!!!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\\
\\
!!Segment Ordering Sample
Interchange file segment ordering example:
\\
*ISA\\
*GS\\
*ST\\
*BGN\\
*REF\\(employee and dependent details following)
**DTP ...
**1000A N1
**1000B N1
**1000C N1 (situational/optional)
***2000 INS ...
***2000 REF (0F)
***2000 REF (1L)
***2000 REF (F6) (situational/optional)
***2000 DTP ...
****2100 NM1
****2100A PER
****2100A N3 (required for subscriber)
****2100A N4 (required if 2100A N3 is included)
****2100A DMG
****2100C NM1 (situational/optional)
****2100C N3 (situational/optional)
****2100C N4 (situaional/optional)
****2200 DSB
****2200 DTP ...
*****2300 HD ...
*****2300 DTP ...
*****2300 REF (situational/optional)
*SE
*GE
*IEA
!!Required Set Up
!1) Interface File Definition ([IDIF]) Set Up
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
|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) |
\\
!2) The following User Defined Feld (UDF) is required on [IMUF].
||Data Base Table ||UDF Name|| Used in Segment|| ^
| | | |
|P2K_BE_COVERAGES |REF_DX_LOCATION|member supplemental number('2000 REF02')|
|P2K_BE_BENEFIT_RECIPIENTS|PRIME PHYSICIAN|PHYSICIAN information |
|P2K_HR_CONTACTS |MARITAL_STATUS |Marital status
!!!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|
|__Plan Type__ |Mandatory, LOV Available\\You must select a Benefit plan type to process (Sample Dental,Medical, Vision,Health)|
|__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__\\
\\
__''ISA - Interchange
Control Header __\\ ''
__Purpose: __To start and
identify an interchange of documents \\
__Repeat:__ 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\\
||__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 |IDIF
definition Rec#10 Field#15 (constant value)
|ISA |16 |Component Element Separator |Y |:
\\
__Example: __\\
ISA*00* *00*
*ZZ*9999999*ZZ*ASK*090101*1916*U*00401*999999999*1*T*>~\\
\\
__Processing:__\\
\\
This record is always
created, one record per file.\\
\\
__GS – Functional Group Header record__\\
\\
__Purpose: __To indicate the start of a functional group and provide
control information \\
__Repeat: __1 \\
||__Note: __Required __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)
\\
\\
__Example: __GS*9999999*BCBSKS*20090101*1916*269*X*004010~\\
\\
__Processing:__\\
\\
This record is always
created, one record per file.\\
\\
\\
__''ST – Transaction Set Header __\\ ''
__Purpose: __To indicate the start of a transaction set and to assign a
control number \\
__Repeat: __1 \\
||__Note: __Required __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.
\\
__Processing:__\\
\\
Always create this record,
one per file.\\
\\
__''BGN – Beginning Segment __\\ ''
__Purpose: __To indicate the beginning of a transaction set \\
__Repeat: __1 \\
||__Note: __Required __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
\\
__Processing:__\\
\\
Always create this record,
one per file.\\
\\
__''REF – Transaction Set Policy Number __\\ ''
__Purpose: __To identify master policy number, if available. \\
__Repeat: __1 \\
||__Note: __Required __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
\\
__Processing:__\\
\\
This record always created,
one record per file.\\
\\
__''DTP – File Effective Dates __\\ ''
__Purpose: __To identify employee enrollment date \\
__Repeat: __>1\\
||__Note: __Required __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)
\\
__Processing:__\\
\\
This record always created,
one record per file.\\
\\
__''1000A N1 – Sponsor Name __\\ ''
__Purpose: __To identify the entity paying for the coverage \\
__Repeat: __1 \\
||__Note: __Required __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)
\\
__Processing:__\\
\\
This record always created,
one record per file.\\
\\
__''1000B N1 – Payer Name __\\ ''
__Purpose: __To identify the insurance company providing coverage \\
__Repeat: __1 \\
||__Note: __Required __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)
\\
__Processing:__\\
\\
This record always created,
one record per file.\\
\\
__''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 __\\ \\ __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.
\\
__Processing:__\\
\\
This record always created,
one record per file.\\
\\
__''2000 INS – Insured Benefit __\\ ''
__Purpose: __To provide benefit information on each insured member \\
__Repeat: __>1\\
||__Note: __Required __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. \\
\\
__Processing:__\\
\\
One record per employee
(subscriber), and one record for each dependant.\\
\\
__''2000 REF – Subscriber Number __\\ ''
__Purpose: __To specify identifying information \\
__Repeat: __1\\
||__Note: __Required __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)
\\
__Processing:__\\
\\
__''2000 REF – Group Policy Number __\\ ''
__Purpose: __To identify the group or policy number \\
__Repeat: __1\\
||__Note: __Required __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)
\\
__Processing:__\\
\\
__''2000 REF – Member Identification Number __\\ ''
__Purpose: __To identify the group or policy number \\
__Repeat: __1 \\
||__Note: __Situational - if member is enrolled in Medicare
__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.
\\
__Processing:__\\
\\
__''2000 DTP – Member Level Dates __\\ ''
__Purpose: __To identify member level dates \\
__Repeat: __>1\\
||__Note: __Required. __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
\\
__Processing:__\\
\\
__''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)
\\
__Processing:__\\
\\
__''2100A PER – Member Communications Numbers __\\ ''
__Purpose: __To supply member contact information \\
__Repeat: __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)
\\
__Processing:__\\
\\
__''2100A N3 – Member Residence Street Address __\\ ''
__Purpose: __To supply employee/member Street address \\
__Repeat: __1 \\
||__Note: __Required for Subscriber __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 __
\\
__Processing:__\\
\\
__''2100A N4 – Member Residence City,State,Zip __\\ ''
__Purpose: __To supply employee/member City,State,Zip \\
__Repeat: __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)
\\
__Processing:__\\
\\
__''2100A DMG– Member Demographics __\\ ''
__Purpose: __To supply employee/member birth date, gender, marital
status, and citizenship status. \\
__Repeat: __1 \\
||__Note: __Required. __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)\\
\\
__Processing:__\\
\\
__''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 __\\ \\ __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
\\
__Processing:__\\
\\
__''2100C N3 – Member Mailing Street Address __\\ ''
__Purpose: __To supply employee/member Street address from 2100C
loop \\
__Repeat: __1 (note segments ‘2100C’ will only be created if applicable)\\
||__Note: __Situational __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)
\\
__Processing:__\\
\\
__''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 __\\ \\ __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
\\
__Processing:__\\
\\
__''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)
\\
__Procesisng:__\\
\\
__''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)
\\
__Processing:__\\
\\
__''2300 HD – Health Coverage __\\ ''
__Purpose: __To provide information on employee/member health
coverage \\
__Repeat: __>1\\
||__Note: __Required __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. \\
\\
__Processing:__\\
\\
__''2300 DTP – Member Benefit Dates __\\ ''
__Purpose: __To identify employee benefit dates \\
__Repeat: __>1\\
||__Note: __Required __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
\\
__Processing:__\\
\\
__''2300 REF- Member Policy Number __\\ ''
__Purpose: __To identify member group number \\
__Repeat: __1 \\
||__Note: __Situational __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.
\\
__Processing:__\\
\\
__''SE - Transaction Set Trailer __\\ ''
__Purpose: __To identify end of transaction set and provide count of
transmitted segments \\
__Repeat: __1 \\
||__Note: __Required __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.
\\
__Processing:__\\
\\
__''GE – Functional Group Trailer __\\ ''
__Purpose: __To identify the end of a transaction set \\
__Repeat: __1 \\
||__Note: __Required __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.
\\
__Processing:__\\
\\
__''IEA – Interchange Control Trailer __\\ ''
__Purpose: __To define the end of an Interchange \\
__Repeat: __1 \\
||__Note: __Required __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
\\
__Processing:__\\
\\
\\
\\
__''RECORD LAYOUTS__\\ ''
__ISA – Interchange Control Header record__\\
\\
__''ISA - Interchange
Control Header __\\ ''
__Purpose: __To start and
identify an interchange of documents \\
__Repeat:__ 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\\
||__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 |IDIF
definition Rec#10 Field#15 (constant value)
|ISA |16 |Component Element Separator |Y |:
\\
__Example: __\\
ISA*00* *00*
*ZZ*9999999*ZZ*ASK*090101*1916*U*00401*999999999*1*T*>~\\
\\
__Processing:__\\
\\
This record is always
created, one record per file.\\
\\
__GS – Functional Group Header record__\\
\\
__Purpose: __To indicate the start of a functional group and provide
control information \\
__Repeat: __1 \\
||__Note: __Required __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)
\\
\\
__Example: __GS*9999999*BCBSKS*20090101*1916*269*X*004010~\\
\\
__Processing:__\\
\\
This record is always
created, one record per file.\\
\\
\\
__''ST – Transaction Set Header __\\ ''
__Purpose: __To indicate the start of a transaction set and to assign a
control number \\
__Repeat: __1 \\
||__Note: __Required __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.
\\
__Processing:__\\
\\
Always create this record,
one per file.\\
\\
__''BGN – Beginning Segment __\\ ''
__Purpose: __To indicate the beginning of a transaction set \\
__Repeat: __1 \\
||__Note: __Required __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
\\
__Processing:__\\
\\
Always create this record,
one per file.\\
\\
__''REF – Transaction Set Policy Number __\\ ''
__Purpose: __To identify master policy number, if available. \\
__Repeat: __1 \\
||__Note: __Required __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
\\
__Processing:__\\
\\
This record always created,
one record per file.\\
\\
__''DTP – File Effective Dates __\\ ''
__Purpose: __To identify employee enrollment date \\
__Repeat: __>1\\
||__Note: __Required __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)
\\
__Processing:__\\
\\
This record always created,
one record per file.\\
\\
__''1000A N1 – Sponsor Name __\\ ''
__Purpose: __To identify the entity paying for the coverage \\
__Repeat: __1 \\
||__Note: __Required __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)
\\
__Processing:__\\
\\
This record always created,
one record per file.\\
\\
__''1000B N1 – Payer Name __\\ ''
__Purpose: __To identify the insurance company providing coverage \\
__Repeat: __1 \\
||__Note: __Required __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)
\\
__Processing:__\\
\\
This record always created,
one record per file.\\
\\
__''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 __\\ \\ __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.
\\
__Processing:__\\
\\
This record always created,
one record per file.\\
\\
__''2000 INS – Insured Benefit __\\ ''
__Purpose: __To provide benefit information on each insured member \\
__Repeat: __>1\\
||__Note: __Required __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. \\
\\
__Processing:__\\
\\
One record per employee
(subscriber), and one record for each dependant.\\
\\
__''2000 REF – Subscriber Number __\\ ''
__Purpose: __To specify identifying information \\
__Repeat: __1\\
||__Note: __Required __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)
\\
__Processing:__\\
\\
__''2000 REF – Group Policy Number __\\ ''
__Purpose: __To identify the group or policy number \\
__Repeat: __1\\
||__Note: __Required __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)
\\
__Processing:__\\
\\
__''2000 REF – Member Identification Number __\\ ''
__Purpose: __To identify the group or policy number \\
__Repeat: __1 \\
||__Note: __Situational - if member is enrolled in Medicare
__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.
\\
__Processing:__\\
\\
__''2000 DTP – Member Level Dates __\\ ''
__Purpose: __To identify member level dates \\
__Repeat: __>1\\
||__Note: __Required. __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
\\
__Processing:__\\
\\
__''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)
\\
__Processing:__\\
\\
__''2100A PER – Member Communications Numbers __\\ ''
__Purpose: __To supply member contact information \\
__Repeat: __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)
\\
__Processing:__\\
\\
__''2100A N3 – Member Residence Street Address __\\ ''
__Purpose: __To supply employee/member Street address \\
__Repeat: __1 \\
||__Note: __Required for Subscriber __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 __
\\
__Processing:__\\
\\
__''2100A N4 – Member Residence City,State,Zip __\\ ''
__Purpose: __To supply employee/member City,State,Zip \\
__Repeat: __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)
\\
__Processing:__\\
\\
__''2100A DMG– Member Demographics __\\ ''
__Purpose: __To supply employee/member birth date, gender, marital
status, and citizenship status. \\
__Repeat: __1 \\
||__Note: __Required. __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)\\
\\
__Processing:__\\
\\
__''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 __\\ \\ __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
\\
__Processing:__\\
\\
__''2100C N3 – Member Mailing Street Address __\\ ''
__Purpose: __To supply employee/member Street address from 2100C
loop \\
__Repeat: __1 (note segments ‘2100C’ will only be created if applicable)\\
||__Note: __Situational __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)
\\
__Processing:__\\
\\
__''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 __\\ \\ __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
\\
__Processing:__\\
\\
__''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)
\\
__Procesisng:__\\
\\
__''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)
\\
__Processing:__\\
\\
__''2300 HD – Health Coverage __\\ ''
__Purpose: __To provide information on employee/member health
coverage \\
__Repeat: __>1\\
||__Note: __Required __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. \\
\\
__Processing:__\\
\\
__''2300 DTP – Member Benefit Dates __\\ ''
__Purpose: __To identify employee benefit dates \\
__Repeat: __>1\\
||__Note: __Required __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
\\
__Processing:__\\
\\
__''2300 REF- Member Policy Number __\\ ''
__Purpose: __To identify member group number \\
__Repeat: __1 \\
||__Note: __Situational __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.
\\
__Processing:__\\
\\
__''SE - Transaction Set Trailer __\\ ''
__Purpose: __To identify end of transaction set and provide count of
transmitted segments \\
__Repeat: __1 \\
||__Note: __Required __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.
\\
__Processing:__\\
\\
__''GE – Functional Group Trailer __\\ ''
__Purpose: __To identify the end of a transaction set \\
__Repeat: __1 \\
||__Note: __Required __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.
\\
__Processing:__\\
\\
__''IEA – Interchange Control Trailer __\\ ''
__Purpose: __To define the end of an Interchange \\
__Repeat: __1 \\
||__Note: __Required __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
\\
__Processing:__\\
\\
\\
\\