Vendor Specifications 834 Outbound Benefit Enrollment and Maintenance ASC X12N Version 5010A1 for State of Idaho MMIS Date of Publication: 7/31/2017 Document Number: TL421 Version: 5.0
Revision History Version Date Author Action/Summary of Changes 1.0 07/01/2011 Molina Initial document 2.0 08/09/2011 TQD DHW approved via UB00632B 2.1 06/09/2015 Douglas Greer Review and minor corrections 3.0 08/06/2015 TQD Finalized and published per notification 30-day response agreement. 3.0 12/22/2015 Douglas Greer Semi-annual review no change 3.0 5/25/2016 Cathy Butler Semi-annual review no changes made 3.1 11/29/2016 Cathy Butler New Dental Vendor Changes made to: 1. 2310; added comments to segments NM108 and NM109. 2. Added segments PLA to 2310 3. Added 2320 with segments COB, REF, and DTP 4. Added 2330 with segments NM1, N3, N4 and PER 5. Added 2700 wit segment LS 6. Added 2710 with segment LX 7. Added 2750 with segment N1 and DTP 3.2 12/6/2016 Curtis Loveless, Reviewed; made comments. Stephen Morley, Maria Hurst and Flo Clarke 3.3 12/7/2016 Flo Clarke Per Cher, Molina agreed with revision. Informal approval to submit to TQD for formal delivery to HW. 3.4 12/19/2016 Douglas Greer via Cher Wada Koenig Added the RX qualifier for BGN08 Added the LUI segment in 2100A Added the 2100C and 2100F loops Added the REF segments in the 2300 loop 4.0 1/11/2017 TQD DHW validated 1/6/17. Finalized and published to Molina Medicaid website per State request. 4.1 6/10/2017 J. Phillips Semi-annual review - Corrected hyperlink connection for Idaho Medicaid Web Page 5.0 7/31/2017 TQD Finalized and published per notification 30-day response agreement. The Molina Healthcare Companion Guide for the Idaho MMIS is subject to change prior to January 1, 2012 or at the instruction of the Department. Therefore, it is the responsibility of the trading partner to ensure that the latest version of this guide is used when designing\building X12N 5010 EDI transactions. The trading partner should frequently check for updates to the companion guide. Molina Healthcare accepts no liability for any Last Updated: 7/31/2017 Page ii
costs that the trading partner may incur that arise from or are related to changes to the companion guide. Last Updated: 7/31/2017 Page iii
Table of Contents 1. Companion Guide Purpose... 1 1.1. uired Information... 1 1.2. Trading Partner... 1 1.3. Delimiters... 2 1.4. Additional Information... 2 2.... 3 Table of Figures Figure 1:... 3 Last Updated: 7/31/2017 Page iv
1. Companion Guide Purpose This companion guide documents the transaction type listed below and further defines situational and required data elements that are used for processing benefit enrollment and maintenance for programs administered by Idaho Medicaid. This document is not the complete EDI transaction format specifications. Please refer to the 5010A1 Technical Report Type 3 for information not supplied in this document, such as code lists, definitions, and edits. Benefit Enrollment and Maintenance ASC X12N 834 (005010X220) August 2006 Addenda Benefit Enrollment and Maintenance ASC X12N 834 (005010X220A1) October 2010 For any questions, or to begin testing, please contact the Molina EDI Helpdesk at 1 (866) 686-4272 option 2 and ask for Technical Support, or e-mail us at idedisupport@molinahealthcare.com. 1.1. uired Information Data elements, segments, and loops not included in this guide are not used for processing claims by Idaho Medicaid, but must still be sent if the information is required for compliance with the ASC X12N version 5010A1 format. 1.2. Trading Partner A trading partner is defined as any entity with which Molina exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Idaho Medicaid s Health PAS system supports the following categories of trading partner: Provider Billing Agency Business Associate Clearinghouse Health Plan Molina will assign trading partner s to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. All trading partners must be authorized to submit production EDI transactions. Any trading partner may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control Header (ISA) of an X12 file, indicates if a file is test or production. Authorization is granted on a per transaction basis. For example, a trading partner may be certified to submit 837P professional claims but not certified to submit 837I institutional claim files. Trading partners must submit three test files of a particular transaction type, with a minimum of fifteen transactions within each file, and have no failures or rejections in order to become certified for production. Users will be notified via e-mail and the Trading Partner Status page of Health PAS-OnLine when testing for a particular transaction has been completed. To obtain a trading partner please visit our website at https://www.idmedicaid.com or contact us at 1 (866) 686-4272. Last Updated: 7/31/2017 Page 1 of 26
1.3. Delimiters Idaho Medicaid does not require the use of specific values for the delimiters used in electronic transactions. The suggested values are included in the specifications below. 1.4. Additional Information Please refer to the 5010A1 Technical Report Type 3 for information not supplied in this document, such as code lists, definitions, and edits. Last Updated: 7/31/2017 Page 2 of 26
2. Figure 1: HEADER ISA Interchange Control Header 3 R ISA ISA01 Authorization Information Qualifier 2 I01 R 00 ISA02 Authorization Information AN 10 I02 R Space Fill ISA03 Security Information Qualifier 2 I03 R 00 ISA04 Security Information AN 10 I04 R Space Fill ISA05 Sender Interchange Qualifier 2 I05 R ZZ ISA06 Interchange Sender AN 15 I06 R Molina assigned Trading Partner ISA07 Interchange Receiver Qualifier 2 I05 R ZZ ISA08 Interchange Receiver AN 15 I07 R _MMIS_4MOLINA ISA09 Interchange Date DT 6 I08 R YYMMDD ISA10 Interchange Time TM 4 I09 R HHMM ISA11 Interchange Control and 1 I10 R ^ Last Updated: 7/31/2017 Page 3 of 27
ISA12 Interchange Control Version 5 I11 R 00501 ISA13 Interchange Control Number NO 9 I12 R Must be identical to the interchange trailer IEA02, value is defined by the sending Trading Partner ISA14 Acknowledgement uested 1 I13 R 1=Interchange acknowledgement requested 0=uest not to receive Interchange acknowledgement ISA15 Usage Indicator 1 I14 R P=Production T=Test ISA16 Component element 1 I15 R : GS Functional Group Header 2 R GS GS01 Functional Identifier Code 2 479 R BE GS02 Application Senders Code AN 2/15 142 R Molina assigned Trading Partner Last Updated: 7/31/2017 Page 4 of 27
GS03 Application Receiver's Code AN 2/15 124 R _MMIS_4UNISYS GS04 Date DT 8 373 R CCYYMMDD GS05 Time TM 4/8 337 R Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD GS06 Group Control Number NO 1/9 28 R Assigned by Sender GS07 Responsibility Agency Code 1/2 455 R X GS08 Version/Release/Industry Identifier Code AN 1/12 480 R 005010X220A1 ST Transaction Set Control Number 2 R ST ST01 Transaction Set Identifier Code 3 143 R 834 ST02 Transaction Set Control Number AN 4/9 329 R Unique number assigned by sender, ST02 and SE02 must be equivalent ST03 Implementation Convention Reference AN 1/35 1705 R 005010X220A1 Last Updated: 7/31/2017 Page 5 of 27
BGN Beginning 3 R BGN BGN01 Transaction Set Purpose Code 2 353 R 00 (This field contains the same value as GS08.) BGN02 Reference Identification AN 1/50 127 R Unique number assigned by Sender BGN03 Date DT 8 373 R CCYYMMDD BGN04 Time TM 4/8 337 R HHMM Time expressed in 24- hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD BGN05 Time Code 2 623 S Use the time code if the sender and receiver are not in the same time zone BGN06 Reference Identification AN 1/50 127 S Last Updated: 7/31/2017 Page 6 of 27
BGN08 Action Code 1/2 306 R 2=Change 4=Verify RX = Replace DTP File Effective Date 3 S DTP DTP01 Date/Time Qualifier 3 374 R 007=Effective 303=Maintenance Effective 382=Enrollment 388=Payment Commencement DTP02 Date Time Period Format Qualifier 2/3 1250 R D8 DTP03 Date Time Period AN 1/35 1251 R CCYYMMDD 1000A N1 Sponsor Name 2 R N1 N101 Entity Identifier Code 2/3 98 R P5 N102 Name AN 1/60 93 S Plan Sponsor Name N103 Identification Code Qualifier 1/2 66 R FI=Federal Taxpayer s Identification Number 94=Code assigned by the organization Last Updated: 7/31/2017 Page 7 of 27
that is the ultimate destination of the transaction set N104 Identification Code AN 2/80 67 R Plan Sponsor Identifier 1000B N1 Payer 2 R N1 N101 Entity Identifier Code 2/3 98 R IN N102 Name AN 1/60 93 S Insurer Name N103 Identification Code Qualifier 1/2 66 R FI=Federal Taxpayer s Identification Number XV=Health Care Financing Administration National Plan 94=Code assigned by the organization that is the ultimate destination of the transaction set N104 Identification Code AN 2/80 67 R Insurer Last Updated: 7/31/2017 Page 8 of 27
2000 INS Member Level Detail 3 R INS INS01 Yes/No Condition or Response Code 1 1073 R N=No Y=Yes INS02 Individual Relationship Code 2 1069 R 18 Identification Code INS03 Maintenance Type Code 3 875 R Member Maintenance Type Code INS04 Maintenance Reason Code 2/3 1203 S Member Maintenance Reason Code INS05 Benefit Status Code 1 1216 R A=Active INS06 Medicare Status Code S INS06-1 Medicare Plan Code 1 1218 R A Medicare Part A B Medicare Part B C Medicare Part A and B D Medicare E No Medicare INS07 Consolidated Omnibus Budget 1/2 1219 S Reconciliation Last Updated: 7/31/2017 Page 9 of 27
INS08 Employment Status Code 2 584 S FT, PT, TE 2000 REF Subscriber Number 3 R REF REF01 Reference Identification Qualifier 2/3 128 R 0F REF02 Reference Identification AN 1/50 127 R Subscriber Identification 2000 REF Member Policy Number 3 S REF REF01 Reference Identification Qualifier 2/3 128 R 1L REF02 Reference Identification AN 1/50 127 R Insured Group or Policy Number 2000 REF Member Supplemental identifier 3 S REF REF01 Reference Identification Qualifier 2/3 128 R QQ REF02 Reference Identification AN 1/50 127 R Prior Coverage Month Count 2000 DTP Member Level Dates 3 S DTP DTP01 Date/time Qualifier 3 374 R 356=Eligibility Begin 357=Eligibility End Last Updated: 7/31/2017 Page 10 of 27
DTP02 Date Time Period Format Qualifier 2/3 1250 R D8 DTP03 Date Time Period AN 1/35 1251 R CCYYMMDD 2100A NM1 Member Name 3 R NM1 NM101 Entity Identifier Code 2/3 98 R 74=Corrected Insured IL=Insured or Subscriber NM102 Entity Type Qualifier 1 1065 R 1 NM103 Name Last or Organization Name AN 1/60 1035 R Last Name or Organization Name NM104 Name First AN 1/35 1036 S First Name - uired when NM102 is equal to 1" (person) and the person has a first name. NM105 Name Middle AN 1/25 1037 S Middle Name - uired if supplied by member. NM106 Name Prefix AN 1/10 1038 S Last Updated: 7/31/2017 Page 11 of 27
NM107 Name Suffix AN 1/10 1039 S NM108 Identification Code Qualifier 1/2 66 S 34=Social Security Number ZZ=Mutually Defined NM109 Identification Code AN 2/80 67 S Subscriber Identifier 2100A PER Member Communication Numbers 3 S PER PER01 Contact Function Code 2 366 R IP PER02 Name AN 1/60 93 NU * PER03 Communication Number Qualifier AN 2/2 365 R Communication Number Qualifier PER04 Communication Number AN 1/256 364 R Communication Number 2100A N3 Member Residence Street Address 2 S N3 N301 Address Information AN 1/55 166 R Address Information N302 Address Information AN 1/55 166 S Address Information Last Updated: 7/31/2017 Page 12 of 27
2100A N4 Member Residence City, State, Zip 2 R N4 N401 City name AN 2/30 19 R City Name N402 State or Province Code 2 156 S State or Province Code - uired when the address is in the United States of America, including its territories, or Canada. N403 Postal code 3/15 116 S Postal code - uired when the address is in the United States of America, including its territories, or Canada. 2100A DMG Member Demographics 3 S DMG DMG01 Date Time Period Format Qualifier 2/3 1250 R D8 DMG02 Date Time Period AN 1/35 1251 R Member Birth Date - CCYYMMDD DMG03 Gender Code 1 1068 R F=Female M=Male U=Unknown Last Updated: 7/31/2017 Page 13 of 27
DMG04 Marital Status Code 1 1067 S DMG05-1 Race or Ethnicity Code 1 1109 S Race or Ethnicity Code Separator AN 1 : DMG05-2 Code List Qualifier Code 1/3 1270 S RET Separator AN 1 : DMG05-3 Industry Code AN 1/30 1271 S 2100A LUI Member Language 3 S LUI LUI01 Identification Code Qualifier ½ 66 S LD = NISO Z39.53 Language Codes LE = ISO 639 Language Codes LUI02 Identification Code AN 2/80 67 S Language Code 2100C NM1 Member Name 3 S NM1 NM101 Entity Identifier Code 2/3 98 R 31 = Postal Mailing Address NM102 Entity Type Qualifier 1 1065 R 1 2100C N3 Member Mail Street Address 2 R N3 N301 Address Information AN 1/55 166 R Address Last Updated: 7/31/2017 Page 14 of 27
Information N302 Address Information AN 1/55 166 S Address Information 2100C N4 Member Mail City, State, Zip 2 R N4 N401 City name AN 2/30 19 R City Name N402 State or Province Code 2 156 S State or Province Code - uired when the address is in the United States of America, including its territories, or Canada. N403 Postal code 3/15 116 S Postal code - uired when the address is in the United States of America, including its territories, or Canada. 2100F NM1 Custodial Parent 3 S NM1 NM101 Entity Identifier Code 2/3 98 R S3 = Custodial Parent Last Updated: 7/31/2017 Page 15 of 27
NM102 Entity Type Qualifier 1 1065 R 1 NM103 Name Last or Organization Name AN 1/60 1035 R Custodial Parent Last Name NM104 Name First AN 1/35 1036 R Custodial Parent First Name NM105 Name Middle AN 1/25 1037 S Custodial Parent Middle Name NM106 Name Prefix AN 1/10 1038 S Custodial Parent Name Prefix NM107 Name Suffix AN 1/10 1039 S Custodial Parent Name Suffix NM108 Identification Code Qualifier 1/2 66 S 34=Social Security Number ZZ=Mutually Defined NM109 Identification Code AN 2/80 67 S Custodial Parent Identifier 2100F N3 Custodial Parent Street Address 2 S N3 N301 Address Information AN 1/55 166 R Address Information Last Updated: 7/31/2017 Page 16 of 27
N302 Address Information AN 1/55 166 S Address Information 2100F N4 Custodial Parent City, State, Zip 2 R N4 N401 City name AN 2/30 19 R City Name N402 State or Province Code 2 156 S State or Province Code - uired when the address is in the United States of America, including its territories, or Canada. N403 Postal code 3/15 116 S Postal code - uired when the address is in the United States of America, including its territories, or Canada. 2300 HD Health Coverage 2 S HD HD01 Maintenance Type code 3 875 R Maintenance Type Code Last Updated: 7/31/2017 Page 17 of 27
HD03 Insurance Line Code 2/3 1205 R Insurance Line Code HD04 Plan coverage Description AN 1/50 1204 S Plan coverage Description HD05 Coverage Level Code 3 1207 S Coverage Level Code 2300 DTP Health Coverage Dates 3 R DTP DTP01 Date/Time Qualifier 3 374 R 303=Maintenance Effective 348=Benefit Begin 349=Benefit End 543=Last Premium Paid Date DTP02 Date Time Period Format Qualifier 2/3 1250 R D8 DTP03 Date Time Period AN 1/35 1251 R CCYYMMDD 2300 REF Health Coverage Policy Number 3 S REF REF01 Reference Identification Qualifier 2/3 128 R X9 = Internal Control Number REF02 Reference Identification AN 1/50 127 R EnrollCoverage Last Updated: 7/31/2017 Page 18 of 27
2300 REF Health Coverage Policy Number 3 S REF REF01 Reference Identification Qualifier 2/3 128 R RB = Rate Code Number REF02 Reference Identification AN 1/50 127 R Rate Code 2310 LX Provider Information 2 S LX LX01 Assigned Number N0 1/6 554 R Assigned Number 2310 NM1 Provider Name 3 R NM1 NM101 Entity Identifier Code 2/3 98 R Entity Identifier Code NM102 Entity Type Qualifier 1 1065 R 1=Person 2=Non-Person Entity NM103 Name Last or Organization Name AN 1/60 1035 S NM104 Name First AN 1/35 1036 S NM105 Name Middle AN 1/25 1037 S NM106 Name Prefix AN 1/10 1038 S NM107 Name Suffix AN 1/10 1039 S Last Updated: 7/31/2017 Page 19 of 27
NM108 Identification Code Qualifier 1/2 66 S Identification Code Qualifier (Note: This is intentionally left blank) NM109 Identification Code AN 2/80 67 S Provider Identifier (Note: This is intentionally left blank) NM110 Entity Relationship Code 2 706 R Entity Relationship Code 2310 N3 Provider Address 2 S N3 N301 Address Information AN 1/55 166 R Provider Address Line 1 M302 Address Information AN 1/55 166 S Provider Address Line 2 2310 N4 Provider City, State, Zip Code 2 R N4 N401 City Name AN 2/30 19 R City Name N402 State or Province Code 2 156 S State or Province Code - uired when the address is in the United Last Updated: 7/31/2017 Page 20 of 27
States of America, including its territories, or Canada. N403 Postal code 3/15 116 S Postal Code - uired when the address is in the United States of America, including its territories, or Canada. 2310 PER Provider Communication Numbers 3 S PER PER01 Contact Function Code 2 366 R IC PER02 Communication Number Qualifier AN 1/60 93 NU * PER03 Communication Number Qualifier 2 365 R Communication Number Qualifier PER04 Communication Number AN 1/256 364 R Communication Number 2310 PLA Provider Change Reason 3 S PLA PLA01 Action Code 1/2 306 R 2 PLA02 Entity Identifier Code 2/3 98 R 1P Last Updated: 7/31/2017 Page 21 of 27
PLA03 Date DT 8/8 373 R Provider Effective Date PLA05 Maintenenace Reason Code 2/3 1203 R Maintenenace Reason Code 2320 COB Coordination of Benefits 3 S COB COB01 Payer Responsibility Sequence Number Code 1/1 1138 R Valid s: P, S, T, and U COB02 Reference Identification AN 1/50 127 S Member Group/Policy number COB03 Coordination of Benefits Code 1/1 1143 R Valid s: 1, 5, and 6 2320 REF Additional Coordination of Benefits Identifiers 2 S REF REF01 Reference Identification Qualifier 2/3 128 R Valid s: 60, 6P,SY, and ZZ REF02 Reference Identification AN 1/50 127 R Member Group/Policy number Last Updated: 7/31/2017 Page 22 of 27
2320 DTP Coordination of Benefits Eligibility Dates 2 S DTP DTP01 Date/Time Qualifier 3/3 374 R Valid s: 344, 345 DTP02 Date Time Period Format Qualifier 2/3 1250 R Valid s: D8 DTP03 Date Expressed in Format CCYYMMDD AN 1/35 1251 R Coordination of Benefits Date 2330 NM1 Coordination of Benefits Related Entity 3 S NM1 NM101 Entity Identifier Code 2/3 98 R Valid s: 36, GW, and IN NM102 Entity Type Qualifier 1/1 1065 R 2 NM103 Name Last or Organization Name AN 1/60 1035 S Coordination of Benefits Insurer Name 2330 N3 Coordination of Benefits Related Entity Address 2 S N3 N301 Address Information AN 1/55 166 R Address Information N302 Address Information AN 1/55 166 S Address Information Last Updated: 7/31/2017 Page 23 of 27
2330 N4 Coordination of Benefits Other Insurance Company City, State, Zip Code 3 R N4 N401 City Name AN 2/30 19 R Coordiantion of Benefits Other Insurance Company City Name N402 State or Province Code 2/2 156 S Coordiantion of Benefits Other Company State Code N403 Postal Code 3/15 116 S Coordiantion of Benefits Other Company Postal Zone or Zip Code 2330 PER Administrative Communications Contact 3 S PER PER01 Contact Function Code 2/2 366 R CN PER03 Communication Number Qualifier 2/2 365 R TE PER04 Communication Number AN 1/256 364 R Communication Number Last Updated: 7/31/2017 Page 24 of 27
2700 LS Additional Reporting Categories 2 S LS LS01 Identifier Code AN 1/4 447 R 2700 2710 LX Member Reporting Categories 2 S LX LX01 Assigned Number N0 1/6 554 R 1 2750 N1 Reporting Category 2 S N1 N101 Entity Identifier Code 2/3 98 R 75 N102 Name AN 1/60 93 R Member Reporting Category Name (For example: Pregnancy) 2750 DTP Reporting Category Date 3 S DTP DTP01 Date/Time Qualifier 3/3 374 R 007 DTP02 Date Time Period Format Qualifier 2/3 1250 R RD8 DTP03 Date Time Period AN 1/35 1251 R Member Reporting Category Name Effective Date(s) Trailer SE Transaction Set Trailer 2 R SE Last Updated: 7/31/2017 Page 25 of 27
SE01 Number of Included s N0 1/10 96 R Transaction Count SE02 Transaction Set Control Number AN 4/9 329 R Transaction Set Control Number, ST02 and SE02 must be equivalent GE Functional Group Trailer 2 R GE GE01 Number of Transaction Sets Included N0 1/6 97 R Number of Transaction Sets Included GE02 Group Control Number N0 1/9 28 R Group Control Number IEA Interchange Control Number 3 R IEA IEA01 Number of Included Functional Groups N0 1/5 I16 R Number of Included Functional Groups IEA02 Interchange Control Number N0 9 I12 R Interchange Control Number Last Updated: 7/31/2017 Page 26 of 27