Schedule F2 834 Use Case.docx

STATE OF MICHIGAN

RFP No. 200000001290

SCHEDULE F2

834 Use Case

04/17/2015

Batch Program Extract Health Care Data File

Description:

This batch program is run on a scheduled basis each week and is used to extract data to populate the Health Care Enrollment Data File in order to capture new health care enrollment member information to be sent to each respective health care vendor. When this batch program is requested to run as a resubmission, the data extract is the same as a previous file to a vendor on a specified date.

Data Rules:

Selection Criteria:

Scheduled Job Stream (original file sent to vendors)

Health Care Enrollment Data Tape

Rule 1: This data file must capture and transmit all change instances of a health care plan. Once a record of the modification has been sent, it will not be sent again in a future batch run of this data file.

Examples:

1. If a dependent is added to the coverage of an existing contract, then send the information of the new dependent only.

2. If a dependent was dropped from the coverage, then send the information of the dependent who was dropped from the coverage.

3. If a new contract has been added, then the information on all the dependents covered in the health care contract will be sent to the vendor.

4. If a contract was ended, then the information on all the dependents will be sent to the vendor.

Rule 2: Once a record which represents a modification (an add, end, or update) is included in the batch, a flag field will be set (i.e. turned on) to indicate that the modification has been sent. This will prevent the record from being selected in a future batch run and prevent the health care plan from being deleted.

Rule 3: Whenever a change is made to existing contract policy to update missing contract person information, using a reason code as “updating data”, the batch process should not send the information to the vendor.

· Selection Criteria:

· Select records which have been modified (added, terminated, updated) on and before the date of the current batch run and where the ‘Sent’ indicator (see Rule 2 above) is set to ‘off’ (0) and also the ‘Rdy_in’ is set to 1. This indicator can be set to true (1) or false (0) from Tab Health Care. This will include records where the ‘Change Effective Date’ field may have been set for any date during the week or any time in the past. After conclusion of the batch, set the ‘Sent’ indicator to ‘on’ (1) for all records which were picked up in the selection. Set the sent date to the business date of the batch run.

· Include in this selection, records where the ‘Change Effective Date’ field has been set for a future date up to and including sixty (60) days beyond the date of the batch run. After conclusion of the batch, set the ‘sent’ indicator to ‘on’ (1) for all records which were picked up in the selection. Set the sent date to the business date of the batch run.

· Do not include records where the ‘Change Effective Date’ of the modification is set more than sixty (60) days beyond the date of the batch run.

· Select records which have had an address change on and before the date of the current batch run from the end of the previous batch run. This will include records where be_addr.addr_ln1_nm or be_addr.addr_ln2_nm has been modified for any person owning a health care contract (subscribers). Any address changes made to non-health care owners will not be selected. Additionally, only address information will be selected for health care contract owners who only have changes made to their address information and not their health care contract information. Should a member have an address change and also health care information changes, all relevant address and health care data will be selected and written to the data file.

· Select records which have had a name, birth date or SSN change on and before the date of the current batch run from the end of the previous batch run. This will include records where be_prsn.fst_nm, be_prsn.last_nm, be_prsn.mid_nm, be_prsn.dsgtn.cd, be_prsn.sfx.cd, be_prsn.brth_dt or be_prsn.ss_nr has changed for any person owning a health care contract. Any name or SSN changes made to non-health care owners will not be selected. Additionally, only name and SSN information will be selected for health care contract owners and covered related individuals who only have changes made to their name, birth date and SSN and not their health care contract information. Should a member have a name, birth date or SSN change and also health care information changes, all relevant name, birth date, SSN and health care data will be selected and written to the data file.

Requested Job Stream (for file resubmission to vendors)

Rule 1: This data file must recapture and transmit all change instances of a health care plan based on specific input parameters. The parameters are as follows:

· Selection Criteria:

· Select records where the sent date equals the original run date entered by the user.

Data Population Rules:

Segment ISA

· This is a fixed length segment.

1. Authorization Information Qualifier

00 – No Authorization Information Present

2. Authorization Information

Fill with spaces. File is not reporting authorization information.

3. Security Information Qualifier

00 – No Security Information Present

4. Security Information

Fill with spaces. File is not reporting security information.

5. Interchange ID Qualifier

30 – U.S. Federal Tax Identification Number

6. Interchange Sender ID

Retirement System Tax ID number (be_org.tax_id_nr) with trailing spaces

7. Interchange ID Qualifier

30 – U.S. Federal Tax Identification Number

8. Interchange Receiver ID

Tax ID number of the receiver/health care vendor (be_org.tax_id_nr) with trailing spaces

9. Interchange Date

Denotes the date that the file is created and will always be the business date on which the job is run in YYMMDD format.

10. Interchange Time

Denotes the time that the file is created and will always be the time on the business date on which the job is run in HHMM format.

11. Interchange Control Standards Identifier

^ – U.S. EDI Community of ASC X12, TDCC, and UCS

12. Interchange Control Version Number

00501 – Draft Standards for Trial Use Approved for Publication by ASC X12 Procedures Review Board through October 1997

13. Interchange Control Number

Unique system-defined number given to each file. This number will start with ‘000000001’ and increase by an increment of 1 for each respective file produced.

14. Acknowledgement Requested

0 – No Acknowledgement Requested

15. Usage Indicator

Indicates whether the file produced is a test file or a real production submission (be_834_file_typ.file_typ_cd)

P – Production Data T – Test Data

16. Component Element Separator

: - Component element separator (if needed)

Segment GS

17. Functional Identifier Code

BE – Benefit Enrollment and Maintenance (834)

18. Application Sender’s Code

Retirement System Tax ID number (be_org.tax_id_nr)

19. Application Receiver’s Code

Tax ID number of the receiver/health care vendor (be_org.tax_id_nr)

20. Date

Denotes the date that the file is created and will always be the business date on which the job is run in CCYYMMDD format.

21. Time

Denotes the time that the file is created and will always be the time on the business date on which the job is run in HHMM format.

22. Group Control Number

Unique system-defined number given to each group. This number will start with ‘000000001’ and increase by an increment of 1 for each respective group submitted in a file.

23. Responsible Agency Code

X – Accredited Standards Committee X12

24. Version/Release/Identifier Code

005010X220A1 – Draft Standards Approved for Publication by ASC X12 Procedures Review Board through October 1997, as published in this implementation guide.

Implementation guide used – National Electronic Data Interchange Transaction Set Implementation Guide, Benefit Enrollment and Maintenance, 834, ASC X12N 834 (005010X2201) from the Washington Publishing Company August 2006.

Segment ST

25. Transaction Set ID Code

834 - Benefit Enrollment and Maintenance

26. Transaction Set Control Number

Unique system-defined number given to each record in the file and signifies the beginning of a transaction set with this control number. This number will start with ‘0001’ and increase by an increment of 1 for each respective vendor file produced.

27. Implementation Convention Reference 005010X220A1 – Draft Standards Approved for Publication by ASC X12 Procedures Review Board through October 1997, as published in this implementation guide.

Implementation guide used – National Electronic Data Interchange Transaction Set Implementation Guide, Benefit Enrollment and Maintenance, 834, ASC X12N 834 (005010X2201) from the Washington Publishing Company August 2006.

Segment BGN

28. Transaction Set Purpose Code

00-Original; Used only in the scheduled batch; Number will increase by 1 for each vendor file created 15-Re-Submission; Used only in the JS-Request Health Care Data File Resubmission; Number will increase by 1 for each vendor file created

29. Reference ID #

System generated number which denotes the beginning of a transaction set; Stored in tp_cntrct_prsn_enroll_dtls. This number will increase by 1 for each vendor file created. This number will start with ‘1’ and increase by an increment of 1 for each respective vendor file produced.

30. Date

Denotes the date that the file is created and will always be the business date on which the job is run in CCYYMMDD format.

31. Time

Denotes the time that the file is created and will always be the time on the business date on which the job is run in HHMM format.

32 Action Code

2 – Change; Denotes type of file 4 – Full File

Segment DTP

33. Date/Time Qualifer

007 – Effective

34. Date Time Period Format Qualifer

D8 – Date Expressed in Format CCYYMMDD

35. Date Time Period Format Qualifer

Date of file generation

Loop 1000A, Segment N1

36. Entity ID Code

P5 Plan Sponsor; Designates entity within the Sponsor segment

37. Name

Retirement System Name: ‘Michigan Office of Retirement Services’ (be_org.org_nm)

37. Identification Code Qualifier

FI – Federal Taxpayer’s ID number

38. Identification Code

Retirement System Tax ID number (be_org.tax_id_nr)

Loop 1000B, Segment N1

39. Entity Identifier Code

‘IN’ – Insurer

40. Name

Vendor name (be_org.org_nm)

41. Identification Code Qualifier

FI – Federal Taxpayer’s ID number

42. Identification Code

Vendor Tax ID number (be_org.tax_id_nr)

Loop 2000, Segment INS

43. Yes/No Condition Code

N = No; If member = non-subscriber, insert ‘N’ (where be_cntrct_prsn.hc_reln_typ_cd <> ‘SLF’) Y = Yes; If member = subscriber, insert ‘Y’ (where be_cntrct_prsn.hc_reln_typ_cd = ‘SLF’)

44. Individual Relationship

From be_prsn_reln.reln_typ_cd

01 Spouse – ‘SPOS’ (Spouse) 05 Grandson or Granddaughter – ‘GNDC’ (Grand Child) 07 Nephew or Niece – ‘NEPH’ (Nephew) or ‘NIEC’ (Niece) 09 Adopted Child – ‘ADCH’ (Adopted Child) 13 Mother-in-law or Father-in-law – ‘MILW’ (Mother-in-Law) or ‘FILW’ (Father-in-Law) 14 Brother or Sister – ‘BRO’ (Brother) or ‘SIS’ (Sister) 17 Stepson or Stepdaughter – ‘STCH’ (Step Child) 18 Self – ‘SLF’ (Self from be_hc_cntrct.hc_reln_typ_cd) 19 Child – ‘CHLD’ (Child) 32 Mother – ‘MTHR’ (Mother) 33 Father – ‘FTHR’ (Father)

45. Maintenance Type Code

001-Change; Use when changes to plan 021-Addition; Use when adding a new enrollment 024-Cancellation or Termination; Use when suspending a plan 025-Reinstatement; Use when activating a suspended plan 030-Audit or Compare (Full File)

Specific code to use will be determined by the maintenance reason code in the next field

46. Maintenance Reason Code

Map reason codes to the maintenance type codes (maintenance type codes in parenthesis):

Existing reason codes:

01-Divorce (024) 02-Birth (021) 03-Death (024) 05-Adoption (021) 07-Termination of Benefits (024) 10 – COBRA / Pays-us Premium Paid 11-Surviving Spouse ( 021) 18-Suspended (024) 25-Change in Identifying Data Elements (001); This code will be used for name changes and SSN changes;

28-Initial Enroll (021) 29-Benefit Selection (001) 32-Marriage (021) 41-Re-Enrollment (025) 43-Change of Location (001); This code will be used for name changes and SSN changes;

47. Benefit Status Code

A – Active; Select from be_hc_cntrct where end_dt = ‘2999-12-31 00:00:00.000’; All health care contract owners and their covered dependents will be listed as ‘Active’ if the owner is not deceased and reason code is not ‘Survivor Activation’.

C – COBRA; This value is set if be_cntrct_policy_elctn.cobra_in = 1 S – Surviving Insured; This value is set if the reason code is Survivor Activation and no death date is populated for the contract owner.

48. Medicare Plan Code

A – If Medicare Part A exists;

Select where be_cntrct_prsn.medicare_in = 1 and Part_ A_eff_dt is not null and Part_B _eff_dt is null;

B – If Medicare Part B exists;

Select where be_cntrct_prsn.medicare_in = 1 and Part_ B_eff_dt is not null and Part_A_eff_dt is null;

C – If Medicare Part A and B exists;

Select where be_cntrct_prsn.medicare_in = 1 and Part_A_eff_dt is not null and Part_B_eff_dt is not null;

E – No Medicare; Select where be_cntrct_prsn.medicare_in = 0

Determines if the member is a Medicare recipient

49. Employment Status Code

RT – Retired TE – Terminated; this code will be populated for all records that are terminated.

50. Student Status Code

F – Full-time (where be_cntrct_prsn.student_in = 1) N – Not a Student (where be_cntrct_prsn.student_in = 0)

Determines if the member is a student

51. Yes/No Condition Response Code

N = No Y = Yes

Determines if the member is disabled (be_cntrct_prsn.disabled_in)

52. Date Time Period Format Qualifier

· Populate only if Date of Death exists;

Constant – ‘D8’ (Date Expressed in Format CCYYMMDD)

53. Date Time Period

· Populate only if Date of Death exists;

Date of Death (CCYYMMDD) (be_prsn.deth_dt)

Loop 2000, Segment REF

54. Reference Identification Qualifier

0F – Subscriber Number

55. Reference Identification

Subscriber SSN (be_prsn.ss_nr)

Loop 2000, Segment REF

56. Reference Identification Qualifier

6O – Cross Reference SSN

57. Reference Identification

Cross Reference Owner’s SSN

Loop 2000, Segment REF

58. Reference Identification Qualifier

ZZ – Mutually Defined

59. Reference Identification

Combination of system (be_pln.pln_id), benefit structure type (be_bene_struc_ref. bene_struc_cli_cd) and retirement effective date (be_bene_acct.rtrmt_dt) concatenated

Ex) SERS, SERS DB Classified, 01/01/2004 would write to the file as ‘1&SDBC&20040801’; The Ampersand is the delimiter used to separate the three attributes.

Loop 2000, Segment REF

· Populate only if HIC number is available.

60. Reference Identification Qualifier

F6 – Medicare HIC number

61. Reference Identification

Medicare HIC number - (be_cntrct_prsn.HIB is not null)

Loop 2000, Segment DTP

62. Date/Time Qualifier

286 – Retirement

63. Date/Time Period Format Qualifier

D8 – Date Expressed in Format CCYYMMDD

64. Date Time Period

Retirement Effective Date (be_bene_acct.rtrmt_dt; CCYYMMDD)

65. Date/Time Qualifier

356 – Reason date

66. Date/Time Period Format Qualifier

D8 – Date Expressed in Format CCYYMMDD

67. Date Time Period

Reason Date (be_cntrct_prsn.reason_dt; CCYYMMDD)

Loop 2000, Segment DTP

· Only if Benefit status Code = C (COBRA)

68. Date/Time Qualifier

340 – COBRA Begin

69. Date/Time Period Format Qualifier

D8 – Date Expressed in Format CCYYMMDD

70. Date Time Period

COBRA Start Date

Loop 2000, Segment DTP

· Only if Benefit status Code = C (COBRA)

71. Date/Time Qualifier

341 – COBRA End

72. Date/Time Period Format Qualifier

D8 – Date Expressed in Format CCYYMMDD

73. Date Time Period

COBRA End Date

· Only if Medicare plan code (field #45) is A or C

74. Date/Time Qualifier

338 – Medicare Begin

75. Date/Time Period Format Qualifier

D8 – Date Expressed in Format CCYYMMDD

76. Date Time Period

Populate with the Medicare A effective date (be_cntrct_prsn.part_a_eff_dt); (CCYYMMDD)

Loop 2000, Segment DTP

· Only if Medicare plan code (field #45) is B or C

77. Date/Time Qualifier

338 – Medicare Begin

78. Date/Time Period Format Qualifier

D8 – Date Expressed in Format CCYYMMDD

79. Date Time Period

Populate with the Medicare B effective date (be_cntrct_prsn.part_b_eff_dt); (CCYYMMDD)

Loop 2100A, Segment NM1

80. Entity Identifier Code

IL – Insured or Subscriber; Used when identifying information of a new health care policy owner 74 – Corrected Insured; Used in correcting the identifying information of a member who is already enrolled, including name and SSN changes

81. Entity Type Qualifier

1 – Person

82. Name Last or Organization Name

Member’s last name (be_prsn.last_nm)

83. Name First

Member’s first name (be_prsn.fst_nm)

84. Name Middle

Member’s middle name (be_prsn.mid_nm)

85. Name Prefix

Member’s name prefix (be_prsn.dsgtn_cd)

86. Name Suffix

Member’s name suffix (be_prsn.sfx_cd)

87. Identification Code Qualifier

34 – SSN

88. Identification Code

Member’s SSN (be_prsn.ss_nr)

Loop 2100A, Segment PER

· Populate only if a Home phone number is available for the subscriber

89. Contact Function Code

IP – Insured Party

90. Communication Number Qualifier

HP – Home Phone Number

91. Communication Number

The subscriber’s home phone number (be_tel.tel_nr)

92. Communication Number Qualifier

EM – Electronic Mail

93. Communication Number

The subscriber’s E-mail address Loop 2100A, Segment N3

· Populate Member’s Physical Address

94. Address Information

The member’s physical address line 1 (be_addr.addr_ln1_nm)

95. Address Information

The member’s physical address line 2;

Loop 2100A, Segment N4

· Populate member’s Physical Address

96. City Name The member’s physical address city of residence (be_addr.city_nm)

97. State or Province Code

The member’s physical address state or province code of residence (be_addr_st_cd or be_addr.frgn_prov_cd)

98. Postal Code

The member’s physical address postal code of residence (be_addr.zip_cd)

99. Country Code

The member’s physical address country of residence (be_addr.ctry_cd); The country code is required by 834 format guidelines to be a two character code derived from the ISO 3166 list of country codes. This list is found at:

http://www.iso.org/iso/en/prods-services/iso3166ma/02iso-3166-code-lists/list-en1.html

100. Location Qualifer

· Only populates when State or Province Code is equal to MI

CY – County

101. Location Identifier

Populates the MI County

Loop 2100A, Segment DMG

102. Date Time Period Format Qualifier

D8 – (Date Expressed in Format CCYYMMDD)

103. Date Time Period

Member’s (be_prsn.brth_dt) (Date Expressed in Format CCYYMMDD)

104. Gender Code

F – Female (select where be_prsn.sex_cd = ‘F’) M – Male (select where be_prsn.sex_cd = ‘M’) U – Unknown (select where be_prsn.sex_cd = ‘UKNW’ Loop 2100C, Segment NM1

105. Entity Identifer Code

31 – Postal Mailing Address

106. Entity Type Qualifer

1 – Person

107. Entity Identifer Code

31 – Postal Mailing Address

Loop 2100C, Segment N3

108. Address Information

Member Mailing Address Line 1

109. Address Information

Member Mailing Address Line 2

110. Address Information

Member Mailing Address Line 1

Loop 2100C, Segment N4

111. City Name The member’s Mailing address city

112. State or Province Code

The member’s mailing address state or province code

113. Postal Code

The member’s mailing address postal code of residence

114. Country Code

The member’s mailing address country of residence (be_addr.ctry_cd); The country code is required by 834 format guidelines to be a two character code derived from the ISO 3166 list of country codes. This list is found at:

Loop 2100G, Segment NM1

115. Entity Identifier Code

GD = Guardian

J6 = POA

LR = Conservator

116. Entity Type Qualifer

1 - Person

117. Name Last or Organization Name

Responsible Person Last Name or Organization name

Loop 2100G, Segment N3

118. Address Information

Responsible Person Address Line 1

119. Address Information

Responsible Person Address Line 2

Loop 2100G, Segment N4

120. City Name

The Responsible Person’s City

121. State or Province Code

The Responsible Person’s address state or province code

122. Postal Code

The Responsible Person’s postal code of residence

123. Country Code

The Responsible Person’s country of residence (be_addr.ctry_cd); The country code is required by 834 format guidelines to be a two character code derived from the ISO 3166 list of country codes. This list is found at:

Loop 2200, Segment DSB

· Populate only if the subscriber is a disability retiree

124. Disability Type Code

3 – Permanent or Total Disability (where be_cntrct_prsn.disabled_in = 1)

Loop 2200, Segment DTP

· Populate only if the subscriber is a disability retiree

125. Date/Time Qualifier

360 – Disability Begin

126. Date Time Period Format Qualifier

D8 – Date Expressed in Format CCYYMMDD

127. Date Time Period

Retirement Effective Date (CCYYMMDD)

Loop 2300, Segment HD

128. Maintenance Type Code

Similar to Loop 2000, Segment INS, Maintenance Type Code.

129. Insurance Line Code

The following values will be populated for different vendors DEN – Dental Vendors HLT – Health Vendors HMO – Health Maintenance Organization PDG- Prescription Drug VIS – Vision Vendors

130. Coverage Level Code

The following values will be populated based on the coverage level code EMP – Employee only ESP – Employee and Spouse ECH – Employee and Children FAM – This will be used in the case of Self, Spouse and Children coverage SPO – Spouse Only SPC – Spouse and Children E5D – Employee and one or more dependents – This will be used when parents are covered CHD – Children Only.

DEP – Dependent Only.

Loop 2300, Segment DTP

131. Date/Time Qualifier

303 – Maintenance effective date 348 – Benefit Begin. This denotes the effective date of the coverage. This code should always be send when adding coverage.

349 – Benefit End. This denotes the subscriber’s or dependent’s benefit end.

543 – Last Premium Paid Date

132. Date Time Period Format Qualifier

D8 – Date Expressed in Format CCYYMMDD

133. Date Time Period

Change Effective Date (CCYYMMDD)

Loop 2320,Segment COB To supply information on coordination of benefits

134. Payer Responsibility Sequence Number Code

This is the code identifying the insurance carrier’s level of responsibility for payment of a claim.

P – Primary S – Secondary T – Tertiary U – Unknown

For Medicare retiree this field will have ‘P’.

135. Reference Identification

Always supply the policy number when it is available. For Medicare retiree this field will have the HIB number.

136. Coordination of Benefits Code Code identifying whether there is coordination of benefits.

1 – Coordination of Benefits 5 – Unknown 6 – No Coordination of Benefits.

For Medicare Retiree this field will have 1.

Loop 2320 Segment REF – To specify the identifying information.

The REF segment will not be populated for the Medicare retiree or if the group number is empty.

137. Reference Identification Qualifier

6P – Group Number

138. Reference Identification Member Group or Policy Number

Loop 2320 Segment DTP - This segment will not be sent if the cob effective date is not available.

139. Date/Time Qualifier

344 – Coordination of Benefits Begin

140. Date Time Period Format Qualifier

D8 – Date Expressed in Format CCYYMMDD

141. Date Time Period

Coordination of benefits date.

Loop 2320Segment NM - To identify the party by type of organization, name and code.

142. EntityIdentifier Code

IN – Insurer

143. EntityType Qualifer

2 – Non-Person Entity

144. Name

Send the insurance company name.

For Medicare retiree, if the Medicare plan code is A or C this field will have the value ‘Medicare Part A’. If the Medicare plan code is B or C this field will have the value ‘Medicare Part B’.

Segment SE

145. Number of Included Segments

Calculated; Sum of all segments included in respective vendor file

146. Transaction Set Control Number

Unique system-defined number given to each record in the file and signifies the end of a transaction set with this control number. This number will start with ‘0001’ and increment by 1 for each respective vendor file produced.

Should be the same number as the Transaction Set Control Number listed in the Transaction Set Header segment (Data Element number 2 above).

Segment GE

147. Number of Transaction Sets Included

Count of the number of ST segments included in the file.

148. Group Control Number

Identical to the control number used in data element 22 (GS06)

Segment IEA

149. Number of Included Functional Groups

Count of the number of GS segments included in the file.

150. Interchange Control Number

Identical to the control number used in data element 13 (ISA13)