Hipaa 834 Companion Guide - Excel by qkw21533

VIEWS: 91 PAGES: 8

More Info
									C:\Docstoc\Working\pdf\[593e9a98-d4ef-4d39-9e7c-8713a56cd1d4.xls]Guidelines
 Loop / Segment
    General

    ISA Header
      Header

      2100A

      2100B
      2100C
toc\Working\pdf\[593e9a98-d4ef-4d39-9e7c-8713a56cd1d4.xls]Guidelines
                                                                  Clarification
              Eyemed prefers to receive Full Files. Add/Change/Delete files will be accommodated on an exception basis.
              We can accept Group/Policy Number (REF*1L) in either Loop 2000 or Loop 2300, but not both
              ISA is a fixed record length segment requiring all positions within each of the data elements to be filled (with spaces).
              Use of Master Policy Number (REF*38) in the Header is allowed on an exception basis. Approval from EDI Analyst required.
              Addresses are required on subs. Situational on dependents. An information exception will be reported on each
              load for each dependent without an address. It will not impact file processing but could make the exception
              Foreign addresses should contain a two character identifier for 'State'.
              Inclusion of loop 2100B Incorrect Member will require additional testing validation. Please note at beginning of implementation.
              Mailing address/privacy address. Inclusion will require additional testing validation. Please note at beginning of implementation
d (with spaces).
m EDI Analyst required.



inning of implementation.
ginning of implementation.
                                                                                             834 Inbound Order
Loop ID              Loop Description                 Segment ID Segment Description                             Req Comment

None                 Control                          ISA          Interchange Control Header                    R
                                                      GS           Functional Group Header                       R

   None              Transaction Set Control          ST           Transaction Set Header                        R
                                                      BGN          Beginning Segment                             R
       1000A         Sponsor Name                     N1           Sponsor Name                                  R    Employer Information

       1000B         Payer                            N1           Payer                                         R
       2000          Member Level Detail              INS          Member Level Detail                           R    1 Loop for each Employee & each Covered Dependent
                                                      REF          Subscriber Number                             R
                                                      REF          Member Policy Number                          S    Either 2000 level or 2300 level
                                                      REF          Member Identification Number                  S    Max 5 Loops
                                                      DTP          Member Level Dates                            R*
          2100A      Member Name                      NM1          Member Name                                   R
                                                      PER          Member Communications Numbers                 S
                                                      N3           Member Residence Street Address               S
                                                      N4           Member Residence City, State, Zip Code        S
                                                      DMG          Member Demographics                           R*
                                                      HLH          Member Health Information                     S
          2100C      Member Mailing Address           NM1          Member Mailing Address                        S
                                                      N3           Member Mail Street Address                    S
                                                      N4           Member Mail City, State, Zip Code             S
          2300       Health Coverage                  HD           Health Coverage                               R*   1 Loop for Each Plan
                                                      DTP          Health Coverage Dates                         R
                                                      REF          Health Coverage Policy Number                 R*


   None              Transaction Set Control          SE           Transaction Set Trailer                       R

None                 Control                          GE           Functional Group Trailer                      R
                                                      IEA          Interchange Control Trailer                   R


* Required by EM, shown as Situational in Implementation Guide
Data & File Specifications : Refer to ASC X12N 834 (004010X095A1) Implementation Guide




          Create Date: 08/2002                                                                       834 Order                                                            Page 4 of 8
          Print Date: 5/10/2011                                                       593e9a98-d4ef-4d39-9e7c-8713a56cd1d4.xls                                             Version 3
                                                                                   834 Segment Description

                                  Ref. Des. Usage        EyeMed Element         EyeMed Element Description
Loop: None Segment: ISA Interchange Control Header (Required) -- Fixed Record Length
Authorization Information Qualifier        ISA01   Required             00                No Authorization Information Present Qualifier
Authorization Information                  ISA02   Required          <Blank>
Security Information Qualifier             ISA03   Required             00                No Security Information Present Qualifier
Security Information                       ISA04   Required          <Blank>
Interchange ID Qualifier                   ISA05   Required             30                U.S. Federal Tax Identification Number
Interchange Sender ID                      ISA06   Required        <Fed Tax Id>           Fed Tax Id of the Sender -- TPA should send Tax ID of the client
Interchange ID Qualifier                   ISA07   Required             30                U.S. Federal Tax Identification Number
Interchange Receiver ID                    ISA08   Required         311656473             Fed Tax ID of the Receiver
Interchange Date                           ISA09   Required        <YYMMDD>               Date the Interchange is created
Interchange Time                           ISA10   Required          <HHMM>               Time the Interchange is created
Interchange Control Standards Identifier   ISA11   Required             U                 U.S. EDI ASC X12, TDCC, UCS
Interchange Control Version Number         ISA12   Required           00401               Standards Approved by ACS X12 Review Board
Interchange Control Number                 ISA13   Required      <Unique Number>          Sequential Number Assigned by Internal Processes for each File/Interchange. Increment with each file. Cannot be a constant
                                                                                          value.
Acknowledgment Requested                   ISA14   Required            0 or 1             0 = No Acknowledgement Requested, 1 = Acknowledgment Requested
Usage Identifier                           ISA15   Required            P or T             P = Production, T = Test
Component Element Separator                ISA16   Required              :                Colon (Can be other upon agreement)
Terminator Delimiter                                                 <CR><LF>             EM preference is Carriage Return and Line Feed at end of each segment (Can be other upon agreement)

Loop: None Segment: GS Functional Group Header (Required)
Functional Identifier Code                 GS01    Required             BE                Benefit Enrollment And Maintenance (834)
Application Sender's Code                  GS02    Required         <Fed Tax Id>          Fed Tax Id of the Sender (Can be other upon agreement) but must be unique within EyeMed database. TPA should send Tax ID of
                                                                                          client.
Application Receiver's Code                GS03    Required         311656473             Fed Tax ID of the Receiver
Date                                       GS04    Required       <CCYYMMDD>              Date the Group Header is created.
Time                                       GS05    Required          <HHMM>               Time the Group Header is created.
Group Control Number                       GS06    Required      <Unique Number>          Unique Sequential Number Assigned for each Group Header
Responsible Agency Code                    GS07    Required             X                 Accredited Standards Committee X12
Version/Release/Industry Identifier Code   GS08    Required       004010X095A1            Standards Approved by ACS X12 Review Board

Loop: None Segment: ST Transaction Set Header (Required)
Transaction Set Identifier Code            ST01    Required            834                Benefit Enrollment and Maintenance
Transaction Set Control Number             ST02    Required      <Unique Number>          Unique Sequential Number Assigned for each Transaction Set. Matches value sent in SE02.

Loop: None Segment: BGN Beginning (Required)
Transaction Set Purpose Code               BGN01   Required             00                00 = Original File
Reference Identification                   BGN02   Required      <Unique Number>          Unique Number Assigned for each Transaction Set
Date                                       BGN03   Required       <CCYYMMDD>              Date the Transaction Set is created.
Time                                       BGN04   Required        <HHMMSS>               Time the Transaction Set is created. EyeMed can accept either HHMM; HHMMSS, HHMMSSD or HHMMSSDD
Time Code                                  BGN05   Situational     <Time Code>            Time Zone Code for Sender
Reference Identification                   BGN06   Situational       <Blank>              Blank if BGN01 = 00
Transaction Type Code                      BGN07   Not Used          <Blank>              Not Used
Action Code                                BGN08   Required              4                4 = Verify (Full File)

Loop: 1000A Segment: N1 Sponsor Name (Required)
Entity Identifier Code                     N101    Required              P5               P5 = Sponsor
Name                                       N102    Situational     <Client Name>          Client Name for which the Transmission is being created. Must be unique within EyeMed database.
Identification Code Qualifier              N103    Required              FI               U.S. Federal Tax Identification Number Qualifier or Mutually Defined
Identification Code                        N104    Required         <Fed Tax Id>          Federal Tax Id of Client for which the Transmission is being created. Must be unique within EyeMed database.

Loop: 1000B Segment: N1 Payer (Required)
Entity Identifier Code                     N101    Required             IN                IN = Insurer
Name                                       N102    Situational   EyeMed Vision Care       EyeMed Vision Care Name
Identification Code Qualifier              N103    Required             FI                U.S. Federal Tax Identification Number Qualifier


            Revision Date: 08/2007                                                            SegmentDesc                                                                                            Page 5 of 8
            Print Date: 5/10/2011                                               593e9a98-d4ef-4d39-9e7c-8713a56cd1d4.xls                                                                              Version 2
                                                                                       834 Segment Description

                                     Ref. Des.    Usage             EyeMed Element                 EyeMed Element Description
Identification Code                    N104      Required                 311656473                EyeMed Vision Care Federal Tax Id

Loop: 2000 Segment: INS Member Level Detail (Required)
Yes/No Condition or Response Code      INS01     Required                  Y or N                  Y = Subscriber (Employee) or N = Non-Subscriber (Dependent)
Individual Relationship Code           INS02     Required           <Relationship Code>            Relationship Code
Maintenance Type Code                  INS03     Required                   030                    030=Audit or Compare (Full File)
Maintenance Reason Code                INS04     Situational              <Blank>                  EM will not use
Benefit Status Code                    INS05     Required             <Benefit Status>             Benefit Status Code
Medicare Plan Code                     INS06     Situational       <Medicare Plan Code>            Medicare Plan Code
COBRA Qualifying                       INS07     Situational              <Blank>                  EM will not use. If INS05 sent is a "C", then INS07 becomes required.
Employment Status Code                 INS08     Situational       <Employment Status>             Employment Status Code on subscriber only
Student Status Code                    INS09     Situational         <Student Status>              Applicable on Non-Spouse Dependents Only
Yes/No Condition or Response Code      INS10     Situational        <Handicap Indicator>           EyeMed will not use.

Loop: 2000 Segment: REF Subscriber Number (Required)
Reference Identification Qualifier    REF01      Required                    0F                    Subscriber Number Qualifier. Used to link subscriber with related dependents.
Reference Identification              REF02      Required               <Employee ID>              SSN of Subscriber or Unique Identifier for Subscriber, as agreed upon between parties

Loop: 2000 Segment: REF Member Policy Number (Required either at this level or at Loop 2300)
Reference Identification Qualifier    REF01      Required                     1L                   Group or Policy Number.
Reference Identification              REF02      Required      <Employee ID or Group or Policy #> Client specific identifier. Will be provided by EDI Analyst.


Loop: 2000 Segment: REF Member Identification Number (Situational)
Reference Identification Qualifier    REF01      Required                     23                   Client Number Qualifier
Reference Identification              REF02      Required                                          For subscriber, this value should equal the value in REF*0F (employee SSN). For dependents, this value will be a unique value
                                                                                                   consisting of the employee SSN concatenated with a two digit suffix (eg 01, 02) that is consistently sent on every file for that
                                                                       <Client Number>             particular family member.
Reference Identification Qualifier    REF01      Required                     DX                   Department / Agency Number Qualifier
Reference Identification              REF02      Required              <Division Code>             Division Code. Please note that if EyeMed card are supplied, this value will print on each member ID card.

Loop: 2000 Segment: DTP Member Level Dates (Required)
Date/Time Qualifier                   DTP01      Required               303, 356, 357              EM will use 303 (Maintenance Effective), 356 (Eligibility Begin), and 357 (Eligibility End) only
Date Time Period Format Qualifier     DTP02      Required                    D8                    Date Expressed in Format CCYYMMDD Qualifier
Date Time Period                      DTP03      Required              <CCYYMMDD>                  Employment Begin or Employment End Date

Loop: 2100A Segment: NM1 Member Name (Required)
Entity Identifier Code                NM101      Required                      IL                  Insured or Subscriber Identifier Code. If you will be including the 74 identifier, please work with your EDI Analyst to coordinate
                                                                                                   additional testing.
Entity Type Qualifier                 NM102      Required                       1                  Person Qualifier
Name Last or Organization Name        NM103      Required                <Last Name>               Last Name of Insured or Subscriber
Name First                            NM104      Required                <First Name>              First Name of Insured or Subscriber
Name Middle                           NM105      Situational            <Middle Initial>           Middle Initial of Insured or Subscriber
Name Prefix                           NM106      Situational               <Blank>                 EM will not use
Name Suffix                           NM107      Situational               <Suffix>                Suffix of Insured or Subscriber
Identification Code Qualifier         NM108      Situational                   34                  Social Security Number Qualifier
Identification Code                   NM109      Situational                <SSN>                  Social Security Number of Insured (Dependent) or Subscriber

Loop: 2100A Segment: PER Member Communications Numbers (Situational)
Contact Function Code                 PER01      Required                   IP                     Insured Party
Name                                  PER02      Not Used                 <Blank>                  Not Used
Communication Number Qualifier        PER03      Required           <Telephone Qualifier>          Telephone Qualifier TE = Telephone, HP = Home Phone, WP = Work Phone
Communication Number                  PER04      Required           <Area Code><Phone>             3 Digit Area Code and 7 Digit Phone Number in AAABBBCCCC format. No spaces, punctuation or special characters allowed.
                                                                                                   Max value of 10 numbers.




            Revision Date: 08/2007                                                                  SegmentDesc                                                                                                      Page 6 of 8
            Print Date: 5/10/2011                                                     593e9a98-d4ef-4d39-9e7c-8713a56cd1d4.xls                                                                                        Version 2
                                                                                      834 Segment Description

                                Ref. Des. Usage         EyeMed Element       EyeMed Element Description
Loop: 2100A Segment: N3 Member Residence Street Address (Required). Address requested on both Subscribers and Dependents. (See Guidelines page)
Address Information                     N301    Required             <Address Line 1>             Address Line 1
Address Information                     N302    Situational          <Address Line 2>             Address Line 2

Loop: 2100A Segment: N4 Member Residence City, State, Zip Code (Required)
City Name                               N401    Required               <City Name>                City Name
State of Province Code                  N402    Required           <State or Provience>           State or Provience Code
Postal Code                             N403    Required           <Zip or Postal Code>           Zip or Postal Code. No spaces, punctutation or special characters allowed.
Country Code                            N404    Situational          <Country Code>               Country Code if not USA

Loop: 2100A Segment: DMG Member Demographics (Required)
Date Time Period Format Qualifier      DMG01    Required                    D8                    Date Expressed in Format CCYYMMDD Qualifier
Date Time Period                       DMG02    Required              <CCYYMMDD>                  Birth Date of Subscriber or Dependent
Gender Code                            DMG03    Required                <Gender>                  Gender Code
Martial Status Code                    DMG04    Situational           <Marital Status>            Martial Status

Loop: 2100C Segment: NM1 Member Mailing Address (Situational)
Entity Identifier Code                 NM101    Required                     31                   Postal Mail Address
Entity Type Qualifier                  NM102    Required                      1                   Person Qualifier

Loop: 2100C Segment: N3 Member Mail Street Address (Situational)
Address Information                     N301    Required             <Address Line 1>             Address Line 1 of Subscriber Only
Address Information                     N302    Situational          <Address Line 2>             Address Line 2 of Subscriber Only

Loop: 2100C Segment: N4 Member Mail City, State, Zip Code (Situational)
City Name                               N401    Required               <City Name>                City Name of Subscriber Only
State of Province Code                  N402    Required           <State or Provience>           State or Provience Code
Postal Code                             N403    Required           <Zip or Postal Code>           Zip or Postal Code. No spaces, punctutation or special characters allowed.
Country Code                            N404    Situational          <Country Code>               Country Code if not USA
Location Qualifier                      N405    Situational              <Blank>                  EM will not use
Location Identifier                     N406    Situational              <Blank>                  EM will not use

Loop: 2300 Segment: HD Health Coverage (Required)
Maintenance Type Code                   HD01    Required                    030                   030=Audit
Maintenance Reason Code                 HD02    Not Used                  <Blank>                 Not Used
Insurance Line Code                     HD03    Required                    VIS                   Vision
Plan Coverage Description               HD04    Situational                <Blank>                EDI Analyst will provide a unique value specific to your implementation
Coverage Level Code                     HD05    Situational          <Coverage Level>             Coverage Tier for Subscriber Only, not for Dependents

Loop: 2300 Segment: DTP Health Coverage Dates (Required)
Date/Time Qualifier                    DTP01    Required               348, 349, 543              EM will use 348 (Benefit Begin), 349 (Benefit End), and 543 (Last Premium Paid Date)
Date Time Period Format Qualifier      DTP02    Required                    D8                    Date Expressed in Format CCYYMMDD Qualifier
Date Time Period                       DTP03    Required              <CCYYMMDD>                  Benefit Begin or Benefit End Date

Loop: 2300 Segment: REF Health Coverage Policy Number (Situational) If REF*1L sent in Loop 2000, do not include at this level.
Reference Identification Qualifier     REF01    Required                     1L                   Group or Policy Number
Reference Identification               REF02    Required      <Employee ID or Group or Policy #> Client specific identifier. Will be provided by EDI Analyst.
Reference Identification Qualifier     REF01    Required                    17                    Mutually Defined Qualifier
Reference Identification               REF02    Required             <Reporting Value>            Client specific reporting value. Applicable to subscriber only.



Loop: None Segment: SE Transaction Set Trailer (Required)
Number of Included Segments             SE01    Required                 <Number>                 Count of Segments in Transaction Set
Transaction Set Control Number          SE02    Required                 <Number>                 Same Number as in ST segment, element ST02



            Revision Date: 08/2007                                                                 SegmentDesc                                                                           Page 7 of 8
            Print Date: 5/10/2011                                                    593e9a98-d4ef-4d39-9e7c-8713a56cd1d4.xls                                                             Version 2
                                                                             834 Segment Description

                                      Ref. Des.   Usage      EyeMed Element           EyeMed Element Description

Loop: None Segment: GE Functional Group Trailer (Required)
Number of Transaction Sets Included     GE01      Required       <Number>             Count of All Transaction Sets in Functional Group
Group Control Number                    GE02      Required       <Number>             Same Number as in GS segment, element GS06


Loop: None Segment: IEA Interchange Control Trailer (Required)
Number of Transaction Sets Included     IEA01     Required       <Number>             Count of All Functional Groups in Interchange
Group Control Number                    IEA02     Required       <Number>             Same Number as in ISA segment, element ISA13




           Revision Date: 08/2007                                                         SegmentDesc                                     Page 8 of 8
           Print Date: 5/10/2011                                            593e9a98-d4ef-4d39-9e7c-8713a56cd1d4.xls                       Version 2

								
To top