RBINTERFACE#
PURPOSE#
The RBINTERFACE program creates a HIPPA ANSI 834(ANSI X12N 005010X220A1 (834) standard) File layout for reporting benefit information to carriers.
Interchange file segment ordering example
REQUIRED SET UP#
Interface File Definition Set Up on IDIF#
High Line supplies a standard IDIF file definition, ‘HL$ANSI-X12N834’, for use with this process.
For each vendor required, use the IDIF function and make a copy of this pre-loaded interface layout. Rename the copy to a logical naming convention for the vendor.
Use IDIF to modify the IDIF file definition to contain the required value for the vendor.
A mapping has been created between the IDIF and the RBINTERFACE program.
Only file columns that require a constant value will be needed to be defined inside this IDIF definition.
- The Beginning Position may always be defined as `1`
- The Ending Position must be defined in order for the program to know how many characters are required for each column.
- The Field Type must be defined as ‘Char’
- Constant Value, client must define the element value in this column as it is applicable to their own installation.
| Rec # | Field # | Name/Desc | Beg Posn* | End Posn | Field Type | Constant Value | |
|---|---|---|---|---|---|---|---|
| 1 | 1 | Ref 17 Table Location | 1 | 50 | Char | Values can be: P2K_HR_ASSIGNMENT_DETAILS, P2K_CM_POSITION_DETAILS, P2K_CM_DEPARTMENT_DETAILS If null defaults to P2K_BE_COVERAGES | |
| 5 | 1 | N1 Group Name | 1 | 500 | Char | Default "UNKOWN" if not established | |
| 5 | 2 | N1 Group Tax ID | 1 | 50 | Char | ||
| 5 | 3 | TPA Broker Name | 1 | 500 | Char | ||
| 5 | 4 | TPA Broker Tax ID | 1 | 50 | Char | ||
| 10 | 1 | ISA segment Element 01 | 1 | 2 | Char | ||
| 10 | 2 | ISA segment Element 02 | 1 | 10 | Char | ||
| 10 | 3 | ISA segment Element 03 | 1 | 2 | Char | ||
| 10 | 4 | ISA segment Element 04 | 1 | 10 | Char | ||
| 10 | 5 | ISA segment Element 05 | 1 | 2 | Char | ISA05 = sender (usually ‘30’) | |
| 10 | 6 | ISA segment Element 06 | 1 | ISA06 = sender (usually a FEIN) (Navigate to IDGV and obtain clients FEIN) | |||
| 10 | 7 | ISA segment Element 07 | 1 | 2 | Char | ISA07 = receiver (usually ‘30’) | |
| 10 | 8 | ISA segment Element 08 | 1 | 3 | Char | ISA08 = receiver (usually a FEIN) | |
| 10 | 11 | ISA segment Element 11 | 1 | 1 | Char | ||
| 10 | 12 | ISA segment Element 12 | 1 | 5 | Char | 00501 | |
| 10 | 14 | ISA segment Element 14 | 1 | 1 | Char | ||
| 10 | 15 | ISA segment Element 15 | 1 | 1 | Char | ISA15 = P(Production) or T(Test) | |
| 20 | 1 | GS segment Element 01 | 1 | 2 | Char | ||
| 20 | 2 | GS segment Element 02 | 1 | 7 | Char | GS02 = sender (Usually agency TIN/FEIN) | |
| 20 | 3 | GS segment Element 03 | 1 | 6 | Char | GS03 = receiver (Usually carriers TIN/FEIN) | |
| 20 | 7 | GS segment Element 07 | 1 | 1 | Char | ||
| 20 | 8 | GS segment Element 08 | 1 | 12 | Char | ||
| 50 | 2 | N1(Identifier P5) segment 02 | 1 | 60 | Char | N1P5-Payer Name | |
| 50 | 3 | N1(Identifier P5) segment 03 | 1 | 2 | Char | ‘FI’ | |
| 50 | 4 | N1(Identifier P5) segment04 | 1 | 80 | Char | N1P5-Payer Identification Code | |
| 52 | 2 | N1(Identifier IN) segment 02 | 1 | 6 | Char | N102 = The name of the client group | |
| 52 | 3 | N1(Identifier IN) segment 03 | 1 | 2 | Char | ‘FI’ | |
| 52 | 4 | N1(Identifier IN) segment 04 | 1 | 10 | Char | N104 = Client group TIN (or some other designation) |
User Defined Fields (UDF) Set up on IMUF.#
| Data Base Table | UDF Name | Used in Segment | ^ |
|---|---|---|---|
| P2K_BE_COVERAGES | REF_DX_LOCATION | member supplemental number('2000 REF02 DX') | |
| P2K_BE_BENEFIT_RECIPIENTS | PRIME PHYSICIAN | PHYSICIAN information | |
| P2K_HR_CONTACTS | MARITAL_STATUS | Marital status | |
| P2K_HR_ASSIGNMENT_DETAILS | REF_17 | member supplemental number('2000 REF02 17') | |
| P2K_CM_DEPARTMENT_DETAILS | REF_17 | member supplemental number('2000 REF02 17') | |
| P2K_CM_POSITION_DETAILS | REF_17 | member supplemental number('2000 REF02 17') | |
| P2K_BE_COVERAGES | REF_17 | member supplemental number('2000 REF02 17') |
SYSTEM PROCESSING#
Processing Sequence#
- Select all the employee records where employee has an enrolment in either filtered plan types.
- The following record segments will be written at the beginning of the file: “ISA’, ‘GS’, ‘ST’, ‘BGN’, and ‘REF’, ‘DTP’.
- For each employee, and dependants, who are new to the medical/dental plan coverage, or terminates coverage, or has changes in coverages within the reporting period will be processed, the following record segments will be created:
| Record Segment | Code | Description | Processing Conditions | |
|---|---|---|---|---|
| 1000A N1 | P5 | Plan Sponsor | One per File | |
| 1000B N1 | IN | Insurer | One per File | |
| 1000C N1 | TV | TPA/Broker Name | Situational | |
| 2000 INS | Y | Member is a Subscriber | One record only, either ‘Y’ or ‘N’ | |
| 2000 INS | N | Member is a Dependant | ||
| 2000 REF | 0F | Subscriber Number | ||
| 2000 REF | 1L | Group Number | ||
| 2000 REF | F6 | Medicare HIC Number | Situational | |
| 2000 DTP | 303 | Maintenance Effective Date | ||
| 2000 DTP | 336 | Employ Begin Date (Subscriber only) | ||
| 2000 DTP | 338 | Medicare Begin Date | ||
| 2000 DTP | 339 | Medicare End Date | ||
| 2000 DTP | 356 | Eligibility Begin Date | ||
| 2000 DTP | 357 | Eligibility End/ Termination Date | ||
| 2000 DTP | 394 | Rehire Date | Situational | |
| 2100A NM1 | IL | Member Name | ||
| 2100A PER | IP | Member Communication Numbers | Situational | |
| 2100A N3 | Member Resident Street Address | Required for Subscriber segment | ||
| 2100A N4 | Resident City, State, ZIP | Required if Segment ‘2100A N3’ is sent | ||
| 2100A DMG | Member Demographics | |||
| 2100A NM1 | 31 | Member Mailing Address | Situational | |
| 2100C N3 | Member Mailing Street Address | Situational | ||
| 2100C N4 | Mailing City, State, ZIP | Situational | ||
| 2200 DSB | 2 | Long Term Disability | Situational | |
| 2200 DTP | 360 | Disability Begin Date | Situational | |
| 2200 DTP | 361 | Disability End Date | Situational | |
| 2300 HD | 001 | Health Coverage Change | One record code only | |
| 2300 HD | 021 | Health Coverage Add | One record code only | |
| 2300 HD | 024 | Health Coverage Termination | One record code only | |
| 2300 HD | 030 | Maintenance Type Code Unknown | One record code only | |
| 2300 DTP | 348 | Benefit Begin Date | ||
| 2300 DTP | 349 | Benefit End Date | ||
| 2300 REF | 1L | Member Policy Number |
- The following record segments will be written at the end of the file: “SE’, ‘GE’, ‘IEA’.
Report Parameters#
| Report Parameters | Description | |
|---|---|---|
| Entity | Mandatory, LOV Available You must enter one entity | |
| Interface Format Code | Mandatory, LOV Available You must select an interface code defined on IDIF (Sample ‘HL$ANSI-X12N834’) | |
| ASK Partner Number | Used to populate Segment ‘ISA’ element ‘06’; and Segment ‘GS’ element ’02’. | |
| ISA Control Number | Used to populate Segment ‘ISA’ element ‘13’; and Segment ‘IEA’ element ‘02’. | |
| GS Control Number | Used to populate Segment ‘GS’ element ’06’; and Segment ‘GE’ element ‘02’.. | |
| Master Policy Number | Used to populate Segment ‘REF’ element ’02’. | |
| From Date | The starting date used for records to be included in the file | |
| To Date | The ending date used for records to be included in the file | |
| Unenrolled in last days | Records marked as "Unenrolled" as of the system date - this field, will be included in this file | |
| _Plan Type | Mandatory, LOV Available You must select a Benefit plan type to process (Sample Dental, Medical, Vision, Health) | |
| _Plan Code | Optional, LOV Available Select a Benefit plan code to process | |
| _This is a Test File | Value of ‘Y’ or ‘N’. Used to populate Segment ‘ISA’ element ’15’ (populate with ‘T’ for test file; and ‘P’ for production file). | |
| _This is an Update File | Value of ‘Y’ or ‘N’. Used to populate Segment ‘BGN’ element ’08’ (populate with ‘RX’ for replace action). | |
| _Create File | Value of ‘Y’ or ‘N’. If set to 'N' no file will be created. | |
| _Directory Name | Enter a valid directory name (Directory must be found on the database server) | |
| _File Name | Enter a file name | |
| _Include Exception | Value of ‘Y’ or ‘N’ (to include exception messages on the report) | |
| _Exception Level | Values of ‘0’ to ‘9’ (more exception messages are displayed when a higher level number is used). Use Level-2 if you want to see all the records created (or will be created) on the file listed on the report. |
RECORD LAYOUTS#
ISA – Interchange Control Header record#
_Purpose: To start and identify an interchange of documentsRepeat: 1
Notes: The ISA is a fixed record length segment and all positions with each of the data elements must be filled (i.e. space fill). These segments are always required
Processing: This record is always created, one record per file.
Example: ISA*00* *00* *ZZ*9999999*ZZ*ASK*090101*1916*U*00401*999999999*1*T*>
| Segment ID | Element | Field Name | Req? | Description (HLC source) | |
|---|---|---|---|---|---|
| ISA | 01 | Authorization Info Qualifier | Y | IDIF definition Rec#10 Field#1 (constant value) | |
| ISA | 02 | Authorization Information | Y | IDIF definition Rec#10 Field#2 (constant value) | |
| ISA | 03 | Security Information Qualifier | Y | IDIF definition Rec#10 Field#3 (constant value) | |
| ISA | 04 | Security Information | Y | IDIF definition Rec#10 Field#4 (constant value) | |
| ISA | 05 | Interchange ID Qualifier | Y | IDIF definition Rec#10 Field#5 (constant value) | |
| ISA | 06 | Interchange Sender ID | Y | 7-digit Trading Partner Number assigned by ASK.(from Report run time parameter setting, ‘ASK Partner Number’) | |
| ISA | 07 | Interchange Receiver Qualifier | Y | IDIF definition Rec#10 Field#7 (constant value) | |
| ISA | 08 | Interchange Receiver ID | Y | IDIF definition Rec#10 Field#8 (constant value) | |
| ISA | 09 | Interchange Date | Y | YYMMDD (system date) | |
| ISA | 10 | Interchange Time | Y | HHMM (system time) | |
| ISA | 11 | Interchange Control Standards ID | Y | IDIF definition Rec#10 Field#11 (constant value) | |
| ISA | 12 | Interchange Control Version Number | Y | IDIF definition Rec#10 Field#12 (constant value) | |
| ISA | 13 | Interchange Control Number | Y | Created by Sender Must be unique for each transaction (from Report run time parameter setting, ‘ISA Control Number’ ) | |
| ISA | 14 | Acknowledgement Requested | Y | IDIF definition Rec#10 Field#14 (constant value) | |
| ISA | 15 | Usage Indicator | Y | "This is a Test File" set to "Yes" then value = T otherwise value = P | |
| ISA | 16 | Component Element Separator | Y | : |
GS – Functional Group Header record#
Purpose: To indicate the start of a functional group and provide control informationRepeat: 1
Notes: Required Segment ID
Processing: This record is always created, one record per file.
Example: GS*9999999*BCBSKS*20090101*1916*269*X*004010~
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| GS | 01 | Functional Identifier Code | Y | IDIF definition Rec#20 Field#1 (constant value) |
| GS | 02 | Sender’s Code | Y | IDIF definition Rec#20 Field#2 (constant value) |
| GS | 03 | Receiver’s Code | Y | IDIF definition Rec#20 Field#3 (constant value) |
| GS | 04 | Date | Y | YYMMDD (system date) |
| GS | 05 | Time | Y | HHMM (system time) |
| GS | 06 | Group Control Number | Y | Created by Sender Must be identical in GE02 (from Report run time parameter setting, ‘GS Control Number’) |
| GS | 07 | Responsible Agency’s Code | Y | IDIF definition Rec#20 Field#7 (constant value) |
| GS | 08 | Version/Release Code | Y | IDIF definition Rec#20 Field#8 (constant value) |
ST – Transaction Set Header#
Purpose: To indicate the start of a transaction set and to assign a control numberRepeat: 1
Note: Required
Processing: This record is always created, one record per file.
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| ST | 01 | Transaction Set Header | Y | 834 |
| ST | 02 | Transaction Set Control Number | Y | Populated with a 4-digit number and it should start with 0001. If multiple ST/SE segments are sent in one file, this number will be sequential and ascending. |
| ST | 03 | Transaction Set Control Number | Y | IDIF definition Rec#20 Field#8 (constant value) |
BGN – Beginning Segment #
Purpose: To indicate the beginning of a transaction setRepeat: 1
Note: Required Segment
Processing: Always create this record, one per file.
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| BGN | 01 | Transaction Set Purpose Code | Y | 00 for Original |
| BGN | 02 | Reference Identification | Y | Sender unique transaction set identifier code. (same as Transaction Set Control Number) |
| BGN | 03 | Date | Y | System Date |
| BGN | 04 | Time | Y | System Time |
| BGN | 08 | Action Code | Y | RX - Replace |
REF – Transaction Set Policy Number#
Purpose: To identify master policy number, if available.Repeat: 1
Note: Required Segment
Processing: This record always created, one record per file.
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| REF | 01 | Reference Number Qualifier | Y | 38 for Master Policy Number |
| REF | 02 | Reference Number | Y | Master Policy Number (MPN) provided by Carrier. (from Report run time parameter setting, ‘Master Policy Number’) |
| REF | 03 | Reference Name | Y | Client name provided by the client in IDIF |
DTP – File Effective Dates#
Purpose: To identify employee enrollment dateRepeat: >1
Note: Required Segment
Processing: This record always created, one record per file.
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| DTP | 01 | Date/Time Qualifier | Y | 007 File Effective Date |
| DTP | 01 | Date/Time Period Format Qualifier | Y | D8 (CCYYMMDD) |
| DTP | 01 | Date/Time Qualifier | Y | File Effective Date (bend.effective) |
1000A N1 – Sponsor Name '#
Purpose: To identify the entity paying for the coverageRepeat: 1
Note: Required Segment
Processing This record always created, one record per file.
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| N1 | 01 | Entity Identifier Code | Y | P5 for Plan Sponsor |
| N1 | 02 | Name | Y | IDIF definition Rec#50 Field#2(constant value) |
| N1 | 03 | Identification Code Qualifier | Y | IDIF definition Rec#50 Field#3 (constant value) |
| N1 | 04 | Identification Code | Y | IDIF definition Rec#50 Field#4(constant value) |
1000B N1 – Payer Name#
Purpose: To identify the insurance company providing coverageRepeat: 1
Note: Required Segment
Processing: This record always created, one record per file.
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| N1 | 01 | Entity Identifier Code | Y | IN for Insurer |
| N1 | 02 | Name | Y | IDIF definition Rec#52 Field#2 (constant value) |
| N1 | 03 | Identification Code Qualifier | Y | IDIF definition Rec#52 Field#3 (constant value) |
| N1 | 04 | Identification Code | Y | IDIF definition Rec#52 Field#4 (constant value) |
1000C N1 – TPA/Broker Name#
Purpose: This loop is to be sent if a TPA or Broker is involved. A TPA is “a vendor to handle collecting insured member data if the sponsor chooses not to perform this function”.Repeat: 1 (this record is created only if the UDF ‘GI BROKER NAME’ in the DED table is not null or not blank)
Note: Situational Segment
Processing: This record always created, one record per file.
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| N1 | 01 | Entity Identifier Code | S | TV for TPA |
| N1 | 02 | Name | S | UDF ‘GI BROKER NAME’ attached to the DED table. |
| N1 | 03 | Identification Code Qualifier | S | FI for Federal Tax ID |
| N1 | 04 | Identification Code | S | UDF ‘GI BROKER TAXID’ attached to the DEN table. |
2000 INS – Insured Benefit#
Purpose: To provide benefit information on each insured memberRepeat: >1
Note: Required Segment ID
Processing: One record per employee (subscriber), and one record for each dependant.
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| INS | 01 | Yes/No Condition | Y | Y if the member is a Subscriber. N if the member is a Dependent. |
| INS | 02 | Individual Relationship Code | Y | 01 for Spouse 05 for Grandchild 09 for Adopted Child 15 for Legal Custody Dependent 17 for Step Child 18 for Self (Subscriber) 19 for Child or Student 53 for Domestic Partner |
| INS | 03 | Maintenance Type Code | Y | 001 for Change. 021 for Add 024 for Termination 030 if Maintenance Type Code unknown |
| INS | 04 | Maintenance Reason Code | Y | 01 for Divorce 02 for Birth 03 for Death 04 for Retirement 05 for Adoption 07 for Termination of Benefits 08 for Termination of Employment 15 for PCP Change 21 (preferred) for Disability (send if member becomes disabled. Maintenance Effective Date reflects date the member became disabled.) 25 (preferred) for if member becomes a student. Maintenance Effective date reflects date the member became a student) 28 for Initial Enrollment 31 for Legal Separation 32 for Marriage 3 for Change of Location (Address) AI for No Reason Given (reason unknown) |
| INS | 05 | Benefit Status Code | Y | A if the member is not Cobra. C for Cobra |
| INS | 06 | Medicare Plan Code | S | If the data is available: A for Medicare Part A . B for Medicare Part B. C for Medicare Part A and Part B. |
| INS | 07 | COBRA Qualifying Event Code | S | Optional |
| INS | 08 | Employee Status Code | Y | Subscribers Only. AC for Active RT for Retired Employee. TE for Terminated Employee. |
| INS | 09 | Student Status Code | S | F if the member is identified as a student based on the age criteria between Carrier and the Group. |
| INS | 10 | Handicap Indicator | S | N for No if the member is not handicapped/disabled. Y for Yes if the member is handicapped/disabled. NOTE: Only sent for disabled children. This is not sent on the Insured or Spouse. |
| INS | 11 | Date Time Period Qualifier | S | In the event of a death of the subscriber or dependent, populate with D8. Otherwise, leave blank. |
| INS | 12 | Date Time Period | S | Populate this date for the death of the subscriber/dependent NOTE: If INS11 is populated with D8, the date must also be populated. |
2000 REF – Subscriber Number#
Purpose: To specify identifying informationRepeat: 1
Note: Required Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| REF | 01 | Reference Number Qualifier | Y | 0F for Subscriber Number |
| REF | 02 | Reference Number | Y | Subscriber’s SSN (eid.government_code) |
2000 REF – Group Policy Number #
Purpose: To identify the group or policy numberRepeat: 1
Note: Required Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| REF | 01 | Reference Number Qualifier | Y | 1L for Group Number |
| REF | 02 | Reference Number | Y | Carrier will provide the number (bpn.policy_number) |
2000 REF – Member Identification Number#
Purpose: To identify the group or policy numberRepeat: 1
Note: Situational - if member is enrolled in Medicare Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| REF | 01 | Reference Number Qualifier | S | F6 for Medicare HIC Number |
| REF | 02 | Reference Number | S | UDF ‘MEDICARE HIC REF’ attached to the BPN table. |
2000 DTP – Member Level Dates#
Purpose: To identify member level datesRepeat: >1
Note: Required Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| DTP | 01 | Date/Time Qualifier | Y | 303 for Maintenance Effective Date (bend.effective) |
| DTP | 01 | Date/Time Qualifier | S | Enrollment Signature Date |
| DTP | 01 | Date/Time Qualifier | Y | 336 for Employment Begin for subscribers only. (bend.effective) |
| DTP | 01 | Date/Time Qualifier | Y | 338 for Medicare Begin. (bend.effecitve) NOTE: INS06 must be populated with A, B or C. If the member has both Medicare Part A and B, we will send earliest Effective Date and latest Termination Date between the two. |
| DTP | 01 | Date/Time Qualifier | Y | 339 for Medicare End. (bend.expiry) NOTE: INS06 must be populated with A, B or C. If the member has both Medicare Part A and B, we will send earliest Effective Date and latest Termination Date between the two. |
| DTP | 01 | Date/Time Qualifier | Y | 356 for Eligibility Begin (bend.effective) |
| DTP | 01 | Date/Time Qualifier | Y | 357 for Eligibility End for terminations (bend.expiry) |
| DTP | 01 | Date/Time Qualifier | S | 394 for Rehire Date (eem.hire_date) |
| DTP | 02 | Date/Time Format Qualifier | Y | D8 |
| DTP | 03 | Date Time Period | Y | Date associated with the DTP01 |
2100A NM1 – Member Name
#
_Purpose: To supply employee/member name and SSN Repeat: 1
Note: Required for all members
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| NM1 | 01 | Entity Identifier Code | Y | IL |
| NM1 | 02 | Entity Type Qualifier | Y | 1 for Person |
| NM1 | 03 | Name Last | Y | Last Name (eid.Last_name) |
| NM1 | 04 | Name First | Y | First Name (eid.First_namee) |
| NM1 | 05 | Name Middle | N | Middle Name (eid.middle_name) |
| NM1 | 07 | Name Suffix | N | Suffix (eid.rank) |
| NM1 | 08 | Identification Code Qualifier | Y | 34 |
| NM1 | 09 | Identification Code | Y | SSN – Required for all members on the contract. (eid.government_code) |
2100A PER – Member Communications Numbers #
Purpose: To supply member contact informationRepeat: 1
Note: If only one phone number is available, send it in the first available slot.
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| PER | 01 | Contact Function Code | N | IP for Insured Party |
| PER | 03 | Comm Number Qual | N | HP |
| PER | 04 | Comm Number | N | Member’s Home Phone Number (eps.phone_number) Note: No punctuation within Phone Number |
| PER | 05 | Comm Number Qual | N | WP |
| PER | 06 | Comm Number | N | Member’s Work Phone Number (eps.alt_phone_number) Note: No punctuation within Phone Number |
| PER | 07 | Comm Number Qual | N | EM |
| PER | 08 | Comm Number | N | Member’s E-mail Address (eps.email_address) |
2100A N3 – Member Residence Street Address#
Purpose: To supply employee/member Street addressRepeat: 1
Note: Required for Subscriber Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| N3 | 01 | Address Line 1 | Y | Member’s Address (eps.address_line_1) NOTE: Only send this segment for the dependent if the address is different than the subscriber’s. |
| N3 | 02 | Address Line 2 | N | If the country (N404 <> USA), populate the province in this field |
2100A N4 – Member Residence City,State,Zip#
Purpose: To supply employee/member City,State,ZipRepeat: 1
Note: Required if N3 segment sent
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| N4 | 01 | City | Y | City (eps.locality) |
| N4 | 02 | State/Province | Y | State (dsp.state_province) NOTE: If the member does not reside in the US, pass the province in the N302 field) |
| N4 | 03 | ZIP Code/Postal Code | Y | Postal Code (eps.zip_postal) |
| N4 | 04 | Country Code | Y | If member lives in the United States, pass USA. If not, pass FOR. (dco.country_code) |
2100A DMG– Member Demographics#
Purpose: To supply employee/member birth date, gender, marital status, and citizenship status.Repeat: 1
Note: Required Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| DMG | 01 | Date/Time Format Qualifier | Y | D8 |
| DMG | 02 | Date/Time Period | Y | Member’s Birth Date (eid.birth_date) |
| DMG | 03 | Gender Code | Y | M for Male F for Female (eid.gender) |
| DMG | 04 | Marital Status Code | N | B for Registered Domestic Partner D for Divorced I for Single M for Married S for Separated U for Unmarried W for Widowed X for Legally Separated R for Unreported (eps.martital_status) |
2100C NM1 – Member Mailing Address'#
Purpose: The member’s mailing address is different from the residential address.Repeat: 1 (note segments ‘2100C’ will only be created if applicable)
Note: Situational Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| NM1 | 01 | Entity Identifier Code | S | 31 for Postal Mailing Address |
| NM1 | 02 | Entity Type Qualifier | S | 1 for Person |
2100C N3 – Member Mailing Street Address#
Purpose: To supply employee/member Street address from 2100C loopRepeat: 1 (note segments ‘2100C’ will only be created if applicable)
Note: Situational Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| N3 | 01 | Address Line 1 | S | Address Line 1 (eps.mail_address_line_1) |
| N3 | 02 | Address Line 2 | N | (eps.mail_address_line_2) |
2100C N4 – Member Mailing City,State,ZIP
#
_Purpose: To supply employee/member City,State,ZIP from 2100C loop Repeat: 1 (note segments ‘2100C’ will only be created if applicable)
Note: Situational Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| N4 | 01 | City | S | City (eps.mail_locality) |
| N4 | 02 | State/Province | S | State/Province (dsp.state_province_code) |
| N4 | 03 | ZIP Code/Postal Code | S | Postal Code (eps.mail_zip_postal) |
| N4 | 04 | Country Code | N | USA |
2200 DSB – Disability Information#
Purpose: Used when the member is disabled due to End Stage Renal Disease.Repeat: 1 (this segment is only produced if applicable)
Note: Only send if member is disabled due to End Stage Renal Disease (Medicare).
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| DSB | 01 | Disability Type Code | S | 2 for Long Term Disability |
| DSB | 07 | Product/Service ID Qualifier | S | DX |
| DSB | 08 | Medical Code Value | S | 585 for End Stage Renal Disease (only valid value) |
2200 DTP – Disability Eligibility Dates#
Purpose: Used when the member is disabled.Repeat: >1 (this segment is only produced if applicable)
Note: Only send if member is disabled and dates are known.
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| DTP | 01 | Date/Time Qualifier | S | 360 for Disability Begin 361 for Disability End |
| DTP | 02 | Date/Time Format Qualifier | S | D8 |
| DTP | 03 | Date Time Period | S | Disability date (bend.effective/bend.expiry) |
2300 HD – Health Coverage
#
_Purpose: To provide information on employee/member health coverage Repeat: >1
Note: Required Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| HD | 01 | Maintenance Type Code | Y | 001 for Change. 021 for Add 024 for Termination 030 if Maintenance Type Code unknown (?) |
| HD | 03 | Insurance Line Code | Y | IF r_be_ben.bpt_plan_type='MEDICAL' then v_segment_hd_03:='HLT'; ELSIF r_be_ben.bpt_plan_type='STANDALONE' then --SK20200710 v_segment_hd_03:='AK'; ELSIF r_be_ben.bpt_plan_type='EXCLUSIVE PROVIDER ORGANIZATION' then --SK20200710 v_segment_hd_03:='EPO'; ELSIF r_be_ben.bpt_plan_type='HEARING' then --SK20200710 v_segment_hd_03:='HE'; ELSIF r_be_ben.bpt_plan_type='HEALTH MAINTENANCE ORGANIZATION' then --SK20200710 v_segment_hd_03:='HMO'; ELSIF r_be_ben.bpt_plan_type='MAJOR MEDICAL' then --SK20200710 v_segment_hd_03:='AK'; ELSIF r_be_ben.bpt_plan_type='POINT OF SERVICE' then --SK20200710 v_segment_hd_03:='POS'; ELSIF r_be_ben.bpt_plan_type='PREFERRED PROVIDER ORGANIZATION' then --SK20200710 v_segment_hd_03:='PPO'; ELSIF r_be_ben.bpt_plan_type='PRESCRIPTION' then --SK20200710 v_segment_hd_03:='PDG'; ELSIF r_be_ben.bpt_plan_type='FACILITY' then --SK20200710 v_segment_hd_03:='FAC'; ELSIF r_be_ben.bpt_plan_type='HEALTH' then --SK20200710 v_segment_hd_03:='HLT'; ELSIF r_be_ben.bpt_plan_type='DENTAL' then v_segment_hd_03:='DEN'; ELSIF r_be_ben.bpt_plan_type='VISION' then --SK20200707 v_segment_hd_03:='VIS'; ELSE v_segment_hd_03:=; END IF; |
| HD | 04 | Plan Coverage Description | Y | Carrier will provide the values based on Group coverage. (r_be_ben.bcg_policy_number) Note: Optional for Dependents |
| HD | 05 | Coverage Level Code | Y | Note: (SELECT DECODE (r_be_ben.bcg_coverage_code,'SINGLE','EMP','COUPLE','ESP','FAMILY','FAM','EMPLOYEE ONLY','EMP', 'DEPENDENT ONLY','DEP','EMPLOYEE AND ONE DEPENDENT','E1D','EMPLOYEE AND SPOUSE','ESP','EMPLOYEE AND TWO OR MORE DEPENDENTS','E6D', 'EMPLOYEE AND CHILDREN','ECH','COMPOSITE','FAM','PHARMACY','RX','CHILDREN ONLY','CHD','INDIVIDUAL','IND','SPOUSE & CHILDREN','SPC', 'SPOUSE ONLY','SPO’,r_be_ben.bcg_HIPPA_code) ) A. This is optional for Dependents B. Provided by Carrier. |
2300 DTP – Member Benefit Dates#
Purpose: To identify employee benefit datesRepeat: >1
Note: Required Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| DTP | 01 | Date/Time Qualifier | Y | 348 for Benefit Begin.(bend.effective) |
| DTP | 01 | Date/Time Qualifier | Y | 349 for Benefit End (bend.expiry) Note: Required if member is canceling coverage with Carrier. |
| DTP | 02 | Date/Time Format Qualifier | Y | D8 |
| DTP | 03 | Date/Time Period | Y | Benefit Date |
2300 REF- Member Policy Number#
Purpose: To identify member group numberRepeat: 1
Note: Situational Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| REF | 01 | Reference Number Qualifier | Y | 1L |
| REF | 02 | Reference Identification | Y | UDF ‘DIS POLICY REF’ attached to the BPN table. |
SE - Transaction Set Trailer#
Purpose: To identify end of transaction set and provide count of transmitted segmentsRepeat: 1
Note: Required Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| SE | 01 | Number of Segments | Y | System counter. |
| SE | 02 | Transaction Set Control Number | Y | Same as the ‘Transaction Set Control Number’ in the ST segment. |
GE – Functional Group Trailer#
Purpose: To identify the end of a transaction setRepeat: 1
Note: Required Segment
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
|---|---|---|---|---|
| GE | 01 | Number of Transaction sets | Y | System counter |
| GE | 02 | Group Control Number | Y | Same as the ‘Group Control Number’ in the GS segment. |
IEA – Interchange Control Trailer#
Purpose: To define the end of an InterchangeRepeat: 1
Note: Required Segment
| Note: Required Segment ID | ||||
|---|---|---|---|---|
| Segment ID | Element | Field Name | Req? | Description (HLC source) |
| IEA | 01 | Number of Functional Groups | Y | System counter. |
| IEA | 02 | Interchange Control Number | Y | Same as the ‘Interchange Control Number in the ISA segment |
Scenarios (Examples) #
The following scenarios do not include the ISA, GS, ST, BGN, SE, GE, and IEA segments that are required for all 834 transmissions.
Enrollment of a Subscriber (employee only) who has elected both Medical and Dental Coverage
INS*Y*18*021*AI*A***FT
REF*0F*111223333
REF*1L*888888
DTP*300*D8*20081230
DTP*336*D8*20010101
DTP*356*D8*20090101
NM1*IL*1*SITH*JON*W***34*111223333
PER*IP**HP*2643332343
N3*111 NORTH MAIN*APT B
N4*GREENVILLE*SC*29601
DMG*D8*19681129*M*I
HD*021**HLT**EMP
DTP*348*D8*20090101
REF*1L*888888
HD*021**DEN**EMP
DTP*348*D8*20090101
REF*1L*888888\\
Enrollment of a Dependent (spouse) to the previous Subscriber enrollment
INS*Y*18*001*AI*A***FT
REF*0F*111223333
REF*1L*888888
DTP*300*D8*20090320
DTP*336*D8*20010101
DTP*356*D8*20090101
NM1*IL*1*SITH*JON*W***34*111223333
PER*IP**HP*2643332343
N3*111 NORTH MAIN*APT B
N4*GREENVILLE*SC*29601
DMG*D8*19681129*M*M
HD*001**HLT**ESP
DTP*348*D8*20090401
REF*1L*888888
HD*001**DEN**ESP
DTP*348*D8*20090401
REF*1L*888888\\ INS*N*01*021*32*A
REF*0F*111223333
REF*1L*888888
DTP*300*D8*20090320
DTP*356*D8*20090401
NM1*IL*1*SMITH*VERONICA*T
DMG*D8*19710404*F*M
HD*021**HLT**ESP
DTP*348*D8*20090401
REF*1L*888888
HD*021**DEN**ESP
DTP*348*D8*20090401
REF*1L*888888\\
Enrollment Termination
INS*Y*18*024*AI*A***FT
REF*0F*111223333
REF*1L*888888
DTP*300*D8*20090510
DTP*336*D8*20010101
DTP*356*D8*20090101
DTP*357*D8*20090630
NM1*IL*1*SITH*JON*W***34*111223333
PER*IP**HP*2643332343
N3*111 NORTH MAIN*APT B
N4*GREENVILLE*SC*29601
DMG*D8*19681129*M*M
HD*024**HLT**ESP
DTP*348*D8*20090401
REF*1L*888888\\ HD*024**DEN**ESP
DTP*348*D8*20090401
REF*1L*888888
INS*N*01*024*32*A
REF*0F*111223333
REF*1L*888888
DTP*300*D8*20090320
DTP*356*D8*20090401
DTP*357*D8*20090630
NM1*IL*1*SMITH*VERONICA*T
DMG*D8*19710404*F*M
HD*024**HLT**ESP
DTP*348*D8*20090401
DTP*349*D8*20090630
REF*1L*888888
HD*024**DEN**ESP
DTP*348*D8*20090401
DTP*349*D8*20090630
REF*1L*888888\\
Dependent terminates Medical Coverage and continues on Dental
INS*Y*18*001*AI*A***FT
REF*0F*111223333
REF*1L*888888
DTP*300*D8*20090510
DTP*336*D8*20010101
DTP*356*D8*20090101
NM1*IL*1*SITH*JON*W***34*111223333
PER*IP**HP*2643332343
N3*111 NORTH MAIN*APT B
N4*GREENVILLE*SC*29601
DMG*D8*19681129*M*M
HD*001**HLT**EMP
DTP*348*D8*20090701
REF*1L*888888
HD*001**DEN**ESP
DTP*348*D8*20090401
REF*1L*888888\\ INS*N*01*001*AI*A
REF*0F*111223333
REF*1L*888888
DTP*300*D8*20090320
DTP*356*D8*20090401
NM1*IL*1*SMITH*VERONICA*T
DMG*D8*19710404*F*M
HD*024**HLT**ESP
DTP*348*D8*20090401
DTP*349*D8*20090630
REF*1L*888888
HD*001**DEN**ESP
DTP*348*D8*20090701
REF*1L*888888\\
Subscriber downgrades their Coverage (i.e. Terminates the dependent and goes from ESP to EMP)
INS*Y*18*001*AI*A***FT
REF*0F*111223333
REF*1L*888888
DTP*300*D8*20090720
DTP*336*D8*20010101
DTP*356*D8*20090101
NM1*IL*1*SITH*JON*W***34*111223333
PER*IP**HP*2643332343
N3*111 NORTH MAIN*APT B
N4*GREENVILLE*SC*29601
DMG*D8*19681129*M*M
HD*001**HLT**EMP
DTP*348*D8*20090701
REF*1L*888888\\ HD*001**DEN**EMP
DTP*348*D8*20090701
REF*1L*888888
INS*N*01*024*AI*A
REF*0F*111223333
REF*1L*888888
DTP*300*D8*20090720
DTP*356*D8*20090401
DTP*357*D8*20090630
NM1*IL*1*SMITH*VERONICA*T
DMG*D8*19710404*F*M
HD*024**HLT**ESP
DTP*348*D8*20090401
DTP*349*D8*20090630
REF*1L*888888
HD*024**DEN**ESP
DTP*348*D8*20090701
DTP*349*D8*20090630
REF*1L*888888\\
Subscriber moves from one Group (888888) to another (777777). No need to send a cancel for the old group (888888).
INS*Y*18*001*AI*A***FT
REF*0F*111223333
REF*1L*777777
DTP*300*D8*20090810
DTP*336*D8*20010101
DTP*356*D8*20090901
NM1*IL*1*SITH*JON*W***34*111223333
PER*IP**HP*2643332343
N3*111 NORTH MAIN*APT B
N4*GREENVILLE*SC*29601
DMG*D8*19681129*M*M
HD*001**HLT**EMP
DTP*348*D8*20090901
REF*1L*777777
HD*001**DEN**EMP
DTP*348*D8*20090901
REF*1L*777777\\
Subscriber Terminates Contract
INS*Y*18*024*AI*A***FT
REF*0F*111223333
REF*1L*777777
DTP*300*D8*20090912
DTP*336*D8*20010101
DTP*356*D8*20090901
DTP*357*D8*20091031
NM1*IL*1*SITH*JON*W***34*111223333
PER*IP**HP*2643332343
N3*111 NORTH MAIN*APT B
N4*GREENVILLE*SC*29601
DMG*D8*19681129*M*M
HD*024**HLT**EMP
DTP*348*D8*20090901
DTP*349*D8*20091031
REF*1L*777777
HD*024**DEN**EMP
DTP*348*D8*20090901
DTP*349*D8*20091031
REF*1L*777777\\
Add Dependent to the Current Contract (upgraded to FAM coverage from Employee + Spouse)
INS*Y*18*001*AI*A***FT
REF*0F*111223333
REF*1L*888888
DTP*300*D8*20090920
DTP*336*D8*20010101
DTP*356*D8*20090101
NM1*IL*1*SITH*JON*W***34*111223333
PER*IP**HP*2643332343
N3*111 NORTH MAIN*APT B
N4*GREENVILLE*SC*29601
DMG*D8*19681129*M*M
HD*001**HLT**FAM
DTP*348*D8*20091001
REF*1L*888888\\ HD*001**DEN**FAM
DTP*348*D8*20091001
REF*1L*888888
INS*N*01*001*32*A
REF*0F*111223333
REF*1L*888888
DTP*300*D8*20090920
DTP*356*D8*20090401
NM1*IL*1*SMITH*VERONICA*T
DMG*D8*19710404*F*M
HD*001**HLT**FAM
DTP*348*D8*20091001
REF*1L*888888
HD*001**DEN**FAM
DTP*348*D8*20091001
REF*1L*888888
INS*N*19*021*02*A
REF*0F*111223333
REF*1L*888888
DTP*300*D8*20090920
DTP*356*D8*20091001
NM1*IL*1*SMITH*GABRIELLE*E\\ DMG*D8*20060316*F
HD*001**HLT**FAM
DTP*348*D8*20091001
REF*1L*888888
HD*001**DEN**FAM
DTP*348*D8*20091001
REF*1L*888888\\
Subscriber enrolls in Medical and has Medicare Coverage
NOTE: Subscriber is enrolled in Medicare Part A.
INS*Y*18*021*AI*A*A**FT
REF*0F*111223333
REF*1L*888888
REF*F6*38-111223333A
DTP*300*D8*20081230
DTP*336*D8*20010101
DTP*338*D8*20090201
DTP*356*D8*20090101
NM1*IL*1*SITH*JON*W***34*111223333
PER*IP**HP*2643332343
N3*111 NORTH MAIN*APT B
N4*GREENVILLE*SC*29601
DMG*D8*19681129*M*I
HD*021**HLT**EMP
DTP*348*D8*20090101
REF*1L*888888
HD*021**DEN**EMP
DTP*348*D8*20090101
REF*1L*888888\\
