Schedule I HIPAA 834 File Layouts.pdf

SCHEDULE I –HIPAA 834 FILE LAYOUTS

RFP No. 260000002410

Select the links below to view each document:

MCSC 834 File Layout

MCSC 834 File User Guide

ORS 834 File Layout

ORS 834 File User Guide

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Gray shading indicates areas not used by the State of Michigan

834 Transaction Set

Electronic Data Interchange File

Name Size Comments Where to get the data Control Header A 3 ### Fixed = “###”

Transaction Set

Identifier Code

A 3 834 = Benefit Enrollment and

Maintenance

Fixed = “834”

Insurer Identification

Code

A 30 Insurance Carrier’s Federal

Taxpayer’s Identification Number

BCR-CARRIER-ID from BNCARRIER where

BCR-INS-CARRIER = PRM-Insurer

Region Indicator A 1 Region Indicator “P” If PRODUCT-LINE = “PROD”

“T” If PRODUCT-LINE NOT= “PROD”

Job Name A 10 Job Name CRT-JOB-NAME

Insurer Name

A 30 Insurance Carrier Name BCR-NAME from BNCARRIER where

BCR-INS-CARRIER = PRM-Insurer

~ Segment length = 77 ###xxxxxxxxxxxx PZB206xxx INS

CARRIER NAME

Transaction Set

Header

A 2 ST Fixed = “ST”

Transaction Set

Identifier Code

N 3 834 = Benefit Enrollment and

Maintenance

Fixed = “834”

Transaction Set

Control Number

N 4 Increment beginning with “0001”

Must be a unique number within the set of transactions.

Fixed = “0001”

Implementation

Convention

Reference

N 35 Reference assigned to identify

Implementation Convention

Fixed = “005010X220A1”

~ Segment length = 9 ST8340001

Beginning Segment A 3 BGN Fixed = “BGN”

Transaction Set

Purpose Code

N 2 “00” = Original transaction; used the first time the transaction is sent.

“15” = Re-Submission; used if the first transaction sent has yet to be processed but contains errors, and you are sending a corrected transaction.

“22” = Informational; used when the original transaction was lost or never processed, and you are passing another transaction identical to the original.

Parameter: Rerun

“00” if Rerun Flag = 1 (No).

“15” if Rerun Flag = 2 (Yes, changed file)

“22” if Rerun Flag = 3 (Yes, duplicate file)

Transaction Set

Identifier Code

(Reference

Identification)

A 30 Assign (incrementally) this identifier for future reference to this set.

Consists of three fields to make it unique: Job Name plus

System Date plus Parameter: Identifying Code

(Required)

Transaction Set

Creation Date

(Date)

N 8 Current system date

(CCYYMMDD)

System Date

Transaction Set

Creation Time

(Time)

N 6 Current system time (HHMMSS) System Time

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Time Zone Code

(Time Code)

A 2 “CD” = Central Daylight Time

“CS” = Central Standard Time

“ED” = Eastern Daylight Time

“ES” = Eastern Standard Time

“MD” = Mountain Daylight Time

“MS” = Mountain Standard Time

“PD” = Pacific Daylight Time

“PS” = Pacific Standard Time

**Internal Note: Additional options available**

Parameter: Time Zone.

(May be left blank)

For SOM, only ES and ED codes are used.

Transaction Set

Identifier Code

(Reference

Identification)

A 30 If Transaction Set Purpose Code =

“15” or “22”, then this identifier should be used to cross-reference the original transaction set.

Consists of three fields to make it unique: Job Name plus

System Date plus Parameter: Prior Identifying Code.

(Required if Rerun Flag = 2 or 3, else will be left blank.)

Action Code N 1 “2” = Change (Update), used to identify a set of adds/changes/terms.

“4” = Verify, used to identify full enrollment information to ensure synchronization of sponsor’s and payer’s systems.

“RX” = Replace, Used to identify a full enrollment transmission to be used to identify additions, terminations and changes that need to be applied to the payer’s enrollment system.

Parameter: Transaction Purpose.

“2” if Trans Purpose = 1

“4” if Trans Purpose = 2

“RX” if Trans Purpose = 3

~ Segment length = 82 BGN00ZB206xxx

2003070700000000000120030707093215ES 2

OR

BGN15ZB206xxx

2003070800000000000120030508103502ESZB206xxx

200307070000000000012

Transaction Set

Policy Number

A 3 REF Parameter: Use Master Policy Number

“REF”, if Yes

Else, do not include this segment.

Reference

Identification

Qualifier

N 2 “38” = Master Policy Number Parameter: Use Master Policy Number

“38”, if Yes.

Master Policy

Number

(Reference

Identification)

A 30 BCR-CONTRACT-NMB

from BNCARRIER: where BCR-INS-CARRIER = PRM-

INS-CARRIER

~ Segment length = 35 REF38PA8382983

File Effective Date A 3 DTP Parameter: File Effective Date

“DTP”, if not spaces (zeroes)

Else, leave blank.

This segment is generated only for ‘Verify’ option.

Date/Time Qualifier N 3 “007” = Effective

Parameter: File Effective Date

“007”, if parameter not = spaces (zeroes)

Else, leave blank.

Date/Time Period

Format Qualifier

A 2 “D8” = Format CCYYMMDD Parameter: File Effective Date

If not spaces (zeroes), use “D8”

Else, leave blank.

Date/Time Period N 8 Date, Time, or Date and Time. May also include ranges of Dates and/or

Parameter: File Effective Date

(Convert to 8-digit date format: CCYYMMDD)

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Times.

~ Segment length = 16 DTP007D820030101~

Sponsor Name A 2 N1 Fixed = “N1”

Entity Identifier

Code

A 2 “P5” = Plan Sponsor Fixed = “P5”

Plan Sponsor Name

(Name)

A 30 Used at the sender’s discretion

(Company name)

PRS-NAME for the Company

(PRS-COMPANY = PRM-COMPANY and

PRS-PROCESS-LEVEL = spaces).

Identification Code

Qualifier

A 2 “FI” = Federal Taxpayer’s

Identification Number (adopted as the HIPAA standard).

Fixed = “FI”

Sponsor Identifier

(Identification Code)

A 30 **Must provide a key to the table of plan sponsor’s maintained by the transaction processing party. This is the most efficient method of providing organizational identification.

PLN-SPONSOR-ID from PLAN where

PLN-COMPANY = PRM-COMPANY and

PLN-PLAN-TYPE = PRM-PLAN-TYPE(1).and

PLAN-PLAN-CODE = PRM-PLAN-CODE(1)

~ Segment length = 66 N1P5Lawson Software FI93-2191827

Payer A 2 N1 Fixed = “N1”

Entity Identifier

Code

A 2 “IN” = Insurer Fixed = “IN”

Insurer Name

(Name)

A 30 Used at the sender’s discretion

(Insurance Carrier Name)

BCR-NAME from BNCARRIER where

BCR-INS-CARRIER = PRM-Insurer

Identification Code

Qualifier

A 2 “FI” = Federal Taxpayer’s

Identification Number (to be used until the HIPAA standard identifier is adopted)

“XV” = Health Care Financing

Administration National Plan ID

(required if mandated for use)

BCR-HIPAA-ID-TYPE from BNCARRIER where

BCR-INS-CARRIER = PRM-INS-CARRIER

Insurer Identification

(Identification Code)

A 30 **Must provide a key to the table maintained by the transaction processing party. This is the most efficient method of providing organizational identification.

If preceding field is populated (FI or XV), then get BCR-CARRIER-ID from BNCARRIER where

BCR-INS-CARRIER = PRM-Insurer

~ Segment length = 66 N1INHealthPartners FI28-374857

Broker/TPA A 2 N1 Parameter: Broker or TPA

If not = spaces, use “N1”

Else, leave blank.

SOM does not use Broker/TPA. This segment will not be generated for both ‘Change’ and ‘Verify’ options.

Entity Identifier

Code

A 2 “BO” = Broker

“TV” = Third Party Administrator

BCR-ENTITY-TYPE from BNCARRIER where

BCR-INS-CARRIER = PRM-INS-CARRIER

• If 2, then “BO”

• If 3, then “TV”

• If 1, spaces, or record not found, leave blank.

Broker/TPA Name

(Name)

A 30 Used at the sender’s discretion

(Insurance Carrier Name)

Parameter: Broker or TPA

If not = spaces, get BCR-NAME from BNCARRIER where BCR-INS-CARRIER = PRM-Broker or TPA.

Else, leave blank.

Identification Code

Qualifier

A 2 “FI” = Federal Taxpayer’s

Identification Number (to be used

BCR-HIPAA-ID-TYPE from BNCARRIER where

BCR-INS-CARRIER = PRM-BROKER or TPA

• If 1, then “FI”

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“XV” = Health Care Financing

Administration National Plan ID

(required if mandated for use)

• If 2, then “XV”

• If 3, spaces, or not found, then leave blank.

ERROR: Valid Broker or TPA ID number not found.

Insurer Identification

Code

(Identification Code)

A 30 **Must provide a key to the table maintained by the transaction processing party. This is the most efficient method of providing organizational identification.

If preceding field is populated (FI or XV), then get BCR-

CARRIER-ID, where BCR-INS-CARRIER = PRM-

Broker or TPA.

~ Segment length = 66 N1TVMidwest Administrators FI28-374857

TPA/Broker

Account

Information

A 3 ACT Parameter: Broker or TPA

If not = spaces, use “ACT”

Else, leave blank.

SOM does not use Broker/TPA. This segment will not be generated for both ‘Change’ and ‘Verify’ options.

TPA or Broker

Account Number

(Account Number)

A 30 Account number

(Contract Number from BN01)

Parameter: Broker or TPA

If not = spaces, get BCR-CONTRACT-NMBR from

BNCARRIER where BCR-INS-CARRIER = PRM-

BROKER or TPA.

If spaces or not found, leave blank.

~ Segment length = 33 ACT2384297382

***SEGMENTS THAT FOLLOW ARE BASED ON BNTRANS RECORDS FOUND IN BNTRANS,

OR ON BENEFIT, PARTBEN, AND HRDEPBEN RECORDS***

-------Segments must repeat for each member (Employee, Retiree, COBRA Participant, and Dependent) found to a maximum of 10,000 members. The enrollment data for families must not be split into two transaction sets.------

Member Level

Detail

A 3 INS Fixed = “INS”

Insured Indicator

(Subscriber

Indicator)

A 1 “Y” = Yes; used for subscriber

(employee)

“N” = No; used for dependent

Tran Purpose = 1 (Update)

“Y” if BNT-DEPENDENT on BNTRANS record is blank.

Else, “N”

Tran Purpose = 2 (Validate)

“Y” for BENEFIT and

PARTBEN records

“N” for HRDEPBEN records.

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Individual

Relationship Code

N 2 “01” = Spouse

“03” = Parent

“04” = Grandparent

“05” = Grandchild

“06” = Uncle or Aunt

“07” = Nephew or Niece

“08” = Cousin

“09” = Adopted Child

“10” = Foster Child

“11” = Son/Daughter-in-law

“12” = Brother/Sister-in-law

“13” = Mother/Father-in-law

“14” = Brother or Sister

“15” = Ward

“16” = Stepparent

“17” = Stepchild

“18” = Self

“19” = Child

“23” = Sponsored Dependent

“24” = Dependent of a Minor Dep

“25” = Ex-Spouse

“26” = Guardian

“31” = Court Appointed Guardian

“38” = Collateral Dependent

(relative related by blood or marriage who resides in the home and is dependent on the insured for a major portion of their support)

“48” = Stepfather

“49” = Stepmother

“53” = Life Partner

“60” = Annuitant

“D2” = Trustee

“G8” = Other Relationship

“G9” = Other Relative

If prior field = “Y”, then use “18”.

If prior field = “N”, get EMD-REL-CODE for the dependent on the record in question.

Then get PCO-HIPAA-REL-CODE from PCODES where PCO-TYPE = ‘DP’ and

PCO-CODE = EMD-REL-CODE

Maintenance Type

N 3 “001” = Change

“021” = Addition

“024” = Cancellation or

Termination

“030” = Audit or Compare

Tran Purpose = 1 (Update):

From BNTRANS record get

BNT-TRAN-ACTION

• “001” if = C

• “021” if = A

• “024” if = S or D

Tran Purpose = 2 (Verify):

Fixed = “030”

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Maintenance Reason

Code

A 2 “01” = Divorce

“02” = Birth

“03” = Death

“04” = Retirement

“05” = Adoption

“06” = Strike

“07” = Termination of Benefits

“08” = Termination of Employment

“09” = COBRA

“10” = COBRA Premium Paid

“11” = Surviving Spouse

“14” = Voluntary Withdrawal

“16” = Quit

“17” = Fired

“18” = Suspended

“20” = Active

“21” = Disability

“22” = Plan Change

“25” = Chg in Identifying Data

Elements

“26” = Declined Coverage

“27” = Pre-Enrollment (used for expected newborns)

“28” = Initial Enrollment

“29” = Benefit Selection (for changing benefits within a plan)

“31” = Legal Separation

“32” = Marriage

“33” = Personnel Data

“37” = Leave of Absence with

Benefits

“38” = Leave of Absence without

Benefits

“39” = Layoff with Benefits

“40” = Layoff without Benefits

“41” = Re-enrollment

“43” = Change of Location

“59” = Non Payment

“AA” = Dissatisfied with Off staff

“AB” = Dissatisfied with Services

“AC” = Inconvenient Office loc

“AD” = Dissatisfied w Office Hrs

“AE” = Unable to schedule appts

“AF” = Dissatisfied w Ref Policy

“AG” = Less Respect and Attention

“AH” = Patient moved to a new loc

“AI” = No reason given

“AJ” = Appt Times not met

“AL” = Assigned benefit selection

“EC” = Member benefit selection

“XN” = Notification only (used for audit transactions)

“XT” = Transfer

Tran Purpose = 1 (Update):

From BNTRANS record, get

BNT-TRAN-REASON.

If spaces, use “AI”.

If BNT-COVER-TYPE =

“C” (COV-TYPE, COBRA

Participant) use “09”

Fixed = “XN”

Benefit Status Code A 1 “A” = Active

“C” = COBRA

Tran Purpose = 1 (Update):

“C” if BNT-COVER-TYPE on BNTRANS record is “C”

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Else, “A” “C” for PARTBEN records where Participant not = spaces, Else, “A”

Medicare Plan Code A1 “A” = Medicare Part A

“B” = Medicare Part B

“C” = Medicare Part A and B

“D” = Medicare

“E” = No Medicare

COBRA Qualifying

Event Code

N 1 “1” = Termination of Employment

“2” = Reduction of work hours

“3” = Medicare

“4” = Death

“5” = Divorce

“6” = Separation

“7” = Ineligible Child

“8” = Bankruptcy of a Retired

Employee Former Employer

“9” = Layoff

“10” = Leave of Absence

ZZ = Mutually Defined

BNT-EVENT-CODE

If spaces, or record not found, ERROR: COBRA event / not identified. (Insert PAR-

OCCUR-TYPE.)}

Employment Status

Code

A 2 “AO” = Active Military – Overseas

“AU” = Active Military – USA

“FT” = Full-time (Full-time Active)

“L1” = Leave of Absence

“PT” = Part-time (Part-time Active)

“RT” = Retired

“TE” = Terminated

From BNT-COVER-TYPE determine the Employment

Status Code.

If Coverage Type = “A”, Employment Status Code =“FT”

If Coverage Type = “R”, Employment Status Code = “RT”

If Coverage Type = “C”, Employment Status Code = “L1”

Student Status Code A 1 “F” = Full-time

“N” = Not a student

Parameter: Student Status

If Y, and this is a non-spouse Dependent get student flag from EMDEPEND:

“F”, if EMD-STUDENT = Y or F or P

“N” if EMD-STUDENT = N

Else, leave blank.

Handicap Indicator A 1 “N” = No

“Y” = Yes

Parameter: Disabled Status

If Y, and this is a Dependent (BNT-DEPENDENT or

HRDEPBEN record) get disabled flag from EMDEPEND.

Else, leave blank.

Date Time Period

Format Qualifier

A 2 “D8” = Date expressed as

CCYYMMDD

Tran Purpose = 1 (Update):

If BNTRANS, BNT-TRAN-

REASON = 03 (Death), use

“D8”, else leave blank.

Tran Purpose = 2 (Verify):

Leave this field and following field blank.

Insured Individual

Death Date

N 8 Holds the date of death of the insured or dependent (Does not replace the use of a termination date)

If BNTRANS, BNT-TRAN-REASON = 03 (Death), then from EMPLOYEE USE EMP-DEATH-DATE

If spaces, ERROR: Date of death for Emp / not identified.

(Insert EE Number.)

Birth Sequence

Number

N 4 Required in the event you are reporting more than one family member with the same birth date.

If this is a Dependent (BNT-DEPENDENT > zeroes or

HRDEPBEN record) whom has the same birthdate as another family member dependent, get EMD-SEQ-NBR.

~ Segment length = 32 INSY1802128A 0FT 000000000000

OR

INSN0102128A 0 FN000000000001

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Subscriber Number A 3 REF Fixed = “REF”

Reference

Identification

Qualifier

A 2 “0F” = Subscriber Number Fixed = “0F” (Zero – F)

Subscriber Identifier

(Reference

Identification)

A 15 Information defined for the transaction set.

Tran Purpose = 1 (Update):

From BNTRANS, get

BNT—MEMBER-ID value:

If 1, get:

EMP-FICA-NBR for EE

(and their dependents), PAR-FICA-NBR for

COBRA participants (and their dependents). The SSN should not contain hyphens in the output.

If 2, then get EMP-

EMPLOYEE for EE (and their dependents), PAR-

PARTICIPNT for COBRA

Participants and their dependents.

We will assume Member ID

= Social Number.

Get:

EMP-FICA-NBR for EE

(and their dependents), PAR-FICA-NBR for

COBRA participants (and their dependents). The SSN should not contain hyphens in the output.

~ Segment length = 20 REF0F384928394

Member Policy

Number

A 3 REF Fixed = “REF”

Reference

Identification

Qualifier

A 2 “1L” = Group or Policy Number Fixed = “1L”

Subscriber Identifier

(Reference

Identification)

A 30 Insured Group or Policy Number PLN-CONTRACT-NMBR

~ Segment length = 35 REF1L238233849498237

Member

Identification

Number

A 3 REF Fixed = “REF”

Reference

Identification

Qualifier

A 2 “DX” = Department/Agency

Number

“23” = Client Number

Fixed = “DX”

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Subscriber Identifier

(Reference

Identification)

A 30 For “DX” - Consists of 6 fields separated by spaces: Process Level, Bargaining Unit, Plan Code, Coverage Option, Occurrence Type and Original FICA Number

For “23” – Consists of Employee

Number as alternative identifier

“DX” - Process Level = EMP-PROCESS-LEVEL

Bargaining Unit = EMP-UNION-CODE

Plan Code = BEN-PLAN-CODE

(Active Employee) or

PRT-PLAN-CODE

(COBRA or DC Retiree)

Coverage Option = BEN-COV-OPTION

(Active Employee) or

PTB-COV-OPTION

(COBRA and DC Retiree)

Occurrence Type = PAR-OCCUR-TYPE

(COBRA only)

Original FICA Number = EMP-FICA-NBR from original Employee’s record

This segment is provided for both Subscribers and Dependents.

“23” – For Employees use

Employee Number = EMP-EMPLOYEE

For Participants use

Employee Number = PAR-EMPLOYEE

The segment will be generated for both

Verify and Update options for

Subscriber only, not dependents

~ Segment length = 35 REFDX7501 A31 HAEX

Prior Coverage

Months

A 3 REF Parameter: Prior Months Coverage

“REF” if Y

Else, do not include this segment.

SOM does not capture prior month’s coverage. This segment will not be generated for both ‘Change’ and

‘Verify’ options.

Reference

Identification

Qualifier

A 2 “QQ” = Unit Number Parameter: Prior Months Coverage

If Y, then “QQ”

Prior Coverage

Month Count

(Reference

Identification)

N 2 Identify the number of prior month’s insurance coverage that may apply under the portability provisions of

HIPAA; to be sent on new enrollments when available.

PEM-PRIOR-COV-MO

~ Segment length = 7 REFQQ18

Member Level

Dates

A 3 DTP Tran Purpose = 1 (Update):

Fixed = “DTP”

Tran Purpose = 2 (Verify):

Leave blank

See comments below.

Date/Time Qualifier N 3 “303” = Maintenance Effective

“356” = Eligibility Begin

“357” = Eligibility End

“301” = COBRA Qualifying Event

“340” = COBRA Begin

“341” = COBRA End

Do the following for Update files:

From BNTRANS record get BNT-START-DATE

For Employees, use BENSET and if a record is found with stop date 1 day less than BNTRANS BNT-EFFECT-

DATE this will be treated as a “Change”.

For FC = C, or A with prior benefit, use “303”

Date/Time Period

Format Qualifier

A 2 “D8” = Format CCYYMMDD Tran Purpose = 1 (Update):

Fixed = “D8”

Tran Purpose = 2 (Verify):

Leave blank.

Status Information

Effective Date

N 8 Date, Time, or Date and Time. May also include ranges of Dates and/or

Tran Purpose = 1 (Update):

Use BNT-EFFECT-DATE

Leave blank.

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(Date/Time Period) Times. on the BNTRANS record.

(CCYYMMDD)

~ Segment length = 16 DTP303D820090301

Member Level

Dates

A 3 DTP Tran Purpose = 1 (Update):

Fixed = “DTP”

Tran Purpose = 2 (Verify):

Fixed = “DTP”

Date/Time Qualifier N 3 “356” = Eligibility Begin

Do the following for Update and Verify files:

From EMPLOYEE record get EMP-DATE-HIRED

A 2 “D8” = Format CCYYMMDD Tran Purpose = 1 (Update):

Fixed = “D8”

Tran Purpose = 2 (Verify):

“D8”

Status Information

Effective Date

(Date/Time Period)

N 8 Date, Time, or Date and Time. May also include ranges of Dates and/or

Times.

Tran Purpose = 1 (Update):

Use EMP-DATE-HIRED on the EPLOYEE record.

(CCYYMMDD)

Tran Purpose = 2 (Verify):

Use EMP-DATE-HIRED on the EPLOYEE record.

(CCYYMMDD)

~ Segment length = 16 DTP356D820020301

Member Name A 3 NM1 Fixed = “NM1”

Entity Code

Identifier

A 2 “IL” = Insured or Subscriber Fixed = “IL”

Entity Type Qualifier N 1 “1” = Person Fixed = “1”

Subscriber Last

Name

(Name Last)

A 30 Individual last name EMP-LAST-NAME for Employees, Retirees

EMD-LAST-NAME for Dependents

PAR-LAST-NAME for COBRA participants

Subscriber First

Name

(Name First)

A 15 Individual first name EMP-FIRST-NAME for Employees, Retirees

EMD-FIRST-NAME for Dependents

PAR-FIRST-NAME for COBRA participants

Subscriber Middle

Name

(Name Middle)

A 15 Individual middle name EMP-MIDDLE-NAME for Employees, Retirees

EMD-MIDDLE-INIT for Dependents

PAR-MIDDLE-INIT for COBRA participants

Subscriber Name

Prefix

(Name Prefix)

A 10 Prefix to individual name EMP-LAST-NAME-PRE for Employees, Retirees

EMD-LAST-NAME-PRE for Dependents

(N/A for COBRA Participants)

Subscriber Name

Suffix

(Name Suffix)

A 4 Suffix to individual name EMP-NAME-SUFFIX for Employees, Retirees

EMD-NAME-SUFFIX for Dependents

(N/A for COBRA Participants)

Identification Code

Qualifier

A 2 “34” = Social Security Number

“ZZ” = Mutually defined (required if the National Individual identifier is mandated)

From BNTRANS record, get BNT-MEMBER-ID:

If 1 or 2, then “34”

Subscriber Identifier

(Identification Code)

A 15 SSN when available and allowed;

until the HIPAA individual identifier is available.

If prior field = 34, then get EMP-FICA-NBR for EE, EMD-FICA-NUMBER for Dependents, and PAR-FICA-

NBR for COBRA participants. The SSN should not contain hyphens in the output. If prior field = ZZ, then get

EMP-EMPLOYEE for EE, EMD-EMPLOYEE and EMD-

SEQ-NBR for Dependents, and PAR-PARTICIPNT for

COBRA Participants.

If prior field blank, leave blank.

~ Segment length = 97 NM1IL1Smith John Paul

34123456789

Member

Communications

Numbers

A 3 PER Parameter: Emp Contact Numbers:

“PER”, if not = spaces.

Else, do not include this segment.

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SOM does not have contact numbers for all members. This segment will not be generated for both ‘Change’ and

‘Verify’ options.

Contact Function

Code

A 2 “IP” = Insured Party Fixed = “IP”

Communication

Number Qualifier

A 2 “EM” = Electronic Mail

“EX” = Telephone Extension

“FX” = Facsimile

“HP” = Home Phone Number

“TE” = Telephone

“WE” = Work Phone Number

Parameter: Emp Contact Numbers:

If 1 or 3, then “HP”

If 2, then “WE”

Communication

Number

A 20 Complete communications number including country or area code when applicable.

Parameter: Emp Contact Numbers:

If 1 or 3, use PEM-HM-PHONE-NBR

If 2, use PEM-WK-PHONE-NBR PEM followed by WK-

PHONE-EXT.

Communication

Number Qualifier

A 2 “EM” = Electronic Mail

“EX” = Telephone Extension

“FX” = Facsimile

“HP” = Home Phone Number

“TE” = Telephone

“WE” = Work Phone Number

Parameter: Emp Contact Numbers:

If 3, then “WE”

Else, leave spaces.

Communication

Number

A 21 Complete communications number including country or area code when applicable.

Parameter: Emp Contact Numbers:

If 3, then PEM-WK-PHONE-NBR followed by PEM-WK-

PHONE-EXT.

Else, leave spaces.

~ Segment length = 50 PERIPHP6517374657 WE651767400046311

Member Residence

Street Address

A 2 N3 Parameter: Resident Address

“N3”, if not spaces.

Else, leave all fields in segment spaces.

Subscriber Address

Line

(Address

Information)

A 30 Address Line 1 Parameter: Resident Address

For EMPLOYEES/RETIREES:

If 1, use EMP-ADDR1

If 2, use PEM-SUPP-ADDR1

For PARTICIPANTS:

Use PAR-ADDR1

For DEPENDENTS:

Use EMD-ADDR1. If spaces, follow what is used for

Employee.

Subscriber Address

Line

(Address

Information)

A 30 Address Line 2 Parameter: Resident Address

For EMPLOYEES/RETIREES:

If 1, use EMP-ADDR2

If 2, use PEM-SUPP-ADDR2

For PARTICIPANTS:

Use PAR-ADDR2

For DEPENDENTS:

Use EMD-ADDR2. If spaces, follow what is used for

Employee.

~ Segment length = 62 N31410 E 18th Street Apt 5

Member Residence

City, State, Zip

Code

A 2 N4 Parameter: Resident Address

“N4”, if not spaces.

Else, leave all fields in segment spaces.

Subscriber City

Name

(City Name)

A 18 City Parameter: Resident Address

For EMPLOYEES/RETIREES:

If 1, use EMP-CITY

If 2, use PEM-SUPP-CITY

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For PARTICIPANTS:

Use PAR-CITY

For DEPENDENTS:

Use EMD-CITY. If spaces, follow what is used for

Employee.

Subscriber State

Code

(State or Province

Code)

A 2 Valid state or province code as defined by government authority.

Parameter: Resident Address

If 1, use EMP-STATE

If 2, use PEM-SUPP-STATE

For DEPENDENTS:

Use EMD-STATE. If spaces, follow what is used for

Employee.

Subscriber Postal

Zone or ZIP Code

(Postal Code)

A 10 Postal Code Parameter: Resident Address

If 1, use EMP-ZIP

If 2, use PEM-SUPP-ZIP

For DEPENDENTS:

Use EMD-ZIP. If spaces, follow what is used for

Employee.

Country Code A 2 Valid country code Parameter: Resident Address

Only use if value is not “US”

If 1, use EMP-COUNTRY-CODE

If 2, use PEM-SUPP-CNTRY-CD

For DEPENDENTS:

Use EMD-COUNTRY-CODE. If spaces, follow what is used for Employee.

~ Segment length = 34 N4Minneapolis MN55457 US

Member

Demographics

A 3 DMG Fixed = “DMG”

Date Time Period

Format Qualifier

A 2 “D8” = Format CCYYMMDD Fixed = “D8”

Member Birth Date

(Date Time Period)

N 8 Date of Birth Get PEM-BIRTHDATE (Employee, Retiree), EMD-

BIRTHDATE (Dependent) or PAR-BIRTHDATE

(COBRA).

Gender Code A 1 “F” = Female

“M” = Male

“U” = Unknown (should only be used when the gender cannot be obtained)

Check PEM-SEX (Employee, Retiree), EMD-SEX

(Dependent), or PAR-SEX (COBRA):

F = “F”

M = “M”

Blank = “U”

Marital Status Code A 1 “B” = Registered Domestic Partner

“D” = Divorced

“I” = Single

“M” = Married

“R” = Unreported

“S” = Separated

“U” = Unmarried (single, divorced, or widowed; used if previous status is unknown)

“W” = Widowed

“X” = Legally Separated

Parameter: Marital Status

If Yes, check PEM-TRUE-MAR-STAT (Employees and

Retirees ONLY):

D = “D”

S = “I”

M = “M”

S = “S”

U = “U”

W = “W”

L = “X”

O = “R”

P = “B”

C = “M”

Note: Blank, if (BNT-DEPENDENT = spaces, or

HRDEPBEN record.) or COBRA.

~ Segment length = 15 DMGD819650512FS

Member Health

Information

A 3 HLH Parameter: Smoker Status

“HLH”, if Yes

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Else, leave blank.

SOM does not capture smoker information. This segment will not be generated for both ‘Change’ and ‘Verify’ options.

Health-Related Code A 1 “N” = None

“S” = Substance Abuse

“T” = Tobacco Use

“U” = Unknown

“X” = Tobacco Use and Substance

Abuse

Parameter: Smoker Status

If Yes, Get PEM-SMOKER (Employee, Retiree), EMD-

SMOKER (Dependent), or PAR-SMOKER (COBRA):

use “T”, If Smoker = Y use “N”, If Smoker = N

Else use “U”

If parameter = No, leave blank.

~ Segment length = 4 HLHT

Member Mailing

Address

A 3 NM1 Parameter: Mailing Address use “NM1”

Entity Identifier

N 2 “31” = Postal Mailing Address Parameter: Mailing Address

Use “31”

Entity Type Qualifier N 1 “1” = Person Parameter: Mailing Address

Use “1”

~ Segment length = 6 NM1311

Member Mail Street

Address

A 2 N3 Parameter: Mailing Address

“N3”.

Only send Member Mail Street Address and Member Mail

City, State, Zip Code when different than Resident Mail

Street Address and Resident Mail City, State, Zip Code

Subscriber Address

Line

(Address

Information)

A 30 Address Line 1 Parameter: Mailing Address

For EMPLOYEES/RETIREES:

If 1, use EMP-ADDR1

If 2, use PEM-SUPP-ADDR1

For PARTICIPANTS:

Use PAR-ADDR1

For DEPENDENTS:

Use EMD-ADDR1. If spaces, follow what is used for

Employee.

Subscriber Address

Line

(Address

Information)

A 30 Address Line 2 Parameter: Mailing Address

For EMPLOYEES/RETIREES:

If 1, use EMP-ADDR2

If 2, use PEM-SUPP-ADDR2

For PARTICIPANTS:

Use PAR-ADDR2

For DEPENDENTS:

Use EMD-ADDR2. If spaces, follow what is used for

Employee.

~ Segment length = 62 N3P.O. Box 1234

Member Mail City, State, Zip Code

A 2 N4 Parameter: Mailing Address

Only send Member Mail Street Address and Member Mail

City, State, Zip Code when different than Resident Mail

Street Address and Resident Mail City, State, Zip Code

Subscriber City

Name

(City Name)

A 18 City Parameter: Mailing Address

For EMPLOYEES/RETIREES:

If 1, use EMP-CITY

If 2, use PEM-SUPP-CITY

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For PARTICIPANTS:

Use PAR-CITY

For DEPENDENTS:

Use EMD-CITY. If spaces, follow what is used for

Employee.

Subscriber State

Code

(State or Province

Code)

A 2 Valid state or province code as defined by government authority.

Parameter: Mailing Address

If 1, use EMP-STATE

If 2, use PEM-SUPP-STATE

For DEPENDENTS:

Use EMD-STATE. If spaces, follow what is used for

Employee.

Subscriber Postal

Zone or ZIP Code

(Postal Code)

A 10 Postal Code Parameter: Mailing Address

If 1, use EMP-ZIP

If 2, use PEM-SUPP-ZIP

For DEPENDENTS:

Use EMD-ZIP. If spaces, follow what is used for

Employee.

Country Code A 2 Valid country code Parameter: Mailing Address

Only use if not = “US’

If 1, use EMP-COUNTRY-CODE

If 2, use PEM-SUPP-CNTRY-CD

For DEPENDENTS:

Use EMD-COUNTRY-CODE. If spaces, follow what is used for Employee.

~ Segment length = 34 N4Minneapolis MN55457-1234US

Health Coverage A 2 HD Fixed = “HD”

Maintenance Type

Code

N 3 “001” = Change

“002” = Delete

“021” = Addition

“024” = Cancellation or

Termination

“030” = Audit or Compare

Tran Purpose = 1 (Update):

If 1, then value here is based on BNT-TRAN-ACTION.

• If FC = A, then “021”

• If FC = C, then “001”

• If FC = S, then “024”

• If FC = D, then 002”

Tran Purpose = 2 (Validate):

Fixed = “030”

Insurance Line Code A 3 “AG” = Preventative Care/Wellness

“AH” = 24 Hour Care

“AJ” = Medicare Risk

“AK” = Mental Health

“DCP” = Dental Capitation (for

DMO)

“DEN” = Dental

“EPO” = Exclusive Provider

Organization

“FAC” = Facility

“HE” = Hearing

“HLT” = Health (both Hospital and

Professional Care)

“HMO” = Health Maintenance

Organization

“LTC” = Long Term Care

“LTD” = Long Term Disability

“MM” = Major Medical

“MOD” = Mail Order Drug

“PDG” = Prescription Drug

“POS” = Point of Service

For Plan Type and Plan from PLAN, PLN-HIPAA-INS-CODE.

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“PPO” = Preferred Provider

Organization

“PRA” = Practitioners

“STD” = Short Term Disability

“UR” = Utilization Review

“VIS” = Vision

Plan Coverage

Description

A 30 Free form descriptive information PLN-DESC for the Plan Type, Plan on the PLAN record.

Coverage Level Code A 3 “ECH” = Employee and Children

“EMP” = Employee Only

“ESP” = Employee and Spouse

“FAM” = Family

Parameter: Include Coverage Options.

If Y, then use Cov-Dependents and Nbr-Dependents from

BNCOVOPT for the BEN-COV-OPTION (Employee) or

PTB-COV-OPTION (COBRA or Retiree) for the subscriber.

• If Cov-Dependents = N, use “EMP”

• If Cov-Dependents = S, use “ESP”

• If Cov-Dep = D or B, and Nbr-Dependents = 1, use “E1D”

• If Cov-Dep = D or B, and Nbr-Dependents = 2, use “E2D”

• If Cov-Dep = D or B, and Nbr-Dependents = 3, use “E3D”

• If Cov-Dep = D or B, and Nbr-Dependents > 3, use “FAM”

If N, leave blank.

If Coverage Option = 3, use “ECH”

***This element must be blank for dependents!!***

~ Segment length = 41 HD021HLTStandard Indemnity Health Plan EMP

Health Coverage

Dates

A 3 DTP Fixed = “DTP”

Date/Time Qualifier N 3 “303” = Maintenance Effective

“348” = Benefit Begin

“349” = Benefit End

“543” = Cobra Last Premium Paid

Date

Tran Purpose = 1 (Update):

From BNTRANS get BNT-

TRAN-ACTION:

If FC = A, use “348”

& 543 for Cobra Participant and DC Retiree

If FC=C, use “303” & “348”

& 543 for Cobra Participant and DC Retiree

If FC = S or D, use “349” & “303” & “348”

& 543 for Cobra Participant and DC Retiree

Fixed = “348”

& 543 for Cobra Participant and DC Retiree

A 2 “D8” = Format CCYYMMDD Fixed = “D8”

Coverage Period

(Date/Time Period)

N 8 Date, Time, or Date and Time. May also include ranges of Dates and/or

Times.

Tran Purpose = 1 (Update):

From BNTRANS get BNT-

EFFECT-DATE

(CCYYMMDD).

Tran Purpose = 2 (Verify):

Use the Start Date of the benefit record for all types.

~ Segment length = 16 DTP348D820020601

Health Coverage

Policy

A 3 AMT Parameter: Include Premium Amounts

If Y, use “AMT”

Else, leave blank.

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This segment will be generated only for Flexible Spending

Accounts (vendor = FBMC).

Amount Qualifier

Code

A 2 “B9” = Co-Insurance – Actual

“C1” = Co-Payment Amount

“D2” = Deductible Amount

“P3” = Premium Amount

Parameter: Include Premium Amounts

If Y, use “P3”

Else, leave blank.

Contract Amount

(Monetary Amount)

N 13 Amount Parameter: Include Premium Amount

If Y, use BEN-TOT-CONTRIB

Else, leave blank (zeroes).

~ Segment length = 18 AMTP300000000186.38

Identification Card A 3 IDC Parameter: Identification Cards Requested

If not = zero, use “IDC”

Else, leave blank.

This segment will not be generated for both ‘Change’ and

‘Verify’ options.

Plan Coverage

Description

N 1 (If not used, include a single zero) Fixed = “0”

Identification Card

Type Code

A 1 “D” = Dental Insurance

“H” = Health Insurance

“P” = Prescription Drug Service

Parameter: Identification Cards Requested

If not = zero, get Plan Type (Key3) from BNTRANS record.

If HL, use “H”

If DN, use “D”

Else, leave blank

Identification Card

Count

N 1 Send a value only if greater than 1. Parameter: Identification Cards Requested

If > 1, use the value entered

Else leave blank (zero).

~ Segment length = 5 IDCH2

Provider

Information

A 2 LX Parameter: Primary Care Provider.

If Y, use “LX”

If N, leave blank.

SOM does not capture provider information. This segment will not be generated for both ‘Change’ and ‘Verify’ options.

Assigned Number N 2 Automatically assigned number

(incremental).

Parameter: Primary Care Provider.

If Y, use = “01”

~ Segment length = 4 LX01

Provider Name A 3 NM1 Parameter: Primary Care Provider.

If Y, use “NM1”, and fill in segments that follow, Else leave blank.

SOM does not capture provider information. This segment will not be generated for both ‘Change’ and ‘Verify’ options.

Entity Identifier

Code

A 2 “3D” = Obstetrics and Gynecology

Facility

“OD” = Doctor of Optometry

“P3” = Primary Care Provider

“QA” = Pharmacy

“QN” = Dentist

“Y2” = Managed Care Organization

Parameter: Primary Care Provider.

If Y, use “P3”

Else leave blank

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Entity Type Qualifier N 1 “1” = Person

“2” = Non-Person Entity

Parameter: Primary Care Provider.

If Y, get PEM-PRIMARY-CARE, for EE, EMD-PRIMARY-CARE for Dependents, From HRUTILITY:

System = BN

Release = 7

Rel Level = 2

Key1 = HR80F9

Key2 = PC

Key3 = PEM-PRIMARY-CARE

If positions 32-61 in HUT-DATA are not = spaces, use

“1”.

Else, use “2”

If no record found, or parameter = N, leave blank (zero).

Provider Last or

Organization Name

(Name Last or

Organization Name)

A 30 Name only used when not able to provide the standard ID number

Parameter: Primary Care Provider

If Y, from HRUTILITY (record identified above), If field above = “1”, get positions 32-61.

If field type = “2”, get positions 78-107.

If field above is blank, or parameter = N, leave blank.

Provider First Name

(Name First)

A 15 Name only used when not able to provide the standard ID number

Parameter: Primary Care Provider

If Y, from HRUTILITY (record identified above), If field above = “1”, get positions 62-76.

Else, leave blank.

Provider Middle

Name

(Name Middle)

A 1 Name only used when not able to provide the standard ID number

Parameter: Primary Care Provider

If Y, from HRUTILITY (record identified above), If field above = “1”, get positions 77.

Else, leave blank.

Identification Code

Qualifier

A 2 “34” = Social Security Number

“FI” = Federal Taxpayer’s

Identification Number

“XX” = Health Care Financing

Administration National Provider

Identifier (required if mandated for use)

Parameter: Primary Care Provider

If Y, from HRUTILITY (record identified above), Get position 31.

If 1, then use “34”

If 2, then use “FI”

Else, leave blank

Provider Identifier

(Identification Code)

A 30 Parameter: Primary Care Provider

If Y, from HRUTILITY (record identified above), Get positions 1-30.

Entity Relationship

Code

N 2 “25” = Established Patient

“26” = Not Established Patient

“72” = Unknown

Parameter: Primary Care Provider

If Y, then get record from HRUTILITY:

System = BN

Release = 7

Rel Level = 2

Key1 = HR11

Key2 = Company

Key3 = Employee

Get position 9 from HUT-DATA.

If 1, use “26”

If 2, use “25”

Else, use “72”.

If Parameter = N, leave blank (zeroes).

~ Segment length = 86 NM1P32Fairview Clinic FI35-

2348763 25

***END OF REPEATING SEGMENTS***

Transaction Set

Trailer

A 2 SE Fixed = “SE”

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Transaction Segment

Count

N 10 Total number of data segments, including ST and SE.

Cannot exceed 10,000.

Transaction Set

Control Number

N 4 Must match the control number used in the ST segment; used as a unique identifier?

Fixed = “0001”

(Must match number in beginning segment.)

~ Segment length = 16 SE00000000530001

834 Companion Guide and File Layout

ASC X12N (005010) Transaction Set 834 Benefit Enrollment and Maintenance Transactions for

Active Employees and COBRA Participant Eligibility

The State of Michigan Civil Service Commission and

Department of Technology, Management and Budget

Revised 05/19/2025

The State of Michigan 834 Companion Guide and File Layout

Comments in Blue text is SOM use only.

Comments in Red text indicate important file details. Page 2 of 26

Table of Contents

Preface 3 General Information 3

• Delimiters

• ASC Version

Attributes 4

• Element Reference Number

• Element Format

• Element Length

• Requirement Designator

Weekly Membership Change File 5

• Change File Standards

Quarterly Audit Full File 5

• Full File Standards

Eligibility 6

• Subscribers, Spouses and Dependents

• Spouses and Dependents

• Dependents

• COBRA

File Discrepancy Process 7 Layout Overview 8 File Layout Detail

• ISA Interchange Control Header 9

• GS Functional Group Header 10

• ST Transaction Set Header 10

• BGN Beginning Segment 11

• REF Transaction Set Policy Number 11

• DTP File Effective Date 12

• N1 Sponsor Name 12

• N1 Payer 12

• INS Member Level Detail 13

• REF Subscriber Number (0F) 15

• REF Member Policy Number (1L) 15

• REF Member Identification Number (DX) 15

• REF Member Policy Number (23) 15

• DTP Member Level Dates 16

• NM1 Member Name 16

• N3 Member Residence Street Address 17

• N4 Member Residence City, State, Zip Code 17

• DMG Member Demographics 17

• NM1 Member Mailing Address 18

• N3 Member Mailing Street Address 18

• N4 Member Mailing City, State, Zip Code 18

• HD Health Coverage 19

• DTP Health Coverage Dates 19

• SE Transaction Set Trailer 20

• GE Functional Group Trailer 20

• IEA Interchange Control Trailer 20

File Layout Example 21 Standard Transaction Examples 22 Structure Definitions and Concepts 23

Comments in Red text indicate important file details. Page 3 of 26

Preface

This Companion Guide to the ASC X12N (005010) Implementation Guides adopted under HIPAA clarifies and specifies the data content being sent when data is transmitted electronically from the State of Michigan, Department of Civil Service. This document does not replace any ASC HIPAA Transaction Set Implementation Guides. Transmissions based on this companion document, used in tandem with the ASC X12N HIPAA Implementation Guides, are compliant with both ASC X12 (005010) syntax and those guides.

General Information

Delimiters A delimiter is a character used to separate two data elements or component elements or to terminate a segment. The delimiters are an integral part of the data. Delimiters are specified in the interchange header segment, ISA. Once specified in the interchange header, the delimiters are not to be used in a data element value elsewhere in the interchange.

The State of Michigan will use the following symbols as delimiters:

• Element Separator Pipe ( | )

• Segment Separator Tilde ( ~ )

• Component Separator Right Brace ( } )

ASC Version The State of Michigan will provide transactions in accordance with the following ASC X12N HIPAA Implementation Guide version:

• Transaction Set 834: Version 005010X220A1

Comments in Red text indicate important file details. Page 4 of 26

Attributes

Attributes will be listed below each segment in the following order:

Data Element Reference Number, Element Format, Element Length and Requirement Designator

Element Reference Number Data elements are assigned a unique reference number which indicates the position/location of an individual data element.

Element Format Indicates the format type of an individual data element.

• ID = Identifier o An identifier data element always contains a value from a predefined list of codes that is maintained by the ASC X12 Committee or some other body recognized by the Committee.

• AN = String o A string data element is a sequence of any characters from the basic or extended character sets. The string data element must contain at least one non-space character.

• DT = Date o A date data element is used to express the standard date in either YYMMDD or CCYYMMDD format in which CC is the first two digits of the calendar year, YY is the last two digits of the calendar year, MM is the month (01 to 12), and DD is the day in the month (01 to 31). Users of this guide should note that all dates within transactions are 8-character dates (millennium compliant) in the format CCYYMMDD. The only date data element that is in format YYMMDD is the Interchange Date data element in the ISA segment and the TA1 segment where the century is easily determined because of the nature of an interchange header.

• TM = Time o A time data element is used to express the ISO standard time HHMMSS format in which HH is the hour for a 24 hour clock (00 to 23), MM is the minute (00 to 59) and SS is the second (00 to 59).

• Nn = Numeric o A numeric data element is represented by one or more digits with an optional leading sign representing a value in the normal base of 10. The value of a numeric data element includes an implied decimal point. It is used when the position of the decimal point within the data is permanently fixed and is not to be transmitted with the data. This set of guides denotes the number of implied decimal positions. The representation for this data element type is "Nn" where N indicates that it is numeric and n indicates the number of decimal positions to the right of the implied decimal point.

Element Length Each data element is assigned a minimum and maximum length. The length of the data element value is the number of character positions used.

Requirement Designator Indicates the requirement of an individual element’s usage.

• M = Mandatory o The designation of mandatory is absolute in the sense that there is no dependency on other data elements. This designation may apply to either simple data elements or composite data structures.

• O = Optional o The designation of optional means that there is no requirement for a simple data element or composite data structure to be present in the segment.

• X = Relational o Relational conditions may exist among two or more simple data elements within the same data segment based on the presence or X- Relational absence of one of those data elements (presence means a data element must not be empty).

Comments in Red text indicate important file details. Page 5 of 26

Weekly Membership Change File

Membership change files will be transmitted to carriers once a week, on Monday evenings. If a schedule change is necessary, carriers will be notified in advance via email and provided the adjusted transmission date.

Change File Standards The information detailed below includes examples of scenarios that may be encountered.

• If a “001” Change record is received on the same file as a “021” Add or “024” Term record for the same member and does not include a DTP01 “543” qualifier then the “001” Change record can be removed from the file load.

• If a “001” Change record is received with “C” in INS05 and a “543” qualifier in DTP01, then COBRA eligibility will be added or extended through the “543” date provided in DTP02.

• If two or more “021” Add records are received with different DTP02 “348” dates or two or more “024” Term records are received with different DTP02 “349” dates for the same member, the records must be referred to SOM for clarification via the file discrepancy process.

• If an address change is received for a subscriber, the address change applies to all members on the account.

• If a subscriber’s coverage is terminated, all covered dependents are to be terminated as well. A subscriber must be enrolled in benefits in order for a spouse or dependents to remain covered.

Quarterly Audit Full File

Audit full files will be transmitted to carriers on a quarterly basis. Carriers will be notified of full file scheduling in advance via email.

Full File Standards The information detailed below includes examples of scenarios that may be encountered.

• Quarterly full files are provided for auditing use only and are not to be loaded without SOM approval.

• Carriers must provide SOM with a summary of the audit results, detailing the types and volume of all identified discrepancies.

• Members impacted by an identified discrepancy must be sorted by discrepancy type and provided to SOM for further review and direction.

• Members that appear active in the carrier’s system, but do not appear on the full file will be researched by the carrier to determine the correct termination date using weekly change files from the previous quarter. If the correct termination date is unable to be determined, the carrier will include the member on the full file discrepancy report.

SOM will then provide the carrier with the correct membership term date.

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Eligibility

Subscribers, Spouses and Dependents

• Members are not eligible to be dual enrolled in benefits under any SOM plans. If a dual enrollment is identified by the carrier it must be reported to SOM via the file discrepancy process.

Spouses and Dependents

• A subscriber must be enrolled in benefits in order for a spouse or dependents to remain covered. If a spouse or dependent is identified as being enrolled in coverage when the subscriber is terminated, it must be reported to SOM for further review via the file discrepancy process.

Dependents

• Eligibility is contingent on SOM’s Dependent Eligibility Guidelines. Under the met criteria, dependents are eligible for benefits through the end of the month in which they turn age 26, unless the dependent is deemed incapacitated, indicated with a “Y” in segment INS\10. Coverage that exceeds the specified age maximums must be reported to SOM for further review via the file discrepancy process.

COBRA

• SOM is responsible for the administration of COBRA benefits. Members transmitted on a COBRA record, indicated by “C” in INS05, are only eligible for coverage if a “543” qualifier is present in DTP01.

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File Discrepancy Process

Files from the State of Michigan (SOM) are transmitted Monday evening and available to carriers Tuesday mornings of each week on the File Transfer Service (FTS). It is SOM’s expectation that all transmitted benefit enrollment and maintenance transactions are loaded into the carrier’s membership system. Discrepancy reporting must include all records unable to be processed through automation, manual corrections completed by the carrier, as well as records needing further direction from the SOM. Records appearing on the discrepancy report must indicate manual changes completed or no action was taken by the carrier and a brief explanation. Upon completion of the membership updates, all transmitted records will be compared to the carrier’s membership and eligibility system to identify any discrepancies. This review must take place by an eligibility specialist of each carrier to confirm if a discrepancy exists and report back to the State within 48 hour or no later than Thursday morning of that same week.

The discrepancy file needs to be in Excel format and include a column for each of the following fields:

• Benefit status code

• Subscriber’s SSN

• Subscriber’s first and last name

• Dependent’s SSN (if applicable)

• Dependent’s first and last name (if applicable)

• Group Number

• Current eligibility start date

• Current eligibility stop date

• File date the discrepancy was identified

• What the perceived discrepancy is

It is SOM’s expectation that the carriers will provide a response for each file transmission. If no discrepancies are identified in a given week, it is required that EBD still receive notification within the weekly discrepancy report by indicating “none” in the excel document.

All discrepancy files will be sent securely to MiFTS.state.mi.us.

Carriers must retain benefit enrollment and maintenance files for a minimum of 12 months for research and audit purposes.

Carriers must provide SOM with the names and email addresses of the contact person and their backup who will be responsible for this eligibility process and the discrepancy file. SOM must also be provided with the carrier’s Mailbox and Application/User ID that is used to access the File Transfer Service; we will need this information in order to send a file specifically to your organization. In the event a discrepancy report is not received, the Account Manager and person(s) responsible for discrepancy reporting will be contacted immediately.

file://HCS084VSNAPF008/DMB/MCSC/SHARED/EMPBEN/EBD/Carriers/Carrier%20FTS/834%20File%20Correspondence/MiFTS.state.mi.us

Comments in Red text indicate important file details. Page 8 of 26

File Layout Overview

834 files are built using Transaction sets containing segments of data related to that transaction. Each segment contains detailed data elements. In traditional file layouts, the segments would be equivalent to records and the elements are equivalent to fields within that record. Similar transaction sets are bound together as a "functional group" and then submitted together as a file transmission.

Below is an overview of the construction of the 834 file layout, with headers, transactions sets, segment detail and trailers.

Header Loop – Interchange Control Header

I N T

E R

C H

A N

G E

N V

E L

O P

ISA Segment Header Loop – Functional Group Header

F U

N C

T I

O N

A L

G

R O

U P

GS Segment

Header Loop – Transaction Set Header

T R

A N

S A

C T

I O

S

ST Segment Header Loop – Beginning Segment

D E

T A

I L

S

G

M E

BGN Segment Header Loop – Transaction Set Policy Number REF Segment 1000A Loop – Sponsor Name N1 Segment 1000B Loop - Payer N1 Segment 2000 Loop – Member Level Detail INS Segment 2000 Loop – Subscriber Number REF Segment 2000 Loop – Member Policy Number REF Segment 2000 Loop – Member Identification Number REF Segment 2000 Loop – Member Level Dates DTP Segment 2100A Loop – Member Name NM1 Segment 2100A Loop – Member Residence Street Address N3 Segment 2100A Loop – Member Residence City, State, Zip Code N4 Segment 2100A Loop – Member Demographics DMG Segments 2100C Loop – Member Mailing Address NM1 Segment 2100C Loop – Member Mailing Street Address N3 Segment 2100C Loop – Member Mailing City, State, Zip Code N4 Segment 2300 Loop – Health Coverage HD Segment 2300 Loop – Health Coverage Dates DTP Segment Trailer Loop – Transaction Set Trailer SE Segment

Trailer Loop – Functional Group Trailer GE Segment Trailer Loop –…