Commonwealth of Virginia (State Programs) 834 Benefit Enrollment and Maintenance: Audit File

Transcription

1 Sample: ISA*00* *00* *30* *30* *050503*1436*U*00401* *0*P*~ GS*BE*COMMW VIRGINIA* * *053645* *X*004010X095A1~ ST*834*1001~ BGN*00*125839* *053645*ET***4~ DTP*007*D8* ~ N1*P5*COMMONWEALTH OF VA*FI* ~ N1*IN*CARRIER NAME*FI* ~ INS*Y*18*030*XN*A***RT~ REF*0F* XU~ REF*1L* ~ REF*DX* ~ REF*Q4*C ~ DTP*303*D8* ~ NM1*IL*1*TESTY*TESTOR*T***34* ~ PER*IP**WP* *HP* ~ N3*PO BOX 324~ N4*SURRY*VA* ~ DMG*D8* *M~ HD*030**HLT*042*ESP~ DTP*348*D8* ~ INS*N*01*030*XN*A***RT~ REF*0F* XU~ REF*1L* ~ REF*DX* ~ REF*Q4*C ~ DTP*303*D8* ~ NM1*IL*1*TESTY*WIFEE*L***34* ~ DMG*D8* *F~ HD*030**HLT*042~ DTP*348*D8* ~ SE*45350*1001~ GE*1* ~ IEA*1* ~ Audit File Layout (2).docRevised 02/25/2005 Page 1 of 9

2 Table 1 Interchange Control Header Pos. # Seg. ID Name Valid Values and Description ISA Interchange Control Header ISA01 Authorization Information Qualifier: 00: No Authorization Information Present ISA02 Authorization Data Identification: 10 spaces ISA03 Security Information Qualifier: 00: No Security Information Present ISA04 Security Information: 10 spaces ISA05 Interchange ID Qualifier: 30: U. S. Federal Tax Identification Number ISA06 ISA07 ISA08 ISA09 ISA10 ISA11 ISA12 ISA13 ISA14 ISA15 ISA16 Sender s Code: with 5 spaces Interchange ID Qualifier: 30: U. S. Federal Tax Identification Number Receiver s Code: with 5 spaces (Anthem) with 5 spaces (Delta Dental) with 5 spaces (Medco) with 5 spaces (Value Options) with 5 spaces (AON) Interchange Date formatted YYMMDD Interchange Time formatted HHMM Interchange Control Standards Identifier: U: U.S. EDI Community of ASC X12, TDCC, and UCS Interchange Control Version Number: 00401: Draft Standards for Trial Use Approved for Publication by ASC X12 Procedures Review Board through October 1997 Interchange control number Acknowledgement Requested: 0: No acknowledgement requested Usage Indicator: P: Production Data T: Test Data Component Element Separator: ~ used by COV Audit File Layout (2).docRevised 02/25/2005 Page 2 of 9

3 Table 2 Functional Group Header GS Functional Group Header GS01 GS02 GS03 GS04 GS05 GS06 GS07 GS08 Table 2 Transaction Set Header 010 ST Transaction Set Header ST01 ST BGN Beginning Segment BGN01 BGN02 BGN03 BGN04 BGN05 BGN DTP File Effective Date DTP01 DTP02 DTP03 Functional Identifier Code: BE: Benefit Enrollment and Maintenance (834) Application Sender s Code: COMMW VIRGINIA Application Receiver s Code: Receiver s defined code or Receiver s tax identification number Date header created: expressed CCYYMMDD Time header created: expressed in 24-hour clock time Group Control Number: Assigned by the Sender Responsible Agency Code: X: Accredited Standards Committee X12 Version/Release/Industry Identifier Code: X095A1: Draft Standards Approved for Publication by ASCX12 Procedures Review Board through October 1997, as published in the implementation guide. Transaction Set Identifier Code: 834: Benefit Enrollment and Maintenance Transaction set control number: Assigned by the Sender Transaction Set Purpose Code: 00: Original Reference Identification: Assigned by the Sender Date file created: expressed CCYYMMDD Time file created: expressed in 24-hour clock time Time code: ET: Eastern Time Action Code: 4: Verify Date/Time Qualifier: 007: Effective Date Time Period Format Qualifier: D8: Date format expressed CCYYMMDD Date Time Period: CCYYMMDD (Snapshot date) Audit File Layout (2).docRevised 02/25/2005 Page 3 of 9

4 Loop ID 1000A Sponsor Name 070 N1 Sponsor Name N101 N102 N103 N104 Loop ID 1000B Payer 070 N1 Payer N101 N102 N103 N104 Table 3 Member Level Detail Loop ID 2000 Member Level Detail 010 INS Member Level Detail INS01 INS02 INS03 INS04 INS05 Entity Identifier Code: P5: Plan Sponsor Name: Commonwealth of VA Identification Code Qualifier: FI: Federal Taxpayer s Identification number Identification Code: Entity Identifier Code: IN: Insurer Name of administrator (one of five): Anthem Delta Dental Medco Value Options AON Identification Code Qualifier: FI: Federal tax identification number Identification Code: Denotes the federal tax identification number for the administrator identified in N102: (Anthem) (Delta Dental) (Medco) (Value Options) (AON) There will be up to 9950 INS segments within the ST/SE group Yes/No Condition or Response Code: Y: Participant record N: Dependent record Individual Relationship Code: 01: Spouse 18: Self 19: Child Maintenance Type Code: 030: Audit or compare Maintenance Reason Code: XN: Notification only Benefit Status Code: A: Active C: COBRA Audit File Layout (2).docRevised 02/25/2005 Page 4 of 9

5 INS06 INS07 INS08 INS09 INS REF Subscriber Number REF REF Member Policy Number REF01 Pos. 1-3 Medicare Plan Code: D: Medicare - Part Unknown E: No Medicare Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying: 1: Termination of Employment 2: Reduction of work hours 3: Medicare 4: Death 5: Divorce 6: Separation 7: Ineligible Child 8: Bankruptcy of a Retired Employee Participant s Employment Status Code: FT: Full-time active employee L1: Eligible employee on leave of absence RT: Retired TE: COBRA participant Dependent s Student Status Code: F: Full-time N: Not a student Yes/No Condition or Response Code: Denotes the dependent s handicap status: N: Not handicapped Y: Handicapped Reference Identification Qualifier: 0F: Subscriber number Reference Identification: This is a nine-character alphanumeric identification number assigned by the Commonwealth. Depending on the effective date, it may be nnnnnnn, Connnnnnn, or nnnnnnnxu where n is a digit 0 9. Beginning 07/01/2005 numbers will be transitioned to the format nnnnnnnxu. As of 01/01/2006 all records will use the format nnnnnnnxu. Used by COV to send data as one numeric string of 18 digits where the following field positions have specific meaning. Reference Identification Qualifier: 1L: Group or policy number Reference Identification: Denotes the member s health coverage plan: 000: Waived Coverage 002: Option I 003: Option II 006: Kaiser Permanente HMO Audit File Layout (2).docRevised 02/25/2005 Page 5 of 9

6 Pos Pos. 13 Pos : Pos Pos : Advantage : Option II + Dnt,Vsn 037: Advantage 65 + Dnt,Vsn 042: Basic COVA Care 043: CC + OON 044: CC + ExpDnt 045: CC + OON & ExpDnt 046: CC + Vsn,Hrg & ExpDnt 047: CC + OON & Vsn,Hrg,ExpDnt Denotes the member s program: : State Program for those not eligible for Medicare : State Program for those eligible for Medicare : The Local Choice (future use) Denotes the member s classification or status: 0: Employee 2: Retiree 4: Extended Coverage (COBRA) Denotes the member s premium status: 02: COV s Billing Agent collects premium 03: VRS collects premium 06: Agency collects premium 07: COV s Dept. of Accounts pays premium 09: Premium Not Paid Suspend Claims Payment Denotes the member s leave of absence: 00: Not on leave of absence, do not send conversion letter 01-98: On leave of absence, do not send conversion letter 99: Did not return from leave of absence, conversion letter may be sent Denotes the member s eligibility for Medicare: 0: Not Medicare eligible, group pays primary 6: Medicare eligible, group pays as if Medicare is primary 7: Exempt from Medicare, group pays primary 020 REF Member ID Number Used by COV to send data as one numeric string of 9 digits where the following field positions have specific meaning. Each agency/group is assigned a single Benefits Administrator contact. The Contacts Database is updated and distributed by to each vendor monthly and is used to distribute materials. REF01 Reference Identification Qualifier: DX: Department/Agency Number Reference Identification: Audit File Layout (2).docRevised 02/25/2005 Page 6 of 9

7 Pos. 1-3 Pos. 4-6 Pos REF Prior Identifier Number REF DTP Date or Time or Period DTP01 DTP02 DTP03 Loop ID 2100A Member Name 030 NM1 Member Name NM101 NM102 NM103 NM104 NM105 NM107 NM108 NM PER Member Communications Denotes the member s assigned agency: 005: The Virginia Retirement System 006: DHRM: Office of Health Benefits 007: The Member s Last Employing Agency : Active State Agency (refer to the Contacts Database Table) Denotes the member s assigned group within an agency: : (refer to the Contacts Database Table for each entry) Denotes the member s last employing agency when the member s agency is 007: 000: Unknown : Active State Agency (refer to the Contacts Database) Reference Identification Qualifier: Q4: Prior Identifier Number Nine-character alphanumeric denoting the prior identification number for this person when coverage was effective prior to 07/01/2005. It may be nnnnnnnnn or C0nnnnnnn where n is a digit 0 9. Date/Time Qualifier: 303: Maintenance effective Date Time Period Format Qualifier: D8: Date format expressed as CCYYMMDD CCYYMMDD (date of snapshot) Entity Identifier Code: IL: Insured or Subscriber Entity Type Qualifier: 1: Person Name Last or Organization Name: up to 25 characters Name First: up to 25 characters Name Middle: up to 2 characters Name Suffix: up to 3 characters Identification Code Qualifier: 34: Social Security Number Identification Code: Social security number: 9 digits Audit File Layout (2).docRevised 02/25/2005 Page 7 of 9

8 PER01 PER03 PER04 PER05 PER06 Numbers 050 N301 Member Residence Street Address N N4 Member Residence City, State, Zip Code N401 N402 N403 N DMG Member Demographics DMG01 DMG02 DMG03 Loop ID 2300 Health Coverage 260 HD Health Coverage HD01 HD03 HD04 Contact Function Code: IP: Insured Party Communication Number Qualifier: WP: Work Phone Communication Number: 10 digits beginning with area code Communication Number Qualifier: HP: Home Phone Communication Number: 10 digits beginning with area code Participant s Address Information if only one line: may contain up to 35 characters Participant s Address Information if second line: may contain up to 35 characters Participant s City: up to 25 characters Participant s State: 2 standardized characters Participant s Postal Code: up to 9 digits Participant s Country: 2 standardized characters if not US; see Nations at Tables htm Date Time Period Format Qualifier: D8: Date format expressed as CCYYMMDD Member s Date Of Birth: CCYYMMDD (birth date) Gender Code: F: Female M: Male Maintenance Type Code: 030: Audit or compare Insurance Line Code: AK: Mental Health for ValueOptions DEN: Dental for Delta Dental HLT: Health for Anthem and AON PDG: Prescription Drug for Medco Plan Coverage Description: 000: Waived Coverage 002: Option I 003: Option II 006: Kaiser Permanente HMO 027: Advantage : Option II + Dnt,Vsn Audit File Layout (2).docRevised 02/25/2005 Page 8 of 9

9 HD DTP Health Coverage Dates DTP01 DTP02 DTP03 Table 4 Transaction Set Trailer 690 SE Transaction Set Trailer SE01 SE02 Table 5 Functional Group Trailer GE Functional Group Trailer GE01 GE02 Table 6 Interchange Control Trailer IEA Interchange Control Trailer IEA01 IEA02 037: Advantage 65 + Dnt,Vsn 042: Basic COVA Care 043: CC + OON 044: CC + ExpDnt 045: CC + OON & ExpDnt 046: CC + Vsn,Hrg & ExpDnt 047: CC + OON & Vsn,Hrg,ExpDnt Coverage Level Code: E1D: Self Plus Child ESP: Self Plus Spouse IND: Self Only FAM: Family Date/Time Qualifier: 348: Benefit Begin Date Time Period Format Qualifier: D8: Date format expressed as CCYYMMDD Date Time Period: CCYYMMDD (The latter of the Plan Begin Date, Coverage Level Begin Date, and the Bill Premium Date; the date the current coverage described on this transaction started.) Number of Included Segments Transaction Set Control Number Number of Transaction Sets Included Group Control Number Number of Included Functional Groups Interchange Control Number Audit File Layout (2).docRevised 02/25/2005 Page 9 of 9