Required 834 EDI Segment Name 834 EDI Data Element 834 EDI ... · 834 EDI Segment Name 834 EDI Data...

834 EDI Segment Name 834 EDI Data Element 834 EDI Data TypeRequired

(Y/N)

ISA - Interchange Control Header

Authorization Information Qualifier VARCHAR2(2) Y

Authorization Information VARCHAR2(10) Y

Security Information Qualifier VARCHAR2(2) Y

Security Information VARCHAR2(10) Y

Interchange ID Qualifier VARCHAR2(2) Y

Interchange Sender ID VARCHAR2(15) Y

Interchange ID Qualifier VARCHAR2(2) Y

Interchange Receiver ID VARCHAR2(15) Y

Interchange Date (YYMMDD) DATE Y

Interchange Time (HHMM) TIME Y

Repetition Separator VARCHAR2(1) Y

Interchange Control Version Number VARCHAR2(5) Y

Interchange Control Number VARCHAR2(9) Y

Acknowledgment Requested NUMBER(1) Y

Interchange Usage Indicator VARCHAR2(1) Y

Component Element Separator VARCHAR2(1) Y

GS-Functional Group Header

Functional Identifier Code. VARCHAR2(2) Y

Application Sender’s Code VARCHAR2(15) Y

Application Receiver’s Code VARCHAR2(15) Y

Date (CCYYMMDD) DATE Y

Time (HHMM) TIME Y

Group Control Number NUMBER(9) Y

Responsible Agency Code VARCHAR2(2) Y

Version/Release/Industry/Identifier Code VARCHAR2(12) Y

Header

100 ST - Transaction Set Header

Transaction Set Identifier Code NUMBER(3) Y

Transaction Set Control Number VARCHAR2(9) Y

Implementation Convention Reference VARCHAR2(35) Y

200 BGN - Beginning Segment

Transaction Set Purpose Code VARCHAR2(2) Y

Reference Identification VARCHAR2(50) Y

Date date Y

Time Time Y

300 REF - Transaction Set Policy Number

Reference Identification Qualifier NUMBER(3) Y

Action Code VARCHAR2(2) Y


400 DTP - File Effective Date

Date/Time Qualifier NUMBER(3)

Date Time Period Format Qualifier VARCHAR2(3) Y

Date Time Period VARCHAR2(35) Y

1000A Sponsor

700 N1 - Sponsor Name

Entity Identifier Code VARCHAR2(3) Y

Name VARCHAR2(60) N

Identification Code Qualifier VARCHAR2(2) Y

1000B Payer

700 N1 - Payer


Name VARCHAR2(60) N

Identification Code Qualifier VARCHAR2(2) Y

Identification Code VARCHAR2(80) Y

2000 Member Level Detail

100 INS - Member Level Detail

Yes/No Condition or Response Code VARCHAR2(1) Y

Benefit Status Code VARCHAR2(1) Y

Individual Relationship Code VARCHAR2(2) Y

VARCHAR2(80)

Maintenance Type Code VARCHAR2(3) Y

Identification Code Y

Maintenance Reason Code VARCHAR2(3) N

Date Time Period Format Qualifier VARCHAR2(3) N

Date Time Period VARCHAR2(35) N

200 REF - Subscriber Identifier

Reference Identification Qualifier VARCHAR2(3) Y


200 REF - Member Supplemental Identifier



250 DTP - Member Level Dates



2100A Member Name

300 NM1 - Member Name

Entity Type Qualifier NUMBER(1) Y

Name Last or Organization Name VARCHAR2(60) Y

Name First VARCHAR2(35) N

Name Middle VARCHAR2(25) N

Name Prefix VARCHAR2(10) N

Name Suffix VARCHAR2(10) N

Identification Code Qualifier VARCHAR2(2) N

Identification Code VARCHAR2(80) N

400 PER - Member Communications Numbers

Contact Function Code VARCHAR2(2) Y

Communication Number Qualifier VARCHAR2(2) Y

Communication Number VARCHAR2(256) Y





Date/Time Qualifier NUMBER(3) Y


500 N3 - Member Residence Street Address

Address Information VARCHAR2(55) Y

Address Information VARCHAR2(55) N

600 N4 - Member City, State, ZIP Code

City Name VARCHAR2(30) Y

State or Province Code VARCHAR2(2) N

Postal Code VARCHAR2(15) N

Country Code VARCHAR2(3) N

Location Qualifier VARCHAR2(2) N

Location Identifier VARCHAR2(30) N

800 DMG - Member Demographics



1300 HLH - Member Health Information

Marital Status Code VARCHAR2(1) Y

Gender Code VARCHAR2(1) Y

Citizenship Status Code NUMBER(2) N

Race or Ethnicity Code VARCHAR2(1) N

Health-Related Code VARCHAR2(1) N

1500 LUI - Member Language



Description VARCHAR2(80) N

Use of Language Indicator NUMBER(2) N

2100B Incorrect Member Name

300 NM1 - Incorrect Member Name

Entity Identifier Code NUMBER(3) Y








800 DMG - Incorrect Member Demographics

Date Time Period Format Qualifier VARCHAR2(3) N

Date Time Period VARCHAR2(35) N

Marital Status Code VARCHAR2(1) N

Race or Ethnicity Code VARCHAR2(1) N

Citizenship Status Code NUMBER(2) N

2100C - Member Mailing Address

300 NM1 - Member Mailing Address



500 N3 - Member Mail Street Address



600 N4 - Member Mail City, State, ZIP Code





2100D - Member Employer (Only applicable for SHOP)

300 NM1 - Member Employer


Gender Code VARCHAR2(1) N



Name Last or Organization Name VARCHAR2(60) N





Identification Code Qualifier NUMBER(2) N


400 PER - Member Employer Communications Numbers


Name VARCHAR2(60) N



Communication Number Qualifier VARCHAR2(2) N

Communication Number VARCHAR2(256) N

500 N3 - Member Employer Street Address



600 N4 - Member Employer City, State, ZIP Code





2100G - Responsible Person

300 NM1 - Responsible Person








400 PER - Responsible Person Communications Numbers


Entity Identifier Code VARCHAR2(3)) Y




Communication Number Qualifier VARCHAR2(2) N

Communication Number VARCHAR2(256) N

500 N3 - Responsible Person Street Address



600 N4 - Responsible Person City, State, ZIP Code





2300 - Health Coverage

2300 HD - Health Coverage

Insurance Line Code VARCHAR2(3) Y

Plan Coverage Description VARCHAR2(50) N

Yes/No Condition or Response Code VARCHAR2(1) N

2700 DTP - Health Coverage Dates

Maintenance Type Code VARCHAR2(3) Y


Coverage Level Code VARCHAR2(3) N


2800 AMT - Health Coverage Policy

Amount Qualifier Code VARCHAR2(3) Y

Monetary Amount R Y

Additional Reporting Categories

6880 LS - Additional Reporting Categories

Loop Identifier Code VARCHAR2(4) Y

2700 - Member Reporting Categories

6881 LX - Member Reporting Categories

Assigned Number NUMBER (6) Y

2750 - Reporting Category

6882 N1 - Reporting Category


6883 REF - Reporting Category Reference


Name VARCHAR2(60) Y




6884 DTP - Reporting Category Date

Date/Time Qualifier VARCHAR2(3) Y



6885 LE - Additional Reporting Categories Loop Termination

Loop Identifier Code VARCHAR2(4) Y

Transaction Set Trailer

Number of Included Segments NUMBER(10) Y

Transaction Set Control Number VARCHAR2(9) Y

GE- Functional Group Trailer

Number of transaction sets included NUMBER(6) Y

Group control number NUMBER(9) Y

IEA-Interchange Control Trailer

Number of included functional groups NUMBER(5) Y

Interchange control number NUMBER(9) Y


Mapping Logic

This field will be populated with 00 – No Authorization information.

This field will be populated with Spaces.

This field will be populated with 00 – No Security information.

This field will be populated with Spaces.

30= U.S. Federal Tax Identification Number

Tax ID number of HBE

30= U.S. Federal Tax Identification Number

Tax ID number of the Issuer

This field will be populated with System Date Format - YYMMDD

This field will be populated with System Time Format = HHMM

Use ^ for repetition separator.

This field will be populated with 00501

This field will be populated with the Interchange Control Number. Note ISA13 =

IEA02

This field will be populated with 0 – no Acknowledgement

This field will be populated with “P‟ in Production Mode and “T‟ in Test Mode.

This field will be populated with Value = ":"

This field will be populated with ‘BE’ – Benefit Enrollment

Tax ID number of HBE

Tax ID number of the Issuer

This field will be populated with System Date Format - YYMMDD

This field will be populated with System Time Format = HHMM

This field will be populated with Group Control Number. Note GS06 = GE02

This field will be populated with ‘X’ for X12.

This field will be populated with ‘005010X220A1’ version number for the 834

transaction.

This Field will be populated with “834”

Calculated sequential number

This field will be same as GS08 i.e. ‘005010X220A1’

“00” – Original. Copy of the original will be available from archive.

This field will be populated with the Sender’s Reference Number. This will be a

unique number generated by the HBE.

The date the file was created

The time of day the file was created

Values to be allowed:

“2” = Change (Update). Used to identify a transaction of additions, terminations and

changes to the current enrollment.

“4” = Verify (Audit)

This field will be populated with “38”

This be the QHP Plan ID.

303 = Maintenance Effective

D8 = Date expressed in format CCYYMMDD

File Effective Date. Format is “CCYYMMDD”.

This will be the primary applicant for an individual application and employer for a

SHOP application.

This field will be populated with “FI” and “24”

This will be the issuer information. Will default to IN

This will be the issuer name

Will be FI

Issuer FEIN

The INS01 indicates the status of the insured. A “Y” value indicates the insured is a

subscriber: an “N” value indicates the insured is a dependent. If the subscriber and

the insured are always the same individual, you can default this to “Y”.

01 – Spouse

19 – Child

18 – Self

G8 – Other Relationship

Code Values used:

• 001 – Change

• 021 – Additions

• 024 – Terminations

• 025 – Reinstatement

• 030 – Audit

a. 01 = Divorce

b. 02 = Birth

c. 03 = Death

d. 05 = Adoption

e. 07 = Termination of Benefits

f. 08 = Termination of Employment

g. 22 = Plan Change

h. 28 = Initial Enrollment

i. 32 = Marriage

j. 59 = Non Payment

k. AI = No Reason Given

Populated with “A” Active or left out for other reason codes.

“D8” Send when required by X12 syntax. This element captures date of death.

Client Date of Death in the CCYYMMDD format.

This field is populated with “0F” Subscriber Number(Person ID).

This will be the unique exchange Person ID (Subscriber ID) created by the HBE.

This field is populated with “ZZ” Person ID for dependents.

This will be the unique exchange Person ID created by the HBE.

050 = Enrollment application received

303 = Maintenance Effective

336 = Employment Begin

337 = Employment End

356 = Eligibility Begin

357 = Eligibility End

This field is populated with “D8”

This field is populated with Status Information Effective Date in CCYYMMDD format.

This field is populated with “IL” (Insured or Subscriber) or “74” (Corrected Insured).

This code identifies if this is a correction to a previous enrollment or if it is a new, or

update, enrollment transaction.

Will be 1

This field is populated with Client’s Last Name.

This field is populated with Client’s First Name.

This field is populated with Client’s Middle Initial.

Send if supplied by subscriber

Send if supplied by subscriber

Client ID Qualifier This field is populated with “34” – Social Security Number.

This field is populated with the Client’s Social Security Number (when available).

Insured Party This field is populated with “IP” for Insured Party.

System will send the primary and alternate phone numbers captured in the HBE and

the email address (if available).

TE = Phone number (As the 1st occurance)

AP = Alternate phone number

EM = email

This field is populated with Client’s primary phone number.

System will send the alternate phone number if available.

AP = Alternate phone number

This field is populated with Client’s alternate phone number.

System will send the email address (if available).

EM = email

This field is populated with the email.

Address Information Line 1. Note: This is the client’s residence address.

Address Information Line 2 – Populated if second address line exists. Note: This is the

client’s residence address.

City Name Note: This is the client’s residence address.

State or Province Code Note: This is the client’s residence address.

Postal Code Medical Residential Zip Code. Note: This is the client’s residence address

This field will be populated if the country code is other than “US”

Populated with “60”

Populated with the Rate Region Code

N/A

Recipient Birth Date Populated with Client’s Date of Birth in the CCYYMMDD format.

“M” – Male

“F” – Female

“U” – Unknown

“D” – Divorced

“M” – Married

“S” – Single

“W” – Widowed

7 – Not Provided

8 – Not Applicable

A – Asian or Pacific Islander

B – Black

C – Caucasian

D – Subcontinent Asian American

E – Other Race or Ethnicity

F – Asian Pacific American

G – Native American

H – Hispanic

I – American Indian or Alaskan Native

J – Native Hawaiian

N – Black (Non-Hispanic)

O – White (Non-Hispanic)

P – Pacific Islander

Z – Mutually Defined

Citizen Status

“1” – US citizen

“3” – Resident Alien

“4” – Illegal Alien

This will have values:-

N: None

T: Tobacco Use

Populated with “LE”.

Populated with Language Code

N/A

N/A

When the Incorrect Member loop 2100B is used and NM101 = 70, the entity

identifier in loop 2100A must be NM101 = 74.

“1” Person

Prior incorrect insured last name.

Note: This is called “Name Last or Organizational Name” in 834 PDF

Prior incorrect insured first name

Prior incorrect insured middle name

Prior incorrect insured name prefix. Send if supplied by the subscriber

Prior incorrect insured name suffix. Send if supplied by the subscriber

Populated with “34” Prior incorrect insured Social Security Number (when available)

Prior incorrect insured Social Security Number (when available).

This field will be populated with “D8”

This field will be populated with the Prior incorrect insured birth date.

This field will be populated with the Prior incorrect insured gender code.

“F” – Female

“M” – Male

“U” – Unknown

N/A

N/A

N/A

This is the member mailing address if different from the residence address in 2100A

or when a dependent's address is different from the subscriber.

This is “31” for Postal mailing address.

This is “1” for Person.

Address Information Line 1

Address Information Line 2

City Name

State

Postal code

This field will be populated if the country code is other than “US”.



This field will be the name of the individual assigned as the administrator for the

organization

N/A

N/A

N/A

N/A

This field will be populated with either “24” – Employer Identification Number or

“34” - SSN

N/A

Head of Household This field is populated with “EP”.

Member Employer communication contact

“TE” - Phone Number

This field is populated with the Employer contact’s Phone Number.

“TE” - Phone Number (when available)

This field is populated with the Employer Contact’s Other Phone Number (when

available).

Address Information Line 1.

Address Information Line 2 – populated if second address line exists.

City Name

State or Province Code

Postal Code

Country Code

“QD” for Responsible Party

“E1” for Person or Other Entity Legally Responsible for a child

“S1” Parent

“X4” Spouse

“9K” Tax Filer

“1” Person

Head of Household’s last name.

Note: This is called “Name Last or Organizational Name” in 834 PDF

Head of Household’s first name

Head of Household’s middle name

Head of Household’s name prefix. Send if supplied by the subscriber

Head of Household’s name suffix. Send if supplied by the subscriber

Populated with “34” Head of Household’s Social Security Number (when available)

Head of Household’s Social Security Number (when available).

Head of Household This field is populated with “RP”.

“TE” - Phone Number

This field is populated with the Head of Household’s Phone Number.

“TE” – Phone Number (when available)

This field is populated with the Head of Household’s Other Phone Number (when

available).

Address Information Line 1.

Address Information Line 2 – populated if second address line exists.

City Name

State or Province Code

Postal Code

Country Code

Populated with:

“001” - Change

“021” – Addition

“024” – Cancellation or Termination

“030” – Audit

This field is populated with “MM” or “DEN” (Standalone Dental).

The value in this field will be the plan name.

This will be populated with:

CHD = Children Only

DEP = Dependents Only

E1D = Employee and One Dependent

E2D = Employee and Two Dependents

E3D = Employee and Three Dependents

E5D = Employee and One or More Dependents

E6D = Employee and Two or More Dependents

E7D = Employee and Three or More Dependents

E8D = Employee and Four or More Dependents

E9D = Employee and Five or More Dependents

ECH = Employee and Children

EMP = Employee Only

ESP = Employee and Spouse

FAM = Family

IND = Individual

SPC = Spouse and Children

SPO = Spouse Only

TWO = Two Party

Late enrollment indicator

“303” = Transaction Effective Date

“348” = Health Plan coverage Begin Date

“349” = Health Plan coverage End Date.

"357" = Eligibility End

Please refer section 4 “Reporting of Dates in the 834” for the dates reported for each

maintenance type code.


CCYYMMDD

Date Plan Coverage Begins/Ends in Update file or first day of the Month (for which

premium info is

being sent) in the Audit file.

“P3” – Premium Amount

Absolute premium amount.

Set to 2700

Squential number for member's additional reporting categories.

This will be 75

The code values will be:-

APTC AMT

CSR AMT

TOT IND RES AMT

TOT EMP RES AMT

RATING AREA

OTH PAY AMT 1

OTH PAY AMT 2

CSR ELIG CAT

REL TO TAX FILER

SOURCE EXCHG ID

SEP REASON

ADDL MAINT

DENRIDER

PRE AMT TOTAL

This will be 9V - Payment Category for APTC AMT, TOT IND RES AMT, TOT EMP RES

AMT

This will be 9X - Account Category for PRE AMT TOTAL, Rating Area

This will be ZZ for CSR Category and Dental Rider Indicator

This will be:

PRE AMT TOTAL

TOT IND RES AMT

TOT EMP RES AMT

APTC Amount

CSR Eligibility Category

Dental Rider Indicator

“007” – Effective Date


CCYYMMDD

Set to 2700

This field will be populated with the number of included segments.

This field will be populated with the Transaction Set Control Number.

Total number of transaction sets included in the functional group

Assigned number originated and maintained by the sender. Needs to match GS06

Number of functional groups included in an interchange

A control number assigned by the interchange sender

Required 834 EDI Segment Name 834 EDI Data Element 834 EDI ... · 834 EDI Segment Name 834 EDI Data...

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