 834 Benefit Enrollment and Maintenance transaction. 834 Benefit Enrollment and Maintenance Functional Group Trailer (GE) Segment Reference Designator(s) Value Definitions and Notes Specific to Anthem West GE Functional Group Trailer GE01 Number of Transaction Sets Included (n) Format positions, numeric GE02 Group Control Number (Identical to GS06) Format positions, numeric Value must be unique. Value must be greater than zero. 834 Benefit Enrollment and Maintenance Interchange Control Trailer (IEA) Segment Reference Designator(s) Value Definitions and Notes Specific to Anthem West IEA Interchange Control Trailer IEA01 Number of Included Functional Groups (n) Format positions, numeric Value must equal the number of functional groups (GS/GE pairs) included in the interchange. 13

14 IEA02 Interchange Control Number (Identical to ISA13) Format - 9 positions, numeric Value must be unique. Value must be greater than zero. 14