834 Benefit Enrollment and Maintenance 5010 Companion Guide

Transcription

1 834 Benefit Enrollment and Maintenance 5010 Companion Guide HIPAA/V A1/834 Version 1.3 Company: Blue Cross of Idaho Created 5/29/2013 Updated 1/21/2016 An Independent Licensee of the Blue Cross and Blue Shield Association

2 Table of Contents Introduction...3 Enrollment...3 EDI File...4 Notations and Conventions in This Guide...4 ISA Interchange Control Header...5 GS Functional Group Header...5 ST Transaction Set Heade r...6 BGN Beginning Segment...6 REF Transaction Set Policy Number...7 DTP File Effective Date...7 Q TY Transaction Set Control Total A N1 Sponsor Name B Loop Payer N1 Payer C Loop TPA/Broker Name N1 TPA/Broker Name C Loop TPA/Broker Account Information ACT TPA/Broker Account Information Loop Member Level Detail INS Member Level Detail...10 REF Subscriber Identifier...11 REF Member Policy Number...11 REF Member Supplemental Identifier...11 DTP Member Level Dates A Loop Member Name NM1 Member Name...13 PER Member Communications Numbers...13 N3 Member Residence Street Address...14 N4 Member City, State, ZIP Code...14 DMG Member Demographics Loop Health Coverage HD Health Coverage...16 DTP Health Coverage Dates...17 REF Health Coverage Policy Number...17 AMT Health Coverage Policy Loop Provider Information LX Provider Information...19 NM1 Provider Name...19 N3 Provider Address...20 N4 Provider City, State, Zip Code...20 PER Provider Communications Numbers...20 PLA Provider Change Reason Loop Flexible Spending Account FSA Flexible Spending Account...22 AMT Monetary Amount Information...23 DTP Date or Time or Period...23 SE Transaction Set Trailer...24 GE Functional Group Trailer...24 IEA Interchange Control Trailer

3 1 Introduction 1.1 Disclaimer Blue Cross of Idaho (BCI) created this Companion Guide for 834 Benefit Enrollment and Maintenance, to use in conjunction with the 5010A1 version of the ANSI X12 Implementation Guide. This document is not a replacement for the ANSI X12 Implementation Guide, but as an additional source of information created to assist employers and business partners of Blue Cross of Idaho. The Implementation Guide is available from the Washington Publishing Company website at Document Purpose The purpose of this companion guide is to describe those aspects of processing an electronic 834 Benefit Enrollment and Maintenance requests that are specific to Blue Cross of Idaho. This companion guide contains data clarifications derived from specific business rules that apply exclusively to claims processing done by Blue Cross of Idaho. In addition, this guide includes useful information about sending and receiving data to and from Blue Cross of Idaho. Though Blue Cross of Idaho continually updates this document, the current version is always available on the website bcidaho.com 2 Enrollment 2.1 EDI Support The Blue Cross of Idaho EDI Support Desk assists users with questions about electronic transactions. The Blue Cross of Idaho EDI Support Desk is available to all Idaho providers and vendors Monday through Friday from 8:00 a.m. to 5:00 p.m. MST at or The Blue Cross of Idaho EDI Support Desk: Provides information on services offered Enrolls users for claims submission and data retrieval and vendors for 27x transactions Verifies receipt of electronic transmissions Provides technical assistance to users who are experiencing transmission difficulties 2.2 General Business Information Blue Cross of Idaho complies with HIPAA regulations. Below are specific coding requirements used by Blue Cross of Idaho, but the eligibility information returned by Blue Cross of Idaho is not a guarantee of claims payment. Blue Cross of Idaho responds to all eligibility requests with the coverage information available for the patient identified, per the date provided. 3

4 3 EDI File The EDI file naming convention is GroupName_elig_edi834_ccyymmdd.dat, where GroupName indicates the name of the Group whose members are shown in the file, and ccyymmdd is the file date. For test files, please use a filename that is not in this format, for example GroupName_Test_ccyymmdd.txt. The format of the file is text, with an element separator of asterisk (*) and segment terminator of tilde (~). 4 Notations and Conventions in This Guide Under each Segment header it will say either or. means the segment must always be sent. means the segment can be sent at the sender s discretion or conditionally required by the receiver. The Req. () column describes whether the element is required, given the segment is present. In cases where Date Time Period is populated, the associated Date Time Period element must be populated, and vice versa. 4

5 ISA Interchange Control Header ISA Authorization Number Y 00 ISA Code set Summary Y Should contain spaces or zeroes ( ). ISA Security information Y 00 ISA Security information Y Should contain spaces or zeroes ( ). ISA Interchange ID Y 30 Denotes Federal Tax ID in the following segment. ISA Interchange Sender ID Y Federal Tax ID of the sender ISA Interchange ID Y 30 Denotes Federal Tax ID in the following segment. ISA Interchange Receiver ID Y BCI Federal Tax ID ISA Interchange Date Y CCYYMMDD Date of the interchange ISA10 I09 Interchange Time Y HHMM Time of the interchange ISA11 I65 Repetition Separator Y ^ Separator used to identify repeated data within an element ISA Interchange Control Version Number Y Code used to identify the version submitted ISA13 I12 Interchange Control Number Y Unique number identified by the sender ISA14 I13 Acknowledgment Requested Y 0 A code sent by the submitter requesting acknowledgement ISA15 I14 Interchange Usage Y P, T Code indicating Production or ISA16 I15 Indicator Component Element Separator Test Y > Delimiter separator GS Functional Group Header GS Functional Identifier Code Y BE Code identifying the application related transaction sets 5

6 GS Application Senders Code GS Application Receivers Code Y Y Federal Tax ID of the Sender (Can also be another code identified by the sender) Code identifying receiving transmission (code must be agreed upon by sender and receiver) GS Group Date Y CCYYMMDD GS Group Time Y HHMMSSDD GS06 28 Group Control Number (must match GE02) Y Unique Number created by Sender GS Responsible Agency Code Y X Code identified by the standard GS Version/Release Code Y X220A1 ST Transaction Set Header ST Transaction Set Identifier Y 834 Code identifying Transaction Set ST Transaction Set Control Number Y Unique Number that must be unique to each transaction ST Implementation Convention Reference Y X220A1 Reference assigned to Identify Implementation Convention BGN Beginning Segment BGN Transaction Set Purpose Y 00 00=Original Code BGN Reference Identification Y 1 Reference information for a particular Transaction Set BGN Date Y File date in format CCYYMMDD BGN Time Y File time in format HHMM (24 hour clock) BGN Time Code Y MT Time zone Mountain Time BGN Reference Identification N Not Used. BGN07 Transaction Type Code N Not Used. 6

7 BGN Action Code Y 2, 4 2=Change(update), 4=Verify REF Transaction Set Policy Number Ref # ID Name Req. Code(s) Notes REF Reference Identification 38 REF Reference Identification Y Master Policy Number DTP File Effective Date DTP Date/Time Y 007 Code indicating date or time or both DTP Date Time Y D8 Code indicating date, time or date and time format CCYYMMDD DTP Date Time Period Y CCYYMMDD Actual date, time or range of dates, times or dates and times. QTY Transaction Set Control Totals QTY Quantity Y DT, ET, TO Code specifying the type of quantity. DT = Dependent Total ET = Employee Total TO = Total QTY Quantity Y Numeric value of quantity 7

8 Loop 1000A N1 Sponsor Name N Entity Identifier Code Y P5 Code identifying a physical location, property or individual N Name Y Sponsor/Group name N Code Y FI Denotes Federal Tax ID in following element N Identification Code Y Federal Tax ID of the Sponsor/Group At least one of N102 or N103 is required Loop 1000B N1 Payer N Entity Identifier Code Y IN Organizational entity, physical location, property or individual N Name Y Blue Cross of Idaho N Identification Code N FI Denotes Federal Tax ID in following element N Identification Code N BCI s Federal Tax ID If N103 or N104 is present then the other is also required. 8

9 Loop 1000C N1 TPA/Broker Name N Entity Identifier Code Y BO, BO=Broker or Sales Office TV TV=Third Party Administrator N Name Y TPA/Broker Name N Code N 94, FI, XV Denotes type of identifier in following element. 94=Code assigned by receiver FI=Federal Tax ID XV=CMS Plan ID N Identification code N Code referenced in N103 At least N102 or N103 is required. Loop 1100C ACT TPA/Broker Account Information ACT Account Number Y TPA/Broker Account number assigned ACT Account Number N TPA/Broker second, optional account number assigned 9

10 Loop 2000 INS Member Level Detail INS Yes/No Condition Y Y, N Subscriber indicator Y=insured is subscriber N=insured is a dependent INS Individual Relationship Code Y 01,18, 19 INS Maintenance Type Code Y 001, 021, =Spouse, 18=Self, 19=Child (See Implementation Guide for complete list) 001=Change, 030=Audit or Compare (030 should always be used for full files) INS Maintenance Reason Code Y XN Codes to identify maintenance change entities (see Guide for complete list) INS Benefit Status Code Y A Actual code identifying Status. A=Active INS06 C052 Medicare Status Code N Blank, D, E Identifies Medicare coverage and associated reason for Medicare Eligibility. D=Medicare, E=No Medicare INS Medicare Plan Code N Code identifying Medicare Plan when INS06 is used INS Eligibility Reason Code N Reason for Eligibility 02 INS Consolidated Omnibus N Please leave blank Budget INS Employment Status Code Y FT, PT, RT Code displaying employment status of claimant INS Student Status Code N F, N, P Code displaying student status of a patient if 19 or older, not handicapped and not insured INS Condition Response code N Y/N Handicapped indicator. Y=Handicapped, N=not handicapped INS Date Time Period N D8 INS Date Time Period N Date of Death in format CCYYMMDD INS Confidentiality Code N Please leave blank 10

11 INS Number N Generic Number if family members have the same birthdate (For dependents) REF Subscriber Identifier REF Reference Identification Y 0F Reference Identification for Subscriber number REF Reference Identification Y Social Security Number of the Subscriber REF Member Policy Number REF Reference Identification Y 1L REF Reference Identification Y BCI supplied 8-digit Group Number REF Member Supplemental Identifier REF Reference Identification N 23 23=Client Number REF Reference Identification N Company Assigned Employee ID If REF02 is present, REF03 is required. REF Reference Identification Y DX DX=Department/Agency Number 11

12 REF Reference Identification Y BCI supplied Subgroup Number REF Reference Identification Y 17 17=Client Reporting Category REF Reference Identification Y BCI supplied Class Code or Benefit Level Code DTP Member Level Dates DTP Date Time Y 336, =Employment Begin Date 337=Employment End Date DTP Date Time Period Y D8 DTP Date Time Period Y Date in format CCYYMMDD DTP Date Time Y 356, =Eligibility Begin Date 357=Eligibility End Date DTP Date Time Period Y D8 DTP Date Time Period Y Date in format CCYYMMDD 12

13 Loop 2100A NM1 Member Name NM Entity ID Y IL NM Entity Type Y 1 NM Last Name or Org Name Y Last name or Organizational Name NM Name, First Y First Name NM Name, Middle N Middle Name or Initial NM Name Prefix N Prefix to Name NM Name Suffix N Suffix to Name NM Identification Code N 34 Denotes NM109 is a Social Security Number, required if NM109 is populated. NM Identification Code N Social Security Number. Numeric characters only. PER Member Communications Numbers PER Contact Function Code Y IP IP=Insured Party PER Communication Number N HP, TE=Telephone, HP= Home Phone TE PER Communication Number N Actual phone number if PER03 is populated. Only numeric characters. PER Communication Number N EM EM= PER Communication Number N address if PER05 is populated PER Communication Number N Please leave blank PER Communication Number N Please leave blank If either PER03 or PER04 is present then the other is required. If either PER05 or PER06 is present then the other is required. 13

14 N3 Member Residence Street Address N Address Information Y Address Line 1 N Address Information N Address Line 2 N4 Member City, State, and Zip Code N City Name Y City name (free form) N State or Providence Code Y State N Postal Code Y Postal Code N Country Code N Country Code N Location N Please leave Blank N Location Identifier N Please leave Blank N Country Subdivision Code N Please leave Blank DMG Member Demographics DMG Date and Time period Y D8 Format DMG Date Time Period Y Date of Birth in format CCYYMMDD DMG Gender Code Y F,M Female, Male DMG Marital Status N I, M, B I=Single, M=Married, B=Registered Domestic Partner See Guide for additional codes. DMG05 C056 Composite Race or N Please leave blank DMG05-01 Ethnicity Information 1109 Race or Ethnicity Code N 7, 8, A, B, C, D, 7=Not Provided, 8=Not applicable, A=Asian or Pacific Islander, B= Black, 14

15 E, F, G, H, I, J, N, O, P, Z C=Caucasian, D=Subcontinent Asian American, E=Other Race, F=Asian Pacific America, g=native American, H=Hispanic, N=Black (Non Hispanic), O=White (Non Hispanic), P=Pacific Islander, Z=Mutually defined DMG Code List Code N RET Classification of Race or Ethnicity DMG Industry Code N Please leave blank 03 DMG Citizen Status code N Please leave blank DMG Code List code N Please leave blank DMG Industry Code N Code from a specific industry code list If DMG11 is present then DMG05 is required. 15

16 Loop 2300 HD Health Coverage (at least one) HD Maintenance Type Code Y 001, 021, 001=Change, 021=Addition, 024, =Cancellation or Termination, HD Insurance Line code Y MM HLT EPO PPO HMO DEN PDG POS VIS 030=Audit or Compare MM=Major Medical HLT=Health EPO=Exclusive Provider Org. PPO=Preferred Provider Org. HMO=Health Maintenance Org. DEN=Dental PDG=Prescription Drug POS=Point of Service VIS=Vision HD Plan Coverage Description Y HD Coverage Level Code Y CHD, DEP, E1D, E2D, E3D, E5D, E6D, E7D, E8D, E9D, ECH,EMP, ESP, FAM, IND, SPC, SPO, TWO Plan Code CHD=Children Only, DEP=Dependents Only, E1D=Employee and One dependent, E2D=Employee and Two dependents, E3D=Employee and Three dependents, E5D=Employee and One or More Dependents, E6D=Employee and Two or More Dependents, E7D=Employee and Three or More Dependents, E8D=Employee and Four or More Dependents, E9D=Employee and Five or more Dependents, ECH=Employee and Children EMP=Employee Only ESP=Employee and Spouse, FAM=Family, IND=Individual, SPC=Spouse and Children, SPO=Spouse Only, TWO=Two Party 16

17 DTP Benefit Coverage Dates DTP Date Time Y 303, 348, =Maintenance Effective, 348=Benefit Begin Date 349=Benefit End Date DTP Date Time Period Y D8 DTP Date Time Period Y Date in format CCYYMMDD REF Health Coverage Policy Number REF Reference Identification Y 1L REF Reference Identification Y Group or Policy Number. May contain if Group or Policy number is not available REF Health Coverage Policy Number REF Reference Identification Y 17 REF Reference Identification Y Attestation Indicator Possible Values: 0=Do not send claims and do not send eligibility 1=Send claims only 2=Send eligibility only 3=Send claims and eligibility 17

18 AMT Health Coverage Policy AMT Amount Code Y B9 C1 D2 EBA AMT Monetary Amount Y FK P3 R B9=Co-insurance-Actual C1=Co-Payment Amount D2=Deductible Amount EBA=Expected Expenditure Amount FK=Other Unlisted Amount P3=Premium Amount R=Spend Down 18

19 Loop 2310 LX Provider Information LX Assigned Number Y 1 Number assigned to separate within transaction sets. Should contain 1 NM1 Provider Name NM Entity Identifier Code Y P3 P3=Primary Care Physician NM Entity Type Y 1, 2 1=Person, 2=Non-Person Entity NM Name Last or Organization Y NM Name First N NM Name Middle N NM Name Prefix N NM Name Suffix N NM Identification Code Name of Primary Care Physician Y 34,FI,SV,XX 34=SSN, FI=Federal Tax ID, SV=Service Provider Num, XX=CMS NPI NM Identification Code Y Provider ID NM Entity Relationship Code Y 25,26, 72 25=Established Patient 26=Not Established Patient 72=Unknown 19

20 N3 Provider Address N Address Information Y Provider Address N Entity Type N N4 Provider City, State, Zip Code N City Name Y N State or Province Y N Postal Code Y N Country Code N PER Provider Communications Numbers PER Contact Function Code Y IC Information Contact PER02 93 Not Used N PER Communication Number Y HP, TE, WP HP-Home Phone Number TE-Telephone WP-Work Phone Number 20

21 PLA Provider Change Reason PLA Action Code Y 2 Change PLA02 98 Entity Identifier Code Y 1P Provider PLA Date Y Provider Effective Date in format CCYYMMDD PLA Time N Time PLA Maintenance Reason Code N 14, 22, 46, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ 14 Voluntary Withdrawal 22 Plan Change 46 Current Customer Information File in Error AA Dissatisfaction with Office Staff AB Dissatisfaction with Medical Care AC Inconvenient Office Location AD Dissatisfaction with Office Hours AE Unable to Schedule Appointments in a Timely Manner AF Dissatisfaction with Physician s Referral Policy AG Less Respect and Attention Time Given than to Other Patients AH Patient Moved to a New Location AI No Reason Given AJ Appointment Times not Met in a Timely Manner 21

22 Loop 2500 FSA Flexible Spending Account FSA Maintenance Type Code Y 001, 021,024, =Change, 021=Addition, 024=Cancellation or Termination, 030=Audit or Compare Y D, H D=Dependent Care, H=Healthcare FSA Flexible Spending Account Selection Code FSA Reason Code Y 36 36=Contribution or Plan Allocation FSA Account Number N Account number assigned FSA Frequency Code N 1, 2, 3, 4, 5, 6, 7, 8, 9, B, C, H, Q, X, U, Z 1=Weekly, 2=Biweekly, 3=Semimonthly, 4=Monthly, 5=Other, 6=Daily, 7=Annual, 8=Two Calendar Months, 9=Lump-Sum Separation Allowance, B=Year to Date, C=Single, H=Hourly, Q=Quarterly, S=Semiannual, U=Unknown, Z=Mutually Defined FSA Plan Coverage Description N Plan or coverage description FSA Product Option Code N 1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, N, O, S, 10, 11, 12, 13, 14, 15, 28, 29 1=Pretax, 2=Post tax, 3=Qualified, 4=Non Qualified, 5=401K, 6=Individual Retirement Account, 7=Keogh, 8=Simplified Employee Pension, 9=Single Premium, A=First to Die, B=Last to Die, C=Child Rider, D=discontinue one Bill Submission, N=Benefit Continuation, O=One bill Submission, S=Salary Continuation, 10=Flexible premium, 11=Variable Premium, 12=Fixed Premium, 13=Registered under the Income Tax Act of Canada, 14=Non Registered und the Income Tax Act of Canada, 22

23 15=registered Spousal case, 28=Exclusive, 29=Shopped FSA Product Option Code N Not FSA Product Option Code N Not FSA04 is the flexible spending account policy number. FSA05 specifies the frequency of contribution. AMT Monetary Amount Information AMT Amount Code Y 1 Code to qualify amount AMT Monetary Amount Y Actual Monetary Amount AMT Credit/Debit Flag Code N C, D Code indicating if it is a credit or debit DTP Date or Time or Period Payroll Dates DTP Date/Time N 390, =Payroll Begin Date 391=Payroll End Date DTP Date Time Period Format N D8 DTP Date Time Period N Date in format CCYYMMDD 23

24 SE Transaction Set Trailer SE01 96 Number of Included Y Total number of Segments Segments included in the transaction set SE Transaction Set Control Number Y including ST and SE segments Control number that must be unique within the transaction set functional group, assigned by the Originator. Must match element ST02. GE Functional Group Trailer GE01 97 Number of Transaction Y Sets Included Total number of transaction sets included in the functional group or interchange GE02 28 Group Control Number Y Assigned number originated and maintained by the sender. Must match element GS06. IEA Interchange Control Trailer IEA Number of Included Y A count of the number of Functional Groups functional groups included in an IEA Interchange Control Number Y interchange A control number assigned by the Interchange sender. Must match ISA13. 24