RFP 2025HCA5 Att 4 - 834 Companion Guide.xlsx

XLSX spreadsheet 59 KB Posted Oct 12, 2026

Attached to: Fully-Insured Medical Plans
Solicitation number: 2025HCA5
Issued by: Adams County, Asotin County, Benton County, Chelan County, Clallam County, Clark County, Columbia County, Cowlitz County, Douglas County, Ferry County, Franklin County, Garfield County, Grant County, Grays Harbor County, Island County, Jefferson County, King County, Kitsap County, Kittitas County, Klickitat County, Lewis County, Lincoln County, Mason County, Okanogan County, Pacific County, Pend Oreille County, Pierce County, San Juan County, Skagit County, Skamania County, Snohomish County, Spokane County, Stevens County, Thurston County, Wahkiakum County, Walla Walla County, Whatcom County, Whitman County, Yakima County, Asotin City, Clarkston City, Clarkston Heights-Vineland CDP, West Clarkston-Highland CDP, Benton City, Chelan City, Chelan Falls CDP, Clallam Bay CDP, Lewisville CDP, Rock Island City, Pacific Beach CDP, Whidbey Island Station CDP, Mercer Island City, Pacific City, Bainbridge Island City, Kingston CDP, Kitsap Lake CDP, Kittitas City, Klickitat CDP, Okanogan City, Anderson Island CDP, Fort Lewis CDP, Fox Island CDP, Herron Island CDP, Ketron Island CDP, North Fort Lewis CDP, Raft Island CDP, Stevenson City, Hat Island CDP, Lake Stevens City, Snohomish City, Spokane City, Spokane Valley City, Puget Island CDP, Garfield Town, Yakima City, Washington

About this file

Written by GovTribe AI · Oct 19, 2026

This is an 834 Benefit Enrollment and Maintenance Companion Guide prepared by the Washington State Health Care Authority (HCA) for the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB). The guide serves as a technical specification document supplementing the standard HIPAA 834 Implementation Guide and addresses enrollment file requirements specific to HCA's Employee and Retiree Benefits (ERB) Division and its trading partners. The document provides detailed technical specifications for both monthly audit files and daily change files, with audit files generated on the first working day of each month containing full positive enrollment data effective on the first of the upcoming month, while daily change files contain enrollment modifications only. Files are created Monday through Friday, excluding state holidays, at 11 PM and are transmitted via Secure File Transfer Protocol (SFTP) through the State of Washington Consolidated Technical Services portal.

The companion guide establishes standardized data format requirements for 834 enrollment files, utilizing specific delimiters including asterisks for element separation, colons for sub-element separation, tildes for segment terminators, and carets for repetition separation. All dates within files follow the CCYYMMDD format except for the Interchange Date (ISA09), which uses YYMMDD format, while times are expressed in HHMM and HHMMSS military time formats. File naming conventions follow the pattern HIPAA.[PEBB or SEBB].AUDIT or CHANGE.834.[Plan ID].OUT.D[Date Stamp].T[Time Stamp] to facilitate identification and retrieval. The guide reflects multiple updates through version 4.11 (dated May 29, 2024), with the most recent clarification addressing Loop 2700 series information specific to Regence coverage.

View the file

Other files

File	Type	Posted
RFP 2025HCA5 Exhibit I - Subc List.xlsx	XLSX spreadsheet	Oct 12, 2026
RFP 2025HCA5 Exhibit C1.2 - Written P1.docx	DOCX document	Oct 12, 2026
RFP 2025HCA5 Exhibit G - Plan Design Outline.xlsx	XLSX spreadsheet	Oct 12, 2026
RFP 2025HCA5 Attachment 1_APM Framework_RFP.pdf	PDF	Oct 12, 2026
RFP 2025HCA5 Att 7 - Disaster Plan.docx	DOCX document	Oct 12, 2026
RFP 2025HCA5 Exhibit H - Bree Collab.xlsx	XLSX spreadsheet	Oct 12, 2026
RFP 2025HCA5 Final 10.12.26.pdf	PDF	Oct 12, 2026
RFP 2025HCA5 Exhibit C2 Written P2.docx	DOCX document	Oct 12, 2026
RFP 2025HCA5 Exhibit A - Forms and Certs.docx	DOCX document	Oct 12, 2026
RFP 2025HCA5 Attachment 9 - claim data.xlsx	XLSX spreadsheet	Oct 12, 2026
RFP 2025HCA5 Exhibit E - Service Area.xlsx	XLSX spreadsheet	Oct 12, 2026
RFP 2025HCA5 EXHIBIT C1.1 Attestations.docx	DOCX document	Oct 12, 2026
RFP 2025HCA5 Attachment 3_MFT User Guide_RFP.pdf	PDF	Oct 12, 2026

Show all 13

On GovTribe

Work with this file

Download the original file
Contacts named in this file
Similar government files
Ask GovTribe AI about this file

Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

Cover 834 Benefit Enrollment and Maintenance

Companion Guide - DRAFT of v4

Public Employees Benefits Board (PEBB) and

School Employees Benefits Board (SEBB)

March 1, 2013

Modification History:

Version 4.00 - 05/20/2020

Version 4.01 - 07/29/2020

Version 4.02 - 08/28/2020

Version 4.03 - 03/15/2021

Version 4.04 - 09/23/2022

Version 4.05 - 10/27/2022

Version 4.06 - 07/05/2023

Version 4.07 - 10/02/2023

Version 4.08 - 05/01/2024

Version 4.09 - 05/06/2024

Version 4.10 - 05/20/2024

Version 4.11 - 05/29/2024

Blank Page

WSHCA-PEBB 834 (10/2014) Page &P of &N

Release Notes Release Notes

Date	Information
5/29/24	Clarified the 'notes' for Loop 2700 series to state this information is for Regence. Removed the reference to MAPD.

Technical Information PURPOSE: This Companion Guide provides information about the 834 Enrollment file that is specific to HCA's Employee and Retiree Benefits (ERB) Division and HCA trading partners. It will include both the 834 Audit and 834 Update. This guide is intended to supplement rather than replace the standard Implementation Guide.

The monthly audit file is a full positive enrollment and is available on the 1st working day of every month; therefore, the effective date of coverage is always the 1st of the upcoming month. For example, the monthly audit file on 6/30/2014 will contain all enrolled members for July, 2014.

The daily change file is a changes only file.

Item Subject Topics Additional Information or Examples

1	File Creation	Schedule	Monday - Friday (except state holidays) at 11 PM.
		Naming Convention	HIPAA.<PEBB or SEBB>.AUDIT.834.<PlanID>.OUT.D<Date Stamp>.T< Time Stamp>

Examples: HIPAA.PEBB.AUDIT.834.ABC.OUT.D130623.T183216 or HIPAA.SEBB.AUDIT.834.ABC.OUT.D130623.T183216

HIPAA.<PEBB or SEBB>.CHANGE.834.<PlanID>.OUT.D<Date Stamp>.T< Time Stamp> Examples: HIPAA.PEBB.CHANGE.834.ABC.OUT.D130623.T183216 or HIPAA.SEBB.CHANGE.834.ABC.OUT.D130623.T183216

Plan IDs	See Ref. table
Date Stamp	YYMMDD
Time Stamp	HHMMSS in military time format

		Data Retrieval	Secure File Transfer Protocol (SFT) through the State of Washington Consolidated Technical Services - https://sft.wa.gov/
2	Data Format	Delimiters
		Element separator	Asterisk (*)
		Sub-element separator	Colon (:)
		Segment Terminator	Tilde (~)
		Repetition Separator	Caret (^)
		Dates	All dates within the file are in CCYYMMDD except the Interchange Date (ISA09) which is in YYMMDD
		Time	HHMM
		Phone Numbers	AAAPPPNNNN (8005551212) <= 800-555-1212

3	Contact	Level 1 (primary)	HCA Help Desk, 360-725-1111, servicedesk@hca.wa.gov
		Level 2 (secondary)	Grant Stromsdorfer, 360-725-5324, Grant.Stromsdorfer@hca.wa.gov
		Blank Page

WSHCA-PEBB 834 (10/2014) Page &P of &N

Transaction Specifications

				DRAFT
HIPAA Field Name	HIPAA Ref. Des.	HIPAA Usage	HIPAA Element	HIPAA Element Description	Transformation Needed / Note

Header Segments
Loop: None Segment: ISA Interchange Control Header (Required)
Authorization Information Qualifier	ISA01	R	00	No Authorization Information Present Qualifier
Authorization Information	ISA02	R	<Blank>	10 spaces
Security Information Qualifier	ISA03	R	00	No Security Information Present Qualifier
Security Information	ISA04	R	<Blank>	10 spaces
Interchange ID Qualifier	ISA05	R	30	Qualifier for U.S. Federal Tax Identification Number
Interchange Sender ID	ISA06	R	<HCA Fed TIN>	WA HCA Federal Tax ID (911412780) followed by 6 spaces
Interchange ID Qualifier	ISA07	R	30	Qualifier for U.S. Federal Tax Identification Number
Interchange Receiver ID	ISA08	R	<HLT Plan Fed TIN>	Health Plan Federal Tax ID (9-digit) followed by 6 spaces
Interchange Date	ISA09	R	<YYMMDD>	Date the Interchange is created
Interchange Time	ISA10	R	<HHMM>	Time the Interchange is created
Repetition Separator	ISA11	R	^	Carret
Interchange Control Version Number	ISA12	R	00501	Standards Approved by ACS X12 Review Board
Interchange Control Number	ISA13	R	<Unique Number>	Unique Sequential Number Assigned for each Interchange (Same as IEA02)
Acknowledgment Requested	ISA14	R	0	Interchange Acknowledgment Request; 0 = No, 1 = Yes acknowledgement
Usage Identifier	ISA15	R	P or T	Production or Test
Component Element Separator	ISA16	R	:	Colon
Loop: None Segment: GS Functional Group Header (Required)
Functional Identifier Code	GS01	R	BE	Benefit Enrollment And Maintenance (834)
Application Sender's Code	GS02	R	<HCA Fed TIN>	Federal Tax ID of the Sender (HCA = 911412780)
Application Receiver's Code	GS03	R	<HLT Plan Fed TIN>	Federal Tax ID of the Receiver (Health Plan)	Hard code CES for United Health Care
Date	GS04	R	<CCYYMMDD>	Date the Group Header is created
Time	GS05	R	<HHMM>	Time the Group Header is created
Group Control Number	GS06	R	<Unique Number>	Unique Sequential Number Assigned for each Group Header
Responsible Agency Code	GS07	R	X	Accredited Standards Committee X12
Version/Release/Industry Identifier Code	GS08	R	005010X220A1	Standards Approved by ACS X12 Review Board
Loop: None Segment: ST Transaction Set Header (Required)
Transaction Set Identifier Code	ST01	R	834	Benefit Enrollment and Maintenance
Transaction Set Control Number	ST02	R	<0001>	1 Segment only, ever
Implementation Convention Reference	ST03	R	005010X220A1	Same as GS08
Loop: None Segment: BGN Beginning (Required)
Transaction Set Purpose Code	BGN01	R	00	Original Submission
Reference Identification	BGN02	R	<Reference Number>	Reference number to uniquely identify the transaction for future reference
Date	BGN03	R	<CCYYMMDD>	Date the Transaction Set is created
Time	BGN04	R	<HHMM>	Time the Transaction Set is created
Time Code	BGN05	S	PT	Time Zone Code
Reference Identification	BGN06	Not Used	<Blank>	Not Used
Transaction Type Code	BGN07	Not Used	<Blank>	Not Used
Action Code	BGN08	R	2 or 4	2 = Change and 4 = Verify (Monthly Full Enrollment file)

Loop: None Segment: REF - Transaction Set Policy Number (Situational)
Reference Identification	REF01	R	38	Master Policy Number
Reference Identification	REF02	R	<Master Policy Nbr>	Group ID (only for DeltaCare, UDP Dental, and Regence. See Ref. table)	Hard code WAHCAC/WAHCAFRC/WAHCASPC (Change/Audit/Supplemental) for UHC
Description	REF03	Not Used	<Blank>	Not Used
Reference Identifier	REF04	Not Used	<Blank>	Not Used

Loop: None Segment: DTP - FILE EFFECTIVE DATE (Required)
Date/Time Qualifier	DTP01	R	007	File Effective date
Date Time Period Format Qualifier	DTP02	R	D8	Date Expressed in Format CCYYMMDD
Date Time Period	DTP03	R	<CCYYMMDD>	Date the 834 outbound interchange file is created	PROCESS DATE

Loop: 1000A Segment: N1 Sponsor Name (Required)
Entity Identifier Code	N101	R	P5	P5 = HCA
Name	N102	S	<Sender Name>	WASHINGTON STATE HCA ERB
Identification Code Qualifier	N103	R	FI	Qualifier for U.S. Federal Taxpayer Identification Number
Identification Code	N104	R	<HCA Fed TIN>	WA HCA Federal Tax ID (911412780)

Loop: 1000B Segment: N1 Payer (Required)
Entity Identifier Code	N101	R	IN	Health Plan
Name	N102	S	<Health Plan Name>	Name of Health Plan Carrier
Identification Code Qualifier	N103	R	FI	Qualifier for U.S. Federal Taxpayer Identification Number
Identification Code	N104	R	<HLT Plan Fed TIN>	Federal Tax ID of the Payer (Health Plan carrier)

Member Level Detail segments
Loop: 2000 Segment: INS Member Detail (Required)
Yes/No Condition Response Code	INS01	R	Y/N	Y=subscriber; N=else
Individual Relationship Code	INS02	R	18, 01, 19, 10, 53	Y*18=Subscriber;

N*01=Sps;N*19=Dep;N*10=Foster; N*53=Dom. Partner;

INS*N*19*030*XN*A*E****N*D8*20130215 SUB-RETIRED-DT;MBR-COVERAGE-EFF-DT;

MBR-MEDICARE-EFF-DT;

MBR-COVERAGE-TERM-DT;

Maintenance Type Code	INS03	R	001;021; 024; 030	001-Change;021-Addition;024-Termination;030-Audit	Monthly Audit file uses only 030. Change file uses other values.
Maintenance Reason Code	INS04	R	01, 02, 22, …, or XN	See Ref. table for codes list (01=Divorce; 20=Enrolled; 22=Plan Change,…, or XN=Notificantion Only)	Monthly Audit file uses only XN. Change file uses all values.

When INS03 is 024, indicate whether termination is Involuntary (03) or Voluntary (14)

Benefit Status Code	INS05	R	A	A=Active for all records
Medicare Plan Code	INS06	R	A, B, C, or Blank	Medicare Part A, Part B, Part A+B (C=Both), or Blank
Cobra Qualifying Event Code	INS07	S	<Blank>	Not Used
Employment Status Code	INS08	S	AC	AC=Active on all records
Yes/No Condition for Handicap Indicator	INS10	S	Y/N	Handicap Indicator	MBR-DISABLED-IND
Date Time Period Format Qualifier	INS11	S	D8	Date Expressed in Format CCYYMMDD Qualifier
Member Individual Death Date	INS12	S	<CCYYMMDD>	The Date of Death	DECEASED DATE

Loop: 2000 Segment: REF Subscriber Number (Required)
Reference ID Qualifier	REF01	R	0F	Subscriber Number Qualifier	This segment will be repeated on Subscriber, Spouse and all Deps
Reference Identification	REF02	R	<Subscriber SSN>	Subscriber SSN

Loop: 2000 Segment: REF Member Policy Number (Situational)
Reference ID Qualifier	REF01	R	1L	Qualifier for Group Number	This segment will be repeated on Subscriber, Spouse and all Deps
Reference Identification	REF02	R		9 bytes, codes as follows:
1st bytes (Alpha-Numeric)	REF02-1	S	See Ref. tables	REF1L 107A M~	ELIGIBILITY-TYPE (1 byte)
2nd-4th bytes (Alpha-Numeric)	REF02-2	S		REF1L 107A M~	AGENCY-CODE (3 bytes)
5th - 7th bytes (Alpha-Numeric)	REF02-3	S		REF1L 107A M~	SUBAGENCY-CODE (3 bytes)
8th byte (Alpha-Numeric)	REF02-4	S	Blank	REF1L 107A M~	ESRD indicator
9th byte (Alpha-Numeric)	REF02-5	S	M, F or X	REF1L 107A M~	Gender Identity - for KP NW, replaced X with U

Loop: 2000 Segment: REF Member Supplemental Identifier (Situational)
Reference ID Qualifier	REF01	R	F6	Health Insurance Claim (HIC) Number Qualifier
Reference Identification	REF02	R	<HIC Number>	Health Insurance Claim Number

Loop: 2000 Segment: REF Member Supplemental Identifier (Situational)
Reference ID Qualifier	REF01	R	QQ		This segment will be repeated on Subscriber, Spouse and all Deps
Reference Identification	REF02	R		Fixed length of 50 bytes, codes as follows:
position 01-10th (Alpha-Numeric)	REF02-1	S		PCP clinic ID	CLINIC-ID (10 bytes)
position 11-18th (CCYYMMDD)	REF02-2	S		Home Address Effective Date	HOME-ADDR-EFF-DT(8 bytes)
position 19-24th (Alpha-Numeric)	REF02-3	S		Originating Agency/Sub-Agency	ORIGINATE-AGENCY-SUBAGY (6 bytes)
position 25-25th (Alpha-Numeric)	REF02-4	S		Truly New Account	TRULY-NEW-ACCT (1 bytes)
position 26-26th (Alpha-Numeric)	REF02-5	S		Subscriber Qualifying Event	SUBS-QUALIFY-EVENT (1 bytes)
position 27-34th (CCYYMMDD)	REF02-6	S		Medicare Part A Effective Date	MCARE-PART-A-EFF-DT (8 bytes)
position 35-42th (CCYYMMDD)	REF02-7	S		Medicare Part B Effective Date	MCARE-PART-B-EFF-DT (8 bytes)
position 43-50th (CCYYMMDD)	REF02-8	S		Eligibility Effective Date	INS-ELIGIBILITY-EFF-DT (8 bytes)

Loop: 2000 Segment: DTP Member Level Date (Situational)
Date Time Qualifier	DTP01	R	286, 338, 356, 357	286 = Subscriber Retirement Date;

338 = Effective Date - Medicare Part A and/or Part B;

356 = Coverage Begin Date;

357 = Coverage End Date;

Date Format Qualifier	DTP02	R	D8	Date Expressed in Format CCYYMMDD Qualifier
Date Time Period	DTP03	R	<CCYYMMDD>

Loop: 2100A Segment: NM1 MEMBER Name (Required)
Entity Identifier Code	NM101	R	IL, 74	Code 74 when LP2100B is sent, else it will be code IL
Entity Type Qualifier	NM102	R	1	Person
Last Name	NM103	R	Smith	Last Name of Insured or Subscriber	MBR LAST NAME
First Name	NM104	S	John	First Name of Insured or Subscriber	MBR FIRST NAME
Middle Initial	NM105	S	H	Middle Initial of Insured or Subscriber	MBR MIDDLE INITIAL
Name Prefix	NM106	S	<Blank>	Not Used
Name Suffix	NM107	S	JR	Name Suffix of Insured or Subscriber	MBR SUFFIX
ID Code Qualifier	NM108	S	34	Qualifier for Social Security Number
Member ID (SSN)	NM109	S	<Member SSN>	NM1IL1SMITHJOHNHJR34*555667777	MBR SSN

Loop: 2100A Segment: PER Member Communication Numbers (Situational)
Contact Function Code	PER01	R	IP	Insured Party	This segment will be on Subscriber only
Communication Number Qualifier	PER03	R	TE	Home Phone Qualifier
Communication Number	PER04	R	<Area Code; Phone>	3 Digit Area Code+7 Digit Phone in AAABBBCCCC	HOME PHONE
Communication Number Qualifier	PER05	S	WP	Work Phone Qualifier
Communication Number	PER06	S	<Area Code; Phone>	3 Digit Area Code+7 Digit Phone in AAABBBCCCC	WORK PHONE

Loop: 2100A Segment: N3 Member Residence Street Address (Required)
Residential Street address	N301	S	N3*676 CHERRY STREET	ADDRESS LINE 1
Residential Street address	N302	S	N3676 CHERRY STREETSUITE 123	ADDRESS LINE 2

Loop: 2100A Segment: N4 Member Residence City, State, Zip (Required)
Residential City	N401	R	N4*Olympia	CITY
Residential State	N402	R	N4OlympiaWA	STATE
Residential Zipcode	N403	R	N4OlympiaWA*985040001	ZIP
Residential Country Code	N404	S	N4OlympiaWA985040001US	COUNTRY CODE
Location Qualifier	N405	not used
County	N406	not used

Loop: 2100A Segment: DMG Member Demographics (Required)
Date Format Qualifier	DMG01	R	D8	Date Expressed in Format CCYYMMDD Qualifier
Birthdate	DMG02	R	<CCYYMMDD>	Birth Date of Member	MBR BIRTH DATE
Gender Code	DMG03	R	F or M	Female or Male Member Sex at Birth Code	MBR GENDER CODE
Marital Status Code	DMG04	S	I, M	Marital Status of Subscriber (I=Single, M=Married)	FAM-MARITAL-STATUS (for Subscriber only, else blank)

Loop: 2100B Segment: NM1 Incorrect MEMBER Name (Situational)
Entity Identifier Code	NM101	R	70	When LP2100B is sent, code in 2100A.NM101 will be 74
Entity Type Qualifier	NM102	R	1	Person
Last Name	NM103	R	Smyth	NM1701SMYTHJEFFH*34555667777	OLD-LASTNAME
First Name	NM104	S	Jeff	NM1701SMYTHJEFFH*34555667777	OLD-FIRSTNAME
Middle Initial	NM105	S	H	NM1701SMYTHJEFFH*34555667777	OLD-MI
Name Prefix	NM106	S	<Blank>	Not Used
Name Suffix	NM107	S	JR	NM1701SMYTHJEFFHJR34*555667777	OLD-SUFFIX
ID Code Qualifier	NM108	S	34	Qualifier for Social Security Number
Member ID (SSN)	NM109	S	<Member SSN>	NM1701SMYTHJEFFHJR34*555667777	OLD-MEMBER-SSN

Loop: 2100B Segment: DMG Incorrect Member Demographics (Situational)
Date Format Qualifier	DMG01	R	D8	Date Expressed in Format CCYYMMDD Qualifier
Birthdate	DMG02	R	<CCYYMMDD>	Member Birth Date	OLD-BIRTH-DATE
Gender Code	DMG03	R	F or M	Female or Male Member Sex at Birth Code	OLD-GENDER-CODE
Marital Status Code	DMG04	S	S, M	Marital Status of Subscriber	OLD-MARITAL-STATUS

Loop: 2100C Segment: NM1 Member Mail Street Address (Situational) indicator
Entity Identifier Code	NM101	R	31	Postal Mailing Address
Entity Type Qualifier	NM102	R	1	NM1311
Loop: 2100C Segment: N3 Member Mail Street Address (Situational)
Mailing Street Address	N301	S		N3*676 WOODLAND SQ. LOOP	MAILING ADDRESS LINE 1
Mailing Street Address	N302	S		N3676 WOODLAND SQ. LOOPSUITE 123	MAILING ADDRESS LINE 2

Loop: 2100C Segment: N4 Member Mail City, State, Zip (Situational)
Mailing City	N401	R	N4*Lacey	MAILING ADDRESS CITY
Mailing State	N402	S	N4LaceyWA	MAILING ADDRESS STATE
Mailing Zipcode	N403	S	N4LaceyWA*985060001	MAILING ADDRESS ZIP
Mailing Country Code	N404	S	N4LaceyWA985060001US	MAILING ADDRESS COUNTRY CODE

Loop: 2200 Segment: DSB Disability Information (Situational)
Disability Type Code	DSB01	R	1, 3	1=Short-Term; 3=Permanent
Quantity	DSB02	Not used	<Blank>	Not Used

Loop: 2200 Segment: DTP Disability Eligibility Dates (Situational)
Date Time Qualifier	DTP01	R	360, 361	360 = Disability Begin Date; 361 = Disability End Date;
Date Format Qualifier	DTP02	R	D8	Date Expressed in Format CCYYMMDD Qualifier
Date Time Period	DTP03	R	<CCYYMMDD>

Loop: 2300 Segment: HD Health Coverage (Required)
Maintenance Type Code	HD01	R	001; 021; 024; 030	001-Change;021-Addition;024-Termination;030-Audit	Monthly Audit file uses only 030. Change file uses other values.
Maintenance Reason Code	HD02	S	<Blank>	Not Used
Insurance Line Code	HD03	R	HLT, DEN	HLT=Medical Plan; DEN=Dental Plan
Plan Coverage Description	HD04	S	See Ref. tables	HD030HLTCV*FAM	CARRIER-CODE (upto 4 bytes)
Coverage Level Code	HD05	S	EMP;ESP;ECH;FAM;DEP;SPC;SPO	See Implementation Guide for codes description (FAM=Family; Dep=Dep only; SPC=Spouse-dep; SPO=Spouse only;ECH=Employee-Dep)	FAM-COMPOSITION

Loop: 2300 Segment: DTP Health Coverage Date (Required)
Date Time Qualifier	DTP01	R	348 or 349	348=Benefits Begin Date; 349=Benefits End Date	Audit may have 349 on subscriber of dep only acct. Change file uses both
Date Format Qualifier	DTP02	R	D8	Date Expressed in Format CCYYMMDD Qualifier
Date Time Period	DTP03	R	<CCYYMMDD>		MBR-COVERAGE-EFF-DT, MBR-COVERAGE-TERM-DT

Loop: 2300 Segment: DTP Member Level Date (Situational)
Date Time Qualifier	DTP01	R	300	300 = Signature Date

For HD01 = 001-Change;021-Addition;030-Audit, the Signature Effective Date will be provided.

For HD01 = 024-Termination, the Signature End Date will be provided.	For MAPD, KPWA, KPNW and Regence
	Date Format Qualifier	DTP02	R	D8	Date Expressed in Format CCYYMMDD Qualifier
	Date Time Period	DTP03	R	<CCYYMMDD>

Loop: 2300 Segment: REF Health Coverage Policy Number (Situational)
Reference ID Qualifier	REF01	R	17	Client Reporting Category	This segment will be for dental plans and is sent only on Subscriber record
Reference Identification	REF02	R		Fixed length, codes as follows:
position 01-05th (Alpha-Numeric)	REF02-1	S	<Blank>	Not Used
position 06-06th (Alpha-Numeric)	REF02-2	S	Y/N	Flag indicate family enrolled in HSA/CDHP health plan	FAM-HSA-FLAG (1 byte)

Loop: 2700 Segment: LS Additonal Reporting Categories (Situational)
Maintenance Type Code	LS01	R	2700	2700 = Medicare Part D Data	For Regence

Loop: 2710 Segment: LX Member Reporting Categories (Situational)
Assigned Number	LX01	R	1	1 = Medicare Part D Indicator	For Regence

Loop: 2750 Segment: N1 Reporting Category (Situational)
Entity Identifier Code	N101	R	75		For Regence
Entity Identifier Name	N102	R	MCARE PRTD IND	Medicare Part D Indicator

Loop: 2750 Segment: REF Reporting Category Reference (Situational)
Reference Identification Qualifier	REF01	R	ZZ		For Regence
Reference Identification	REF02	R	Y or N	Medicare Part D Indicator
Loop: 2710 Segment: LX Member Reporting Categories (Situational)
Assigned Number	LX01	R	2	2 = Medicare Part D Date	For Regence
Loop: 2750 Segment: N1 Reporting Category (Situational)
Date Time Qualifier	N101	R	75		For Regence
Date Format Qualifier	N102	R	MCARE PRTD DT	Medicare Part D Date
Loop: 2750 Segment: DTP Reporting Category Date (Situational)
Date Time Qualifier	DTP01	R	007	007 = Medicare Part D Date	For Regence
Date Format Qualifier	DTP02	R	D8	Date Expressed in Format CCYYMMDD Qualifier
Date Time Period	DTP03	R	<CCYYMMDD>
Loop: 2700 Segment: LE Additional Reporting Categories Loop Terminations (Situational)
Loop Identifer Code	LE01	R	2700	2700 = Loop Termination	For Regence

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

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

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

Transaction Specifications

WSHCA-PEBB 834 (10/2014) Page &P of &N

PEBB Codes Description

CARRIER-CODE in HD04	Ins. Line Codes (HD03)	Carrier TIN in 1000B-N103	Carrier Name in 1000B-N102	Customized Code by Carrier in REF02*(38)	Carrier Name for Code in HD04
C	HLT		Kaiser WA Classic
CV	HLT		Kaiser WA Value
CHSA	HLT		Kaiser WA CDHP
CMED	HLT		Kaiser WA Medicare
CW	HLT		Kaiser WA Classic SmartHealth
CVW	HLT		Kaiser WA Value SmartHealth
CHSW	HLT		Kaiser WA CDHP SmartHealth
C1	HLT		Kaiser WA Sound Choice
C1W	HLT		Kaiser WA Sound Choice SmartHealth
D	HLT		Kaiser NW Classic
DHSA	HLT		Kaiser NW CDHP
DW	HLT		Kaiser NW Classic SmartHealth
DHSW	HLT		Kaiser NW CDHP SmartHealth
F	HLT		PBC Medicare Supp Plan F
G	HLT		PBC Medicare Supp Plan G
MB	HLT		United Health Care (UHC) Medicare Advantage Prescription Drug (MAPD) Balance
MC	HLT		UHC MAPD Complete
U	HLT		Uniform Medical Plan	10003948	UMP Classic
UHSA	HLT		Uniform Medical Plan	10003948	UMP CDHP
US	HLT		Uniform Medical Plan	10003948	UMP Select
UW	HLT		Uniform Medical Plan	10003948	UMP Classic SmartHealth
UHSW	HLT		Uniform Medical Plan	10003948	UMP CDHP SmartHealth
USW	HLT		Uniform Medical Plan	10003948	UMP Select SmartHealth
U1	HLT		Uniform Medical Plan Accountable Care Plan (ACP)		UMP Plus UW Medicine Accountable Care Network (ACN)
U1W	HLT		Uniform Medical Plan Accountable Care Plan (ACP) SmartHealth		UMP Plus UW Medicine Accountable Care Network (ACN)
U2	HLT		Uniform Medical Plan Accountable Care Plan (ACP)		UMP Plus Puget Sound High Value Network
U2W	HLT		Uniform Medical Plan Accountable Care Plan (ACP) SmartHealth		UMP Plus Puget Sound High Value Network
1	DEN		Uniform Dental Plan	ET03000
3	DEN		Willamette Dental
4	DEN		DeltaCare	ET03100
T1P	VIS		Davis Vision
T2P	VIS		EyeMed Vision
T3P	VIS		MetLife Vision

Eligibility Type Codes in 2000-REF02*(1L) at 1st Position
	Y = State employee	C = COBRA
	X = K-12 or employer group employee	S = Self-pay
	R = Retiree	E = Self-pay dental-only
	K = K-12 retiree	T = COBRA dental-only
	G = COBRA retiree	N = not enrolled
	D = COBRA K-12 retiree	H = COBRA Dental Only ER Grp
		Q = COBRA Retiree ER Grp
		U = COBRA vision-only
		P = Self-pay vision-only
Coverage Level in 2300-HD05
	FAM = Family	DEP = Dependent only
	EMP = Employee	SPO = Spouse only
	ESP = Employee and Spouse	SPC = Spouse and Dependents
	ECH = Employee and Dependents

Maint. Reason Codes in 2000-INS04
	01 - Divorce	09 - COBRA
	02 - Birth	20 - Active
	03 - Death	21 - Disable
	04 - Retire	22 - Plan Change
	07 - Terminate

Reference Tables

WSHCA-PEBB 834 (10/2014) Page &P of &N

SEBB Codes Description

CARRIER-CODE in HD04	Ins. Line Codes (HD03)	Carrier TIN in 1000B-N103	Carrier Name in 1000B-N102	Customized Code by Carrier in REF02*(38)	Carrier Name for Code in HD04
KN1	HLT		Kaiser Permanente NW 1
KN2	HLT		Kaiser Permanente NW 2
KN3	HLT		Kaiser Permanente NW 3
KN1W	HLT		Kaiser Permanente NW 1 SmartHealth
KN2W	HLT		Kaiser Permanente NW 2 SmartHealth
KN3W	HLT		Kaiser Permanente NW 3 SmartHealth
KW1	HLT		Kaiser Permanente WA Core 1
KW2	HLT		Kaiser Permanente WA Core 2
KW3	HLT		Kaiser Permanente WA Core 3
KW1W	HLT		Kaiser Permanente WA Core 1 SmartHealth
KW2W	HLT		Kaiser Permanente WA Core 2 SmartHealth
KW3W	HLT		Kaiser Permanente WA Core 3 SmartHealth
KWS	HLT		Kaiser Permanente WA SoundChoice
KWSW	HLT		Kaiser Permanente WA SoundChoice SmartHealth
KO1	HLT		Kaiser Permanente WA Options Access PPO 1
KO2	HLT		Kaiser Permanente WA Options Access PPO 2
KO3	HLT		Kaiser Permanente WA Options Access PPO 3
KO1W	HLT		Kaiser Permanente WA Options Access PPO 1 SmartHealth
KO2W	HLT		Kaiser Permanente WA Options Access PPO 2 SmartHealth
KO3W	HLT		Kaiser Permanente WA Options Access PPO 3 SmartHealth
KP1	HLT		Kaiser Permanente WA Summit PPO 1
KP2	HLT		Kaiser Permanente WA Summit PPO 2
KP3	HLT		Kaiser Permanente WA Summit PPO 3
KP1W	HLT		Kaiser Permanente WA Summit PPO 1 SmartHealth
KP2W	HLT		Kaiser Permanente WA Summit PPO 2 SmartHealth
KP3W	HLT		Kaiser Permanente WA Summit PPO 3 SmartHealth
PH	HLT		Premera High PPO
PHW	HLT		Premera High PPO SmartHealth
PM			Premera HMO
PMW			Premera HMO SmartHealth
PP	HLT		Premera Peak Care EPO
PPW	HLT		Premera Peak Care EPO SmartHealth
PS	HLT		Premera Standard PPO
PSW	HLT		Premera Standard PPO SmartHealth
V	HLT		Uniform Medical Plan	10003948	UMP Achieve 1
VW	HLT		Uniform Medical Plan	10003948	UMP Achieve 1 SmartHealth
VA	HLT		Uniform Medical Plan	10003948	UMP Achieve 2
VAW	HLT		Uniform Medical Plan	10003948	UMP Achieve 2 SmartHealth
VB	HLT		Uniform Medical Plan	10003948	UMP Achieve 3
VBW	HLT		Uniform Medical Plan	10003948	UMP Achieve 3 SmartHealth
VHSA	HLT		Uniform Medical Plan	10003948	UMP CDHP
VHSW	HLT		Uniform Medical Plan	10003948	UMP CDHP SmartHealth
V1	HLT		Uniform Medical Plan Accountable Care Plan (ACP)		UMP Plus UW Medicine Accountable Care Network (ACN)
V1W	HLT		Uniform Medical Plan Accountable Care Plan (ACP) SmartHealth		UMP Plus UW Medicine Accountable Care Network (ACN)
V2	HLT		Uniform Medical Plan Accountable Care Plan (ACP)		UMP Plus Puget Sound High Value Network
V2W	HLT		Uniform Medical Plan Accountable Care Plan (ACP) SmartHealth		UMP Plus Puget Sound High Value Network
T1	VIS		Davis Vision
T2	VIS		EyeMed
T3	VIS		MetLife
1S	DEN		Uniform Dental Plan	ET03000
3S	DEN		Willamette Dental
4S	DEN		DeltaCare	ET03100

Eligibility Type Codes in 2000-REF02*(1L) at 1st Position
	Z = Employee (6d)	C = COBRA
	W = Employee (6e)	S = Self-pay
	D = COBRA K-12 retiree	E = Self-pay dental-only
	P = Self-pay vision-only	T = COBRA dental-only
	V = COBRA vision-only	N = not enrolled
	X = Tribal School Employees and Employees of Organizations Representing School Employees	B = Self-Pay School Board Member

Coverage Level in 2300-HD05
	FAM = Family	DEP = Dependent only
	EMP = Employee	SPO = Spouse only
	ESP = Employee and Spouse	SPC = Spouse and Dependents
	ECH = Employee and Dependents

Maint. Reason Codes in 2000-INS04
	01 - Divorce	09 - COBRA
	02 - Birth	20 - Active
	03 - Death	21 - Disable
	04 - Retire	22 - Plan Change
	07 - Terminate

Reference Tables

WSHCA-PEBB 834 (10/2014) Page &P of &N image1.png

File details come from the government source that posted it. Updated Oct 19, 2026.