Schedule K 834 Use Case and Example.docx

Schedule K – 834 Use case and example RFP No. 230000003226 Office of Retirement Services (ORS) ORS File Layouts

· ORS HIPAA 834 Use Case

· ORS HIPAA 834 File Layout Example

ORS HIPAA 834 Use Case

Description:

The ORS 834 batch process is run on a weekly basis on Friday evenings. The batch process generates a change only 834 HIPAA compliant file and is sent to the appropriate insurance carrier on Monday mornings via a secure FTP process through the File Transfer Service (FTS). Currently, for health or prescription drug vendors that facilitate a Medicare and Non-Medicare plan, ORS sends two files containing Medicare and Non-Medicare enrollees separately.

The ORS sends an 834 full audit file to the appropriate insurance carriers bi-annually to audit our enrollment records with those of the insurance carrier(s). Below are the details and list of segment and indicators that are sent on the ORS 834 file.

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 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 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

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

19. Application Receiver’s Code

Tax ID number of the receiver/health care vendor

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 (005010X220A1) from the Washington Publishing Company February 2011.

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 (005010X220A1) from the Washington Publishing Company February 2011.

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

29. Reference ID #

System generated number which denotes the beginning of a transaction set. 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 Qualifier

007 – Effective

34. Date Time Period Format Qualifier

D8 – Date Expressed in Format CCYYMMDD

35. Date Time Period Format Qualifier

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’

37. Identification Code Qualifier

FI – Federal Taxpayer’s ID number

38. Identification Code

Retirement System Tax ID number

Loop 1000B, Segment N1

39. Entity Identifier Code

‘IN’ – Insurer

40. Name

Vendor name

41. Identification Code Qualifier

FI – Federal Taxpayer’s ID number

42. Identification Code

Vendor Tax ID number

Loop 2000, Segment INS

43. Yes/No Condition Code

N = No; If member = non-subscriber, insert ‘N’ Y = Yes; If member = subscriber, insert ‘Y’

44. Individual Relationship

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) 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 terminating or voiding a enrollment 025-Reinstatement; Use when re-enrolling a terminated 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) 14 Voluntary Withdrawal (024) 18-Suspended (024) 25-Change in Identifying Data Elements (001); This code will be used for name, DOB, phone, e-mail, etc 28-Initial Enroll (021) 32-Marriage (021) 41-Re-Enrollment (025) 43-Change of Location (001); This code will be used for address changes;

59-Non-Payment (024)

47. Benefit Status Code

A – Active;

C – COBRA;

S – Surviving Insured;

48. Medicare Plan Code

A – If Medicare Part A only exists;

B – If Medicare Part B only exists;

C – If Medicare Part A and B exists;

E – No Medicare;

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 N – Not a Student

Determines if the member is a student

51. Yes/No Condition Response Code

N = No Y = Yes

Determines if the member is disabled

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)

Loop 2000, Segment REF

54. Reference Identification Qualifier

0F – Subscriber Number

55. Reference Identification

Subscriber SSN

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, benefit structure type and retirement effective date 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 MBI number is available.

60. Reference Identification Qualifier

F6 – Medicare MBI number

61. Reference Identification

Medicare MBI number

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 (CYYMMDD)

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 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 #48) 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 (CCYYMMDD)

Loop 2000, Segment DTP

· Only if Medicare plan code (field #48) 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 (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

83. Name First

Member’s first name

84. Name Middle

Member’s middle name

85. Name Prefix

Member’s name prefix

86. Name Suffix

Member’s name suffix

87. Identification Code Qualifier

34 – SSN

88. Identification Code

Member’s SSN

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

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

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

97. State or Province Code

The member’s physical address state or province code of residence

98. Postal Code

The member’s physical address postal code of residence

99. Country Code

The member’s physical address country of residence The country code is required by 834 format guidelines to be a two character code derived from the ISO 3166 list of country codes.

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 birth date (Date Expressed in Format CCYYMMDD)

104. Gender Code

F – Female M – Male U – Unknown

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. The country code is required by 834 format guidelines to be a two character code derived from the ISO 3166 list of country codes.

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. The country code is required by 834 format guidelines to be a two character code derived from the ISO 3166 list of country codes.

Loop 2200, Segment DSB

· Populate only if the subscriber is a disability retiree

124. Disability Type Code

3 – Permanent or Total Disability

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 AK-Mental Health 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

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 MBI 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’.

Loop 2700 – Additional Reporting Categories – Race and Ethnicity LS2700

145. Additional Miscellaneous Reporting

LS*2700

146. Reporting Category

LX*1

147. Name of Reporting Category

N1*75*Race

148. Race Elections

REF*ZZ* See chart below. If more than one is elected they are separated by commas.

149. Additional Miscellaneous Reporting

LS*2700

150. Reporting Category

LX*2

151. Name of Reporting Category

N2*75*Ethnicity

152. Race Elections REF*ZZ* See chart below. If more than one is elected they are separated by commas.

Segment SE

153. Number of Included Segments

Calculated; Sum of all segments included in respective vendor file

154. 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

155. Number of Transaction Sets Included

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

156. Group Control Number

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

Segment IEA

157. Number of Included Functional Groups

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

158. Interchange Control Number

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

ORS HIPAA 834 File Layout Example ISA*00* *00* *30*386000134 *30*<Vendor Tax ID#> *120504*2359*^*00501*000000001*0*P*:~ GS*BE*386000134*<Vendor Tax ID#>*20120504*2359*1*X*005010X220A1~

ST*834*0235*005010X220A1~

BGN*00*235*20120504*2359****2~

DTP*007*D8*20120504~

N1*P5*MICHIGAN OFFICE OF RETIREMENT SERVICES*FI*386000134~

N1*IN*<Vendor Name>*FI*<Vendor Tax ID#>~

INS*Y*18*021*28*A*E**RT*N*N~

REF*0F*123456789~

REF*6O*123456789~

REF*ZZ*2&MIPG&20040501~

REF*F6*123456789A~

DTP*286*D8*20040501~

DTP*356*D8*20120701~

NM1*IL*1*DOE*JANE*L***34*123456789~

PER*IP**HP*1234567890~

N3*123 FIRST ST~

N4*BELLEVUE*MI*49021~

DMG*D8*19500101*F~

HD*021**HLT**SPO~

DTP*348*D8*20120701~

LS*2700

LX*1

N1*75*RACE

REF*ZZ*E,H

LS*2700

LX*1

N1*75*ETHNICITY

REF*ZZ*1

INS*Y*18*001*43*A*C**RT*N*N~

REF*0F*987654321~

REF*6O*987654321~

REF*ZZ*2&MIPG&19980701~

REF*F6*987654321A~

DTP*286*D8*19980701~

DTP*356*D8*20080401~

DTP*338*D8*20080401~

DTP*338*D8*20080401~

NM1*IL*1*DOE*JOHN*H***34*987654321~

PER*IP**HP*1234567890~

N3*111 MAIN ST~

N4*SALINE*MI*48176~

DMG*D8*19450401*M~

HD*001**HLT**ESP~

DTP*303*D8*20120501~

COB*P*987654321A*1~

DTP*344*D8*20080424~

NM1*IN*2*MEDICARE PART A~

COB*P*987654321A*1~

DTP*344*D8*20080424~

NM1*IN*2*MEDICARE PART B~

LS*2700

LX*1

N1*75*RACE

REF*ZZ*P

LS*2700

LX*1

N1*75*ETHNICITY

REF*ZZ*7

INS*Y*18*001*29*A*C**RT*N*N~

REF*0F*123456789~

REF*6O*123456789~

REF*ZZ*2&MIPG&19990801~

REF*F6*123456789A~

DTP*286*D8*19990801~

DTP*356*D8*20131201~

DTP*338*D8*20131201~

DTP*338*D8*20131201~

NM1*IL*1*PERRY*KATIE*W***34*123456789~

PER*IP**HP*6164539312~

N3*987 FRONT ST~

N4*GRAND BLANC*MI*49534~

DMG*D8*19481212*M~

HD*001**HLT**ESP~

DTP*303*D8*20131201~

COB*P*123456789A*1~

DTP*344*D8*20131201~

NM1*IN*2*MEDICARE PART A~

COB*P*123456789A*1~

DTP*344*D8*20131201~

NM1*IN*2*MEDICARE PART B~

LS*2700

LX*1

N1*75*RACE

REF*ZZ*O

LS*2700

LX*6

N1*75*ETHNICITY

REF*ZZ*7

INS*Y*18*024*07*A*C**TE*N*N~

REF*0F*987654321~

REF*6O*987654321~

REF*ZZ*2&BASC&20100701~

REF*F6*162406896A~

DTP*286*D8*20100701~

DTP*356*D8*20130831~

DTP*338*D8*20130501~

DTP*338*D8*20130501~

NM1*IL*1*SMITH*JOE*M**JR*34*987654321~

PER*IP**HP*1234567890~

N3*9999 TEST DRIVE~

N4*LANSING*MI*48075~

DMG*D8*19480523*M~

HD*024**HLT**ESP~

DTP*349*D8*20130831~

COB*P*987654321A*1~

DTP*344*D8*20130501~

NM1*IN*2*MEDICARE PART A~

COB*P*9876543216A*1~

DTP*344*D8*20130501~

NM1*IN*2*MEDICARE PART B~

LS*2700

LX*1

N1*75*RACE

REF*ZZ*B

LS*2700

LX*6

N1*75*ETHNICITY

REF*ZZ*4

SE*86*0235~

GE*1*1~

IEA*1*000000001~