Post on 14-Sep-2018
A service of Maryland Health Benefit Exchange
834 Business RulesJuly 18, 2013
Agenda
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Effectuation
Version
Scheduling
834 Transmission Business Rules
834 Transaction Set
Loop 2000 – Member Level Detail
Loop 2300 – Health Coverage
Loop 2750 – Reporting Categories
Q&A
834 Effectuation
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All carriers must enroll individuals and employees
upon receipt of the 834
834 Version
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Version for 10/1
– 5010220A1 standard for enrollment (834)
– Batch file processing only, no real time enrollment
transactions
– Outbound standard for Individual, SHOP,
reconciliation, CMS reporting
– Inbound standard from Carriers and TPAs utilize
same version
Inbound, Outbound Scheduling
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834 files from the Maryland Health Connection will be
transmitted during the nightly batch process
– Midnight to 5:00 am (pending production volume)
Maryland Health Connection expects
acknowledgements to be delivered within a 24 hour
window
834 files from the Carrier and TPAs will be
processed starting at 9:00 am
Maryland Health Connection generates
acknowledgements within a 24 hour window
834 EDI Transmission Business Rules
Transaction Set
Transaction Set
– We create one ST-SE transaction per family.
– Each family member will be indicated with INS
loop.
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Loop ID 2000 – Member Level Detail
Identifying the Member in 834 Transmissions.
This unique identifier HIX ID, is communicated to
the Carrier in the 834 transactions within the 2000
Member Level Detail loop.
The subscriber will have his/her own HIX ID while
each additional member eligible for coverage will
also have his/her own HIX ID.
Once an individual is assigned a HIX ID, he/she
keeps this identifier for as long as he/she
conducts business with the Exchange.
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Loop ID 2000 – Member Level Detail
Table below describes the various enrollee identifiers and their associated qualifier.
In addition, the enrollee’s SSN, if available, is transmitted in the NM1 segment on the initial enrollment transactions.
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Member Identifier Ref ID Qualifier
Notes
Exchange Assigned ID 0F When transmitted in the Subscriber
Identifier REF
Issuer Assigned Subscriber ID ZZ When transmitted in the Member
Supplemental Identifier REF
Exchange Assigned Member ID 17 Transmitted in the Member
Supplemental Identifier REF
Insurer Assigned Member ID 23 Transmitted in the MemberSupplemental Identifier REF
Loop ID 2000 – Member Level Detail
Each family member will be indicated with INS
loop.
The Exchange will send explicit
enrollment/terminations/cancellation in the INS
segment for each member.
Maintenance code will be reported specifically for
each member at INS and reporting category loop.
– INS*Y*18*021*28*A~
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Loop ID 2100A – Member Name
Communication contacts will be sent in the
following order:
1st – Primary Phone (TE)
2nd – Secondary Phone (AP)
3rd – Preferred Communication Method (EM for
email or BN for text message), either an email
address or phone number for receiving text
messages.
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Loop ID 2100A – Member Name
Member Health Information
Health Related Code – Information about tobacco
use will be sent on every enrollment transaction.
The three valid responses a QHP Issuer may
receive are:
– “N” No Tobacco Use, if indicated with QHP
selection
– “T” Tobacco Use, if indicated with QHP
selection
– “U” Unknown Tobacco Use, if not “N” or “T”
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LOOP ID 2300 – Health Coverage
An Enrollment effective Date is send on enrollment update transactions.
(DTP*303)
An Enrollment Period start Date is only send on initial enrollment transactions.
(DTP*348)
An Enrollment Period End Date is sent when cancelling or terminating an enrollment period.
(DTP*349)
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LOOP ID 2300 – Health Coverage
Maryland Health Connection creates single transaction for individual enrolled in medical and dental plans.
Maryland Health Connection sends one 2000 loop with one 2300 loop for the Medical Coverage and another 2300 loop for the Dental Coverage if individual elected both medical and dental plan from same carrier.
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LOOP ID 2310 – Provider Information
Maryland Health Connection sends 2310 loop only if
Plans require PCP to be selected. If not, this loop will
not be send.
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Loop 2750 – Reporting Categories
All information associated with the insurance premium
will be reported under the 2700 Member Reporting
Categories loop of the subscriber.
Financial information reported in the 2750 Loops
(within the 2700 loop) include the premium
amount (PRE AMT TOTAL), the APTC amount
(APTC) and the member premium amounts (PRE
AMT 1).
Maryland Health Connection derives the total
premium amount by adding all individual member
premium amounts.
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Loop 2750 – Reporting Categories
N101 – 75 (Participant)
N102 – APTC AMT
REF02 – will send APTC AMT
DTP03 – Effective Date of APTC AMT
APTC
– Amount the QHP issuer can expect to receive
toward the total premium payment (APTC)
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Loop 2750 – Reporting Categories
N101 – 75 (Participant)
N102 – Carrier to Bill
REF02 – Carrier ID
DTP03 – Start date of coverage
If an individual elects to pay the Carrier, this
information is sent in this reporting category loop
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Loop 2750 – Reporting Categories
N101 – 75 (Participant)
N102 – Premium Medical Amount
REF02 – Premium rate for Medical Coverage
DTP03 – Effective date of coverage
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Loop 2750 – Reporting Categories
N101 – 75 (Participant)
N102 – Premium Dental Amount
REF02 – Premium rate for Dental Coverage
DTP03 – Effective date of coverage
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Loop 2750 – Reporting Categories
N101 – 75 (Participant)
N102 – ADDL MAINT REASON
REF02 – TERM/CANCEL
DTP03 – Last day of coverage
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QUESTIONS?
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