Business Requirements Document SR102488 2018 Affordable Care Act (ACA) Reporting Changes
Document Information Document Attributes ID Owner Author(s) Contributor(s) Information SR102488 Payroll Coordination and Tax Services Marcia Johnson, John Barrett Elizabeth Burkart, Nadine Schumaker Revision History Version Issue Date Changes 1 st draft 1.1 10/9/18 B. Burkart updated with suggested changes, updated before and after meeting with John and Marcia. 1.2 10/16/18 B. Burkart updated based on email from John. 1.3 10/17/18 B. Burkart updated during discussion with Nadine. 1.4 10/25/18 B. Burkart updated with John, Marcia and Nadine. 1.5 10/30/18 B. Burkart updated in team meeting with John, Marcia, Nadine. 1.6 10/31/18 B. Burkart updated for team review. 1.7 11/1/18 B. Burkart Updated based on John s feedback. Also, Nadine and Beth worked on scenarios for attachments. 1.8 11/6/18 B. Burkart updated a scenario to make it more realistic. Added error report sample. Also updated in kick-off meeting. 1.9 11/7/18 B. Burkart finalized for posting Document Approvals Role Name Signature Date Controller Peggy Arrivas 2
Table of Contents 1 Overview... 4 2 Product/Solution Scope... 6 3 Business Services and Processes... 11 4 Business Rules... 11 5 Business Requirements... 12 6 Non-Functional Requirements... 16 7 External References... 16 9 Modified File Layout Resident File Record type E for Employee... 17 10 Proposed New File Layout Resident File record type D for Dependent... 20 11 Employee/Dependent Scenarios for Residents... 24 12 Error Report Sample... 30 3
1 Overview The Affordable Care Act (ACA) reporting process occurs annually at the beginning of each year to report on the previous calendar year. This process fulfills the requirement to produce the Forms 1095-C that are sent to applicable employees and the Form 1094-C that is transmitted electronically to the IRS. This BRD will address any ACA reporting changes for 2018. 1.1 Background IRC section 4980H of the Affordable Care Act requires large employers to provide full-time employees with health insurance coverage or possibly face tax penalties. Full-time employee is defined under the ACA as one who works 30 hours or more per week. The reporting requirements outlined in Sections 6055 and 6056 of the IRS code enable the IRS to identify employees who have essential minimum coverage or are eligible for such coverage through an employer. It also gives the IRS sufficient information about whether the coverage provides minimum value, as well as the cost of the coverage to the employee, in order to determine if the individual can qualify for premium tax credits or cost sharing subsidies. Large employers are required to offer coverage to 95% of their full time employees. 1.2 Objectives The ACA reporting processes that will be addressed in this BRD are as follows: Postdoc rate change Medical HMO (P1) rate changed from $10.01 to $10.78 for 2018. The 2017 rate was not changed in PPS from $9.76 to $10.01. The Medical PPO (P2) rate remains at $20.00. A new centralized Resident/Fellows program was implemented effective 7/1/2018. There are two plans, a PPO (self-insured) plan and an HMO (flex-funded) plan. Both plans will be treated as self-insured for ACA reporting and therefore UC is responsible for completing Part III of the 1095-C in addition to Parts I and II. All locations with Resident/Fellows except UC San Diego participate in the centralized program. There will be no changes in reporting for the s January through June. The self-insured plans offered to employees remain UC Care (AU), CORE (AC), and Health Savings Plan (AP). 4
1.3 Related Projects & Dependencies SR100508 (R2162) SR100843 (R2193) Service Hub RITM0227345 requests a modification to ACA processing for UCLA and UCSB, due to their mid-2018 cutover to UCPath. For MO, PPS will report January through August on Form 1095-C. For BW, PPS will report January through September on the form. This is being handled as a local change. 1.4 Stakeholders Acronym Description Role * Authorize Has ultimate signing authority for any changes to the document R Responsible Responsible for creating this document A Accountable Accountable for accuracy of this document (e.g. project manager) S C I Supports Consulted Informed Provides supporting services in the production of this document Provides input Must be informed of any changes Name Position * R A S C I John Barrett Director X X X X X Peggy Arrivas Controller X Marcia Johnson Business Analyst X X X Beth Burkart Business Analyst X X X Nadine Schumaker Programmer Analyst X X Santhosh Katakam QA Analyst X X 1.5 Proposed Strategy Modify the P1 Postdoc rate that is used for line 15 on the 1095-C 5
Modify the file layout and processing of the external files received from the medical centers so that employee and dependent self-insured coverage data can be collected and reported on the 1095-C, Part III. Testing will be needed with at least one medical center, given the new file layout. Since the input is more complicated and hand created, edits and a report mode (non-update mode) are important. It is recommended that campuses run in the report mode first to correct data with invalid values. Once fixed, the file should be sent back to PPS for processing. Once the errors have been corrected, the process can be run in update mode. 1.6 Glossary Term UC UCPATH Residency Program Relationship Code (EDB0635) Dependent Number (EDB0632) Description University of California UC Payroll, Academic Personnel, Timekeeping & HR Residency programs that offer health care coverage may include veterinary, pharmacy, dental, and medical. Values in PPS for EDB0635: S - Spouse C - Child (natural or adopted) T - Non Tax Dependent Child (natural or adopted) O - Other Child (e.g., foster child) P - Stepchild W - Legal ward G - Grandchild D - Same Sex Domestic Partner L - Opposite Sex Domestic Partner K - Child/Grandchild of Domestic Partner A - Adult Dependent Relative N - Non Tax Dependent Overage Disabled Child Dep Num two digit unique number identifying the dependent of the employee 2 Product/Solution Scope 2.1 Included in Scope Postdoc rate change for 2018 reporting 6
External file processing for medical resident 1 coverage that is not captured in PPS. The existing process assumes that all coverage data coming in from the external resident files is for fully insured plans. This logic, as well as the external file layout, must be modified. 2.2 Excluded from Scope The processing changes for medical residents only need to be installed at locations that send in the external coverage files. (However, the P1 postdoc rate change program(s) must be installed at all locations.) For example, UCSB will need to install only the P1 rate change. 2.3 Assumptions & Constraints ID Assumption / Constraint 2.3.1 UCPath processing will be impacted by these requirements. The P1 rate change applies to all locations. The external resident file changes apply to any location that processes such files. 2.3.2 UCSD does not participate in the centralized self-insured program for medical residents/fellows. We expect that any resident/fellow coverage data for UCSD will be for fully insured plan(s). The new file layout will have an indicator for self-insured vs. fully insured coverage, so we should not need special logic for the different UCSD coverage. In the San Diego file, we will only expect record type E for employee, and the records should have F or N for ly coverage indicators. 2.3.3 Medical residents/fellows are assumed to be MO. (Confirmed 10/29.) This was of interest because, for UCLA, PPS will report January through August on the 1095-C for MO and January through September for BW, due to the transition to UCPath. However, the local modification provided to LA and SB will ignore all data (including data on the external file for residents) after August 2018 for MO employees and all data after September for BW employees. The remaining data for 2018 will be reported by UCPath. 2.3.4 The self-insured plans offered to employees remain UC Care (AU), CORE (AC), and UC Health Savings Plan (AP). 2.3.5 The IRS is now requiring the employee and dependent names to be split up into first, middle initial, and last. The vendor UnifyHR is able to parse and format the names for us, so no changes are needed in PPS or ACA Web to format the names. 1 A variety of residency programs can exist at the locations. For the purpose of this document, medical residents also includes other residents such as veterinary, pharmacy, and dental. 7
2.3.6 The current PPS process only expects to get one medical resident external file per location. Going forward, PPS will continue to expect one file per location, but there will be multiple record types, E record for employee and D record for dependent(s). All locations who provide a file must use the new layout. * The new layout will be used for reporting coverage for all s in 2018 during which the location was on PPS. *UCSD will need to use the new file layout, although they will only be reporting fully insured coverage for 2018 for their residents, and they do not need to send D record types. 2.3.7 It is assumed that dependents will always have the same type of coverage in a given (fully-insured plan or self-insured plan) as the employee. 2.3.8 ACA reporting for UCLA: UCLA has already been provided with suggested local modifications for appropriately reporting September thru December 2018, based on the UCPath cutover timeline. They will need to merge changes from this project (SR102488) into the local modified code. The changed rate for P1 must be merged into their local modified code and the program for the new processing for the medical resident files must also be installed. 2.3.9 Currently, the external files containing resident data are transmitted via email, because they do not contain SSN. Going forward, SAFE email transmission can be used to sufficiently secure the sending of SSN and birth date data. It was determined that GoAnywhere (standard transmission method) does not need to be employed for this short-term need, considering the remaining life of PPS. 8
2.4 Outstanding Items ID Description 2.4.1 Who will coordinate with the locations regarding the new medical resident file layout and the need to provide dependent data? UC Locations with medical residency programs: UCLA (non-hosted, part of 2018 on PPS, part on UCPath) (Wen) UCSF (non- hosted, entire year on PPS) (Luke) Irvine (hosted, entire year on PPS) UCD (hosted, entire year on PPS) UCSD (hosted, entire year on PPS assume still fully insured, NOT selfinsured) Riverside (entire year on UCPath) They have a medical school with residents, although they have no medical center. Resolved: Test files will be needed (by both PPS and UCPath). PPS analyst should coordinate with technical contacts at the hosted locations and with the Payroll Dept. contacts at the non-hosted locations. John will work with Vanessa Jasso at UCPath Center so that she is aware of the file data they need to receive based on PPS methodology. 2.4.2 Will the external medical resident coverage data files submitted to PPS need to include relationship code (EDB0635) and dependent number (EDB0632)? We send those fields to ACA Web. Resolved: Dependent number will be derived in PPS, so it will not need to be included in the incoming file. Data for employee and dependents will be on different record types, so they will be distinguishable in PPS. Eventually, when employee and dependent data is sent to ACA Web, it will be sent on different files. We will not require providers of the external files to include the relationship code for each employee and dependent. (This data is not needed in ACAWeb and is not sent to the vendor.) 9
2.4.3 Past ACA documents (BRDs, etc.) alluded to other kinds of residents besides medical residents. It seems that data for other individuals whose coverage is not stored in PPS is being sent in those external data files. How are they impacted? Do they continue to be assumed to be covered by fully insured plans? If data comes in on external files, do we need to differentiate medical residents/fellows from others, and allow for different processing? Resolved: Jerome provided a table containing the types of residents and their coverage possibilities. However, since the new file layout includes an indicator for fully insured ( F ), self-insured ( S) or not insured for that ( N ), the PPS process will not need to be aware of the specific types of residents and plans at each location. 2.4.4 If dependent SSN is not available, should that field be zero filled on the external medical resident data file? Resolved: Currently, PPS sends blanks for dependent SSN to ACA Web if the SSN is not available. Thus, providers of the external file should send blanks if the dependent SSN is not known. 2.4.5 Will the source of external data files change, since we now need more detailed information, and the insurance is now centrally managed? Will the providers of the information have personal and coverage data for dependents? If the entities who provided the information in past years do not have these details, additional data sources may need to be identified. Information received from Jerome Perez (UC CARE PROGRAM MANAGER) 10/29: This may need to come from the campuses. I do not think Anthem is maintaining Dep SS# s. (John, 10/31/18) Open need to check with residency program contacts to verify they have the dependent SSNs and can forward the data file securely. 2.4.6 Can John provide Nadine with medical center contacts? Jerome Perez provided a list 10/29. John will double check directly with the six locations with residency programs. 10
2.4.7 When running in update mode, if there is still a formatting error in either the employee record or the associated dependent records, should all the records associated with the employee be bypassed or should we update the records that pass the edits? It was decided that the process should be run in report mode until it is free of errors. If there are still errors when the process is run in update mode, then the employees with invalid data will be bypassed and reported. Errors will appear on a report and the location with the residency program must review the employee data and fix it. This is important because the entire employee will be skipped and reported if there is any error in employee or dependent record(s). (This should be included in instructions to the locations.) Submitters will need to re-send their entire file once the errors are corrected, so it can be processed in update mode. Files should be submitted a couple of weeks ahead of the submission deadline, in order to allow plenty of time for the review/edit cycle. 2.4.8 The existing (old) program checks to see if the employee (HCE row) already exists in the database. If so, it will replace any s that are spaces. If an existing does have a value (not spaces) and also med center input was provided for the same, it is considered a mismatch and an error/warning is written to the report and not updated. It was decided that the revised PPS process will report this condition if it appears, and flag it for manual processing. We will process the existing data in the database rather than what is in the incoming resident file, but the campus can correct the employee s 1095-C in ACAWeb for PPS reporting s. 3 Business Services and Processes 4 Business Rules 11
5 Business Requirements 5.1 User Requirements Req ID Requirement Type Requirement Description Priority [L/M/H] 1 Postdoc rate The updated P1 postdoc rate H should be utilized as appropriate for line 15 of 1095-C starting with 2018 ACA reporting. 2 Medical (and other) Resident reporting Reporting for the new selfinsured medical plans for the medical residents and fellows should be aligned with reporting for other existing self-insured plans. Part III, including dependent information, should be completed for any s where there was coverage under a self-insured plan. H Comments Exceptions: UCSD only has a fully insured plan for entire 2018 (no self-insured plan). Part III will not be completed on the 1095-C for their resident/fellow population. UCD some residents have a fully insured plan (WHA HMO), if they live outside the region of the self-insured plan (Anthem Self- Funded PPO). For these individuals, Part III of their 1095-C will not be completed. 12
5.2 Functional Requirements Req ID Requirement Type Requirement Description R0001 Postdoc Rate The postdoc rate for the P1 plan should be updated to $10.78 starting with the 2018 ACA reporting. R0002 Self-insured The residents (medical and other) plans for have medical plans that are not residents captured in PPS. (medical and other) Currently PPS receives external files from the medical centers containing coverage data for this population. Up through the 2017 reporting year, this coverage was fully insured. In July 2018, a new self-insured plan was implemented. January June 2018: For this time period, the medical resident plans were fully insured. They should be reported the same way as they were in the past. Part III should not be completed. The self-insured box should not be checked. Any dependent data provided for January June 2018 will be ignored. July December 2018, and going forward: Some of the medical plans for the medical residents and fellows were self-insured for this time period. They should be reported in accordance with the rules for reporting self-insured plans. Check the self-insured box Report all covered individuals in Part III of the 1095-C Priority [L/M/H] H H Comments P2 rate remains the same. This is handled by the local modifications created for UCLA and UCSB: For UCLA, which converted to UCPath in September 2018, PPS will utilize only the medical resident data for January August. For the s following UCPath conversion (September December), all UCLA employees will be reported by PPS as no offer, not an employee. 13
(including employee and dependents), and check the ly boxes to indicate which s each person was covered. R0003 Self-insured plans for residents (medical and other) Exceptions: San Diego residents (medical resident plan is fully insured) and UC Davis residents who are enrolled in the WHA HMO The file layout will be modified in order to differentiate between fully insured coverage and self-insured coverage and to collect data for dependents who were covered under a self-insured plan. Providers of the external files will need to indicate if the employee was covered by a fully insured or selfinsured plan (or not covered at all) for each of the year. Providers must furnish dependent information (name, SSN, Date Of Birth, and which s each individual was covered by a selfinsured plan). H This will need to be coordinated with the medical center campuses. A safe method of sending the files and error reports will be needed. SAFE email is sufficient. See attached record layouts. Covered dependent number (needed by ACAWeb) should be assigned by PPS, and the locations will not be asked to put that into the file. R004 Edits The following edits should be added: a) The data in the file must be in the order of Employee record first, followed by applicable dependent records. b) Position 10 must contain either E for employee record or D for dependent record. c) flags must be S (selfinsured plan), F (fully insured plan), or N (not covered that H See error report sample in attachments 14
). d) Dependent SSN can be either all numbers or all spaces but not a combination. e) Dependent name cannot be all spaces. f) Dependent birth date must be all numbers. g) Dependent s of selfinsured coverage must be Y or N only. h) Dependent name must contain a comma. i) Dependent flags need to be consistent with the employee flags in terms of which s are covered. If dependent coverage flag is Y, employee can t be N for that. j) The employee must have a row in the PPPPAY table (needed for SSN for the employee) k) PPS should check if ACA form data has already been stored for the employee. If so, an error will be reported. (See details in R006) Each invalid Employee record or bypassed dependent record should be displayed as a line item on the error report (see sample in attachments). Dependent records should be bypassed if the associated employee record is invalid or if another one of the dependent records is invalid. R005 Edits If employee coverage indicates N or F for a given, the dependent coverage box in Part III of the 1095-C form should not be checked. This is consistent with the following business rules: A dependent can t be covered in H See Employee/Dependent Scenarios chart in Appendix 15
a when the employee is NOT covered Dependent coverage should be reported on the 1095-C only for s in which the employee was covered by a self-insured plan. R006 Error handling PPS should check to see if the employee already exists in the PPS database that is used for ACA processing. If the employee does already exist in the database, the whole employee-dependent set will be rejected. PPS should report this condition if it appears, and flag it for manual processing. This condition is highly unlikely, but possible. The location will need to correct the employee s 1095-C form data in ACAWeb if it does occur. H PPS will process the existing data in the database rather than the incoming data in the resident file, but the campus should fix it in ACAWeb for PPS reporting s. 5.3 Reporting Requirements 6 Non-Functional Requirements 7 External References 16
9 Modified File Layout Resident File Record type E for Employee Resident Non-PPS Health ACA Reporting II SR102488 Employee Record Position Length/ Field Description Values Comments Format 1-9 9 Employee ID Numbers Leading zeroes 10 1 Employee Indicator E No other values allowed 11 1 January S, F or N S: the employee was covered by a self-insured plan this 2 F: the employee was covered by a fully insured plan for this N: the employee was not covered this 12 1 February S, F or N S: the employee was covered by a self-insured plan this F: the employee was covered by a fully insured plan for this N: the employee was not covered this 13 1 March S, F or N S: the employee was covered by a self-insured plan this F: the employee was covered by a fully insured plan for this N: the employee was not covered this 14 1 April S, F or N S: the employee was covered by a self-insured plan this F: the employee was covered by a fully insured plan for this 2 For 2018 reporting, employee records should show F or N for January through June, since the self-insured plan started July 1, 2018. 17
18 N: the employee was not covered this 15 1 May S, F or N S: the employee was covered by a self-insured plan this F: the employee was covered by a fully insured plan for this N: the employee was not covered this 16 1 June S, F or N S: the employee was covered by a self-insured plan this F: the employee was covered by a fully insured plan for this N: the employee was not covered this 17 1 July S, F or N S: the employee was covered by a self-insured plan this F: the employee was covered by a fully insured plan for this N: the employee was not covered this 18 1 August S, F or N S: the employee was covered by a self-insured plan this F: the employee was covered by a fully insured plan for this N: the employee was not covered this 19 1 September S, F or N S: the employee was covered by a self-insured plan this F: the employee was covered by a fully insured plan for this N: the employee was not covered this 20 1 October S, F or N S: the employee was covered by a self-insured plan this
F: the employee was covered by a fully insured plan for this N: the employee was not covered this 21 1 November S, F or N S: the employee was covered by a self-insured plan this F: the employee was covered by a fully insured plan for this N: the employee was not covered this 22 1 December S, F or N S: the employee was covered by a self-insured plan this F: the employee was covered by a fully insured plan for this N: the employee was not covered this 23-80 58 Filler 19
10 Proposed New File Layout Resident File record type D for Dependent Dependent coverage data is needed for July-Dec 2018 self-insured plan coverage, and going forward Resident Non-PPS Health for Self-Insured Plans ACA Reporting Dependent Record Position Length/ Field Description Values Comments Format 1-9 9 Employee ID Numbers Leading zeroes 10 1 Dependent Indicator D No other values allowed 11-19 9 SSN of covered individual Numbers or all spaces 20-45 26 Name of Covered Individual (Last, First MI) 46-53 8 Birth Date of covered individual 54 1 January Self-insured Alpha Numbers (MMDDCCYY) Leading zeroes If SSN is unknown, fill with spaces. Example: Smith, John E No formatting characters. They will be formatted in the program. Y, N Y: the dependent was covered under a selfinsured plan this N: the dependent was not covered under a self-insured plan this 55 1 February Self-insured January 2018 self-insured coverage will be N 3 Y, N Y: the dependent was covered under a selfinsured plan this N: the dependent was not covered under a self-insured 3 Since the self-insured plan began on 7/1/18, self-insured coverage indicators for January through June 2018 on the Dependent record will be N. 20
plan this 56 1 March Self-insured February 2018 selfinsured coverage will be N Y, N Y: the dependent was covered under a selfinsured plan this N: the dependent was not covered under a self-insured plan this March 2018 self-insured coverage will be N 57 1 April Self-insured Y, N Y: the dependent was covered under a selfinsured plan this N: the dependent was not covered under a self-insured plan this April 2018 self-insured coverage will be N 58 1 May Self-insured Y, N Y: the dependent was covered under a selfinsured plan this N: the dependent was not covered under a self-insured plan this May 2018 self-insured coverage will be N 59 1 June Self-insured Y, N Y: the dependent was covered under a selfinsured plan this N: the dependent was not covered under a self-insured 21
plan this June 2018 self-insured coverage will be N. 60 1 July Self-insured Y, N Y: the dependent was covered under a selfinsured plan this N: the dependent was not covered under a self-insured plan this 61 1 August Self-insured 62 1 September Self-insured 63 1 October Self-insured 64 1 November Self-insured Y, N Y: the dependent was covered under a selfinsured plan this N: the dependent was not covered under a self-insured plan this Y, N Y: the dependent was covered under a selfinsured plan this N: the dependent was not covered under a self-insured plan this Y, N Y: the dependent was covered under a selfinsured plan this N: the dependent was not covered under a self-insured plan this Y, N Y: the dependent was covered under a selfinsured plan this N: the dependent was not covered under a self-insured plan this 65 1 December Self-insured Y, N Y: the dependent was 22
66-80 15 Filler spaces covered under a selfinsured plan this N: the dependent was not covered under a self-insured plan this 23
11 Employee/Dependent Scenarios for Residents Scenario 1: Employee has fully-insured coverage all year. D record type (dependent data) not required for ACA reporting. Employee Record: Position Length/ Field Description Value Format 1-9 9 Employee ID 800000000 10 1 Employee Indicator E 11 1 January F 12 1 February F 13 1 March F 14 1 April F 15 1 May F 16 1 June F 17 1 July F 18 1 August F 19 1 September F 20 1 October F 21 1 November F 22 1 December F 23-80 58 Filler 24
Scenario 2: Employee has fully-insured coverage from January through June and has selfinsured coverage from July through December. Employee has 2 dependents. Employee Record: Position Length/ Field Description Value Format 1-9 9 Employee ID 800000001 10 1 Employee Indicator E 11 1 January F 12 1 February F 13 1 March F 14 1 April F 15 1 May F 16 1 June F 17 1 July S 18 1 August S 19 1 September S 20 1 October S 21 1 November S 22 1 December S 23-80 58 Filler Corresponding Dependent records: 1-9 9 Employee ID 8000000001 10 1 Dependent Indicator D 11-19 9 SSN of covered individual 555667777 20-45 26 Name of Covered Individual Jones, Barney J (Last, First MI) 46-53 8 Birth Date of covered 08301995 individual 54 1 January Self-insured N 4 55 1 February Self-insured N 4 The self-insured plan for residents began July 1, 2018, so the self-insured coverage flags on the dependent records will be N for January June of 2018. 25
56 1 March Self-insured N 57 1 April Self-insured N 58 1 May Self-insured N 59 1 June Self-insured N 60 1 July Self-insured Y 61 1 August Self-insured Y 62 1 September Self-insured Y 63 1 October Self-insured Y 64 1 November Self-insured Y 65 1 December Self-insured Y 66-80 15 Filler spaces 1-9 9 Employee ID 8000000001 10 1 Dependent Indicator D 11-19 9 SSN of covered individual 666778888 20-45 26 Name of Covered Individual Jones, Edith K (Last, First MI) 46-53 8 Birth Date of covered 10021998 individual 54 1 January Self-insured N 55 1 February Self-insured N 56 1 March Self-insured N 57 1 April Self-insured N 58 1 May Self-insured N 59 1 June Self-insured N 60 1 July Self-insured Y 61 1 August Self-insured Y 62 1 September Self-insured Y 26
63 1 October Self-insured Y 64 1 November Self-insured Y 65 1 December Self-insured Y 66-80 15 Filler spaces 27
Scenario 3: Employee had no coverage from Jan through March. April June they had fully insured coverage and then they had self-insured coverage from July to December. Employee has 1 dependent. Employee Record: Position Length/ Field Description Value Format 1-9 9 Employee ID 800000002 10 1 Employee Indicator E 11 1 January N 12 1 February N 13 1 March N 14 1 April F 15 1 May F 16 1 June F 17 1 July S 18 1 August S 19 1 September S 20 1 October S 21 1 November S 22 1 December S 23-80 58 Filler Corresponding Dependent record: 1-9 9 Employee ID 8000000002 10 1 Dependent Indicator D 11-19 9 SSN of covered individual 777889999 20-45 26 Name of Covered Individual Smith, Margaret L (Last, First MI) 46-53 8 Birth Date of covered 09301996 individual 54 1 January Self-insured N 55 1 February Self-insured N 56 1 March Self-insured N 28
57 1 April Self-insured N 58 1 May Self-insured N 59 1 June Self-insured N 60 1 July Self-insured Y 61 1 August Self-insured Y 62 1 September Self-insured Y 63 1 October Self-insured Y 64 1 November Self-insured Y 65 1 December Self-insured Y 66-80 15 Filler spaces 29
12 Error Report Sample 30