Docstoc

834 Companion Guide

Document Sample
834 Companion Guide Powered By Docstoc
					      HIPAA Transaction Standard Companion Guide

Refers to the Technical Reports Type 3 Based on ASC
                          X12 version 005010X220A1

             834 – Benefit Enrollment and Maintenance

              Companion Guide Version Number: 1.0

                                           July 2011
                                 Disclaimer

Florida Health Care Plan, Inc. (FHCP) Companion Guide for EDI Transactions
(Technical Reports, Type 3 (TR3) provides guidelines in submitting electronic
batch transactions. Because the HIPAA ASC X12- TR3s require transmitters and
receivers to make certain determinations /elections (e.g., whether, or to what
extent, situational data elements apply), this Companion Guide documents those
determinations, elections, assumptions or data issues that are permitted to be
specific to FHCP business processes when implementing the HIPAA ASC X12
5010 TR3s.

This Companion Guide does not replace or cover all segments specified in the
HIPAA ASC X12 TR3s. It does not attempt to amend any of the requirements of
the TR3s, or impose any additional obligations on trading partners of FHCP that
are not permitted to be imposed by the HIPAA Standards for Electronic
Transactions. This Companion Guide provides information on FHCP specific
codes relevant to FHCP business processes and rules and situations that are
within the parameters of HIPAA. Readers of this Companion Guide should be
acquainted with the HIPAA ASC X12 TR3s, their structure, and content.

Nothing contained in this Companion Guide is intended to amend, revoke,
contradict or otherwise alter the terms and conditions of your applicable Trading
Partner Agreement. If there is an inconsistency between the terms of this
Companion Guide and the terms of your applicable Trading Partner Agreement,
the terms of the Trading Partner Agreement will govern. If there is an
inconsistency between the terms of this Companion Guide and any terms of the
TR3, the relevant TR3 will govern with respect to HIPAA edits, and this
Companion Guide will control with respect to business edits.
                                                   Table of Contents


DISCLAIMER .................................................................................................................................. 2

I.     INTRODUCTION .................................................................................................................... 4

        What is HIPAA 5010?........................................................................................................... 4

        Purpose of the Technical Reports Type 3 Guides............................................................ 4

        How to Obtain Copies of the Technical Reports Type 3 Guides .................................... 4

        Purpose of this 834 Companion Guide ............................................................................. 4

II.    ASC X12 TRANSACTIONS SUPPORTED............................................................................ 4

III.   GENERAL INFORMATION .................................................................................................... 5

IV.    CONTROL SEGMENTS & ENVELOPES .............................................................................. 5

        Global Information ............................................................................................................... 5

        Enveloping Information....................................................................................................... 6

        Business Requirements.................................................................................................... 10

V.     DIRECT CONNECT WITH FHCP......................................................................................... 30




FHCP 834 Companion Guide Version: 1.0                                                                                                        3
I. Introduction

 What is HIPAA 5010?

 The Health Insurance Portability and Accountability Act (HIPAA) requires that the
 health care industry in the United States comply with the electronic data
 interchange (EDI) standards as established by the Secretary of Health and
 Human Services. The ASC X12 005010X220 is the established standard for
 Benefit Enrollment and Maintenance.


 Purpose of the Technical Reports Type 3 Guides

 The Technical Reports Type 3 Guides (TR3s) for the 834 Benefit Enrollment and
 Maintenance transaction specifies in detail the required formats. It contains
 requirements for the use of specific segments and specific data elements within
 segments, and is written for all health care providers and other submitters.


 How to Obtain Copies of the Technical Reports Type 3 Guides

 TR3 Guides for ASC X12 005010X220 Benefit Enrollment and Maintenance 834
 and all other HIPAA standard transactions are available electronically at
 http://www.wpc-edi.com.


 Purpose of this 834 Companion Guide

 This 834 Companion Guide was created for FHCP trading partners to
 supplement the 834 TR3. It describes the data content, business rules, and
 characteristics of the 834 transaction.

II. ASC X12 Transactions Supported

 FHCP processes the ASC X12 834 transaction for Benefit Enrollment and
 Maintenance.




 FHCP 834 Companion Guide Version: 1.0                                          4
III. General Information

  EDI Technical Assistance

  To request technical assistance from FHCP, please send an email to
  edisupport@fhcp.com.




IV. Control Segments & Envelopes

                                  Global Information


       Loop ID – Segment           Reference                 Plan Requirement
   Description & Element Name      Description

  All Segments                                    Only loops, segments, and data elements
                                                  valid for the 834 HIPAA-AS TR3 Guides
                                                  ASC X12 005010X220 &
                                                  ASC X12 005010X220A1 will be used for
                                                  processing.


  Negative Values                                 Submission of any negative values in the
                                                  834 transaction will not be processed or
                                                  forwarded.


  Date fields                                     All dates submitted on an incoming 834
                                                  Health Care Institutional Claim must be a
                                                  valid calendar date in the appropriate
                                                  format based on the respective HIPAA-
                                                  AS TR3 qualifier. Failure to do so may
                                                  cause processing delays or rejection.


  Batch Transaction Processing                    Generally, FHCP accepts transmissions
                                                  24 hours a day, 7 days a week.


  Multiple Transmissions           All Segments   Any errors detected in a transaction set
                                                  will result in the entire transaction set
                                                  being rejected.




  FHCP 834 Companion Guide Version: 1.0                                                       5
                                Enveloping Information



     Loop ID – Segment             Reference                  Plan Requirement
 Description & Element Name        Description

Interchange Control Header              ISA       All transactions utilize delimiters from the
                                                  following list: >,*,~,^,| and :. Submitting
                                                  delimiters not supported within this list
                                                  may cause an interchange (transmission)
                                                  to be rejected.


Interchange Control Structure           ISA       Must submit incoming enrollment data
Basic Character Set/Extended                      using the basic character set as defined
Character Set                                     in Appendix B of the 005010X220A1 TR3.
                                                  In addition to the basic character set, you
                                                  may choose to submit lower case
                                                  characters and the ‘@’ symbol from the
                                                  extended character set. Any other
                                                  characters submitted from the extended
                                                  character set may cause the interchange
                                                  (transmission) to be rejected by the Plan.


Interchange Control Header           ISA02        FHCP requires 10 spaces in this field.
Authorization Information


Interchange Control Header           ISA04        FHCP requires 10 spaces in this field.
Security Information


Interchange Control Header        ISA05 & ISA06   FHCP requires submission of the ZZ
Interchange Sender ID                             qualifier with your individually assigned
                                                  FHCP sender mailbox number in these
                                                  fields.


Interchange Control Header           ISA08        FHCP will only accept the submission of
Interchange Receiver ID                           FHCP tax ID number 593222484 in this
                                                  field.


Interchange Control Header           ISA09        YYMMDD
Interchange Date                                  Requires submission of the relevant date
                                                  of the interchange.


Interchange Control Header           ISA10        HHMM
Interchange Time                                  Requires submission of relevant time of
                                                  the interchange.




FHCP 834 Companion Guide Version: 1.0                                                         6
     Loop ID – Segment           Reference                 Plan Requirement
 Description & Element Name      Description

Interchange Control Header          ISA11      > Delimiters
Repetition Separator                           :
                                               ^
                                               FHCP requires the use of the above
                                               delimiters to separate component data
                                               elements within a composite data
                                               structure.


Interchange Control Header          ISA12      00501 – Draft Standards for Trial Use
Interchange Control Version                    Approved by ASC X12, etc.
Number
                                               FHCP requires submission of the above
                                               value in this field.


Interchange Control Header          ISA13      This is a unique control number that is
Interchange Control Number                     assigned by the sender and the number
                                               in this field must be identical to the
                                               associated interchange trailer in the
                                               IEA02 segment.


Interchange Control Header          ISA14      0 – No Interchange Acknowledgement
Acknowledgment Requested                       Requested (TA1) 1 – Interchange
                                               Acknowledgement Requested (TA1)

                                               The TA1 will not be provided without a
                                               code value of 1 in the field.


Interchange Control Header          ISA15      P – Production Data
Usage Indicator                                T – Test Data

                                               The above values designate if the
                                               transaction is destined for production
                                               processing or testing only.

                                               Use a P in this field to indicate the data
                                               enclosed in this transaction is a
                                               production file.

                                               A T would indicate the interchange is for
                                               testing purposes only.




FHCP 834 Companion Guide Version: 1.0                                                       7
     Loop ID – Segment            Reference                Plan Requirement
 Description & Element Name       Description

Interchange Control Header          ISA16       > Delimiters
Component Element Separator                     :
                                                ^
                                                FHCP requires the use of the above
                                                delimiters to separate component data
                                                elements within a composite data
                                                structure.


Interchange Control Trailer         IEA01       A count of the number (#) of functional
Number of Included Functional                   groups included in an interchange.
Groups

Interchange Control Trailer         IEA02       A control number (#) assigned by the
Interchange Control Number                      interchange sender. This number must
                                                be identical to the number assigned in
                                                ISA13.


Interchange Control Header          GS-GE       FHCP will only process one transaction
Functional Group                   ISA-IEA      type per GS-GE (functional group).
Header/Functional Group Trailer                 However, we will process multiple ST’s
                                                within one (1) GS segment as long as
                                                they are all the same transaction type.


Functional Group Header             GS01        BE – Benefit Enrollment and Maintenance
Functional Identifier Code                      FHCP requires submission of the above
                                                value in this field.


Functional Group Header             GS02        FHCP requires the ID published y the
Application Sender’s Code                       Sender


Functional Group Header             GS03        FHCP requires 593222484 in this field
Application Receiver’s Code


Functional Group Header             GS04        CCYYMMDD
Date
                                                FHCP requires submission of relevant
                                                date for the functional group creation
                                                date.




FHCP 834 Companion Guide Version: 1.0                                                     8
     Loop ID – Segment            Reference                Plan Requirement
 Description & Element Name       Description

Functional Group Header             GS05        HHMM
Time
                                                FHCP requires the time associated with
                                                the creation of the functional group
                                                (reference GS04) expressed in the above
                                                format.


Functional Group Header             GS06        This is a unique number that is assigned
Group Control Number                            by the sender and the number in this field
                                                must be identical to the data element in
                                                the associated functional group trailer
                                                GE02.


Functional Group Header             GS07        X – Accredited Standards Committee X12
Responsible Agency Code                         FHCP requires submission of the above
                                                value in this field.


Functional Group Header             GS08        005010X220A1
Version/Release/Industry
Identifier Code                                 FHCP requires submission of the above
                                                HIPAA-AS ANSI X12 834 Benefit
                                                Enrollment version number (#)


Transaction Set Header               ST01       834 – Benefit Enrollment and
Transaction Set Identifier Code                 Maintenance

                                                FHCP requires submission of the above
                                                value in this field.


Transaction Set Header               ST02       An identifying control number assigned by
Transaction Set Control Number                  the sender that must be unique within the
                                                transaction set functional group.

                                                The transaction set control number in the
                                                SE02 segment must be identical to the
                                                number in this field.


Transaction Set Header               ST03       Must contain 005010X220A1
Implementation Convention
Reference




FHCP 834 Companion Guide Version: 1.0                                                   9
     Loop ID – Segment              Reference                Plan Requirement
 Description & Element Name         Description

Beginning Segment                     BGN08       Code indicating type of action.
Action Code                                       2- Change (Update)
                                                  4 – Verify


Transaction Set Trailer                SE01       Must include the total number of
Transaction Segment Count                         segments included in a transaction set
                                                  including ST and SE segments (#).

                                       SE02
Transaction Set Trailer                           An identifying control number assigned by
Transaction set Control Number                    the sender that must be unique within the
                                                  transaction set functional group.

                                                  The transaction set control number in the
                                                  ST02 segment must be identical to the
                                                  number in this field.


Functional Group Trailer              GE01        FHCP requires the submission of the
Number of Transaction Sets                        total number of transaction sets included
Included                                          in the functional group or interchange
                                                  group terminated by the trailer (#).


Functional Group Trailer              GE02        This is a unique number that is assigned
Group Control Number                              by the sender and the number in this field
                                                  must be identical to the same data
                                                  element in the associated functional
                                                  group header GS06.


                                 Business Requirements



     Loop ID – Segment              Reference                Plan Requirement
 Description & Element Name         Description

2000-Member Level Detail              INS01       FHCP Requires Y or N
Subscriber/Dependent


2000-Member Level Detail              INS02       Applicable code 01-60,D2,G8,G9
Relationship Code




FHCP 834 Companion Guide Version: 1.0                                                      10
     Loop ID – Segment            Reference                 Plan Requirement
 Description & Element Name       Description

2000-Member Level Detail            INS03       001 = Change
Maintenance Type Code                           021 = Addition
                                                024 = Termination
                                                025 = Reinstate
                                                030 = Audit/Compare


2000-Member Level Detail            INS04       Applicable Code 01-59, AA-XT
Maintenance Reason Code



2000-Member Level Detail            INS05       Code: A-T
Benefit Status Code


2000-Member Level Detail            INS06
Medicare Status Code


2000-Member Level Detail           INS06-1      A-E
Medicare Plan Code (If
applicable)


2000-Member Level Detail           INS06-2      0-2
Eligibility Reason Code (If
applicable)


2000-Member Level Detail            INS07       1-10,
Consolidated Omnibus Budget                     ZZ
Reconciliation Act (COBRA)


2000-Member Level Detail            INS08       AC-TE
Employment Status Code


2000-Member Level Detail            INS09       F,N,P
Student Status


2000-Member Level Detail            INS10       Y or N
If dependent is handicapped (if
applicable)




FHCP 834 Companion Guide Version: 1.0                                          11
     Loop ID – Segment               Reference                Plan Requirement
 Description & Element Name          Description

2000-Member Level Detail               INS11       D8
Date Time Period Qualifier-Date
of Death-(ccyymmdd)


2000-Member Level Detail               INS12       ccyymmdd
Date Time Period-Date of Death


2000-Member Level Detail               INS13       R or U
Confidentiality Code


2000-Member Level Detail               INS 17      Number assigned to each family member
Number assigned to each family                     if born on the same date.
member if born on the same
date.


2000-Subscriber Identifier             REF01       OF
Reference Identification
Qualifier-Subscriber Number


2000-Subscriber Identifier             REF02       SSN
Subscriber Identification-SSN


2000-Subscriber Identifier             REF01       1L
Group or Policy Number


2000-Subscriber Identifier             REF02       Subscriber Identifier
Reference Identification-Member
Group or Policy Number


2000-Subscriber Identifier             REF01       17,23,3H,4A,60,ABB,D#,DX,F6,P5,Q4,Q
Reference Identification Qualifier                 Q,ZZ

                                                   Applicable Code (s)


2000-Subscriber Identifier             REF02       OF
Reference Identification


2000- Member Level Dates               DTP01       ccyymmdd & applicable code 050-474
Date Time Qualifier




FHCP 834 Companion Guide Version: 1.0                                                   12
     Loop ID – Segment              Reference                  Plan Requirement
 Description & Element Name         Description

2000- Member Level Dates              DTP02       CCYYMMDD
Date Time Period Format
Qualifier


2000- Member Level Dates              DTP03       Begin Date and End Date of the recipient.
Status Information Effective Date
                                                  The End Date will be the actual
                                                  termination date or the last day of the
                                                  Last coverage month.


2100A- Member Name                    NM101       IL = Insured or Subscriber
Entity Identifier Code


2100A- Member Name                    NM102       1 Person
Entity Type Qualifier


2100A- Member Name                    NM103       Last Name
Name Last


2100A- Member Name                    NM104       First Name
Name First


2100A- Member Name                    NM105       Middle Name
Name Middle


2100A- Member Name                    NM106       Prefix
Name Prefix


2100A- Member Name                    NM107       Suffix
Name Suffix


2100A- Member Name                    NM108       34 = Social Security Number ZZ-Other
Identification Code Qualifier


2100A- Member Name                    NM109       Social Security Number or Other
Identification Code




FHCP 834 Companion Guide Version: 1.0                                                       13
     Loop ID – Segment           Reference               Plan Requirement
 Description & Element Name      Description

2100A- Administrative               PER01      IP = Insured Party-Name
Communications Contact
Contact Function Code


2100A- Administrative               PER03      AP-WP Applicable Code (s)
Communications Contact
Communication Number
Qualifier


2100A- Administrative               PER04      Communication Number
Communications Contact
Communication Number


2100A- Administrative               PER05      AP-WP Applicable Code (s)
Communications Contact
Communication Number
Qualifier


2100A- Administrative               PER06      Communication Number
Communications Contact
Communication Number


2100A- Administrative               PER07      AP-WP Applicable Code (s)
Communications Contact
Communications Number
Qualifier


2100A- Administrative               PER08      Communication Number
Communications Contact
Communications Number


2100-Address Information            N301       Address Information
Address Information


2100-Address Information            N302       Second Address Information
Second Address Information


2100A-Geographic Location           N401       Subscriber City Name
City Name




FHCP 834 Companion Guide Version: 1.0                                       14
     Loop ID – Segment           Reference                Plan Requirement
 Description & Element Name      Description

2100A-Geographic Location           N402       Subscriber State Code
State or Province Code


2100A-Geographic Location           N403       Subscriber Postal Code
Postal Code


2100A-Geographic Location           N404       Subscriber Country Code
Country Code


2100A-Geographic Location           N405       Subscriber Area County
Location Qualifier-Area County


2100A-Geographic Location           N406
Location Identifier


2100A-Geographic Location           N407
Country Subdivision Code


2100A-Member Demographics          DMG01       D8 ccyymmdd
Date Time Period Format
Qualifier-Date expressed in
Format ccyymmdd


2100A-Member Demographics          DMG02       Date of Birth
Date time period- Member


2100A-Member Demographics          DMG03       F,M,U Applicable Code (s)
Gender Code


2100A-Member Demographics          DMG04       B-X Applicable Code (s)
Marital Status Code


2100A-Member Demographics          DMG05
Composite Race or Ethnicity
Information


2100A-Member Demographics          DMG05-1     7,8,A-Z Applicable Code (s)
Race or Ethnicity Code- We
need both




FHCP 834 Companion Guide Version: 1.0                                        15
     Loop ID – Segment            Reference                Plan Requirement
 Description & Element Name       Description

2100A-Member Demographics          DMG05-2      RET Race or ethnicity code
Code List Qualifier Code


2100A-Member Demographics          DMG05-3      859
Industry Code-Classification of
Race or Ethnicity


2100A-Member Demographics           DMG06       Applicable Code (s)
Citizenship Status


2100A-Employment Class              EC01        Applicable Code (s)
Employment Class


2100A-Employment Class              EC02        Applicable Code (s)
Employment Class Code


2100A-Employment Class              EC03        Applicable Code (s)
Employment Class Code


2100A-Member Income                 ICM01       Applicable Code (s)
Frequency Code


2100A-Member Income                 ICM02
Monetary Amount


2100A-Member Income                 ICM03
Quantity


2100A-Member Income                 ICM04
Location Indicator


2100A-Member Income                 ICM05
Salary Grade


2100A-Member Policy                 AMT01       Applicable Code (s)
Amounts
Amount Qualifier Code




FHCP 834 Companion Guide Version: 1.0                                         16
     Loop ID – Segment           Reference                 Plan Requirement
 Description & Element Name      Description

2100A-Member Policy                 AMT02
Amounts
Monetary Amount

2100A-Member Health                 HLH01      Applicable Code (s)
Information
Health Related Code including
tobacco use


2100A-Member Health                 HLH02
Information
Height


2100A-Member Health                 HLH03
Information
Weight


2100A-Member Language               LUI01      LD,LE
Identification Code Qualifier


2100A-Member Language               LUI02      Language Code
Identification Code


2100A-Member Language               LUI03      Language Name
Description


2100A-Member Language               LUI04      5-8 Applicable Code (s)
Use of Language Indicator


2100B-Incorrect Member Name         NM101      70
Entity Identifier Code-Prior
Incorrect Insured


2100B-Incorrect Member Name         NM102      1
Entity Type Qualifier-Person


2100B-Incorrect Member Name         NM103      Last Name
Name Last or Organization
Name




FHCP 834 Companion Guide Version: 1.0                                         17
     Loop ID – Segment              Reference                  Plan Requirement
 Description & Element Name         Description

2100B-Incorrect Member Name           NM104       First Name
Name First


2100B-Incorrect Member Name           NM105       Middle Name
Name Middle


2100B-Incorrect Member Name           NM106       Prefix
Name Prefix


2100B-Incorrect Member Name           NM107       Suffix
Name Suffix


2100B-Incorrect Member Name           NM108       34 SS# ,ZZ-Other
Identification Code Qualifier-SSN
or Mutually Defined


2100B-Incorrect Member Name           NM109
Identification Code


2100B-Demographic                     DMG01       D8 = Date expressed in format
Information                                       CCYYMMDD
Date Time Period Format
Qualifier


2100B-Demographic                     DMG02       Member Birth Date
Information
Date Time Period


2100B-Demographic                     DMG03       M = Male
Information                                       U-Unknown
Gender Code                                       F = Female


2100B-Demographic                     DMG04       D = Divorced
Information                                       I = Single
Marital Status Code                               M = Married
                                                  S = Separated




FHCP 834 Companion Guide Version: 1.0                                             18
     Loop ID – Segment           Reference                Plan Requirement
 Description & Element Name      Description

2100B-Demographic                  DMG05
Information
Composite Race or Ethnicity
Information


2100B-Demographic                  DMG05-1     Applicable Code (s)
Information
Race or Ethnicity Code


2100B-Demographic                  DMG05-2     Applicable Code (s)
Information
Code List Qualifier Code

2100B-Demographic                  DMG05-3     Applicable Code (s)
Information
Industry Code


2100B-Demographic                  DMG06       Applicable Code (s)
Information
Citizenship Status Code-
Correction


2100B-Demographic                  DMG10       Applicable Code (s)
Information
Code List Qualifier Code-
Correction


2100B-Demographic                  DMG11
Information
Industry Code-Correction


2100C-Member Mailing                NM101      31 Postal mailing address
Address
Entity Identifier Code-Prior
Incorrect Insured


2100C-Member Mailing                NM102      1 Person
Address
Entity Type Qualifier




FHCP 834 Companion Guide Version: 1.0                                        19
     Loop ID – Segment           Reference               Plan Requirement
 Description & Element Name      Description

2100C-Member Residence              N301       Member Address ( Mailing address)
Street Address
Address Information


2100C-Member Residence              N302       Physical address
Street Address
Second Address Information


2100C-Member City, State, ZIP       N401       Member City, State, ZIP Code
Code
City Name


2100C-Member City, State, ZIP       N402       Member State or Province Code
Code
State or Province Code


2100C-Member City, State, ZIP       N403       Member Postal Code
Code
Postal Code


2100C-Member City, State, ZIP       N404       Member Country Code
Code
Country Code


2100C-Member City, State, ZIP       N405       Area County
Code
Location Qualifier-Area County


2100C-Member City, State, ZIP       N406
Code
Location Identifier


2100C-Member City, State, ZIP       N407
Code
Country Subdivision Code


2100D-Member Employee               NM101      36 EMPLOYER
Entity Identifier Code-




FHCP 834 Companion Guide Version: 1.0                                              20
     Loop ID – Segment            Reference                  Plan Requirement
 Description & Element Name       Description

2100D-Member Employee               NM102       1 Person, 2 Non-Person
Entity Type Qualifier-Person


2100D-Member Employee               NM103       Name Last or Organization Name
Name Last or Organization
Name


2100D-Member Employee               NM104       Name First
Name First


2100D-Member Employee               NM105       Name Middle
Name Middle


2100D-Member Employee               NM106       Name Prefix
Name Prefix


2100D-Member Employee               NM107       Name Suffix
Name Suffix


2100D-Member Employee               NM108       24,34,
Identification Code Qualifier-
Employers Identification Number
or SSN


2100D-Member Employee               NM109
Identification Code


2100D-Member Employer               PER01       EP
Communications Numbers
Contact Function Code-
Employer Contact


2100D-Member Employer               PER02
Communications Numbers
Name of Contact


2100D-Member Employer               PER03       AP-WP Applicable Code (s)
Communications Numbers
Communication Number
Qualifier- Phone types




FHCP 834 Companion Guide Version: 1.0                                            21
     Loop ID – Segment           Reference               Plan Requirement
 Description & Element Name      Description

2100D-Member Employer               PER04
Communications Numbers
Communication Number


2100D-Member Employer               PER05      AP-WP Applicable Code (s)
Communications Numbers
Communication Number
Qualifier-Phone Types


2100D-Member Employer               PER06
Communications Numbers
Communication Number


2100D-Member Employer               PER07      AP-WP Applicable Code (s)
Communications Numbers
Communications Number
Qualifier


2100D-Member Employer               PER08
Communications Numbers
Communications Number


2100D- Employer Residence           N301       Employer Address
Street Address
Address Information


2100D- Employer Residence           N302
Street Address
Second Address Information


2100D- Employer City, State,        N401       Employer City Name
ZIP Code
City Name


2100D- Employer City, State,        N402       Employer State or Province Code
ZIP Code
State or Province Code


2100D- Employer City, State,        N403       Employer Postal Code
ZIP Code
Postal Code




FHCP 834 Companion Guide Version: 1.0                                            22
     Loop ID – Segment           Reference                Plan Requirement
 Description & Element Name      Description

2100D- Employer City, State,        N404       Employer Country Code
ZIP Code
Country Code


2100D- Employer City, State,        N407
ZIP Code
Country Subdivision Code


2100E-Member School                 NM101      M8 Educational Institution
Entity Identifier Code-


2100E-Member School                 NM102      2 – Non Person
Entity Type Qualifier


2100E-Member School                 NM103
School Name


2100E- member School                PER01      SK – School Clerk
Communications Number
Contact function Code


2100E- member School                PER02
Communications Number
Name of Contact


2100E- member School                PER03      AP-WP Applicable Code (s)
Communications Number
Communication Number
Qualifier- Phone types


2100E- member School                PER04
Communications Number
Communication Number


2100E- member School                PER05      AP-WP Applicable Code (s)
Communications Number
Communication Number
Qualifier-Phone Types




FHCP 834 Companion Guide Version: 1.0                                        23
     Loop ID – Segment           Reference               Plan Requirement
 Description & Element Name      Description

2100E- member School                PER06
Communications Number
Communication Number


2100E- member School                PER07      AP-WP Applicable Code (s)
Communications Number
Communications Number
Qualifier


2100E- member School                PER08
Communications Number
Communications Number


2100E- Member School Street         N301       Member School Address
Address
Address Information


2100E- Member School Street         N302
Address
Second Address Information


2100E- Member School City,          N401       Member School City Name
State, ZIP Code
City Name


2100E- Member School City,          N402       Member School State or Province Code
State, ZIP Code
State or Province Code


2100E- Member School City,          N403       Member School Postal Code
State, ZIP Code
Postal Code


2100E- Member School City,          N404       Member School Country Code
State, ZIP Code
Country Code


2100E- Member School City,          N407
State, ZIP Code
Country Subdivision Code




FHCP 834 Companion Guide Version: 1.0                                             24
     Loop ID – Segment           Reference                Plan Requirement
 Description & Element Name      Description

2100F-Custodial Parent              NM101      S3 Custodial Parent
Information
Entity Identifier Code


2100F-Custodial Parent              NM102      1 Person
Information
Entity Type Qualifier


2100F-Custodial Parent              NM103      Custodial Parent Last Name
Information
Name Last


2100F-Custodial Parent              NM104      Custodial Parent First Name
Information
Name First


2100F-Custodial Parent              NM105      Custodial Parent Middle Name
Information
Name Middle


2100F-Custodial Parent              NM106      Prefix
Information
Name Prefix


2100F-Custodial Parent              NM107      Suffix
Information
Name Suffix


2100F-Custodial Parent              NM108      34 = Social Security Number ZZ-Other
Information
Identification Code Qualifier


2100F-Custodial Parent              NM109      Social Security Number or Other
Information
Identification Code


2100F-Custodial Parent              PER03      AP-WP Applicable Code (s)
Communication Numbers
Communication Number
Qualifier




FHCP 834 Companion Guide Version: 1.0                                                 25
     Loop ID – Segment           Reference                 Plan Requirement
 Description & Element Name      Description

2100F-Custodial Parent              PER04      Communication Number
Communication Numbers
Communication Number


2100F-Custodial Parent              PER05      AP-WP Applicable Code (s)
Communication Numbers
Communication Number
Qualifier


2100F-Custodial Parent              PER06      Communication Number
Communication Numbers
Communication Number


2100F-Custodial Parent              PER07      AP-WP Applicable Code (s)
Communication Numbers
Communications Number
Qualifier


2100F-Custodial Parent              PER08      Communication Number
Communication Numbers
Communications Number


2100F-Custodial Parent Street       N301       Custodial Parent Address
Address
Address Information


2100F-Custodial Parent Street       N302
Address
Second Address Information


2100F- Custodial Parent City,       N401       City Name
State, ZIP Code
City Name


2100F- Custodial Parent City,       N402       State or Province Code
State, ZIP Code
State or Province Code


2100F- Custodial Parent City,       N403       Postal Code
State, ZIP Code
Postal Code




FHCP 834 Companion Guide Version: 1.0                                         26
     Loop ID – Segment           Reference                Plan Requirement
 Description & Element Name      Description

2100F- Custodial Parent City,       N404       Country Code
State, ZIP Code
Country Code


2100F- Custodial Parent City,       N407       Country Subdivision Code
State, ZIP Code
Country Subdivision Code


2100G- Responsible Person           NM101      Applicable Code (s)
Information
Entity Identifier Code


2100G- Responsible Person           NM102      1 Person
Information
Entity Type Qualifier


2100G- Responsible Person           NM103      Responsible Person Last Name
Information
Name Last


2100G- Responsible Person           NM104      Responsible Person First Name
Information
Name First

2100G- Responsible Person
Information                         NM105      Responsible Person Middle Name
Name Middle
2100G- Responsible Person
Information                         NM106      Prefix
Name Prefix

2100G- Responsible Person           NM107      Suffix
Information
Name Suffix


2100G- Responsible Person           NM108      34 = Social Security Number ZZ-Other
Information
Identification Code Qualifier


2100G- Responsible Person           NM109      Social Security Number or Other
Information
Identification Code




FHCP 834 Companion Guide Version: 1.0                                                 27
     Loop ID – Segment           Reference               Plan Requirement
 Description & Element Name      Description

2100G- Responsible Person           PER01      RP- Responsible Person
Communication Number
Contact Function Code


2100G- Responsible Person           PER03      AP-WP Applicable Code (s)
Communication Number
Communication Number
Qualifier


2100G- Responsible Person           PER04      Communication Number
Communication Number
Communication Number


2100G- Responsible Person           PER05      AP-WP Applicable Code (s)
Communication Number
Communication Number
Qualifier


2100G- Responsible Person           PER06      Communication Number
Communication Number
Communication Number


2100G- Responsible Person           PER07      AP-WP Applicable Code (s)
Communication Number
Communications Number
Qualifier


2100G- Responsible Person           PER08      Communication Number
Communication Number
Communications Number


2100G- Responsible Person           N301       Responsible Person Address
Information Street Address
Address Information


2100G- Responsible Person           N302
Information Street Address
Second Address Information




FHCP 834 Companion Guide Version: 1.0                                       28
     Loop ID – Segment           Reference                 Plan Requirement
 Description & Element Name      Description

2100G- Responsible Person           N401       City Name
City, State, ZIP Code
City Name


2100G- Responsible Person           N402       State or Province Code
City, State, ZIP Code
State or Province Code


2100G- Responsible Person           N403       Postal Code
City, State, ZIP Code
Postal Code


2100G- Responsible Person           N404       Country Code
City, State, ZIP Code
Country Code


2100G- Responsible Person           N407       Country Subdivision Code
City, State, ZIP Code
Country Subdivision Code


2300-Health Coverage                HD01       001 = Change
Maintenance Type Code                          021 = Addition
                                               024 = Termination
                                               030 = Audit/Compare


2300-Health Coverage                HD03       Applicable Code (s)
Insurance Code Line


2300-Health Coverage                HD04
Plan Coverage Description


2300-Health Coverage                HD05       Applicable Code (s)
Coverage Level Code

2300-Health Coverage                HD09       Late Enrollment Indicator
Yes/No Condition or Response
Code


2300-Health Coverage Dates          DTP01      348 = Benefit Begin
Date Time Qualifier                            349 = Benefit End




FHCP 834 Companion Guide Version: 1.0                                         29
      Loop ID – Segment              Reference                Plan Requirement
  Description & Element Name         Description

 2300-Health Coverage Dates            DTP02       D8
 Date Time Period Qualifier


 2300-Health Coverage Dates            DTP03       Begin Date and End Date of the recipient.
 Status Information Effective Date




V. Direct Connect with FHCP
 FHCP offers a Direct Connect alternative compared to traditional Clearinghouse
 to process the 834 Batch transactions. Each Direct Connect option is unique per
 organization and transactions are sent and received via a secured FTP.




 FHCP 834 Companion Guide Version: 1.0                                                   30

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:54
posted:9/14/2011
language:English
pages:30