RBINTERFACE

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.



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 021 60 Char N1P5-Payer Name
50 3 N1(Identifier P5) segment 031 2 Char ‘FI’
50 4 N1(Identifier P5) segment04 1 80 Char N1P5-Payer Identification Code
52 2 N1(Identifier IN) segment 021 6 Char N102 = The name of the client group
52 3 N1(Identifier IN) segment 031 2 Char ‘FI’
52 4 N1(Identifier IN) segment 041 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_LOCATIONmember supplemental number('2000 REF02 DX')
P2K_BE_BENEFIT_RECIPIENTSPRIME PHYSICIANPHYSICIAN information
P2K_HR_CONTACTS MARITAL_STATUS Marital status
P2K_HR_ASSIGNMENT_DETAILSREF_17member supplemental number('2000 REF02 17')
P2K_CM_DEPARTMENT_DETAILSREF_17member supplemental number('2000 REF02 17')
P2K_CM_POSITION_DETAILS REF_17member supplemental number('2000 REF02 17')
P2K_BE_COVERAGES REF_17member supplemental number('2000 REF02 17')


SYSTEM PROCESSING#

Processing Sequence#


Record SegmentCodeDescriptionProcessing Conditions
1000A N1P5Plan SponsorOne per File
1000B N1INInsurerOne per File
1000C N1TVTPA/Broker NameSituational
2000 INSYMember is a SubscriberOne record only, either ‘Y’ or ‘N’
2000 INSNMember is a Dependant
2000 REF0FSubscriber Number
2000 REF1LGroup Number
2000 REFF6Medicare HIC NumberSituational
2000 DTP303Maintenance Effective Date
2000 DTP336Employ Begin Date (Subscriber only)
2000 DTP338Medicare Begin Date
2000 DTP339Medicare End Date
2000 DTP356Eligibility Begin Date
2000 DTP357Eligibility End/ Termination Date
2000 DTP394Rehire DateSituational
2100A NM1ILMember Name
2100A PERIPMember Communication NumbersSituational
2100A N3 Member Resident Street AddressRequired for Subscriber segment
2100A N4 Resident City, State, ZIPRequired if Segment ‘2100A N3’ is sent
2100A DMG Member Demographics
2100A NM131Member Mailing AddressSituational
2100C N3 Member Mailing Street AddressSituational
2100C N4 Mailing City, State, ZIPSituational
2200 DSB2Long Term DisabilitySituational
2200 DTP360Disability Begin DateSituational
2200 DTP361Disability End DateSituational
2300 HD001Health Coverage ChangeOne record code only
2300 HD021Health Coverage AddOne record code only
2300 HD024Health Coverage TerminationOne record code only
2300 HD030Maintenance Type Code UnknownOne record code only
2300 DTP348Benefit Begin Date
2300 DTP349Benefit End Date
2300 REF1LMember Policy Number

Report Parameters#

Report ParametersDescription
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 FileValue 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 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
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 IDElementField NameReq?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 information 
Repeat:
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 ElementField Name Req?Description (HLC source)
GS 01 Functional Identifier Code IDIF definition Rec#20 Field#1 (constant value)
GS 02 Sender’s Code IDIF definition Rec#20 Field#2 (constant value)
GS 03 Receiver’s Code IDIF definition Rec#20 Field#3 (constant value)
GS 04 Date YYMMDD (system date)
GS 05 Time HHMM (system time)
GS 06 Group Control Number Created by Sender 

Must be identical in GE02 (from Report run time parameter setting, ‘GS Control Number’)
GS 07 Responsible Agency’s Code IDIF definition Rec#20 Field#7 (constant value)
GS 08 Version/Release Code 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 number 
Repeat:
Note: Required
Processing: This record is always created, one record per file.

Segment ID ElementField Name Req?Description (HLC source)
ST 01 Transaction Set Header 834 
ST 02 Transaction Set Control Number 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 IDIF definition Rec#20 Field#8 (constant value)


BGN – Beginning Segment #

Purpose: To indicate the beginning of a transaction set
Repeat: 1
Note: Required Segment
Processing: Always create this record, one per file.

Segment ID ElementField 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 ElementField 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’)
REF03Reference NameYClient name provided by the client in IDIF


DTP – File Effective Dates#

Purpose: To identify employee enrollment date
Repeat: >1
Note: Required Segment
Processing: This record always created, one record per file.

Segment ID ElementField 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 coverage
Repeat: 1
Note: Required Segment
Processing This record always created, one record per file.


Segment ID ElementField 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 coverage
Repeat: 1
Note: Required Segment
Processing: This record always created, one record per file.


Segment ID ElementField 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 ElementField 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 member
Repeat: >1
Note: Required Segment ID
Processing: One record per employee (subscriber), and one record for each dependant.

Segment ID ElementField 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 information
Repeat: 1
Note: Required Segment

Segment ID ElementField 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 number
Repeat: 1
Note: Required Segment
Segment ID ElementField 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 number
Repeat: 1
Note: Situational - if member is enrolled in Medicare Segment
Segment ID ElementField 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 dates
Repeat: >1
Note: Required Segment

Segment ID ElementField 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 ElementField 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 information
Repeat: 1
Note: If only one phone number is available, send it in the first available slot.

Segment ID ElementField 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 address
Repeat: 1
Note: Required for Subscriber Segment
Segment ID ElementField 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,Zip
Repeat: 1
Note: Required if N3 segment sent

Segment ID ElementField 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 ElementField 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 ElementField 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 loop
Repeat: 1 (note segments ‘2100C’ will only be created if applicable)
Note: Situational Segment
Segment ID ElementField 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 ElementField 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 ElementField 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 ElementField 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 ElementField Name Req?Description (HLC source)
HD 01 Maintenance Type Code Y001 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 dates
Repeat: >1
Note: Required Segment

Segment ID ElementField 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 number
Repeat: 1
Note: Situational Segment

Segment ID ElementField 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 segments
Repeat: 1
Note: Required Segment

Segment ID ElementField Name Req?Description (HLC source)
SE 01 Number of Segments YSystem counter.
SE 02 Transaction Set Control Number YSame as the ‘Transaction Set Control Number’ in the ST segment.


GE – Functional Group Trailer#

Purpose: To identify the end of a transaction set
Repeat: 1
Note: Required Segment

Segment ID ElementField 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 Interchange
Repeat: 1
Note: Required Segment

Note: Required Segment

ID
Segment ID ElementField 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\\