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 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)

2) The following User Defined Feld (UDF) is required on IMUF.#

Data Base Table UDF Name Used in Segment ^
P2K_BE_COVERAGES REF_DX_LOCATIONmember supplemental number('2000 REF02')
P2K_BE_BENEFIT_RECIPIENTSPRIME PHYSICIANPHYSICIAN 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 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
  • The following record segments will be written at the end of the file:  “SE’, ‘GE’, ‘IEA’.

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
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 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


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’)

REF03Reference NameYClient 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 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. 


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 YSystem
counter.

SE 02 Transaction Set Control Number YSame 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’)

REF03Reference NameYClient 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 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. 


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 YSystem
counter.

SE 02 Transaction Set Control Number YSame 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:




 

This particular version was published on 26-Nov-2021 10:22 by Kevin Higgs.Top