Physical Interface BCBS Paperless Enrollment

Transcription

1 User Interface Review Physical Interface BCBS Paperless Enrollment Physical Interface BCBS Paperless Enrollment Description: This batch utility is run on a weekly basis to extract all retirees who have enrolled or cancelled coverage since the last report. This information should be sent as a text file to BCBS Rhode Island. File disposition: will produce this file and store it on the server. ERSRI will transfer the file to OLIS or BCBS at their discretion by the method/media of their choice (refer to VBCBS for transmission options). Control Report: The control report produced with this file will display counts of records, grouped by source type and activity code. Example: Source Activity Count B add 383 B cnc 347 C add 210 C cnc 32 Data Rules: File Format: Text file, no delimiters ALL TEXT IN FILE TO BE UPPERCASE. The file consists of records 400 characters in length. Rule 1: Find new policies created since the last extract. Select all policies where the Enrollment Transmittal Date is null and the Bill by Carrier indicator is false or null. Write the add activity record(s)[rule 2] to the extract for the policy owner ( S subscriber record) and set the enrollment transmittal date for that policy (in the LOB database) equal to the current business date. Rule 2: Extract AT LEAST one record for each healthcare policy being initiated (new enrollments). Extract one record for the policy holder, and one record for each covered individual on that policy. For each covered individual, write a D dependent record to the extract. Rule 3: If the write of the subscriber or any dependents for a policy fail, do not update the transmittal date and write an error to the control report. Rule 4: Find policies that have had end dates put on them since the last extract. Select all policies with an end date AND the Enddate Transmittal Date is null. Write the cnc activity record to the extract and update the enddate transmittal date to the current business date. Extract one record for each healthcare policy being cancelled (the subscriber record). HP-SLED Page 1 of 4 1/7/2011

2 User Interface Review Physical Interface BCBS Paperless Enrollment Required BCBS Item Name Valid Values Description Source source identifier Yes 1 5 PENSb Identifier Position Length source type Yes 6 1 'b', 'c' record type Yes 7 1 's', 'd' 'add', activity code Yes 8 3 'chg','cnc' subscriber id number No SPACES dependent number No 26 3 SPACES subscriber social security number Yes 29 9 dependent social security number Yes 38 9 group number -- right justified 47 6 subgroup number -- right justified 53 3 new group number -- right justified 56 6 SPACES new subgroup number -- right justified 62 3 SPACES carrier code of the policy being reported, record type being reported. activity being reported BCBS ID number BCBS ID number group number that identifies ERSRI Data Rule Where b stands for Blank. It is always PENSb 'b' for BCBS, 'c' for CHip 'S' for subscriber, 'd' for dependent; report at least one record for each policy; if coverage is for family, report one dependent record for each covered individual 'add' = new coverage(policy) being reported, 'cnc' =cancel exisiting policy; Always an 'add' or 'cnc', ERSRI will never report 'changes' spaces spaces If 'record type' is 's' or 'd', populate with policy holder SSN. If 'record type' is 'd', populate with covered individual SSN. Carrier_Grp_Id from BE_HC_Pkg; Right justified Always Blanks; Right justified only used by BCBS for 'changes' which we will not report - always pop. W/ SPACES only used by BCBS for 'changes' which we will not report - always pop. W/ SPACES HP-SLED Page 2 of 4 1/7/2011

3 User Interface Review Physical Interface BCBS Paperless Enrollment group package number 65 3 last name identifier for 'Healthmate' or 'Plan65', etc. Carrier package Id from be_hc_pln_ref Last name of person being reported; truncated current first name First name of person being reported; truncated new first name SPACES used by BCBS for changes only, always SPACES middle initial Middle Initial; truncated title (jr, sr, iii, etc.) sex code 'm', 'f' relationship code marital status 'm', 's' subscriber contract type 'ind', 'fam' relationship of reported person to policy holder Name suffix of person being reported sub' = subscriber, 'sps' = spouse, 'chd' = child, 'stu' = student, 'hcd' = handicap; from database 'family relationship', dependent child = chd; dependent adult = hcd if rel. code = 'sps' then 'm'; marital status if child, stu, hcd then 's'; of person for subscriber, indicate being reported actual marital status. policy coverage coverage of the policy being reported; Individual or Family two-person indicator SPACES not used by ERSRI current date of birth (yyyymmdd) new date of birth (yyyymmdd) SPACES not used by ERSRI subscriber address 1 Yes Address Line 1 subscriber address 2 Yes Address Line 2 subscriber address 3 (foreign address use only) No Address Line 3, only if foreign address city No not for foreign addresses state No not for foreign addresses zip No not for foreign addresses pharmacy number No From the Policy; with leading ZERO s PCP number No From the Policy; with leading zeroes Start date of policy in effective date (yyyymmdd) Yes HP-SLED Page 3 of 4 1/7/2011

4 User Interface Review Physical Interface BCBS Paperless Enrollment termination reason Yes 258 always use 'ml' indicating a voluntary cancellation of 2 'd', 'ml', 'dv', 'oi', 'oa', 'sr', 'nc' coverage employee number No SPACES not used by ERSRI department number No SPACES not used by ERSRI current health insurance indicator SPACES not used by BCBS current dental insurance indicator SPACES not used by BCBS cob id number SPACES not used by BCBS subscriber phone number only pop if record type is 's' subscriber filler SPACES primary care physician cancel indicator SPACES not used by ERSRI pharmacy cancel indicator 351 1SPACES not used by ERSRI effective change date indicator SPACES not used by BCBS former health insurance carrier SPACES not used by BCBS Medicare (HCFA) identification number Medicare number of covered individual CHiP division (group) number SPACES not used by BCBS employer status SPACES not used by BCBS employee hire date (yyyymmdd) SPACES not used by BCBS filler SPACES filler HP-SLED Page 4 of 4 1/7/2011

5 Billing Rec File Physical Interface Billing Rec File Description: This batch utility is monthly, after the pension run, to extract all retirees who had a payroll deduction for Medicare Complete. This file is extracted from the file created by the batch utility Extract Healthcare information. Data Rules: 1.File Format: Text file, comma delimited File Layout: Last name: First name: Char(30) Char(20) Social security Number: Char(9) Months being paid: Amount being paid: Char(60) Char(10) Package code : Char(5) HP SLED Page 1 of 1 1/7/2011

6 User Interface Review Physical Interface - COBRA Expiration File Physical Interface PI-COBRA Expiration File Description: The COBRA Expiration File is used for creating the COBRA Expiration Letters. The COBRA Expiration File is generated through an SQR process that reads the information from a temporary table in the database and creates a text file. This text file will be used to generate the COBRA Expiration Letters to be sent to the recipients. Data Rules: The following information must be reported on the file: Field Datatype Position Format Comments First Name, Middle Initial, Last Name Alphanumeric 51 char from position 1 to 51; 20 char First Name + 1 char Middle Initial + 34 char Last Name Address 1 Alphanumeric 30 char from position 52 to 82; Address 2 Alphanumeric 30 char from position 83 to 113 Address 3 Alphanumeric 30 char from position 114 to 144 City Alphanumeric 28 char from position 145 to 173; State Alphanumeric 2 char from position 174 to 175; Zip 5 Numeric 5 char from position to 180; Zip 4 Numeric 4 char from position to 184; Province Alphanumeric 20 char from position 185 to 205; Postal Code Alphanumeric 10 char from position 206 to 216; Country Alphanumeric 30 char from position 217 to 247; Greeting Alphanumeric 40 char from position 248 to 288; Termination Numeric 6 char from position mm/cc/yy Date User First Name, User Middle Initial, User Last Name Alphanumeric 289 to char from position 296 to 347 User Title Alphanumeric 51 char from position 348 to char User First Name + 1 char User Middle Initial + 34 char User Last Name HP-SLED Page 1 of 2 1/7/2011

7 User Interface Review Physical Interface - COBRA Expiration File HP-SLED Page 2 of 2 1/7/2011

8 Dental-record format State of Rhode Island payment file layout Field Name Field Type Field Length Example Group Code Character Sub Location Character SSN Character 9 XXXXXXXXX Contract Character 3 IND or FAM Last_Name Character 24 Espo First_Name Character 20 Anthony Begin_Date Character End_Date Character Premium Numeric 6, Retro_Premium Numeric 6, months coverage HP-SLED Page 1 of 1 1/7/2011

9 Eligibility Rec File Physical Interface Eligibility Rec File Description: This batch utility is monthly, after the pension run, to extract all retirees who had a payroll deduction for United Medicate Complete HMO. This file is extracted from the file created by the batch utility Extract Healthcare information. Data Rules: File Format: Text file, comma delimited 1. Termination date would be blank if there is no end date 2. If the permanent address is not present the temporary address would be displayed. Layout: Last name: First name: Char(30) Char(20) Social security Number: Char(9) Billing period date: Char(8) Termination date :Char(8) Street Address :Char(30) City: Char(20) State : Char(2) Zip code 5 :Char(5) Group number: Char(5) HP SLED Page 1 of 1 1/7/2011

10 Healthcare Information File Description Position Length Valid Values Description data rules Subscriber Record : Group/Sub- Group Numbers Package Number Carrier_Grp_id from BE_HC_pkg char(6) + Carrier_Sub_Grp_id from BE_HC_pkg char(3) Carrier_Pkg_id from be_hc_pln_ref. Owner SSN We will just retain the Will list the owner 13 field length but it SSN will only by 9 char Subscriber Social 26 9 Socail Security Security Number Number SSN of the subscriber Subscriber 35 3 policy coverage 'FAM' if family, 'IND' Contract Type 'FAM', 'IND' if Individual Relationship 38 3 Code SUB' always 'SUB' Last Name truncate if necessary First Name truncate if necessary Middle Initial 66 1 Marital Status : 67 1 M = Married if a spouse policy, 'M'; if a retiree policy, if spouse relationship exists, 'M', else, 'S'; divorced, widowed and seperated not used 'M','S','D','W','P' in Date-of-Birth : 68 8 Date of birth of the Billing Period : From Date Billing Period : Thru Date CCYYMMDD CCYYMMDD CCYYMMDD policy person 1 st day of the month following the pension run (9/26/2002 pension run deducts premiums for October, so start date = 10/01/2002) Last day of the month following the pension run (9/26/2002 pension run deducts premiums for October, so end date = 10/31/2002) HP-SLED Page 1 of 4 1/7/2011

11 Healthcare Information File premium amount Tier 1 subsidy amount Tier 2 subsidy amount Tier 2 Subsidy category Retro premium amount Retro Subsidy Amount Tier 1 Retro Subsidy Amount Tier 2 RetroPayment Health Care Amount V V V '0','10','20','30','40','50','60','70','80','90',' 100' V V V V99 Regular Health care deduction amount Regular basic state subsidy amount Regular state subsidy amount Subsidy percentage Retro Health Care Deductions Retro deduction basic state subsidy amount Retro deduction state subsidy amount Retro Payments for Health Care if item type is 'Healthcare - retiree', 'Healthcare - spouse', Dental, Vision, pharmacy regardless of coverage (family or individual) put the pyrl_adj_hist amount here 'Basic' state subsidy - the fixed subsidy amount the graduated subsidy amount that is based on service credit, etc. The percentage subsidy determined when the premiums were calculated. if item type is 'Retro Healthcare Retiree', 'Retro Healthcare Spouse', 'retro vision', 'retro dental' or 'retro pharm', regardless of coverage (family or individual) put the pyrl_adj_hist amount here If a retro premium was deducted, this represents the First (Tier 1 / Basic) subsidy amount of the retro premium If a retro premium was deducted, this represents the Tier 2 subsidy amount (variable) of the retro premium if item type is 'Retro Payment Healthcare Retiree', 'Retro Payment Healthcare Spouse', 'retro payment vision', 'retro payment dental' or 'retro payment pharm', regardless of coverage (family or individual) put the HP-SLED Page 2 of 4 1/7/2011

12 Healthcare Information File pyrl_adj_hist/fnc_item amount here Retro Payment Subsidy Amount Tier 1 Retro Payment Subsidy Amount Tier Rule # V V99 char(5) Rule Description record type 'HC','V','D','P' Payroll Date CCYYMMDD Policy Owner Retro payment basic state subsidy amount Retro payment State Subsidy amount If a retro payment premium amount represents the First (Tier 1 / Basic) subsidy amount of the premium amount deducted If a retro payment premium amount represents the Tier 2 subsidy amount (variable) of the premium amount deducted Client rule code from Rule Cli Cd from plan healthcare rule BE_HC_Rule_Ref table Rule Description client rule description from from healthcare rule BE_HC_Rule_Ref table Is this a record for Health, Vision, Dental or Pharmacy? (what was the payroll deduction type?) date of last pension payroll '1','2' 1 = retiree; 2 = spouse Vendor vendor org_id associated with the associated policy Billed By Carrier boolean Retirement Plan Benefit Structure the retirement plan the retiree is part of (ERS, MERS, JDGS, STPL) plan_cli_cd from be_pln (policy - rcpnt_acct - bene_acct - plan) client cd from bene_struc_ref (policy HP-SLED Page 3 of 4 1/7/2011

13 Healthcare Information File Employee Group Retirement Type ERSRI healthcare plan ID rcpnt_acct - bene_acct - bene_struc_ref) emp group from bene_struc_ref (policy - rcpnt_acct - bene_acct - bene_struc_ref) Retirement Type of the benefit account HealthCare plan Id ERSRI Healthcare Plan Name Health Care plan name Owner sex Employer start 362 date Date of retirement CCYYMMDD CCYYMMDD Service credit V99 Recipient Gender Recipient DoB Policy start date Health care contribution percentage CCYYMMDD CCYYMMDD 999V99 this field will show the health care percentage that the retiree will be paying If a policy is a family policy then there will a record for every covered individual in the policy, for all the dependent records premium amount,tier 1 subsidy amount,tier 2 subsidy amount,tier 2 Subsidy category,retro premium amount,retro Subsidy Amount Tier 1,Retro Subsidy Amount Tier 2,RetroPayment Health Care Amount,Retro Payment Subsidy Amount Tier 1,Retro Payment Subsidy Amount Tier 2 will be showns as ZERO And Rule #,Rule Description,Vendor,Billed By Carrier,Retirement Plan,Benefit Structure,Employee Group,Retirement Type,ERSRI healthcare plan ID,ERSRI Healthcare Plan Name will be have the value that of the subscriber details HP-SLED Page 4 of 4 1/7/2011

14 Medicare Billing File Layout Column Headings Field Name: Position Start: Position End: Field Length: Required: Description: Values In: Identifies what specific data should be placed in this field. Indicates the starting position of the field. Indicates the ending position of the field. Indicates the maximum number of bytes for the data. Identifies whether the field should be completed for the employee, dependent, or both. The following codes are used in this field: E = Indicates field is required for employee (subscriber) record D = Indicates field is required for dependent B = Indicates field is required for both employee and dependent Identifies if the customer is required to populate this field with data. The following codes are used in this field: R = Required: The customer is required to populate this field as noted. O = Optional: The customer can determine through their eligibility process if they want to populate this field. C = Conditional: The customer may be required to populate these fields based on the values in other fields. Defines the "Field Name". Specifies the Gateway Standard Format values that the customer will use to populate fields. Header Record Requirements: The header record must be the very first record on the file, and the format must be as follows: Field Name Position Position Field Field Required Description Values In Start End Length Type Header Filler R Filler area must be spaces. Blank Header Detail R Total number of detail records Must be a right justified, record Count excluding the Header Record. zero filled, numeric value. Header Filler 28 R Must be a pipe delimiter. A carriage return should immediately follow the pipe delimiter. No spaces or added characters should be sent between the pipe and the return. Member Record Requirements Fields highlighted in yellow are required fields and must be sent on the file. All data should be left justified. No default or filler values should be placed in trailing spaces. All uppercase character data is preferred, but it some instances it is required. Fields requiring uppercase data are noted. Your Electronic Eligibility Analyst will advise you if any of the filler fields should be populated. Field Name Position Position Field Field Required Description Values In Start End Length Type Version Indicator B R Indicates layout version submitted. Use code: V1.20 HP-SLED Page 1 of 8 1/7/2011

15 Medicare Billing File Layout Field Name Submission Group ID Relationship Code Position Start Position End Field Length Field Type Required Description Values In B R The 4-8 character ID assigned Your Electronic Eligibility by the Electronic Eligibility Analyst will inform you of Analyst for this submission this code. group. The submission group ID must be in all capital letters B R LEAVE BLANK Blank B R Identifies if the record is for an employee or dependent. Note: If a relationship code of 20 (student) is sent, UHG will generate a Student Status Verification letter that will be mailed to the member. Do not use relationship code 20 if UHG is not verifying student status for your group. Employee ID B R The unique employee identifier. (See eligibility guide for information on alternate identification numbers.) Member Social Security Number Former EE ID *not commonly used Personnel ID *not commonly used Employment Date Member Last Name Member First Name Member Middle Initial Member Birth Date 18= Employee 01= Spouse 19= Child 20= Student 34= Retiree 02= Surviving Spouse 38= Collateral Dep 23= Sponsored Dep 09= Stepchild 21= Handicapped Dep 22= Handicapped Student 35= New Born 53= Life Partner 36= Other Subscriber social security number should be used. Format: digit SSN B R LEAVE BLANK Blank B O The member's Social Security Member's social security Number. If unknown this number. Format: field must be Leave Blank digit SSN Duplicate SSN's are not permitted B R LEAVE BLANK Blank E O If the employee ID is changing the prior employee ID is entered in this field for reporting. The prior employee ID Format: digit SSN E O Personnel ID number B R LEAVE BLANK Blank E R The date the employee YYYYMMDD started work with the company B R LEAVE BLANK Blank B R The member's last name. Member's last name No punctuation should be included B R The member's first name. Member's first name Note: Due to system constraints, do not include middle name or middle initial in this field. No punctuation should be included B R LEAVE BLANK Blank B O The member's middle initial. Member's middle initial B R LEAVE BLANK Blank B R The member's date of birth. YYYYMMDD B R LEAVE BLANK Blank HP-SLED Page 2 of 8 1/7/2011

16 Medicare Billing File Layout Field Name Position Position Field Field Required Description Values In Start End Length Type Member Gender B R The member's gender. M = Male F = Female U = Unknown Member Marital Status B R The member's marital status. B= Registered Domestic Partner D= Divorced I= Single M= Married R= Unreported S= Separated W= Widowed U= Unmarried/Unknown COB Flag *not commonly used COB Date *not commonly used Language *not commonly used Permanent Street Address 1 Permanent Street Address B O Indicates if member has other coverage. If used should only be sent for new enrollees and then the information should be dropped from the file B O Start date of Coordination of Benefits (COB). If used should only be sent for new enrollees and then the information should be dropped from the file E O Indicates primary language of member B R Member's street address. This field is required for all members. No punctuation should be included. Both subscribers and dependents must have a permanent address passed on your file B O The member's second line of street address (Apt Number, PO Box, Care of Address, Etc.). No punctuation should be included. This is an optional field and should be used only if Permanent Street address 1 is completed. Y = Yes other coverage N or Blank = No other coverage YYYYMMDD Field should be left blank Member's primary street address Member's secondary street address Permanent City B R The member's city. This field is required for all members. No punctuation should be included. Both subscribers and their dependents must have a permanent city passed on your file. Member's city address Permanent State B R The member's state. No Member's state address punctuation should be included. Must be in all capital letters. Permanent Zip Code 5-digit zip code and 4- digit zip code extension B R 5-digit zip code and 4-digit zip code extension. The 5-digit zip code is a required field for domestic addresses; the zip code extension is optional and can be left blank. Note: Do not include a dash (-) between the 5 digit zip code and the 4 digit zip code extension. Canadian zip code format: Canadian alphanumeric codes must have a space between the third and fourth byte of the postal code in this field. For example, A9A_9A9. HP-SLED Page 3 of 8 1/7/2011

17 Medicare Billing File Layout Field Name Permanent Country Code Mailing Street Address 1 Mailing Street Address 2 Position Start Position End Field Length Field Type Required Description Values In B R The Country the employee Must be 2 characters in resides in. length. For example, USA = US. For a complete listing of country codes use the following web address ds-services/iso3166ma/02iso code-lists/index.html B R LEAVE BLANK Blank B C Member's mailing street Member's primary mailing address. The Mailing address street address fields should be used if the member has a mailing address different from that of the Permanent address. No punctuation should be included B C The member's second line of mailing street address (Apt Number, PO Box, Care of Address, Etc.). This is an optional field and should be used only if street address 1 is completed. No punctuation should be included. Member's secondary mailing street address. Mailing City B C Member's mailing city. No Member's mailing city. punctuation should be included. Mailing State B C Member's mailing state. No punctuation should be included. Must be in all capital letters. Member's mailing state Mailing Zip Code B C 5-digit zip code and 4-digit zip 5-digit zip code and 4- code extension. The 5-digit digit zip code extension. zip code is a required field for domestic addresses; the zip code extension is optional and can be left blank. Mailing Country Code Home Phone Number Note: Do not include a dash (-) between the 5 digit zip code and the 4 digit zip code extension B C The Country the employee resides in. Canadian zip code format: Canadian alphanumeric codes must have a space between the third and fourth byte of the postal code in this field. For example, A9A_9A9. Must be 2 characters in length. For example, USA = US. For a complete listing of country codes use the following web address ds-services/iso3166ma/02iso code-lists/index.html B R LEAVE BLANK Blank B R Members 10 digit home phone Members home phone number. No dashes or spaces number. allowed. Death Date E C Members death date YYYYMMDD B R LEAVE BLANK Blank HP-SLED Page 4 of 8 1/7/2011

18 Medicare Billing File Layout Field Name XREF/Payee Indicator XREF/Payee Last Name XREF/Payee First Name Position Start Position End Field Length Field Type Required Description Values In E C This field should be completed 01 = spouse only if this record is for a 11 = Surviving survivor situation, or if Dependent sending an opt-out EE w/optin 18 = Self dependents. The code is 20 = Military used to indicate whom the XREF name/number belongs to E C Last name of survivor. This field should only be completed if the payee indicator field is populated. Survivor's last name E C First name of survivor. Survivor's first name This field should be only completed if the payee indicator field is populated B R LEAVE BLANK Blank XREF/Payee SSN E C Social Security Number of survivor. This field should only be completed if the payee indicator field is populated. Survivor's social security number Format: digit SSN B R LEAVE BLANK Blank Special Util E C Utility field that will feed data to TOPS. Blank or customer specific data. Sub-Department E C The Sub-Department number This field should be left Nbr sorts employees on the blank. *not commonly used invoice within employer's specific sub-departments. Retirement Date B C The date the member retires. YYYYMMDD This is required field for members with a retiree status B R LEAVE BLANK Blank Primary Physician MPIN/Location Primary Physician Start Date Primary Physician Stop Date *not commonly used Primary Physician IPA *not commonly used Primary Physician Current Patient Indicator B C Member's primary care physician identification number. Primary Care Physician identification number Format: digit MPIN+0+2-digit Location Code. For example: B R LEAVE BLANK Blank B C The date the member s YYYYMMDD primary physician became or will become effective B R LEAVE BLANK Blank B O The date the member is no YYYYMMDD longer covered by this primary physician B R LEAVE BLANK Blank B O The independent practice Independent practice association number of the association number primary care physician B O Indicates if the member is a current patient of the primary care physician. Filler Field Blank Blank Filler Field Blank Blank 25= Established Patient 26= Not Established Patient 72= Unknown HP-SLED Page 5 of 8 1/7/2011

19 Medicare Billing File Layout Field Name Position Position Field Field Required Description Values In Start End Length Type Filler Field Blank Blank Special Util Utility field that will feed data to UBH. Blank or customer specific data. Special Util Utility filed that will feed data to Billing. Blank or customer specific data. Salary Year E C CCYY Salary E C Salary In Area E C OOP Salary Out Area E C OOP Salary In Area E C Ded Salary Out Area E C Ded Com-Util B O For future or customer specific field requirements. Com-Util B O For future or customer specific field requirements. Member Utility B O For future or customer specific field requirements. Special Utility B O For future or customer specific field requirements. Coverage 1 Coverage Type Coverage 1 Coverage Start Date B R Field used for first coverage type selected by member. Coverage type must be passed with all capital letters. Note: Normally Coverage type 1 is for Medical Coverage. MM is the recommended code for medical coverage. AK may be used for standalone (S) coverage such as OPTUM B R The date the member's YYYYMMDD coverage becomes effective with UHG B R LEAVE BLANK Blank Product Codes: EXM= Executive Medical DCP= Dental Capitation DEN= Dental EPO= Exclusive Provider Organization HE= Hearing AG= Preventative Care HMO= Health Maintenance Organization MM= Major Medical IND = Indemnity AS= Accident and Sickness MOD= Mail Order Drug PDG= Prescription Drug RX2= Mail Order Drug and Prescription Drug POS= Point of Service PPO= Preferred Provider Plan PRA= Practitioners VIS= Vision AK= Mental Health LTC= Long Term Care LTD= Long Term Disability STD= Short Term Disability UR= Utilization Review BLF= Basic Life SLF= Supplemental Life DEL= Dependent Life SAD= Supplemental AD&D HP-SLED Page 6 of 8 1/7/2011

20 Medicare Billing File Layout Field Name Coverage 1 Coverage End Date Coverage 1 Coverage Paid Thru Date Coverage 1 Structure Field 1 Coverage 1 Structure Field 2 Coverage 1 Structure Field 3 Coverage 1 Structure Field 4 Coverage 1 Structure Field 5 Position Start Position End Field Length Field Type Required Description Values In B C The date member's coverage YYYYMMDD is cancelled or will be cancelled. Note: A Coverage End Date should only be passed if a member is terminating this coverage type with UHC. Coverage End Dates may not be more than 30-days in the future, and once a member terminates all coverage types and a term date is passed that member must be dropped off the file B R LEAVE BLANK Blank B C The date in which the YYYYMMDD member has paid thru his/her COBRA coverage. This field only should be used in COBRA situations B R LEAVE BLANK Blank B R Seven-digit customer number assigned by UHG. The entry will be the same for all records on the file B R LEAVE BLANK Blank B R Policy Number of Customer. This number along with the plan variation code and reporting code make up the account structure. Seven digit Customer Number. NOTE: Must be seven digits long. If shorter than seven digits pre-fill with zeros to make the number seven digits. Seven digit Policy Number NOTE: Must be seven digits long. If shorter than seven digits pre-fill with zeros to make the number seven digits B R LEAVE BLANK Blank B R Four digit numeric Plan Plan Variation Code Variation code within account structure. NOTE: The Plan For example: 0004 Variation and Reporting Code can be found in your copy of the Account Structure for this group. Your Client Services Manager can provide you with a copy of this structure B R LEAVE BLANK Blank B R Four digit numeric reporting Reporting Code code within the account structure. NOTE: The Plan For example: 0004 Variation and Reporting Code can be found in your copy of the Account Structure for this group. Your Client Services Manager can provide you with a copy of this structure B R LEAVE BLANK Blank B C The Plan Code field is required Blanks = No Embedded for plans with Embedded Vision Vision Coverage. VE = Embedded Vision HP-SLED Page 7 of 8 1/7/2011

21 Medicare Billing File Layout Field Name Coverage 1 Structure Field 6 Coverage 1 Structure Field 7 Coverage 1 Structure Field 8 Coverage 1 Structure Field 9 Coverage 1 Structure Field 10 Coverage 1 Members Covered Coverage 1 COBRA Indicator/Cancel Reason Coverage 1 Elig Util-1 Coverage 1 Elig Util-2 Coverage 1 Elig Util-3 Coverage 1 Elig Long Util-1 Coverage 1 Life Flat Amount Coverage 1 Life Benefit Factor Coverage 1 Rider Dep Flag Coverage 1 Rider Critical Illness Position Position Field Field Required Description Values In Start End Length Type B R LEAVE BLANK Blank B C Field is reserved for customer Blank or Customer specific structure data. specific data B C Field is reserved for customer Blank or Customer specific structure data. specific data B C Field is reserved for customer Blank or Customer specific structure data. specific data B C Field is reserved for customer Blank or Customer specific structure data. specific data B C Field is reserved for customer Blank or Customer specific structure data. specific data B O The code indicates which members of the family are covered for this particular coverage. All members of the family should have the same Members Coverage Code. THIS IS AN OPTIONAL FIELD BECAUSE UHG DERIVES THE INFORMATION BASED ON THE ACTIVE FAMILY MEMBERS IN OUR SYSTEM. CHD= Children Only SD1= Employee and 1 Dep ECH= Employee and Children EMP= Employee Only ESP= Employee and Spouse FAM= Family SPO= Spouse Only CH1 = Child Only SPC= Spouse and Children SS1 = Subscriber, Spouse + 1 Dependent B C This field is used to indicate that the coverage being TC = UHC Administered TY = Customer reported is being continued as Administered a result of a COBRA election. NC = No HIPAA Cert Produced. Your Electronic Eligibility Analyst will provide you with the appropriate code to use B O For future or customer specific field requirements B O For future or customer specific field requirements B O For future or customer specific field requirements B O For future or customer specific field requirements E C The flat amount of the life Dollar amount of life benefit. benefit E C Value salary amount is multiplied by to determine dollar amount of benefit E C Indicates whether the subscriber selected the dependent coverage rider E C Indicates whether the subscriber selected the critical illness rider. Benefit factor dollar amount Y= Dependent Rider was selected N= Dependent Rider was not selected Blank= Dependent coverage not available Y= Critical Illness Rider was selected N= Critical Illness Rider was not selected Blank= Critical Illness coverage not available HP-SLED Page 8 of 8 1/7/2011

22 UHG 3005 File Format Specifications Version 1.20 April 8, 2005

23 Overview The UHG 3005 file format was created in order to standardize the processing of electronic eligibility information as it passes through Employer eservices Electronic Eligibility Management System. This standardization will allow customers to benefit from all of the processing benefits of Employer eservices Electronic Eligibility Management System, as well as provide UnitedHealth Group with a more streamlined mapping procedure. The format encompasses processing requirements and incorporates the use of HIPAA input values to allow UnitedHealth Group to remain strategic and flexible within the market place. In the event that there are governmental or industry changes to the data that UnitedHealth Group is required to collect, UnitedHealth Group may modify the UHG 3005 file format. If that occurs, UnitedHealth Group would require the customer to change to the new version of the UHG 3005 file format within a calendar year. This customer change is required because the Electronic Eligibility Management System will not support more than two active versions of the format. The following pages provide detailed specifications on the format of the information that should be passed on the file. The format of the file provides for demographic information to be passed first, with coverage information following. The Employer eservices Electronic Eligibility Management System can currently process up to 4 coverage types. Coverage blocks 5-10 are not currently utilized, and are in dark gray on the file specifications starting on page 19. The UHG 3005 file format has been designed to accommodate future enhancements to our system. There are five categories of information that may be included on each record: Member Identification Information Address Information Survivor Information Primary Physician Information Coverage Information These categories of information are described below. Member Identification Information This category includes information specific to the member such as relationship code, social security number, employment date, full name, and date of birth. This information will uniquely identify each member of the family on the UnitedHealth Group eligibility system. Please note that middle initials or names may not be sent in the first name field as it creates a claim matching issue when a claim is processed for the member. The following special characters are acceptable within the following fields: First name & Payee First name: - ' ()., Hyphen, apostrophe, parentheses, period and comma. These characters will be converted to a space in our system. Middle name: no special characters are allowed. Last name & Payee Last name: - ' Hyphen and apostrophe. These characters will load directly into our system as is. The following characters will be converted to a space in our system:., / * ~ () # % > < " Period, comma, slash, asterisk, tilde, parentheses, pound, percentage, greater than, less than, and quote. HP-SLED Page 2 of 33 1/7/2011

24 Address Information The UnitedHealth Group Eligibility System has the ability to store up to 2 addresses for each family, one permanent and one mailing address. Every record on your file must have the permanent address field(s) populated. This includes both employee and dependent records. The mailing address field(s) should only be populated if it is different from the permanent address field(s). In addition to the standard postal state abbreviations, AP and AE are also valid when used with 'APO' in the state field. Foreign Address Processing UnitedHealth Group prefers that foreign members be passed with the employer s domestic HR mailing address as the expatriate s permanent address. In the event that this is not an option, UnitedHealth Group has a special handling procedure for expatriates. If a foreign address is passed on your electronic file, we will load a UnitedHealth Group internal mailing address for the mailing address of the member, and the members foreign address in a permanent address field in our system. All member correspondence, including claim payments, EOB's, and ID cards, are routed internally for special handling of the member's mail. Mail is then r ed to the member's foreign address, with the correct postage affixed. Note: Puerto Rico and the Virgin Islands are U.S. Territories, therefore those addresses are considered domestic. However, Canadian addresses are considered foreign addresses. Survivor Information UnitedHealth Group requires that surviving member's coverage continue to be passed on the file under the deceased employee's identification number, along with the deceased employee's record. The four survivor information fields are: XREF/Payee Indicator position 453 XREF/Payee Last Name 455 XREF/Payee First Name 475 XREF/Payee SSN 495 These fields are used only for deceased employee records. When the Payee Indicator field is populated, UnitedHealth Group will direct all correspondence (ID cards, Explanations of Benefits, etc.) to the Payee name. The XREF data is passed on the deceased employee's record only, along with a date of death (position 433). No XREF data is to be passed on the surviving dependent records. Each member continuing coverage after the employee's death should be passed on the file along with the deceased employee's record. The relationship code (position 26) for each member continuing coverage must be populated with the appropriate code: 02 (surviving spouse) 19 (child) The XREF/Payee Indicator (position 453) should be populated with a 01 (surviving spouse) or 11 (surviving dependent). HP-SLED Page 3 of 33 1/7/2011

25 The employee identification number for the entire family will continue to be the deceased employee s identification number, and the XREF/Payee's social security number will be used as a cross-reference. If a claim is submitted under either the employee identification number or the XREF/Payee's social security number, this family s record will be retrieved. Continuing the coverage under the deceased employee record allows for accurate claim history to be maintained for the family. Primary Physician Information If Primary Physician information will be passed on your eligibility file for new enrollees in a gatekeeper (managed care) medical plan, please pass the following fields: Primary Physician MPIN & Location Code Primary Physician Start Date Primary Physician Current Patient Indicator Coverage Data While the layout provides for up to 3005 bytes, the file format should be treated as a variable length file based on the number of coverage types/blocks being passed on the file. You should adjust your file length based on the maximum number of coverage types that will be passed for each member. With the exception of the header record, each record for every member should end at the same byte. For example, if you send Medical and RX coverage for every member on the file, then you should adjust your record length to be 1206 bytes as position 1206 follows the last field related to coverage type two. Instead of sending spaces out to position 3005 at the end of each record, we require that you truncate the record and send an "end of record indicator". The end of record indicator is a pipe ( ). Each record on your file must have an end of record indicator as the last character, and this indicator must not appear anywhere other than at the end of each record. Please use the following guidelines when programming your file based on the coverage types you will be passing on your file to UnitedHealth Group: One Coverage Type: Each record would end in Position 0981 with a pipe delimiter ( ). Two Coverage Types: Each record would end in Position 1206 with a pipe delimiter ( ). Three Coverage Types: Each record would end in Position 1431 with a pipe delimiter ( ). Four Coverage Types: Each record would end in Position 1656 with a pipe delimiter ( ). Your Account Management Team will supply the account structure (policy number, plan variation & reporting codes) to you. HP-SLED Page 4 of 33 1/7/2011

26 Fields & Descriptions The following pages describe the file format in detail. If you have any questions regarding the file specifications, please contact your deployment analyst. Column Headings Field Name: Position Start: Position End: Field Length: Field Type: Required: Description: Values In: Identifies what specific data should be placed in this field. Indicates the starting position of the field. Indicates the ending position of the field. Indicates the maximum number of bytes for the data. Identifies whether the field should be completed for the employee, dependent, or both. The following codes are used in this field: E = Indicates field is required for employee (subscriber) record D = Indicates field is required for dependent B = Indicates field is required for both employee and dependent Identifies if the customer is required to populate this field with data. The following codes are used in this field: R = Required: The customer is required to populate this field as noted. O = Optional: The customer can determine through their eligibility process if they want to populate this field. C = Conditional: The customer may be required to populate these fields based on the values in other fields. Defines the "Field Name". Specifies the Gateway Standard Format values that the customer will use to populate fields. File Name Requirements Your file name must be formatted as follows: SUBMITID.U.YYYYMMDDHHMM.gsf SUBMITID = Submitter ID or Submission Group name (8 characters maximum). All capital letters are required. Your Electronic Eligibility Analyst will provide you with the Submitter ID. U = Indicates the UnitedHealth Group UNET system platform. The U must be a capital letter. YYYYMMDDHHMM = The Date and time stamp is the creation time and date of the file. It must be supplied by the customer on every file submitted for processing. The date and time stamp, along with the Submitter ID, creates the unique customer file name, which will be linked to the Employer eservices Electronic Eligibility Management System to provide eligibility statistics to the customer. gsf = Is the file extension used to denote the UHG 3005 Format. All lowercase letters are required. Header Record Requirements: The header record must be the very first record on the file, and the format must be as follows: HP-SLED Page 5 of 33 1/7/2011

27 Field Name Position Position Field Field Required Description Values In Start End Length Type Header Filler R Filler area must be spaces. Blank Header Detail R Total number of detail records Must be a right justified, record Count excluding the Header Record. zero filled, numeric value. Header Filler 26 R Must be a pipe delimiter. A carriage return should immediately follow the pipe delimiter. No spaces or added characters should be sent between the pipe and the return. Member Record Requirements Fields highlighted in yellow are required fields and must be sent on the file. All data should be left justified. No default or filler values should be placed in trailing spaces. All uppercase character data is preferred, but it some instances it is required. Fields requiring uppercase data are noted. Your Electronic Eligibility Analyst will advise you if any of the filler fields should be populated. Note: Attached is a sample of the UHG 3005 file format, with the header record and member records. The file is best viewed with TextPad or UltraEdit. Field Name Position Start Position End Field Length Field Type Required Description Values In Version Indicator B R Indicates layout version Use code: V1.20 submitted. Submission Group ID Relationship Code B R The 4-8 character ID assigned by the Electronic Eligibility Analyst for this submission group. The submission group ID must be in all capital letters B R LEAVE BLANK Blank B R Identifies if the record is for an employee or dependent. Note: If a relationship code of 20 (student) is sent, UHG will generate a Student Status Verification letter that will be mailed to the member. Do not use relationship code 20 if UHG is not verifying student status for your group. Employee ID B R The unique employee identifier. (See eligibility guide for information on alternate identification numbers.) B R LEAVE BLANK Blank Your Electronic Eligibility Analyst will inform you of this code. 18= Employee 01= Spouse 19= Child 20= Student 34= Retiree 02= Surviving Spouse 38= Collateral Dep 23= Sponsored Dep 09= Stepchild 21= Handicapped Dep 22= Handicapped Student 35= New Born 53= Life Partner 36= Other Subscriber social security number should be used. Format: digit SSN HP-SLED Page 6 of 33 1/7/2011

28 Field Name Member Social Security Number Former EE ID *not commonly used Personnel ID *not commonly used Employment Date Member Last Name Member First Name Member Middle Initial Member Birth Date Position Start Position End Field Length Field Type Required Description Values In B O The member's Social Security Member's social security Number. If unknown this number. Format: field must be Leave Blank digit SSN Duplicate SSN's are not permitted B R LEAVE BLANK Blank E O If the employee ID is The prior employee ID changing the prior employee Format: ID is entered in this field for digit SSN reporting E O Personnel ID number B R LEAVE BLANK Blank E R The date the employee YYYYMMDD started work with the company B R LEAVE BLANK Blank B R The member's last name. Member's last name No punctuation should be included B R The member's first name. Member's first name Note: Due to system constraints, do not include middle name or middle initial in this field. No punctuation should be included B R LEAVE BLANK Blank B O The member's middle initial. Member's middle initial B R LEAVE BLANK Blank B R The member's date of birth. YYYYMMDD B R LEAVE BLANK Blank Member Gender B R The member's gender. M = Male F = Female U = Unknown Member Marital Status COB Flag *not commonly used COB Date *not commonly used Language *not commonly used B R The member's marital status. B= Registered Domestic Partner D= Divorced I= Single M= Married R= Unreported S= Separated W= Widowed U= Unmarried/Unknown B O Indicates if member has other coverage. If used should only be sent for new enrollees and then the information should be dropped from the file B O Start date of Coordination of Benefits (COB). If used should only be sent for new enrollees and then the information should be dropped from the file E O Indicates primary language of member. Y = Yes other coverage N or Blank = No other coverage YYYYMMDD Field should be left blank HP-SLED Page 7 of 33 1/7/2011

29 Field Name Permanent Street Address 1 Permanent Street Address 2 Position Start Position End Field Length Field Type Required Description Values In B R Member's street address. Member's primary street This field is required for all address members. No punctuation should be included. Both subscribers and dependents must have a permanent address passed on your file B O The member's second line of Member's secondary street address (Apt Number, street address PO Box, Care of Address, Etc.). No punctuation should be included. This is an optional field and should be used only if Permanent Street address 1 is completed. Permanent City B R The member's city. This field is required for all members. No punctuation should be included. Both subscribers and their dependents must have a permanent city passed on your file. Member's city address Permanent State B R The member's state. No Member's state address punctuation should be included. Must be in all capital letters. Permanent Zip Code 5-digit zip code and 4- digit zip code extension. Permanent Country Code Mailing Street Address 1 Mailing Street Address B R 5-digit zip code and 4-digit zip code extension. The 5-digit zip code is a required field for domestic addresses; the zip code extension is optional and can be left blank. Note: Do not include a dash (-) between the 5 digit zip code and the 4 digit zip code extension B R The Country the employee resides in. For a complete listing of country codes use the following web address ds-services/iso3166ma/02iso code-lists/index.html Canadian zip code format: Canadian alphanumeric codes must have a space between the third and fourth byte of the postal code in this field. For example, A9A_9A9. Must be 2 characters in length. For example, USA = US B R LEAVE BLANK Blank B C Member's mailing street Member's primary mailing address. The Mailing address street address fields should be used if the member has a mailing address different from that of the Permanent address. No punctuation should be included B C The member's second line of mailing street address (Apt Number, PO Box, Care of Address, Etc.). This is an optional field and should be used only if street address 1 is completed. No punctuation should be included. Member's secondary mailing street address. HP-SLED Page 8 of 33 1/7/2011