834 Enrollment Transaction Deep Dive

Transcription

1 834 Enrollment Transaction Deep Dive May 2, 2013 A service of Maryland Health Benefit Exchange

2 Agenda Version Scheduling Validation Connectivity Security 834 file format Reconciliation Q&A 2

3 834 Version Version for 10/ A1 standard Batch file processing only, no real time enrollment transactions Outbound standard for Individual, SHOP, reconciliation, CMS reporting Inbound standard from Carriers and TPAs utilize same version 3

4 Inbound Scheduling 834 files from the Maryland Health Connection will be transmitted during the nightly batch process Midnight to 5:00 am (pending production volume) Maryland Health Connection expects acknowledgements to be delivered within a 24 hour window 4

5 Outbound Scheduling 834 files from the Carrier and TPAs will be processed starting at 9:00 am Maryland Health Connection generates acknowledgements within a 24 hour window 5

6 Inbound and Outbound Validation Carrier and TPA must follow SNIP 1 and SNIP 2 edits mandated by HIPAA Maryland Health Connection will follow the SNIP 1 and SNIP 2 edits mandated by HIPAA 6

7 Connectivity SFTP server where a Carrier/TPA picks up the file Inbox Inbound files from Maryland Health Connection to Carrier/TPA Outbox Outbound files from Carrier/TPA to Maryland Health Connection Files are archived in corresponding archive folders for future reference and/or error resolution 7

8 Security Files that contain PHI must be encrypted: Inbound files from the Maryland Health Connection sent to the Carrier and TPA will be encrypted using PGP with the respective Carrier and TPA public key Outbound files from Carrier and TPA sent to the Maryland Health Connection will be encrypted using PGP with the Maryland Health Connection s public key 8

9 ISA Interchange Control Header ISA06 Interchange Sender ID HIX01MD ISA08 Interchange Receiver ID Assigned to Carrier and TPA as per the Business Agreement ISA13 Interchange Control Number Unique control number for each file sent must increment from one day to the next ISA15 Usage Indicator T = Test Data P = Production Data 9

10 GS Functional Group Header GS02 Application Sender's Code Must be the same value as ISA06 GS03 Application Receiver s Code Must be the same value as ISA08 GS06 Group Control Number Unique control number for each group sent must increment from one day to the next GS08 Version Identifier Code Must be X220A1 10

11 ST Transaction Set Header SE Transaction Set Trailer Individual Market One individual information will be looped in one ST- SE transaction SHOP Market One group information will be looped in one ST-SE transaction 11

12 Loop 1000A Sponsor Name Individual Market N102 Subscriber name or Responsible Person name N103 FI N104 SSN is required as the identification code SHOP Market N102 Employer group name N N104 Employer TIN is required as the identification code 12

13 Loop 1000B Payer N102 Carrier Name N103 FI N104 Assigned to Carrier as per the Business Agreement (same as ISA08 & GS03) 13

14 Loop 1000C / 1100C TPA/Broker/Navigator Individual Market Navigator Information Broker Information SHOP Market Navigator Information Broker Information TPA and Broker Information N102 Navigator or Broker Name N103 FI N104 Navigator or Broker Tax ID ACT01 Navigator, Broker, or TPA Account Number 14

15 INS Member Level Detail INS01 Response Code Y = Insured N = Dependent INS03 Maintenance Type Code Maryland Health Connection uses this code to identify the specific type of maintenance 001-Change 021-Addition 024-Cancellation 025-Reinstatement 030-Audit or Compare 15

16 REF Subscriber Identifier REF01 0F (0F=Subscriber Number) REF02 Subscriber Number assigned by Maryland Health Connection for identification 16

17 Loop 2100A Demographic Information NM103 Last Name NM104 First Name NM NM109 SSN N3/N4 Address DMG02 Date of Birth DMG03 Gender Code DMG05-1 Race Code HLH01 Tobacco Usage Indicator 17

18 HD Health Coverage HD01 same as INS03 HD03 Insurance Line Code (DEN, HLT) Used to identify the insurance type under coverage HD05 Coverage Level Code (EMP, FAM, etc.) Level of coverage being provided 18

19 DTP Health Coverage Dates DTP01 303/348 Effective date of coverage DTP Coverage termination date 19

20 REF Health Coverage Policy Number REF01 1L (1L = Qualifier for Policy Number or Plan ID) Will transmit when the Exchange Assigned Policy Identifier will be conveyed in the associated REF02 element. REF02 Policy Number or Plan ID 20

21 Loop 2310 Provider Information LX Provider Information is sent when required by Carrier NM108 Provider Identification Code Qualifier SV = Service Provider Number XX = Centers for Medicare and Medicaid Services National Provider Number NM109 Provider Identification Code 21

22 Loop 2750 MD-Specific Reporting Categories N101 Participant N102 Carrier to Bill/CSR AMT/APTC AMT REF02 CSR AMT/APTC AMT DTP03 Effective Date APTC Amount the QHP issuer can expect to receive toward the total premium payment (APTC) CSR Advance CSR payment amount If an individual elects to pay the Carrier, this information is sent in this reporting category loop 22

23 Reconciliation Reconciliation files will be processed on the 15 th of each month Refer to the Carrier Integration Package, Section 10.5 for a list of required reconciliation data elements 23

24 QUESTIONS? 24