Appendix_7_8_Benefits_Administration_834_Guidance_Manual_v5.pdf

Benefits Administration 834 Guidance Manual Revised: 01/16/2024

Version 5.0

Benefits Administration 834 Guidance Manual: v 5.0 1

Content Purpose

File Transmission

TN State File Characteristics

Testing Process

Errors

Contact information

State of TN 834 File Format – Tables

Tables 1 ‐ 7B: Header Information

Table 1: Interchange Control Header

Table 2: Functional Group Header

Table 3: Transaction Set Header

Table 4: Beginning Segment

Table 5: DTP – File Effective Date in Header

Table 6: DTP – File Effective Date in Header

Table 7A: Header 1000A Loop

Tables 8A – 8Q: Member Detail

8A: INS

8B‐8C: REF

8D‐8E: DTP

8F: NM1

8G: PER

8H: N3

8I: N4

8J: DMG

8K: EC

8L: HLH

8M: NM1

8N: N3

8O: N4

8P: HD

8Q: DTP

Table Notes 8A‐8Q File Detail

Tables 9A – 9C: Trailer Information

Table 9A: Transaction Set Trailer

Benefits Administration 834 Guidance Manual: v 5.0 2

Table 9B: Functional Group Trailer

Table 9C: Interchange Control Trailer

Test Scenarios

Scenario 1 – Use of REF03 and REF04 fields

Scenario 2 – Two different addresses for the same member

Scenario 3 – Dependents in the same family sharing same birthdate or name

Scenario 4 ‐ Changes to demographics

Scenario 5 ‐ Changes in relationship to head of contract (HOC)

Scenario 6 ‐ Plan code change

Scenario 7 ‐ Entire family is terminating coverage

Scenario 8 ‐ Removing one dependent and remaining family members keep coverage

Scenario 9 ‐ Death of the head of contract/HOC (medical benefit only)

Scenario 10 ‐ Future‐dated benefit end ‐ (potentially present up to four times)

Scenario 11 ‐ Reinstatement of benefits

Scenario 12 ‐ Member has two active coverages

Scenario 13 ‐ Employee transfers

Scenario 14 ‐ Secondary insurance (pharmacy benefit only)

Scenario 15 ‐ Surviving spouse (medical benefit only)

Scenario 16 ‐ Dependent only coverage (not applicable for dental)

Scenario 17 ‐ COBRA enrollments

Appendix

List # 1: Benefit Program Codes [REF03]

List # 2: Benefit Plan Coverage Codes [HD04]

Benefits Administration 834 Guidance Manual: v 5.0 3

Purpose

The State of Tennessee’s Benefits Administration 834 Guidance Manual accompanies the HIPAA ASC X12N 834

(005010X220A1) standard required by the HIPAA Transaction Rules (generally referred to as the “834 file”.

Even though the State of Tennessee does use an 834 file, you will need to customize your system to process the file’s information accurately. This manual contains business practice information, technical information, contact information and key details. The purpose of this manual is to inform you of the unique features found in our 834 file so you can prepare for its processing.

File Transmission

The 834 files normally generate weekly on Saturdays and they move to the State of TN’s server on Sunday mornings at 4am. Occasionally the time the file will be available can temporarily change as a result of holidays or system maintenance or upgrades. If we anticipate a change in the availability of the file, we will notify you via email. The State does not submit files. You will need to retrieve them from the server and you can set up a sweep to pick up the file or retrieve it manually. We will provide you with the Business Partner Interfaces Quick Start Guide to help you obtain access to the server. The first production file is ready by the week of Thanksgiving.

TN State File Characteristics

1. The State has two file servers: one for test environments and one for production. You will need to support both servers. The State requires a separate SSH Keypair for each server. The state can only accept SSH for authentication.

2. The 834 file is a full replacement file every time. We do not send change files in between. Since it is a full population file, one would expect only the latest or most recent plan id or coverage type present on the file. However, the State of TN’s files can show dual coverage for the same member so you will need to be able to customize for a member being enrolled in two coverages at the same time. Additional information on this situation is in the testing scenarios section of this manual.

3. The REF03 and the REF04 fields are being used. In the current ASC X12N/005010X220 834 file, these fields are supposed to be empty. These fields contain State of TN specific information which some vendors use to categorize members by benefits group or agency. These fields populated can cause the file to fail compliance on your system. You will need to prepare for this situation.

4. The file can transmit both the home address and the mailing address. If the mailing address is present, it will need to load to your system. If it is not, load the home address.

5. The file will send coverage begin dates prior to the start of your contract with the State of TN if the existing benefit plan codes are used for your product. These dates can go back many years and are not necessarily

Benefits Administration 834 Guidance Manual: v 5.0 4 the true coverage begin date. The effective date provided will be the date a change in plan or coverage level was last made. Your system will need to be able to accept effective dates that are prior to the start of the contract go live date (usually January 1 of following year).

6. The file will only send a DTP*348 (effective date) or a DTP*349 (coverage end date) on a record; not both.

Benefit coverage end dates (DTP*349 line) will always be on the file as the 1st of a month, however the actual last day of coverage is the day before (last day of the month before). Termination dates can also change. You will need to tailor your system in order to collect the true last day of coverage.

7. Benefit coverage terminations can appear on the file in advance for many weeks or they could only appear once. It will depend on the file maintenance date and the date of the termination. You will need to make sure your system can handle the same terminations appearing in subsequent files (see test scenario #10)

Also, if the termination is a date in the past (prior to the maintenance file date) you must be able to capture and load it even though it’s at least 30 days in the past. The date will only appear once.

8. The file can have dependent only coverage levels for medical plans. The coverage will be associated with the Head of Contract’s (HOC) record on the file. You will need to figure out how to “split” the HOC coverage from the dependent coverage on your system since they will be together on the file (see test scenario # 16).

9. The primary identifier on the file is the employee id found on the REF*OF line of a record instead of the social security number found on the NM1* line.

10. There is no way to predict the “order” of the member records appearing on the file. For instance, a new coverage entry appears before the termination entry. Or the same member appears more than once on the same file and not necessarily in subsequent order (see test scenario #12).

Testing Process Once the contract is signed and your access to the state’s SFTP server is set up, we can provide you with a test enrollment file to begin testing. We can provide as many test files as you need. The State has two file servers:

one for test environments and one for production. You will need to support both servers. The username will be the same for each server (example: ebeneadmin). The State requires a separate SSH Keypair for each.

Additionally, the State only requires your public key for each key pair. Password authentication is no longer allowed. The state can only accept SSH for authentication.

Also during testing, make sure you are testing all the scenarios applicable to your file mentioned in the testing scenarios section. We can send you the first test file and then a second test file with these scenarios so you can compare the two files. We can provide some member id numbers to look for in the file that are in these known scenarios. The test files do contain production data, it will not be the most current data but it is production data and will look just like a production file. Be sure to take extra caution and avoid unintentionally loading a test file into your production environment.

Benefits Administration 834 Guidance Manual: v 5.0 5

Errors During testing we can work with you on the types of errors you encounter and help determine which errors are necessary to report back to us after implementation.

Contact information The State of TN file team is available Monday – Friday 8:00am to 4:00pm CT

Primary file contacts during testing/implementation:

Alicia Johnson Ian Harris

(615) 524‐1803 (615) 253‐1684 Alicia.M.Johnson@tn.gov Ian.Harris@tn.gov

Primary file contacts after implementation:

ben.admin.syssup@tn.gov ‐ use this email address for ongoing processing questions, errors, file transmission or connectivity issues

Charlotte.Gamache@tn.gov; Ian.Harris@tn.gov ‐ Please contact Charlotte and Ian in order to escalate an issue

Alicia.M.Johnson@tn.gov ‐ Contact Alicia to further escalate an issue or as back up to Charlotte and Ian

Benefits Administration 834 Guidance Manual: v 5.0 6

State of TN 834 File Format – Tables

Tables 1 ‐ 7B: Header Information

Table 1: Interchange Control Header

Reference Description Name Codes Comments

ISA Interchange Control Header Segment

ISA01 Authorization Information Qualifier 00 State of Tennessee will always send 00

ISA02 Authorization Information Always Blank

ISA03 Security Information Qualifier 00 State of Tennessee will always send 00

ISA04 Security Information Always Blank

ISA05 Interchange ID Qualifier ZZ Mutually Defined

ISA06 Interchange Sender ID TN01 Internal Partner ID. Will default to TN01 unless otherwise requested.

ISA07 Interchange ID Qualifier ZZ Mutually Defined

ISA08 Interchange Receiver ID Defined by Vendor. If not specified, State of Tennessee will use vendor name.

ISA09 Interchange Date YYYYMMDD Date File Generated

ISA10 Interchange Time HHMM Time File Generated using 24‐hr clock

ISA11 Repetition Separator ^ (Carat) State of Tennessee will always use a ^

ISA12 Interchange Control Version Number 00501 State of Tennessee will always send 00501

ISA13 Interchange Control Number Number Updates sequentially for each file sent

ISA14 Acknowledgement Requested 0 State of Tennessee will always send 0

ISA15 Interchange Usage Indicator P T

Production Test

ISA16 Component Element Separator : (Colon) State of Tennessee will always use a :

Table 2: Functional Group Header Reference Description

Name Codes Comments

GS Functional Group Header Segment

GS01 Functional Identifier Code BE State of Tennessee will always send BE

GS02 Application Sender’s Code Defined by Vendor. If not defined, TN01 will be used.

GS03 Application Receiver’s Code Defined by Vendor. If not defined, TN01 will be used.

GS04 Date CCYYMMDD Date File Generated

GS05 Time HHMM Time File Generated using 24‐hr clock

GS06 Group Control Number 1 State of Tennessee will always send 1

GS07 Responsible Agency Code X State of Tennessee will always send X

GS08 Accredited Standards Committee X12 005010X220A

State of Tennessee will always send 005010X220A1

Benefits Administration 834 Guidance Manual: v 5.0 7

Table 3: Transaction Set Header

Reference Description

Name Codes Comments

ST Transaction Set Header

ST01 Transaction Set Identifier Code 834 State of Tennessee will always send 834

ST02 Transaction Set Control Number 0001, 0002, 0003, etc.

Sequential segment number. There are multiple segments sent on file. This number indicates which segment is beginning.

ST03 Implementation Convention Reference 005010X220A1 State of Tennessee will always send 005010X220A1.

Table 4: Beginning Segment Reference Description

Name Codes Comments

BGN Beginning Segment

BGN01 Transaction Set Purpose Code 00 Original ‐ State of Tennessee will always send 00

BGN02 Reference Identification Code will be ISA08+ISA13+ST02

BGN03 Date CCYYMMDD Always CCYYMMDD

BGN04 Time HHMM Time File Generated using 24‐hr clock

BGN05 Time Code CS State of Tennessee will always send CS

BGN06 Reference Identification Not used

BGN07 Transaction Type Code Not used

BGN08 Action Code 4 State of Tennessee will always send 4

BGN09 Security Level Code Not used

Table 5: DTP – File Effective Date in Header Reference Description

Name Codes Comments

DTP File Effective Date

DTP01 Date/Time Qualifier 007 Effective

DTP02 Date Time Period Format Qualifier D8 State of Tennessee will always send D8

DTP03 Date Expressed in Format CCYYMMDD State of Tennessee will always send CCYYMMDD format. Date File was generated.

Table 6: DTP – File Effective Date in Header Reference Description

Name Codes Comments

DTP File Effective Date

DTP01 Date/Time Qualifier 382 Enrollment

DTP02 Date Time Period Format Qualifier D8 State of Tennessee will always send D8

DTP03 Date Expressed in Format CCYYMMDD State of TN will always send CCYYMMDD format ‐ date the file was generated.

Benefits Administration 834 Guidance Manual: v 5.0 8

Table 7A: Header 1000A Loop Loop

ID

Reference Description

Name Codes Comments

1000A N1 Sponsor Name

1000A N101 Entity Identifier Code P5 Plan Sponsor

1000A N102 Name State of Tennessee Non Payroll

Always State of Tennessee Non Payroll

1000A N103 Identification Code Qualifier 24 Employer’s Identification Number

1000A N104 Identification Code 626001445 Always 626001445 (State of Tennessee EIN)

1000A N105 Entity Relationship Code Not used

1000A N106 Entity Identifier Code Not used

Table 7B: Header 1000B Loop

Loop

ID

Reference Description Name Codes Comments

1000B N1 Vendor Name

1000B N101 Entity Identifier Code IN State of Tennessee will always send IN

1000B N102 Name Vendor Name

1000B N103 Identification Code Qualifier FI Federal Taxpayer’s Identification Number

1000B N104 Identification Code Vendor EIN State of Tennessee will always send the Vendor’s EIN

1000B N105 Entity Relationship Code Not used

1000B N106 Entity Identifier Code Not used

Tables 8A – 8Q: Member Detail (INS thru DTP lines)

8A: INS

Loop

ID

Reference Description Name Codes Comments

2000 INS Member Level Detail

2000 INS01 Subscriber Identifier Y N

Member (Head of Contract) Dependent

2000 INS02 Individual Relationship Code

Spouse Self Child Ex‐Spouse Collateral Dependent * See Note 1

2000 INS03 Maintenance Type Code 030 State of Tennessee will always send a Full File

(BGN08 = ‘4’)

2000 INS04 Maintenance Reason Code XN Notification Only

2000 INS05 Benefit Status Code A C

Active

COBRA

2000 INS06 Medicare Status Code Not used

Benefits Administration 834 Guidance Manual: v 5.0 9

2000 INS06‐01 Medicare Plan Code

A

E

A – Only applicable to Pharmacy vendors.

Indicates the State’s prescription drug coverage is secondary.

E – Only applicable to Pharmacy vendors.

Indicates the State’s prescription drug coverage is primary

2000 INS06‐02 Medicare Eligibility Reason Code Not used

2000 INS06‐03 Eligibility Reason Code Not used

2000 INS06‐04 Eligibility Reason Code Not used

2000 INS07 COBRA Qualifying

Termination Reduction in Hours Death Divorce Married Dependent

2000 INS08 Employment Status Code

FT

L1

PT

RT

TE

Full‐time Leave of Absence Part‐time Retired Terminated

2000 INS09 Student Status Code Not used

2000 INS10 Disability Indicator Y N

Disabled Not Disabled

2000 INS11

Date Time Period Format Qualifier

Not used

2000 INS12 Date Time Period Not used

2000 INS13 Confidentiality Code Not used

2000 INS14 City Name Not used

2000 INS15 State Code Not used

2000 INS16 Country Code Not used

2000 INS17 Dependent Sequence Number

Number assigned to differentiate between dependents with the same birthdate.

8B‐8C: REF

B

Loop ID Reference Name Codes Comments

2000 REF Subscriber Identifier

2000 REF01 Reference Identification Qualifier 0F State of Tennessee will always send 0F

2000 REF02 Subscriber Identifier 8 digit number

Head of Contract’s Edison Employee ID Number. See Note 2

2000 REF03 Description Not used

2000 REF04 Reference Identifier Not used

C Loop

ID

Reference Description Name Codes Comments

2000 REF Member Policy Number

Benefits Administration 834 Guidance Manual: v 5.0 10

2000 REF01 Reference Identification Qualifier 1L Group Number

2000 REF02 Member Group Number Group Number

Group Number Member is defined by Vendor, if unassigned, will send

BLANK_VALU

2000 REF03 Description Benefit Program

Benefit Program and Description.

Substring first three characters. Refer to the Appendix for a list of benefit program codes See Note 3

2000 REF04 Reference Identifier ZZ:number ZZ + Budget Code. Substring first three characters ZZ: See Note 3

8D‐8E: DTP

D Loop

ID

Reference Description

Name Codes Comments

2000 DTP Health Coverage Dates

2000 DTP01 Date Time Qualifier 303 Maintenance Effective (or “as of” date)

2000 DTP02 Date Time Period Format Qualifier D8 Date Format

2000 DTP03 Status Information Effective Date CCYYMMDD Status Effective Date

E Loop

ID

Reference Description Name Codes Comments

2000 DTP Health Coverage Dates This line not sent for dependents

2000 DTP01 Date Time Qualifier

Retirement Employment Begin Medicare Begin Medicare End

2000 DTP02 Date Time Period Format Qualifier D8 Date Format

2000 DTP03 Status Information Effective Date CCYYMMDD Employment Begin Date

8F: NM1

Loop

ID

Reference Description Name Codes Comments

2100A NM1 Member Name

2100A NM101 Entity Identifier Code IL Insured

2100A NM102 Entity Type Qualifier 1 Person

2100A NM103 Member Last Name Last Name Last Name

2100A NM104 Member First Name First Name First Name

2100A NM105 Member Middle Name Middle Name

Middle Name or Middle Initial

2100A NM106 Member Name Prefix Name Prefix

Name Prefix

2100A NM107 Member Name Suffix Name Suffix

Name Suffix

2100A NM108 Identification Code Qualifier 34 Social Security Number

Benefits Administration 834 Guidance Manual: v 5.0 11

2100A NM109 Member Identifier 9 digit number

Member’s Social Security Number

2100A NM110 Entity Relationship Code Not used

2100A NM111 Entity Identifier Code Not used

2100A NM112 Name Last or Organization Name Not used

8G: PER

Loop

ID

Reference Description Name Codes Comments

2100A PER Member Communication Numbers

2100A PER01 Contact Function Code IP Insured Party

2100A PER02 Name Not used

2100A PER03 Communication Number Qualifier HP Phone Number

2100A PER04 Communication Number

10 digit number (no dashes)

Member’s Phone Number

2100A PER05 Communication Number Qualifier AP or EM or not used

Will either be alternate phone or email or not used. See Note 8

2100A PER06 Communication Number

10 digit number (no dashes) and/or email

Member’s Alternate Phone Number or Email Address (file may have none, one, or both)

2100A PER07 Communication Number Qualifier

EM (if the record already has

AP)

Member’s email address if the record has an alternate phone number in

PER06)

2100A PER08 Communication Number Email address

Member’s email address if there is one in the database

2100A PER09 Contact Inquiry Reference Not used

8H: N3 Loop

ID

Reference Description Name Codes Comments

2100A N3 Member Residence Street Address

2100A N301 Member Address Line Street Address or P O Box Number See Note 4

2100A N302 Member Address Line Continuation of Address, if needed

8I: N4 Loop

ID

Reference Description Name Codes Comments

2100A N4 Member City, State, Zip Code

2100A N401 Member City Name City Name

Benefits Administration 834 Guidance Manual: v 5.0 12

2100A N402 Member State Code 2 Letter

Abbreviation State

2100A N403 Member Zip Code 9 digit number

Zip Code + 4 digits

2100A N404 Country Code 3 Letter

Abbreviation

Only used if member’s residence is outside of the United States. 3 Letter abbreviation for the name of the Country

2100A N405 Location Qualifier Not used

2100A N406 Location Identifier Not used

2100A N407 Country Subdivision Code Not used

8J: DMG

Loop

ID

Reference Description

Name Codes Comments

2100A DMG Member Demographics

2100A DMG01 Date Time Period Format Qualifier D8 Date Format CCYYMMDD

2100A DMG02 Member Birth Date CCYYMMDD Birth Date

2100A DMG03 Gender Code F M

Female Male

2100A DMG04 Marital Status Code

D I M R S U W

Divorced Single Married Unknown Separated Common Law or Head of Household Widowed See Note 5

2100A DMG05

Composite Race or Ethnicity Information

Not used

2100A DMG05‐1 Race or Ethnicity Code Not used

2100A DMG05‐2 Code List Qualifier Not used

2100A DMG05‐3 Industry Code Not used

2100A DMG06 Citizenship Status Code Not used

2100A DMG07 Country Code Country

Abbreviation If applicable, country abbreviation sent

2100A DMG08 Basis of Verification Code Not used

2100A DMG09 Quantity Not used

2100A DMG10 Code List Qualifier Code Not used

2100A DMG11 Industry Code Not used

8K: EC

Loop

ID

Reference Description

Name Codes Comments

2100A EC Employment Class Not applicable to Dependents

2100A EC01 Employment Class Code

Hourly Salaried

Benefits Administration 834 Guidance Manual: v 5.0 13

2100A EC02 Employment Class Code Not used

2100A EC03 Employment Class Code Not used

2100A EC04 Percentage as Decimal Not used

2100A EC05 Information Status Code Not used

2100A EC06 Occupation Code Not used

8L: HLH

Loop

ID

Reference Description Name Codes Comments

2100A HLH Member Health Information

2100A HLH01 Health‐Related Code T U

Tobacco Use Unknown Ignore this field, not used for eligibility

2100A HLH02 Height Not used

2100A HLH03 Member Weight Not used

2100A HLH04 Weight Not used

2100A HLH05 Description Not used

2100A HLH06 Current Health Condition Code Not used

2100A HLH07 Description Not used

8M: NM1

Loop

ID

Reference Description

Name Codes Comments

2100C NM1 Member Mailing Address

Sent when member mailing address is different from home address. This line will be sent, followed by Loop ID 2100C N3 and Loop ID 2100C N4 lines containing the mailing address.

2100C NM101 Entity Identifier Code 31 Postal Mailing Address See Note 4

2100C NM102 Entity Type Qualifier Code 1 Person

2100C NM103 Member Last Name Not used

2100C NM104 Member First Name Not used

2100C NM105 Member Middle Name Not used

2100C NM106 Member Name Prefix Not used

2100C NM107 Member Name Suffix Not used

2100C NM108 Member Identification Code Qualifier Not used

2100C NM109 Member Identification Code Not used

2100C NM110 Entity Relationship Code Not used

2100C NM111 Entity Identifier Code Not used

2100C NM112 Name Last or Organization Name Not used

8N: N3 Loop

ID

Reference Descriptio n

Name Codes Comments

2100C N3 Member Mailing Address

Benefits Administration 834 Guidance Manual: v 5.0 14

2100C N301 Member Mail Address Line P O Box Number See Note 4

2100C N302 Member Mail Address Line Continuation of Address, if needed

8O: N4 Loop

ID

Reference Description

Name Codes Comments

2100C N4 Member Mail City, State, Zip Code

2100C N401 Member Mail City Name City Name

2100C N402 Member Mail State Code 2 Letter

Abbreviation State

2100C N403 Member Mail Zip Code 9 digit number

Zip Code + 4 digits

2100C N404 Country Code 3 Letter

Abbreviation

Only used if member’s residence is outside of the United States. 3 Letter abbreviation for the name of the Country

2100C N405 Location Qualifier Not used

2100C N406 Location Identifier Not used

2100C N407 Country Subdivision Code Not used

8P: HD

Loop

ID

Reference Description Name Codes Comments

2300 HD Health Coverage

2300 HD01 Maintenance Type Code

024 ‐Cancellation or Termination 030 ‐Audit or Compare

2300 HD02

Maintenance Reason Code

Not used

2300 HD03 Insurance Line Code

DEN

HLT

VIS

Dental Health (sent to medical, pharmacy and behavioral health) Vision

2300 HD04

Plan Coverage Description

Description

Refer to the Appendix for a list of benefit plan coverage codes

2300 HD05 Coverage Level Code

EMP

FAM

ESP

ECH

SPO

DEP

CHD

SPC

Employee Only

Family

Employee plus Spouse

Employee + Child(ren)

Spouse Only See Note 6

Two or more Children See Note 6

Children Only See Note 6

Spouse + Children See Note 6

2300 HD06 Count Not used

2300 HD07 Count Not used

Benefits Administration 834 Guidance Manual: v 5.0 15

2300 HD08

Underwriting Decision Code

Not used

2300 HD09

Last Enrollment Indicator

Not used

2300 HD10 Drug House Code Not used

2300 HD11

Yes/No Condition or Response Code

Not used

8Q: DTP

Loop

ID

Reference Description

Name Codes Comments

2000 DTP Health Coverage Dates

2000 DTP01 Date Time Qualifier

Benefit Begin Benefit End See Note 7

2000 DTP02 Date Time Period Format Qualifier D8 Date Format

2000 DTP03 Status Information Effective Date CCYYMMDD Coverage Begin Date

Table Notes 8A‐8Q File Detail Note 1 The relationship code 38 denotes a child claimed on income tax (CT) or a child intended to be claimed on income tax (CI).

Note 2 The identifier will be present on all records unless enrolled in COBRA. COBRA enrollees sometimes have an ID number starting with a “C” and the employee ID number may not be only eight digits.

Note 3 These fields contain TN specific information that is not defined on a typical 834 file. Since these fields contain information and are not empty, it can cause the 834 file not to pass your HIPAA compliance process.

Note 4 The mailing address following [NM1*31*1] shall be loaded if available (Loop ID 2100A). Otherwise, residence address should be loaded (Loop ID 2100A).

Note 5 The marital status is not sent for dependents.

Note 6 The Head of Contract (HOC) records will be present on the file for these coverage codes. These codes are how to identify the coverage is dependent only.

Note 7 The 349 loop will only be present when an end‐date exists otherwise, eligibility is open‐ended (default

12/31/9999).

Note 8 A member’s entry will stop at PER04, PER06, or PER08 depending upon what information is in the system.

Tables 9A – 9C: Trailer Information

Table 9A: Transaction Set Trailer Reference Description

Name Codes Comments

SE Transaction Set Trailer

SE01 Number of Included Segments Number The number of rows in previous segment

SE02 Transaction Set Control Number Number Segment Number ‐ There are multiple segments sent on file. This number indicates which segment is ending.

Benefits Administration 834 Guidance Manual: v 5.0 16

Table 9B: Functional Group Trailer Reference Description

Name Codes Comments

GE Functional Group Trailer

GE01 Number of Transaction Sets Included Number Number of transaction sets sent in file

GE02 Group Control Number 1 State of Tennessee will always send 1

Table 9C: Interchange Control Trailer Reference Description

Name Codes Comments

IEA Interchange Control Trailer

IEA01 Number of Included Functional Groups 1 State of Tennessee will always send 1

IEA02 Group Control Number Will match ISA13

Test Scenarios

Scenario 1 – Use of REF03 and REF04 fields The State of TN uses the ASC X12N/005010X220 version of the 834 file. The accepted guidelines for this file format indicate the REF03 and REF04 remain empty. However, the 834 files from the State do have these lines populated on all the records. Since these fields have data present, it can cause the files to not pass HIPAA compliance measures on your end or not pass other various file upload pre‐checks on your system. You will need to determine if the file can upload on your system with these fields filled in.

REF*OF line has the employee id number

REF*1L line has the member benefits group and budget code (agency number)

File extract example – All members, Heads of Contract (HOC) and Dependents (Dep) will have these REF03 and REF04 lines populated.

INS*Y*18*030*XN*A*E**FT**N~

REF*0F*00999999~

REF*1L*0717111*CSA Central State Active*ZZ:32712~

DTP*303*D8*20180501~

DTP*336*D8*20020516~

NM1*IL*1*Ball*Krystal*H***34*888888888~

PER*IP**HP*7777777777~

N3*31 Fortune Drive~ N4*Majestic*TN*555556666~

DMG*D8*19720118*M*I~

EC*08~

HLH*U~

HD*030**HLT*PRPV1N*ECH******~

DTP*348*D8*20180101~

INS*N*19*030*XN*A*E****N~

REF*0F*00999999~

REF*1L*0717111*CSA Central State Active*ZZ:32712~

DTP*303*D8*20180501~

NM1*IL*1*Ball*Ray*S***34*878787878~

PER*IP**HP*7777777777~

N3*31 Fortune Drive~ N4*Majestic*TN*555556666~

DMG*D8*20020119*M~

HLH*U~

HD*030**HLT*PRPV1N*******~

DTP*348*D8*20180101~

HOC

Dep 1

Benefits Administration 834 Guidance Manual: v 5.0 18

Scenario 2 – Two different addresses for the same member Members can keep more than one active address on our database, one of which is a “home” address and the other a “mailing” address. The file can provide two addresses for the same member. When two addresses are present use the “mailing address.”

NM1*31*1 line is present on the file for a member when there is a mailing address o LoopID 2100C N3 o LoopID 2100C N4

File extract example – Member has more than one active address. The mailing address follows the NM1*31*1 line.

INS*Y*18*030*XN*A*E**FT**N~

REF*0F*00989898~

REF*1L*0717111*CSA Central State Active*ZZ:31705~

DTP*303*D8*20180501~

DTP*336*D8*19960401~

NM1*IL*1*Daize*Summer*G***34*777777777~

PER*IP**HP*6666666666~

N3*317 Poppy Street~ N4*Moony*TN*555554444~

DMG*D8*19771212*F*I~

EC*08~

HLH*U~

NM1*31*1~

N3*PO Box 31212~ N4*Moony*TN*555554444~

HD*030**HLT*PRPV1N*ECH******~

DTP*348*D8*20180101~

INS*N*19*030*XN*A*E****N~

REF*0F*00989898~

REF*1L*0717111*CSA Central State Active*ZZ:31705~

DTP*303*D8*20180501~

NM1*IL*1*Daize*Jack*F***34*767676767~

PER*IP**HP*6666666666~

N3*317 Poppy Street~ N4*Moony*TN*555554444~

DMG*D8*19970418*M~

HLH*U~

HD*030**HLT*PRPV1N*******~

Benefits Administration 834 Guidance Manual: v 5.0 19

Scenario 3 – Dependents in the same family sharing same birthdate or name Occasionally the file will include dependents in the family with the same birthdate or same name. These are not duplicates. The file assigns a different dependent sequence number to each dependent record when the birthdate is the same. If the dependents’ names are the same, this sequence number is not assigned. You will have to decipher one dependent from the other using other demographic information such as birthdate or

SSN. In this situation the indicators would be:

For same birthdate: DMG* line will have the exact same birthdate for two or more dependents

For same birthdate and/or same name: NM1* line will often have different SSN#’s (There are times when the file does not have accurate SSN#’s for newborns for a few months however.)

For same birthdate: INS* line will have a dependent sequence number at the very end (only present when sharing same birthdate)

For same name: NM1* line not necessarily both the first and last name are shared by dependents. One of these names will be different.

File extract example ‐ Dependent (Dep) 1 and 2 share the same birthdate. Indicator present on the INS line

INS*N*19*030*XN*A*E****N*******1~

REF*0F*00979797~

REF*1L*0717111*RCS Retiree Central State*ZZ:71100~

DTP*303*D8*20180601~

NM1*IL*1*Day*Avery*L***34*676676767~

PER*IP**HP*5555555555~

N3*1234 Golden Valley~ N4*Sunrise*FL*444443333~

DMG*D8*20121224*F~

HLH*U~

HD*030**HLT*PRPV1N*******~

DTP*348*D8*20180101~

INS*N*19*030*XN*A*E****N*******2~

REF*0F*00101325~

REF*1L*0717111*RCS Retiree Central State*ZZ:71100~

DTP*303*D8*20180601~

NM1*IL*1*Day*Holly*M***34*676676768~

PER*IP**HP*5555555555~

N3*1234 Golden Valley~ N4*Sunrise*FL*444443333~

DMG*D8*20121224*F~

HLH*U~

HD*030**HLT*PRPV1N*******~

Dep 2

File extract example ‐ Dependent (Dep) 1 and 2 share the same first name. No indicator present on the INS line since their birthdates are different. However, their last names are different, birthdates are different, and

SSNs are different

INS*N*19*030*XN*A*E****N~

REF*0F*00979797~

Benefits Administration 834 Guidance Manual: v 5.0 20

REF*1L*0717111*RCS Retiree Central State*ZZ:71100~

DTP*303*D8*20180601~

NM1*IL*1*Day*Avery*L***34*676676767~

PER*IP**HP*5555555555~

N3*1234 Golden Valley~ N4*Sunrise*FL*444443333~

DMG*D8*20121224*F~

HLH*U~

HD*030**HLT*PRPV1N*******~

DTP*348*D8*20180101~

INS*N*19*030*XN*A*E****N~

REF*0F*00101325~

REF*1L*0717111*RCS Retiree Central State*ZZ:71100~

DTP*303*D8*20180601~

NM1*IL*1*Knight*Avery*M***34*676676768~

PER*IP**HP*5555555555~

N3*1234 Golden Valley~ N4*Sunrise*FL*444443333~

DMG*D8*20121224*F~

HLH*U~

HD*030**HLT*PRPV1N*******~

Benefits Administration 834 Guidance Manual: v 5.0 21

Scenario 4 ‐ Changes to demographics Sometimes the demographic information of an existing enrolled member is changed. This change can cause an issue with the vendor that loads the file because the vendor’s system creates a new enrollment record for the member. However, it is the same member and only has a demographic data change. A file will provide the new demographic information and no other indicators of the change. Any of these file lines may be different from one file to the next depending on what demographic information changed.

NM1*, PER*, N3*, N4*, DMG* lines will have the new information

Same coverage begin date on DTP*348 line, no new effective date on the DTP*348 line for the recent change

File extract example ‐ Dependent (Dep) 1 of the Head of Contract (HOC) had a last name change. The only line different is the NM1*.

Before the change After the change

INS*Y*18*030*XN*A*E**FT**N~

REF*0F*00969696~

REF*1L*0717111*CSA Central State Active*ZZ:31501~

DTP*303*D8*20180401~

DTP*336*D8*20150209~

NM1*IL*1*Christmas*Tim*B***34*565656565~

PER*IP**HP*4444444444~

N3*32 Northern Lights~ N4*Pole*TN*333332222~

DMG*D8*19861226*M*I~

EC*08~

HLH*U~

HD*030**HLT*PPOV1N*ESP******~

DTP*348*D8*20180101~

INS*N*01*030*XN*A*E****N~

REF*0F*00969696~

REF*1L*0717111*CSA Central State Active*ZZ:31501~

DTP*303*D8*20180401~

NM1*IL*1*Daniels*Mary*N***34*454545454~

PER*IP**HP*4444444444~

N3*32 Northern Lights~ N4*Pole*TN*333332222~

DMG*D8*19840301*F~

HLH*U~

HD*030**HLT*PPOV1N*******~

DTP*348*D8*20180101~

H O e p

INS*Y*18*030*XN*A*E**FT**N~

REF*0F*00969696~

REF*1L*0717111*CSA Central State Active*ZZ:31501~

DTP*303*D8*20180401~

DTP*336*D8*20150209~

NM1*IL*1*Christmas*Tim*B***34*565656565~

PER*IP**HP*4444444444~

N3*32 Northern Lights~ N4*Pole*TN*333332222~

DMG*D8*19861226*M*I~

EC*08~

HLH*U~

HD*030**HLT*PPOV1N*ESP******~

DTP*348*D8*20180101~

INS*N*01*030*XN*A*E****N~

REF*0F*00969696~

REF*1L*0717111*CSA Central State Active*ZZ:31501~

DTP*303*D8*20180401~

NM1*IL*1*Christmas*Mary*N***34*454545454~

PER*IP**HP*4444444444~

N3*32 Northern Lights~ N4*Pole*TN*333332222~

DMG*D8*19840301*F~

HLH*U~

HD*030**HLT*PPOV1N*******~

Benefits Administration 834 Guidance Manual: v 5.0 22

Scenario 5 ‐ Changes in relationship to head of contract (HOC) This scenario occurs when a member has a coverage change that also includes a change in relationship with one of the covered dependents. One common situation is a divorce typically when a dependent is terming coverage. Similar to the demographic change scenario, this relationship code change sometimes creates an issue with the vendor that loads the file because the vendor’s system creates a new member however; it is the same member as before but with a relationship code data change. For a list of the relationship codes refer to

Table 8A: INS.

New relationship code on the dependent’s INS* line

New DTP*349 line sent for terminating dependent’s coverage

File extract example –The INS* line updates from the spouse relationship code to ex‐spouse do to a divorce

Before the change After the change

INS*Y*18*030*XN*A*E**FT**N~

REF*0F*00959595~

REF*1L*0717111*GA2 Local Gov Active Prem Level

2*ZZ:50937~

DTP*303*D8*20180401~

DTP*336*D8*20160401~

NM1*IL*1*Myer*Oscar*Preston***34*434343434~

PER*IP**HP*3333333333~

N3*40 Buds Lane~ N4*Reneiw*TN*111119999~

DMG*D8*19830405*M*M~

EC*08~

HLH*U~

HD*030**HLT*PPOV1N*ESP******~

DTP*348*D8*20160501~

INS*N*01*030*XN*A*E****N~

REF*0F*00959595~

REF*1L*0717111*GA2 Local Gov Active Prem Level

2*ZZ:50937~

DTP*303*D8*20180401~

NM1*IL*1*Myer*Michelle*S***34*232323232~

PER*IP**HP*3333333333~

N3*40 Buds Lane~ N4*Reneiw*TN*111119999

DMG*D8*19841121*F~

HLH*U~

HD*030**HLT*PPOV1N*******~

DTP*348*D8*20160501~

H p

INS*Y*18*030*XN*A*E**FT**N~

REF*0F*00959595~

REF*1L*0717111*GA2 Local Gov Active Prem Level 2*ZZ:50937~

DTP*303*D8*20180401~

DTP*336*D8*20160401~

NM1*IL*1*Myer*Oscar*Preston***34*434343434~

PER*IP**HP*3333333333~

N3*40 Buds Lane~ N4*Reneiw*TN*111119999~

DMG*D8*19830405*M*M~

EC*08~

HLH*U~

HD*030**HLT*PPOV1N*EMP******~

DTP*348*D8*20180401~

INS*N*25*030*XN*A*E***N*N~

REF*0F*00959595~

REF*1L*0717111*GA2 Local Gov Active Prem Level 2*ZZ:50937~

DTP*303*D8*20180401~

NM1*IL*1*Myer*Michelle*S***34*232323232~

PER*IP**HP*3333333333~

N3*40 Buds Lane~ N4*Reneiw*TN*111119999

DMG*D8*19841121*F~

HLH*U~

HD*024**HLT*PPOV1N*******~

DTP*349*D8*20180401~

Benefits Administration 834 Guidance Manual: v 5.0 23

Scenario 6 ‐ Plan code change There are times when the plan code will change mid‐year due to a special qualifying event where the member can make enrollment changes. The file will not provide the end date on a DTP*349 line for the former plan code. For a list of the State of TN’s plan codes, refer to the Appendix. This situation is not an additional member record; it is updated information to an existing member record. Indicators of a plan code change would be:

New (plan) code appearing on HD* line for the covered HOC and any dependent (Dep).

New date on DTP*348 line for covered HOC and any enrolled dependents

File extract example ‐This member has changed from a Standard PPO plan to a CDHP/HSA plan instead resulting in a plan code change to both the HOC and covered Dep 1.

Before the change After the change

INS*Y*18*030*XN*A*E**FT**N~

REF*0F*00949494~

REF*1L*FA06165*CSA Central State Active*ZZ:33503~

DTP*303*D8*20180501~

DTP*336*D8*20080602~

NM1*IL*1*Mellow*Graham*A***34*121212121~

PER*IP**HP*2222222222~

N3*840 Camp Dr~ N4*Smoreville*TN*111118888~

DMG*D8*19690317*M*I~

EC*08~

HLH*U~

HD*030**HLT*PPOV2N*ECH******~

DTP*348*D8*20150901~

INS*N*19*030*XN*A*E****N~

REF*0F*00949494~

REF*1L*FA06165*CSA Central State Active*ZZ:33503~

DTP*303*D8*20180501~

NM1*IL*1*Mellow*Marsha*B***34*010101011~

PER*IP**HP*2222222222~

N3*840 Camp Dr~ N4*Smoreville*TN*111118888~

DMG*D8*19960129*F~

HLH*U~

HD*030**HLT*PPOV2N*******~

DTP*348*D8*20150901~

H p

INS*Y*18*030*XN*A*E**FT**N~

REF*0F*00949494~

REF*1L*FA06165*CSA Central State Active*ZZ:33503~

DTP*303*D8*20180501~

DTP*336*D8*20080602~

NM1*IL*1*Mellow*Graham*A***34*121212121~

PER*IP**HP*2222222222~

N3*840 Camp Dr~ N4*Smoreville*TN*111118888~

DMG*D8*19690317*M*I~

EC*08~

HLH*U~

HD*030**HLT*HSAV2N*ECH******~

DTP*348*D8*20180501~

INS*N*19*030*XN*A*E****N~

REF*0F*00949494~

REF*1L*FA06165*CSA Central State Active*ZZ:33503~

DTP*303*D8*20180501~

NM1*IL*1*Mellow*Marsha*B***34*010101011~

PER*IP**HP*2222222222~

N3*840 Camp Dr~ N4*Smoreville*TN*111118888~

DMG*D8*19960129*F~

HLH*U~

HD*030**HLT*HSAV2N*******~

DTP*348*D8*20180501~

Benefits Administration 834 Guidance Manual: v 5.0 24

Scenario 7 ‐ Entire family is terminating coverage The State of TN 834 files are full population files. As a result, sometimes vendors choose to replace the data each week. This replacement can cause problems if the DTP*348 effective date line is missing for members. In the case of terminating coverage, the state of TN 834 files do not provide both a DTP*348 line and a DTP*349 line for terminating members. The file only provides the

DTP*349 line for terminating HOC’s and/or dependents o The coverage term dates found on the DTP*349 line be the 1st of the month, however the actual date coverage ended is the last day of the previous month.

File extract example ‐ This family is terminating coverage as of 5/01/2018.

Before the change After the change

INS*Y*18*030*XN*A*E**FT**N~

REF*0F*00939393~

REF*1L*FA06165*MSC Miscellaneous*ZZ:30401~

DTP*303*D8*20180401~

DTP*336*D8*20040901~

NM1*IL*1*Flowers*Walter*N***34*020202020~

PER*IP**HP*1111111111~

N3*6767 Rose Court~ N4*Verano*TN*111117777~

DMG*D8*19761005*M*M~

EC*08~

HLH*U~

HD*030**HLT*PRPV2B*FAM******~

DTP*348*D8*20180101~

INS*N*19*030*XN*A*E****N~

REF*0F*00939393~

REF*1L*FA06165*MSC Miscellaneous*ZZ:30401~

DTP*303*D8*20180401~

NM1*IL*1*Flowers*April*A***34*010101010~

PER*IP**HP*1111111111~

N3*6767 Rose Court~ N4*Verano*TN*111117777~

DMG*D8*20100401*F~

HLH*U~

HD*030**HLT*PRPV2B*******~

DTP*348*D8*20180101~

INS*N*01*030*XN*A*E****N~

REF*0F*00939393~

REF*1L*FA06165*MSC Miscellaneous*ZZ:30401~

DTP*303*D8*20180401~

NM1*IL*1*Flowers*May*R***34*030303030~

PER*IP**HP*1111111111~

N3*6767 Rose Court~ N4*Verano*TN*111117777~

DMG*D8*19800525*F~

HLH*U~

HD*030**HLT*PRPV2B*******~

INS*Y*18*030*XN*A*E**TE**N~

REF*0F*00939393~

REF*1L*FA06165*MSC Miscellaneous*ZZ:30401~

DTP*303*D8*20180501~

DTP*336*D8*20040901~

NM1*IL*1*Flowers*Walter*N***34*020202020~

PER*IP**HP*1111111111~

N3*6767 Rose Court~ N4*Verano*TN*111117777~

DMG*D8*19761005*M*M~

EC*08~

HLH*U~

HD*024**HLT*PRPV2B*FAM******~

DTP*349*D8*20180501~

INS*N*19*030*XN*A*E****N~

REF*0F*00939393~

REF*1L*FA06165*MSC Miscellaneous*ZZ:30401~

DTP*303*D8*20180501~

NM1*IL*1*Flowers*April*A***34*010101010~

PER*IP**HP*1111111111~

N3*6767 Rose Court~ N4*Verano*TN*111117777~

DMG*D8*20100401*F~

HLH*U~

HD*024**HLT*PRPV2B*******~

DTP*349*D8*20180501~

INS*N*01*030*XN*A*E****N~

REF*0F*00939393~

REF*1L*FA06165*MSC Miscellaneous*ZZ:30401~

DTP*303*D8*20180501~

NM1*IL*1*Flowers*May*R***34*030303030~

PER*IP**HP*1111111111~

N3*6767 Rose Court~ N4*Verano*TN*111117777~

DMG*D8*19800525*F~

HLH*U~

HD*024**HLT*PRPV2B*******~

DTP*349*D8*20180501~

Benefits Administration 834 Guidance Manual: v 5.0 25

Scenario 8 ‐ Removing one dependent and remaining family members keep coverage This scenario includes whenever a dependent is removed from coverage for various reasons such as aging off at 26yrs old, aging off at 65 years old, dependent is offered insurance elsewhere or a divorce as examples. This situation also occurs with the death of a dependent. Most often the file does not include a date of death for the deceased member. In these scenarios, the file will transmit:

New date on DTP*348 line only for remaining HOC and dependents only o No DTP*348 line sent for terminating dependent

New DTP*349 line sent for terminating dependent

(Sometimes) a new coverage level code on the HD* line for HOC and any dependents remaining on. A list of these coverage codes can be found on Table 8P: HD.

File extract example 1 ‐ This family has Dep 2 terminating while the HOC and Dep 1 remain. There is a coverage level change on the HOC’s record.

Before the change After the change

INS*Y*18*030*XN*A*E**FT**N~

REF*0F*00929292~

REF*1L*FA06165*CSA Central State Active*ZZ:32901~

DTP*303*D8*20180501~

DTP*336*D8*20050601~

NM1*IL*1*Cane*Michael*A***34*040404040~

PER*IP**HP*9999988888~

N3*904 Rush Ridge~ N4*Sweet Field*TN*111116666~

DMG*D8*19650901*F*M~

EC*08~

HLH*U~

HD*030**HLT*PRPV2N*FAM******~

DTP*348*D8*20180101~

INS*N*01*030*XN*A*E***N*N~

REF*0F*00929292~

REF*1L*FA06165*CSA Central State Active*ZZ:32901~

DTP*303*D8*20180501~

NM1*IL*1*Cane*Sugar*D***34*050505050~

PER*IP**HP*9999988888~

N3*904 Rush Ridge~ N4*Sweet Field*TN*111116666~

DMG*D8*19640420*F~

HLH*U~

HD*030**HLT*PRPV2N*******~

DTP*348*D8*20180101~

INS*N*19*030*XN*A*E****N~

REF*0F*00929292~

REF*1L*FA06165*CSA Central State Active*ZZ:32901~

DTP*303*D8*20180501~

NM1*IL*1*Cane*Kandi****34*060606060~

PER*IP**HP*9999988888~

N3*904 Rush Ridge~ N4*Sweet Field*TN*111116666~

DMG*D8*19971031*M~

HLH*U~

HD*030**HLT*PRPV2N*******~

REF*0F*00929292~

REF*1L*FA06165*CSA Central State Active*ZZ:32901~

DTP*303*D8*20180501~

DTP*336*D8*20050601~

NM1*IL*1*Cane*Michael*A***34*040404040~

PER*IP**HP*9999988888~

N3*904 Rush Edge~ N4*Sweet Field*TN*372117028~

DMG*D8*19650901*F*M~

EC*08~

HLH*U~

HD*030**HLT*PRPV2N*ESP******~

DTP*348*D8*20180501~

INS*N*01*030*XN*A*E***N*N~

REF*0F*00929292~

REF*1L*FA06165*CSA Central State Active*ZZ:32901~

DTP*303*D8*20180501~

NM1*IL*1*Cane*Sugar*D***34*050505050~

PER*IP**HP*9999988888~

N3*904 Rush Ridge~ N4*Sweet Field*TN*111116666~

DMG*D8*19640420*F~

HLH*U~

HD*024**HLT*PRPV2N*******~

DTP*348*D8*20180501~

INS*N*19*030*XN*A*E****N~

REF*0F*00929292~

REF*1L*FA06165*CSA Central State Active*ZZ:32901~

DTP*303*D8*20180501~

NM1*IL*1*Cane*Kandi****34*060606060~

PER*IP**HP*9999988888~

N3*904 Rush Ridge~ N4*Sweet Field*TN*111116666~

DMG*D8*19971031*M~

HLH*U~

HD*030**HLT*PRPV2N*******~

Benefits Administration 834 Guidance Manual: v 5.0 26

File extract example 2 ‐ This family has Dep 3 removed and there is no coverage level change on the HOC’s record.

Before the change After the change

INS*Y*18*030*XN*A*E**FT**N~

REF*0F*00919191~

REF*1L*0717111*CSA Central State Active*ZZ:34902~

DTP*303*D8*20180601~

DTP*336*D8*20161003~

NM1*IL*1*Coon*TY*F***34*070707070~

PER*IP**HP*9999977777~

N3*23 Wall Street~ N4*Dinero*TN*111115555~

DMG*D8*19661125*M*M~

EC*08~

HLH*U~

HD*030**HLT*HSAV1B*FAM******~

DTP*348*D8*20180101~

INS*N*01*030*XN*A*E****N~

REF*0F*00919191~

REF*1L*0717111*CSA Central State Active*ZZ:34902~

DTP*303*D8*20180601~

NM1*IL*1*Coon*Rachel****34*080808080~

PER*IP**HP*9999977777~

N3*23 Wall Street~ N4*Dinero*TN*111115555~

DMG*D8*19590517*F~

HLH*U~

HD*030**HLT*HSAV1B*******~

DTP*348*D8*20180101~

INS*N*19*030*XN*A*E****N~

REF*0F*00919191~

REF*1L*0717111*CSA Central State Active*ZZ:34902~

DTP*303*D8*20180601~

NM1*IL*1*Coon*Daniel****34*090909090~

PER*IP**HP*9999977777~

N3*23 Wall Street~ N4*Dinero*TN*111115555~

DMG*D8*19980615*M~

HLH*U~

HD*030**HLT*HSAV1B*******~

DTP*348*D8*20180101~

INS*N*19*030*XN*A*E****N~

REF*0F*00919191~

REF*1L*0717111*CSA Central State Active*ZZ:34902~

DTP*303*D8*20180601~

NM1*IL*1*Coon*Manny****34*898989898~

PER*IP**HP*9999977777~

N3*23 Wall Street~ N4*Dinero*TN*111115555~

DMG*D8*19920629*M~

HLH*U~

HD*030**HLT*HSAV1B*******~

Dep 3

REF*0F*00919191~

REF*1L*0717111*CSA Central State Active*ZZ:34902~

DTP*303*D8*20180701~

DTP*336*D8*20161003~

NM1*IL*1*Coon*TY*F***34*070707070~

PER*IP**HP*9999977777~

N3*23 Wall Street~ N4*Dinero*TN*111115555~

DMG*D8*19661125*M*M~

EC*08~

HLH*U~

HD*030**HLT*HSAV1B*FAM******~

DTP*348*D8*20180701~

INS*N*01*030*XN*A*E****N~

REF*0F*00919191~

REF*1L*0717111*CSA Central State Active*ZZ:34902~

DTP*303*D8*20180701~

NM1*IL*1*Coon*Rachel****34*080808080~

PER*IP**HP*9999977777~

N3*23 Wall Street~ N4*Dinero*TN*111115555~

DMG*D8*19590517*F~

HLH*U~

HD*030**HLT*HSAV1B*******~

DTP*348*D8*20180701~

INS*N*19*030*XN*A*E****N~

REF*0F*00919191~

REF*1L*0717111*CSA Central State Active*ZZ:34902~

DTP*303*D8*20180701~

NM1*IL*1*Coon*Daniel****34*090909090~

PER*IP**HP*9999977777~

N3*23 Wall Street~ N4*Dinero*TN*111115555~

DMG*D8*19980615*M~

HLH*U~

HD*030**HLT*HSAV1B*******~

DTP*348*D8*20180701~

INS*N*19*030*XN*A*E***N*N~

REF*0F*00919191~

REF*1L*0717111*CSA Central State Active*ZZ:34902~

DTP*303*D8*20180701~

NM1*IL*1*Coon*Manny****34*898989898~

PER*IP**HP*9999977777~

N3*23 Wall Street~ N4*Dinero*TN*111115555~

DMG*D8*19920629*M~

HLH*U~

HD*024**HLT*HSAV1B*******~

DTP*349*D8*20180701~

Benefits Administration 834 Guidance Manual: v 5.0 27

Scenario 9 ‐ Death of the head of contract/HOC (medical benefit only) The State of TN offers a six month extension of medical benefits to the surviving dependents of an HOC if they were enrolled in coverage at the time of the HOC’s death. The State of TN’s 834 file most of the time does not include a date of death. The HOC’s coverage and any enrolled dependents remain on the file with DTP*349 lines for the next six months (or sooner if the dependents choose to end coverage sooner). The file will transmit the HOC record as long as the remaining dependents stay enrolled. Indicators on the file would be:

New DTP*349 lines sent for deceased HOC and for the dependents with an end date (usually) six months in the future.

o However it is no definite way to tell this is a deceased HOC situation.

File extract example 1 ‐ This HOC passed away on 01/24/2018. Normally the coverage end date transmitted would have been 02/1/2018. However this HOC and enrolled dependents have a coverage end (DTP*349) of

08/01/2018 which is six months later.

Before the change After the change

INS*Y*18*030*XN*A*E**FT**N~

REF*0F*00909090~

REF*1L*FA06165*RCS Retiree Central State*ZZ:71500~

DTP*303*D8*20180201~

DTP*336*D8*20121201~

NM1*IL*1*Dente*Al*E***34*838383838~

PER*IP**HP*9999966666~

N3*PO Box 52~ N4*Rome*TN*111114444~

DMG*D8*19350704*M*M~

EC*08~

HLH*U~

HD*030**HLT*PPOV2N*ESP******~

DTP*348*D8*20170801~

INS*N*01*030*XN*A*E****N~

REF*0F*00909090~

REF*1L*FA06165*RCS Retiree Central State*ZZ:71500~

DTP*303*D8*20180201~

NM1*IL*1*Dente*Allie*M***34*848484848~

PER*IP**HP*9999966666~

N3*PO Box 52~ N4*Rome*TN*111114444~

DMG*D8*19351221*F~

HLH*U~

HD*030**HLT*PPOV2N*******~

DTP*348*D8*20170801~

INS*Y*18*030*XN*A*E**TE**N~

REF*0F*00909090~

REF*1L*FA06165*RCS Retiree Central State*ZZ:71500~

DTP*303*D8*20180301~

DTP*336*D8*20121201~

NM1*IL*1*Dente*Al*E***34*838383838~

PER*IP**HP*9999966666~

N3*PO Box 52~ N4*Rome*TN*111114444~

DMG*D8*19350704*M*M~

EC*08~

HLH*U~

HD*024**HLT*PPOV2N*ESP******~

DTP*349*D8*20180801~

INS*N*01*030*XN*A*E****N~

REF*0F*00909090~

REF*1L*FA06165*RCS Retiree Central State*ZZ:71500~

DTP*303*D8*20180501~

NM1*IL*1*Dente*Allie*M***34*848484848~

PER*IP**HP*9999966666~

N3*PO Box 52~ N4*Rome*TN*111114444~

DMG*D8*19351221*F~

HLH*U~

HD*024**HLT*PPOV2N*******~

DTP*349*D8*20180801~

File extract example 2 ‐ Occasionally, the date of death will appear on the file for the HOC. If it is present, it will be on the INS line with a D8* indicator. The date of death would appear for dependents on the INS line too and only occasionally.

Before the change After the change

INS*Y*18*030*XN*A*E**FT**N~

REF*0F*00878787~

REF*1L*0717111*CSA Central State Active*ZZ:32732~

HOC INS*Y*18*030*XN*A*E**TE**N*D8*20180306~

REF*0F*00878787~

Benefits Administration 834 Guidance Manual: v 5.0 28

DTP*303*D8*20180401~

DTP*336*D8*19911201~

NM1*IL*1*Bacon*Chris*P***34*818181818~

PER*IP**HP*9999955555~

N3*2396 Forest Trail~ N4*Woodfield*TN*111113333~

DMG*D8*19480207*M*I~

EC*08~

HLH*U~

HD*030**HLT*PRPV1B*EMP******~

DTP*348*D8*20180101~

REF*1L*0717111*CSA Central State Active*ZZ:32732~

DTP*303*D8*20180401~

DTP*336*D8*19911201~

NM1*IL*1*Bacon*Chris*P***34*818181818~

PER*IP**HP*9999955555~

N3*2396 Forest Trail~ N4*Woodfield*TN*111113333~

DMG*D8*19480207*M*I~

EC*08~

HLH*U~

HD*024**HLT*PRPV1B*EMP******~

DTP*349*D8*20180401~

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Scenario 10 ‐ Future‐dated benefit end ‐ (potentially present up to four times) Similar to an HOC death, where the termination of coverage is in the future, there are other times when a

“future‐dated termination” is present on the file. Terminations in the future can be from an upcoming retirement or from the aging off of dependents reaching 26 yrs or 65 yrs old for examples. One common characteristic among future terms is

The date on the new DTP*349 line (benefit‐ending entry) will be after the date on the current DTP*303 line (file maintenance date)

File extract example ‐ The maintenance date on DTP*303 is in May 1 2018. The date on DTP*349 is June 1

2018. The records remain on the file until the DTP*303 date reaches something after June 1, 2018

Before the change After the change

INS*Y*18*030*XN*A*E**TE**N~

REF*0F*00868686~

REF*1L*0717111*RTE Loc Ed Retiree Teacher*ZZ:99105~

DTP*303*D8*20180501~

DTP*336*D8*20160301~

NM1*IL*1*Storm*Gail*S***34*797979797~

PER*IP**HP*9999944444~

N3*PO Box 819~ N4*Weathertown*TN*111112222~

DMG*D8*19590803*F*M~

EC*08~

HLH*U~

HD*024**HLT*PRPV2B*EMP******~

DTP*349*D8*20180601~

No longer on the file since the DTP*303 is after the DTP*349 line After DTP*303*D8*20180602~:

Not present on file

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Scenario 11 ‐ Reinstatement of benefits Sometimes members who were previously terminated appear again on the file and it will look like they never ended coverage in the first place.