834 Companion Guide

834 Companion Guide

Effective Date: 1/1/2016

General Information

This companion guide is a supplement to the HIPAA 834 Benefit and Enrollment Maintenance ASC version X12N/005010X220A1.

This guide highlights the required message segments and notes any specifics about elements within the required segments.

This companion guide does not cover all segments specified in the HIPAA 5010 X12 Implementation Guides.

By agreeing to trade data with North America Administrators you are assuming the liability and ownership for the quality of data we load. Our commitment is to faithfully load the data as we receive it, under the assumption that any quality control has been managed and approved before sending the data.

File Format

Data files must be in all upper case letters

EDI Message Delimiters

Delimiter / Value
Segment Terminator / ‘~’ (tilde)
Data Element Separator / ‘*’ (asterisk)
Sub-Element Separator / ‘:’ (colon)

File Transmission Requirements

North America Administrators does not provide an FTP account in any trading partner scenario. The preferred option is to pick up the file from the trading partner’s FTP server. If you can’t provide an FTP connection than we can receive the file via secure email.

Full Files versus Transaction File

North America Administrators will only receive Full Files.

Subscriber / Dependent Requirements

Any submission of a dependent must follow the submission of the Subscriber. In other words a dependent record will be rejected if there is no subscriber record.

Segment: / ISA Interchange Control Header
Level: / Detail
Usage: / Required – By Implementation Guide

Data Element Summary

Ref Des / Element Name / Element Note
ISA07 / Interchange ID Qualifier / Enter code value: ZZ
ISA08 / Interchange Receiver ID / Enter Value: 650851416

Example

ISA*00* *00* *ZZ*ABCDEFG *ZZ*650851416 *151223*0702*^*00501*001714057*0*P*:~

Segment: / GS Functional Group Header
Level: / Detail
Usage: / Required – By Implementation Guide

Data Element Summary

Ref Des / Element Name / Element Note
GS03 / Application Receiver’s Code / Enter Value: 650851416

Example

GS*BE*ABCDEFG*650851416*20151223*0702*1*X*005010X220A1~

Segment: / DTP File Effective Date
Level: / Header
Usage: / Required – By Implementation Guide

Data Element Summary

Ref Des / Element Name / Element Note
DTP01 / Date/Time Qualifier / The following values are accepted
-  007 (File Effective Date)
-  303 (Maintenance Effective Date)
DTP02 / Date/Time Period Format Qualifier / Value: D8 (Date Expressed in Format CCYYMMDD)
DPT03 / Date/Time Period / Value: Date Associated with file

Note – we allow entry of multiple DPT (File Effective Date) segments.

Example1

DTP*007*D8*20150225~

Example2

DTP*007*D8*20160203~

DTP*303*D8*20160210~

Segment: / QTY File Effective Date
Level: / Header
Usage: / Not Required But Requested

Data Element Summary

Ref Des / Element Name / Element Note
QTY01 / Quantity Qualifier / The following values are accepted
-  DT (Dependent Total)
-  ET (Employee Total)
-  TO (Total)
QTY02 / Quantity / This is the quantity value associated with the qualifier

Note: NAA prefers to receive all 3 QTY segments but it is not required.

Example 1

QTY*DT*272~

Example 2

QTY*ET*215~

Example 3

QTY*TO*487~

Segment: / N1 Sponsor Name
Level: / Header
Usage: / Required

Data Element Summary

Ref Des / Element Name / Element Note
N101 / Entity Identifier Code / Enter Code: P5
N102 / Name / Enter Value: Value is Free From – enter Plan Sponsor’s Name. This should be the group requesting you to send EDI on their behalf.
N103 / Identification Code Qualifier / Enter Value: FI (Federal Taxpayer’s Identification Code)
N104 / Identification Code / Enter Value of Federal Taxpayer’s Identification Code

Example 1

N1*P5*ABC COMPANY*FI*123456789~

Segment: / N1 Payer
Level: / Header
Usage: / Required

Data Element Summary

Ref Des / Element Name / Element Note
N101 / Entity Identifier Code / Enter Code: IN
N102 / Name / Enter Value: North America Administrators
N103 / Identification Code Qualifier / Enter Value: FI (Federal Taxpayer’s Identification Code)
N104 / Identification Code / Enter Value of Federal Taxpayer’s Identification Code

Example 1

N1*IN*North America Administrators*FI*650851406~

Segment: / INS Member Level Detail
Level: / Detail
Usage: / Required

Data Element Summary

Ref Des / Element Name / Element Note
INS02 / Individual Relationship Code / The following values are accepted:
01 (Spouse)
09 (Adopted Child)
10 (Foster Child)
17 (Stepson or Stepdaughter)
25 (Ex-Spouse)
53 (Life Partner)
INS03 / Maintenance Type Code / Enter Value: 030
INS04 / Maintenance Reason Code / Enter Value: XN (not required, but if sent, please use XN)

Example 1

INS*Y*18*030*XN*A***FT~

Segment: / REF Subscriber Number
Level: / Detail
Usage: / Required

Data Element Summary

Ref Des / Element Name / Element Note
REF01 / Reference ID Qualifier / Enter code value: 0F
REF02 / Reference Identification / Enter the value of the subscriber’s ID.

Example 1

REF*0F*123456789~

Segment: / REF Member Policy Number
Level: / Detail
Usage: / Required by North America Administrators

Data Element Summary

Ref Des / Element Name / Element Note
REF01 / Reference ID Qualifier / Enter code value: IL
REF02 / Reference Identification / Enter the value provided by North America Administrators that represents the Group’s business ID with North America Administrators.

Example 1

REF*1L*100153~ (where 100153 is a North America Administrators internal number)

Segment: / REF Member Supplemental Identifier
Level: / Detail
Usage: / Required by North America Administrators

Data Element Summary

Ref Des / Element Name / Element Note
REF01 / Reference ID Qualifier / Enter code value: DX
REF02 / Reference Identification / Enter the value provided by North America Administrators that represents the Group’s business units breakdown (divisions, departments, etc). This data will be provided by North America Administrators

Example1

REF*DX*02~ (Where 02 is a division in the North America Administrator’s claim system)

Segment: / DTP Member Level Dates (Hire Date)
Level: / Detail
Usage: / Not Required But Requested

Data Element Summary

Ref Des / Element Name / Element Note
DTP01 / Date/Time Qualifier / Enter code value: 336
DTP02 / Date/Time Value / Enter Value in format CCYYMMDD

Example1

DTP*336*D8*20110620~

Segment: / NM1 Member Name
Level: / Detail
Usage: / Required

Data Element Summary

Ref Des / Element Name / Element Note
NM101 / Entity Code Qualifier / Enter code value: IL
Nm108 / Identification Code Qualifier / Enter Value: 34

Example1

NM1*IL*1*DOE*JOHN****34*123456789~

Segment: / N3 Member Residence Street Address
Level: / Detail
Usage: / Required by North America Administrators

Data Element Summary

Ref Des / Element Name / Element Note
N301 / Address Information / Free Form field. Enter Address

Example1

N3*8316 Imaginary Lane~

Segment: / N4 Member City, State, Zip Code
Level: / Detail
Usage: / Required by North America Administrators

Data Element Summary

Ref Des / Element Name / Element Note
N401 / City Name / Enter Value: Free Form
N402 / State or Provence / Enter Value: 2 digit State Code
N403 / Postal Code / Enter Value: Valid US Postal Code

Example1

N4*Nashville*TN*37210~

Segment: / DMG Member Demographics
Level: / Detail
Usage: / Required by North America Administrators

Data Element Summary

Ref Des / Element Name / Element Note
DMG01 / Date/Time Format Qualifier / Enter code value: D8
DMG02 / Date/Time Period / Enter Value: CCYYMMDD (Date of Birth)
DMG03 / Gender Code / Enter Value: M,F,U
DMG04 / Marital Code / Enter Value: Choose From the following
-  I = Single
-  M = Married
-  D = Divorced

Example1

DMG*D8*19550128*M*M~

Segment: / ICM Member Income
Level: / Detail
Usage: / Not Required

Data Element Summary

Ref Des / Element Name / Element Note
ICM01 / Frequency Code / Enter code value: 7
ICM02 / Monetary Amount / Enter Value: Enter amount with decimals

Example1

ICM*7*65000.00~

Segment: / HD Health Coverage
Level: / Detail
Usage: / Required

Data Element Summary

Ref Des / Element Name / Element Note
HD01 / Maintenance Type Code / Enter code value: 30
HD03 / Coverage Code / Enter Value:
-  HLT
-  PDG
-  VIS
-  DEN
Note: For some special elections we may require custom codes for HLT03
HD04 / Plan Coverage Description / Enter Value: Free Form
HD05 / Coverage Level Code / Enter Value:
-  FAM (Family)
-  ECH (Employee + Children)
-  ESP (Employee + Spouse)
-  EMP (Employee Only)
**Only Required when INS01 = “Y” and INS02 = “18”

Example1

HD*030**HLT*100153MEDA6NG*FAM~

Important Information

North America Administrators requires a HD*030**PDG segment to be sent with each HD*030**HLT segment. The value of HD04 for the PDG segment will be different than the value for the HD04 HLT segment. These corresponding plan values will be provided to you during the project data mapping phase.

Example1

HD*030**HLT*002996MED124*EMP~

DTP*348*D8*20150101~

DTP*349*D8*20151231~

HD*030**PDG*002996RXD*EMP~

DTP*348*D8*20150101~

DTP*349*D8*20151231~

Segment: / DTP Health Coverage Dates
Level: / Detail
Usage: / Required

Data Element Summary

Ref Des / Element Name / Element Note
DTP01 / Date / Time Qualifier / Enter code value:
-  348 (Benefit Begins)
-  349 (Benefit Ends)
DTP02 / Date / Time Qualifier / Enter Value: D8

Example1 – Effective Date for Benefit

DTP*348*D8*20120101~

Example2 – Termination Date for Benefit

DTP*349*D8*20120101~

Note: Any benefit sent with a DTP*348 remains active in our enrollment system until a DTP*349 segment is sent.

Example3 – When an active member is sent with a termination date

HD*030**HLT*002996MED124*EMP~

DTP*348*D8*20150101~

DTP*349*D8*20151231~

Special Section: Flex (FSA) Data

This section describes how you can add non standard segments to the 834 to pass FSA related data (Flexible Spending, Dependent Care, etc)

Note: For all HD segments that represent a FSA type benefit, a valid DTP*349 must be sent along wit h the DTP*348 segment. In the example below this pairing of DTP segments indicate the coverage for the benefit goes from 1/1/2015 to 12/31/2015.

DTP*348*D8*20150101~ (beginning date)

DTP*349*D8*20151231~ (ending date)

There are two configurations received by North America Administrators. Our preferred method is Example 1.

Example 1

In example 1 the AMT*B9 segment is sent directly after the last DTP segment in Loop 2300.

HD*030**FXM*002996FSA*IND~ (beginning of Loop 2300)

DTP*348*D8*20150101~ (beginning date)

DTP*349*D8*20151231~ (ending date)

AMT*B9*20.00~ (amt*B9 = per pay period contribution)

HD*030**HLT*002996MED124*EMP~ (start of new Loop 2300)

The required segments are FSA, AMT*P3, AMT*B9.

Example2:

FSA*030*FXM~

AMT*P3*520.00~

AMT*B9*20.00~

These segments are to be placed after the last DTP segment for the subscriber and should only be sent for the subscriber. Any FSA related segments sent for a dependent member level detail will be ignored.

Segment: / FSA Health Coverage
Level: / Detail
Usage: / Not Required But Requested

Data Element Summary

Ref Des / Element Name / Element Note
FSA01 / ID Qualifier / Enter code value: 030
FSA02 / FSA Coverage Value / Enter Value: Custom Value agreed upon during mapping phase.
Segment: / AMT Flexible Spending Monetary Amounts
Level: / Detail
Usage:

Data Element Summary

Ref Des / Element Name / Element Note
AMT01 / Amount ID Qualifier / Enter code value:
-  P3 (Annual Contribution)
-  B9 (Per Period Contribution)
AMT02 / Amount / Enter Value: Decimal required.

Example1 – Annual Amount for Benefit

AMT*P3*2500.00~

Example2 – Per Pay Period Amount for Benefit.

AMT*B9*20.00~

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