834 Benefit Enrollment and Maintenance 5010 Companion Guide · REF Member Supplemental Identifier...

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834 Benefit Enrollment and Maintenance 5010 Companion Guide HIPAA/V5010220A1/834 Version 1.3 Company: Blue Cross of Idaho Created 5/29/2013 Updated 1/21/2016 An Independent Licensee of the Blue Cross and Blue Shield Association

Transcript of 834 Benefit Enrollment and Maintenance 5010 Companion Guide · REF Member Supplemental Identifier...

Page 1: 834 Benefit Enrollment and Maintenance 5010 Companion Guide · REF Member Supplemental Identifier Situational Ref # ID Name Req. Codes Notes REF01 128 Reference Identification Qualifier

834 Benefit Enrollment and Maintenance 5010

Companion Guide

HIPAA/V5010220A1/834

Version 1.3

Company: Blue Cross of Idaho Created 5/29/2013

Updated 1/21/2016

An Independent Licensee of the Blue Cross and Blue Shield Association

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Table of Contents Introduction ........................................................................................................................................................................3

Enrollment .........................................................................................................................................................................3

EDI File ..........................................................................................................................................................................4

Notations and Conventions in This Guide ........................................................................................................................4

ISA Interchange Control Header ..............................................................................................................................5

GS Functional Group Header ..................................................................................................................................5 ST Transaction Set Heade r......................................................................................................................................6

BGN Beginning Segment.............................................................................................................................................6

REF Transaction Set Policy Number .........................................................................................................................7

DTP File Effective Date ..............................................................................................................................................7

Q TY Transaction Set Control Total ...........................................................................................................................7

1000A N1 Sponsor Name ....................................................................................................................................................8

1000B Loop Payer N1 Payer ..................................................................................................................................................................8

1000C Loop TPA/Broker Name N1 TPA/Broker Name .............................................................................................................................................9

1100C Loop TPA/Broker Account Information ACT TPA/Broker Account Information .....................................................................................................................9

2000 Loop Member Level Detail INS Member Level Detail........................................................................................................................................10

REF Subscriber Identifier ........................................................................................................................................11

REF Member Policy Number ...................................................................................................................................11

REF Member Supplemental Identifier.....................................................................................................................11

DTP Member Level Dates ........................................................................................................................................12

2100A Loop Member Name NM1 Member Name..................................................................................................................................................13

PER Member Communications Numbers ................................................................................................................13

N3 Member Residence Street Address ..................................................................................................................14

N4 Member City, State, ZIP Code.........................................................................................................................14

DMG Member Demographics ....................................................................................................................................14

2300 Loop Health Coverage HD Health Coverage...............................................................................................................................................16

DTP Health Coverage Dates.....................................................................................................................................17

REF Health Coverage Policy Number......................................................................................................................17

AMT Health Coverage Policy ....................................................................................................................................18

2310 Loop Provider Information LX Provider Information .......................................................................................................................................19

NM1 Provider Name .................................................................................................................................................19

N3 Provider Address .............................................................................................................................................20

N4 Provider City, State , Zip Code .........................................................................................................................20

PER Provider Communications Numbers................................................................................................................20

PLA Provider Change Reason..................................................................................................................................21

2500 Loop Flexible Spending Account FSA Flexible Spending Account...............................................................................................................................22

AMT Monetary Amount Information .......................................................................................................................23

DTP Date or Time or Period ....................................................................................................................................23

SE Transaction Set Trailer ....................................................................................................................................24 GE Functional Group Trailer ................................................................................................................................24

IEA Interchange Control Trailer ............................................................................................................................24

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1 Introduction

1.1 Disclaimer Blue Cross of Idaho (BCI) created this Companion Guide for 834 Benefit Enrollment and

Maintenance, to use in conjunction with the 5010A1 version of the ANSI X12 Implementation Guide. This document is not a replacement for the ANSI X12 Implementation Guide, but as an additional source of information created to assist employers and business partners of Blue Cross of Idaho. The Implementation Guide is available from the Washington Publishing Company

website at http://www.wpc-edi.com/

1.2 Document Purpose The purpose of this companion guide is to describe those aspects of processing an electronic 834 Benefit Enrollment and Maintenance requests that are specific to Blue Cross of Idaho. This companion guide contains data clarifications derived from specific business rules that apply

exclusively to claims processing done by Blue Cross of Idaho. In addition, this guide includes useful information about sending and receiving data to and from Blue Cross of Idaho. Though Blue Cross of Idaho continually updates this document, the current version is always

available on the website bcidaho.com

2 Enrollment

2.1 EDI Support The Blue Cross of Idaho EDI Support Desk assists users with questions about electronic transactions. The Blue Cross of Idaho EDI Support Desk is available to all Idaho providers and vendors Monday through Friday from 8:00 a.m. to 5:00 p.m. MST at 208-331-8817 or

888-224-3341. The Blue Cross of Idaho EDI Support Desk:

Provides information on services offered

Enrolls users for claims submission and data retrieval and vendors for 27x transactions

Verifies receipt of electronic transmissions

Provides technical assistance to users who are experiencing transmission difficulties

2.2 General Business Information Blue Cross of Idaho complies with HIPAA regulations. Below are specific coding requirements used by Blue Cross of Idaho, but the eligibility information returned by Blue Cross of Idaho is not a guarantee of claims payment. Blue Cross of Idaho responds to all eligibility requests with the coverage information available for the patient identified, per the date provided.

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3 EDI File

The EDI file naming convention is GroupName_elig_edi834_ccyymmdd.dat, where GroupName indicates the name of the Group whose members are shown in the file, and ccyymmdd is the file date. For test files, please use a filename that is not in this format, for example GroupName_Test_ccyymmdd.txt.

The format of the file is text, with an element separator of asterisk (*) and segment terminator of tilde (~).

4 Notations and Conventions in This Guide Under each Segment header it will say either Required or Situational. Required means the

segment must always be sent. Situational means the segment can be sent at the sender’s discretion or conditionally required by the receiver.

The “Req.” (Required) column describes whether the element is required, given the segment is present.

In cases where Date Time Period Qualifier is populated, the associated Date Time Period element must be populated, and vice versa.

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ISA Interchange Control Header

Required

Ref # ID Name Req. Codes Notes ISA01 101 Authorization Number Y 00

ISA02 102 Code set Summary Y Should contain spaces or

zeroes (0000000000). ISA03 103 Security information

Qualifier

Y 00

ISA04 104 Security information Y Should contain spaces or zeroes (0000000000).

ISA05 105 Interchange ID Qualifier Y 30 Denotes Federal Tax ID in the following segment.

ISA06 106 Interchange Sender ID Y Federal Tax ID of the sender

ISA07 105 Interchange ID Qualifier Y 30 Denotes Federal Tax ID in the following segment.

ISA08 107 Interchange Receiver ID Y 820344294 BCI Federal Tax ID

ISA09 108 Interchange Date Y CCYYMMDD Date of the interchange ISA10 I09 Interchange Time Y HHMM Time of the interchange

ISA11 I65 Repetition Separator Y ̂ Separator used to identify

repeated data within an element

ISA12 111 Interchange Control Version Number

Y 00501 Code used to identify the version submitted

ISA13 I12 Interchange Control Number

Y Unique number identified by the sender

ISA14 I13 Acknowledgment Requested

Y 0 A code sent by the submitter requesting acknowledgement

ISA15 I14 Interchange Usage Indicator

Y P, T Code indicating Production or Test

ISA16 I15 Component Element Separator

Y > Delimiter separator

GS Functional Group Header

Required

Ref # ID Name Req. Codes Notes

GS01 479 Functional Identifier

Code

Y BE Code identifying the

application related transaction sets

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GS02 142 Application Senders Code

Y Federal Tax ID of the Sender (Can also be another code identified by the sender)

GS03 124 Application Receivers Code

Y Code identifying receiving transmission (code must be agreed upon by sender and

receiver)

GS04 373 Group Date Y CCYYMMDD GS05 337 Group Time Y HHMMSSDD

GS06 28 Group Control Number

(must match GE02)

Y Unique Number created by

Sender GS07 455 Responsible Agency

Code

Y X Code identified by the

standard

GS08 480 Version/Release Code Y 005010X220A1

ST Transaction Set Header

Required

Ref # ID Name Req. Codes Notes

ST01 143 Transaction Set Identifier

Y 834 Code identifying Transaction Set

ST02 329 Transaction Set Control

Number

Y Unique Number that must be

unique to each transaction ST03 1705 Implementation

Convention Reference

Y 005010X220A1 Reference assigned to

Identify Implementation Convention

BGN Beginning Segment

Required

Ref # ID Name Req. Codes Notes

BGN01 353 Transaction Set Purpose Code

Y 00 00=Original

BGN02 127 Reference Identification Y 1 Reference information for a particular Transaction Set

BGN03 373 Date Y File date in format CCYYMMDD

BGN04 337 Time Y File time in format HHMM (24 hour clock)

BGN05 623 Time Code Y MT Time zone – Mountain Time

BGN06 127 Reference Identification N Not Used.

BGN07 Transaction Type Code N Not Used.

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BGN08 306 Action Code Y 2, 4 2=Change(update), 4=Verify

REF Transaction Set Policy Number

Situational

Ref # ID Name Req. Code(s) Notes

REF01 128 Reference Identification Qualifier

38

REF02 127 Reference Identification Y Master Policy Number

DTP File Effective Date

Situational

Ref # ID Name Req. Codes Notes

DTP01 374 Date/Time Qualifier Y 007 Code indicating date or time or both

DTP02 1250 Date Time Qualifier Y D8 Code indicating date, time or date and time format CCYYMMDD

DTP03 1251 Date Time Period Y CCYYMMDD Actual date, time or range of

dates, times or dates and times.

QTY Transaction Set Control Totals

Situational

Ref # ID Name Req. Codes Notes QTY01 673 Quantity Qualifier Y DT, ET, TO Code specifying the type of

quantity. DT = Dependent Total ET = Employee Total TO = Total

QTY02 380 Quantity Y Numeric value of quantity

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Loop 1000A

N1 Sponsor Name

Required

Ref # ID Name Req. Codes Notes

N101 98 Entity Identifier Code Y P5 Code identifying a physical location, property or individual

N102 93 Name Y Sponsor/Group name

N103 66 Code Qualifier Y FI Denotes Federal Tax ID in following element

N104 67 Identification Code Y Federal Tax ID of the Sponsor/Group

At least one of N102 or N103 is required

Loop 1000B

N1 Payer

Required

Ref # ID Name Req. Codes Notes

N101 98 Entity Identifier Code Y IN Organizational entity, physical location, property or individual

N102 93 Name Y Blue Cross of Idaho

N103 66 Identification Code

Qualifier

N FI Denotes Federal Tax ID in

following element N104 67 Identification Code N 820344294 BCI’s Federal Tax ID

If N103 or N104 is present then the other is also required.

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Loop 1000C

N1 TPA/Broker Name

Ref # ID Name Req. Codes Notes

N101 98 Entity Identifier Code Y BO,

TV

BO=Broker or Sales Office

TV=Third Party Administrator

N102 93 Name Y TPA/Broker Name

N103 66 Code Qualifier N 94,

FI,

XV

Denotes type of identifier in

following element. 94=Code

assigned by receiver

FI=Federal Tax ID

XV=CMS Plan ID

N104 67 Identification code N Code referenced in N103

At least N102 or N103 is required.

Loop 1100C

ACT TPA/Broker Account Information

Situational

Ref # ID Name Req. Codes Notes

ACT01 508 Account Number Y TPA/Broker Account number

assigned

ACT06 508 Account Number N TPA/Broker second, optional

account number assigned

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Loop 2000

INS Member Level Detail

Required

Ref # ID Name Req. Codes Notes

INS01 1073 Yes/No Condition Y Y, N Subscriber indicator

Y=insured is subscriber N=insured is a dependent

INS02 1069 Individual Relationship Code

Y 01,18, 19

01=Spouse, 18=Self, 19=Child (See Implementation Guide for complete list)

INS03 875 Maintenance Type Code Y 001, 021, 030

001=Change, 030=Audit or Compare (030 should always be used for full files)

INS04 1203 Maintenance Reason Code Y XN Codes to identify maintenance change entities

(see Guide for complete list)

INS05 1216 Benefit Status Code Y A Actual code identifying Status. A=Active

INS06 C052 Medicare Status Code N Blank, D, E

Identifies Medicare coverage and associated reason for Medicare Eligibility. D=Medicare, E=No Medicare

INS06-

01

1218 Medicare Plan Code N Code identifying Medicare Plan

Required when INS06 is used INS06-

02

1701 Eligibility Reason Code N Reason for Eligibility

INS07 1219 Consolidated Omnibus Budget

N Please leave blank

INS08 584 Employment Status Code Y FT, PT, RT

Code displaying employment status of claimant

INS09 1220 Student Status Code N F, N, P

Code displaying student status of a patient if 19 or older, not

handicapped and not insured INS10 1073 Condition Response code N Y/N Handicapped indicator.

Y=Handicapped, N=not handicapped

INS11 1250 Date Time Period Qualifier

N D8

INS12 1151 Date Time Period N Date of Death in format CCYYMMDD

INS13 1165 Confidentiality Code N Please leave blank

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INS17 1470 Number N Generic Number if family members have the same birthdate (For dependents)

REF Subscriber Identifier

Required

Ref # ID Name Req. Codes Notes

REF01 128 Reference Identification Qualifier

Y 0F Reference Identification for Subscriber number

REF02 127 Reference Identification Y Social Security Number of the Subscriber

REF Member Policy Number

Required

Ref # ID Name Req. Codes Notes

REF01 128 Reference Identification Qualifier

Y 1L

REF02 127 Reference Identification Y BCI supplied 8-digit Group Number

REF Member Supplemental Identifier

Situational

Ref # ID Name Req. Codes Notes

REF01 128 Reference Identification Qualifier

N 23 23=Client Number

REF02 127 Reference Identification N Company Assigned Employee ID If REF02 is present, REF03 is required.

Required

Ref # ID Name Req. Codes Notes REF01 128 Reference Identification

Qualifier

Y DX DX=Department/Agency Number

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REF02 127 Reference Identification Y BCI supplied Subgroup Number Required

Ref # ID Name Req. Codes Notes

REF01 128 Reference Identification

Qualifier

Y 17 17=Client Reporting Category

REF02 127 Reference Identification Y BCI supplied Class Code or

Benefit Level Code

DTP Member Level Dates

Required

Ref # ID Name Req. Codes Notes

DTP01 374 Date Time Qualifier Y 336, 337

336=Employment Begin Date 337=Employment End Date

DTP02 1250 Date Time Period Qualifier

Y D8

DTP03 1251 Date Time Period Y Date in format CCYYMMDD

Situational

Ref # ID Name Req. Codes Notes

DTP01 374 Date Time Qualifier Y 356, 357

356=Eligibility Begin Date 357=Eligibility End Date

DTP02 1250 Date Time Period Qualifier

Y D8

DTP03 1251 Date Time Period Y Date in format CCYYMMDD

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Loop 2100A

NM1 Member Name

Required

Ref # ID Name Req. Codes Notes

NM101 98 Entity ID Y IL

NM102 1065 Entity Type Qualifier Y 1

NM103 1035 Last Name or Org Name Y Last name or Organizational Name

NM104 1036 Name, First Y First Name

NM105 1037 Name, Middle N Middle Name or Initial

NM106 1038 Name Prefix N Prefix to Name NM107 1039 Name Suffix N Suffix to Name

NM108 66 Identification Code

Qualifier

N 34 Denotes NM109 is a Social

Security Number, required if NM109 is populated.

NM109 67 Identification Code N Social Security Number. Numeric characters only.

PER Member Communications Numbers

Situational

Ref # ID Name Req. Codes Notes

PER01 366 Contact Function Code Y IP IP=Insured Party

PER03 365 Communication Number Qualifier

N HP, TE

TE=Telephone, HP= Home Phone

PER04 364 Communication Number N Actual phone number if PER03 is populated. Only numeric characters.

PER05 365 Communication Number Qualifier

N EM EM=Email

PER06 364 Communication Number N Email address if PER05 is

populated PER07 365 Communication Number

Qualifier

N Please leave blank

PER08 364 Communication Number N Please leave blank If either PER03 or PER04 is present then the other is required.

If either PER05 or PER06 is present then the other is required.

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N3 Member Residence Street Address

Situational

Ref # ID Name Req. Codes Notes N301 166 Address Information Y Address Line 1

N302 166 Address Information N Address Line 2

N4 Member City, State, and Zip Code

Required

Ref # ID Name Req. Codes Notes N401 19 City Name Y City name (free form)

N402 156 State or Providence Code Y State

N403 1126 Postal Code Y Postal Code

N404 26 Country Code N Country Code

N405 309 Location Qualifier N Please leave Blank

N406 310 Location Identifier N Please leave Blank

N407 1715 Country Subdivision Code N Please leave Blank

DMG Member Demographics

Situational

Ref # ID Name Req. Codes Notes DMG01 1250 Date and Time period

Format Qualifier

Y D8

DMG02 1251 Date Time Period Y Date of Birth in format CCYYMMDD

DMG03 1068 Gender Code Y F,M Female, Male

DMG04 1067 Marital Status N I, M, B

I=Single, M=Married, B=Registered Domestic Partner See Guide for additional codes.

DMG05 C056 Composite Race or Ethnicity Information

N Please leave blank

DMG05-01

1109 Race or Ethnicity Code N 7, 8, A, B,

C, D,

7=Not Provided, 8=Not applicable, A=Asian or Pacific

Islander, B= Black,

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E, F, G, H, I, J, N, O, P,

Z

C=Caucasian, D=Subcontinent Asian American, E=Other Race, F=Asian Pacific America, g=Native American, H=Hispanic,

N=Black (Non Hispanic), O=White (Non Hispanic), P=Pacific Islander, Z=Mutually defined

DMG05-02

1270 Code List Qualifier Code N RET Classification of Race or Ethnicity

DMG05-

03

1271 Industry Code N Please leave blank

DMG06 1066 Citizen Status code N Please leave blank

DMG10 1270 Code List Qualifier code N Please leave blank

DMG11 1271 Industry Code N Code from a specific industry code list

If DMG11 is present then DMG05 is required.

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Loop 2300

HD Health Coverage

Required (at least one)

Ref # ID Name Req. Codes Notes

HD01 875 Maintenance Type Code Y 001, 021, 024, 030

001=Change, 021=Addition, 024=Cancellation or Termination, 030=Audit or Compare

HD03 1205 Insurance Line code Y MM

HLT EPO PPO HMO

DEN PDG POS VIS

MM=Major Medical

HLT=Health EPO=Exclusive Provider Org. PPO=Preferred Provider Org. HMO=Health Maintenance Org.

DEN=Dental PDG=Prescription Drug POS=Point of Service VIS=Vision

HD04 1204 Plan Coverage

Description

Y Plan Code

HD05 1207 Coverage Level Code Y CHD, DEP, E1D, E2D, E3D, E5D, E6D,

E7D, E8D, E9D, ECH,EMP, ESP,

FAM, IND, SPC, SPO, TWO

CHD=Children Only, DEP=Dependents Only, E1D=Employee and One dependent, E2D=Employee and Two

dependents, E3D=Employee and Three dependents, E5D=Employee and One or More Dependents, E6D=Employee and Two or More

Dependents, E7D=Employee and Three or More Dependents, E8D=Employee and Four or More Dependents, E9D=Employee and

Five or more Dependents, ECH=Employee and Children EMP=Employee Only ESP=Employee and Spouse,

FAM=Family, IND=Individual, SPC=Spouse and Children, SPO=Spouse Only, TWO=Two Party

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DTP Benefit Coverage Dates

Required

Ref # ID Name Req. Codes Notes DTP01 374 Date Time Qualifier Y 303,

348, 349

303=Maintenance Effective,

348=Benefit Begin Date 349=Benefit End Date

DTP02 1250 Date Time Period Qualifier

Y D8

DTP03 1251 Date Time Period Y Date in format CCYYMMDD

REF Health Coverage Policy Number

Situational

Ref # ID Name Req. Codes Notes

REF01 128 Reference Identification Qualifier

Y 1L

REF02 127 Reference Identification Y Group or Policy Number. May contain 12345678 if Group or Policy number is not available

REF Health Coverage Policy Number

Situational

Ref # ID Name Req. Codes Notes

REF01 128 Reference Identification Qualifier

Y 17

REF02 127 Reference Identification Y Attestation Indicator

Possible Values: 0=Do not send claims and do not send eligibility

1=Send claims only 2=Send eligibility only 3=Send claims and eligibility

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AMT – Health Coverage Policy

Situational

Ref # ID Name Req. Codes Notes AMT01 522 Amount Qualifier Code Y B9

C1 D2 EBA

FK P3 R

B9=Co-insurance-Actual

C1=Co-Payment Amount D2=Deductible Amount EBA=Expected Expenditure Amount

FK=Other Unlisted Amount P3=Premium Amount R=Spend Down

AMT02 782 Monetary Amount Y

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Loop 2310

LX Provider Information

Situational

Ref # ID Name Req. Codes Notes

LX01 554 Assigned Number Y 1 Number assigned to separate within transaction sets. Should contain “1”

NM1 Provider Name

Situational

Ref # ID Name Req. Codes Notes

NM101 98 Entity Identifier Code Y P3 P3=Primary Care Physician

NM102 1065 Entity Type Qualifier Y 1, 2 1=Person, 2=Non-Person Entity

NM103 1035 Name Last or

Organization

Y Name of Primary Care

Physician NM104 1036 Name First N

NM105 1037 Name Middle N

NM106 1038 Name Prefix N

NM107 1039 Name Suffix N

NM108 66 Identification Code Qualifier

Y 34,FI,SV,XX 34=SSN, FI=Federal Tax ID, SV=Service Provider Num, XX=CMS NPI

NM109 67 Identification Code Y Provider ID

NM110 706 Entity Relationship Code

Y 25,26, 72 25=Established Patient 26=Not Established Patient

72=Unknown

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N3 Provider Address

Situational

Ref # ID Name Req. Codes Notes N301 166 Address Information Y Provider Address

N302 166 Entity Type Qualifier N

N4 Provider City, State, Zip Code

Situational

Ref # ID Name Req. Codes Notes

N401 19 City Name Y

N402 156 State or Province Y

N403 116 Postal Code Y

N404 26 Country Code N

PER Provider Communications Numbers

Situational

Ref # ID Name Req. Codes Notes

PER01 366 Contact Function Code Y IC Information Contact PER02 93 Not Used N

PER03 365 Communication

Number Qualifier

Y HP, TE, WP HP-Home Phone Number

TE-Telephone WP-Work Phone Number

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PLA – Provider Change Reason

Situational

Ref # ID Name Req. Codes Notes PLA01 306 Action Code Y 2 Change

PLA02 98 Entity Identifier Code Y 1P Provider

PLA03 373 Date Y Provider Effective Date in format CCYYMMDD

PLA04 337 Time N Time

PLA05 1203 Maintenance Reason Code

N 14, 22, 46, AA, AB,

AC, AD, AE, AF, AG, AH, AI, AJ

14 Voluntary Withdrawal 22 Plan Change

46 Current Customer Information File in Error AA Dissatisfaction with Office Staff

AB Dissatisfaction with Medical Care AC Inconvenient Office

Location

AD Dissatisfaction with Office Hours AE Unable to Schedule Appointments in a Timely

Manner AF Dissatisfaction with Physician’s Referral Policy AG Less Respect and

Attention Time Given than to Other Patients AH Patient Moved to a New Location

AI No Reason Given AJ Appointment Times not Met in a Timely Manner

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Loop 2500

FSA Flexible Spending Account

Situational

Ref # ID Name Req. Codes Notes

FSA01 875 Maintenance Type Code Y 001, 021,024, 030

001=Change, 021=Addition, 024=Cancellation or Termination, 030=Audit or

Compare

FSA02 1202 Flexible Spending Account Selection Code

Y D, H D=Dependent Care, H=Healthcare

FSA03 1203 Reason Code Y 36 36=Contribution or Plan Allocation

FSA04 508 Account Number N Account number assigned

FSA05 594 Frequency Code N 1, 2, 3, 4, 5, 6, 7, 8, 9, B, C, H, Q, X,

U, Z

1=Weekly, 2=Biweekly, 3=Semimonthly, 4=Monthly, 5=Other, 6=Daily, 7=Annual, 8=Two Calendar Months,

9=Lump-Sum Separation Allowance, B=Year to Date, C=Single, H=Hourly, Q=Quarterly, S=Semiannual,

U=Unknown, Z=Mutually Defined

FSA06 1204 Plan Coverage Description N Plan or coverage description

FSA07 1161 Product Option Code N 1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, N,

O, S, 10, 11, 12, 13, 14, 15, 28,

29

1=Pretax, 2=Post tax, 3=Qualified, 4=Non Qualified, 5=401K, 6=Individual Retirement Account, 7=Keogh,

8=Simplified Employee Pension, 9=Single Premium, A=First to Die, B=Last to Die, C=Child Rider, D=discontinue

one Bill Submission, N=Benefit Continuation, O=One bill Submission, S=Salary Continuation, 10=Flexible

premium, 11=Variable Premium, 12=Fixed Premium, 13=Registered under the Income Tax Act of Canada,

14=Non Registered und the Income Tax Act of Canada,

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15=registered Spousal case, 28=Exclusive, 29=Shopped

FSA08 1161 Product Option Code N Not Required

FSA09 1161 Product Option Code N Not Required

FSA04 is the flexible spending account policy number.

FSA05 specifies the frequency of contribution.

AMT Monetary Amount Information

Situational

Ref # ID Name Req. Codes Notes

AMT01 522 Amount Qualifier Code Y 1 Code to qualify amount

AMT02 782 Monetary Amount Y Actual Monetary Amount

AMT03 478 Credit/Debit Flag Code N C, D Code indicating if it is a credit or debit

DTP Date or Time or Period – Payroll Dates

Situational

Ref # ID Name Req. Codes Notes

DTP01 374 Date/Time Qualifier N 390, 391

390=Payroll Begin Date 391=Payroll End Date

DTP02 1250 Date Time Period Format Qualifier

N D8

DTP03 1251 Date Time Period N Date in format CCYYMMDD

Page 24: 834 Benefit Enrollment and Maintenance 5010 Companion Guide · REF Member Supplemental Identifier Situational Ref # ID Name Req. Codes Notes REF01 128 Reference Identification Qualifier

24

SE Transaction Set Trailer

Required

Ref # ID Name Req. Codes Notes SE01 96 Number of Included

Segments

Y Total number of Segments

included in the transaction set including ST and SE segments

SE02 329 Transaction Set Control Number

Y Control number that must be unique within the transaction set functional group, assigned by the

Originator. Must match element ST02.

GE Functional Group Trailer

Required

Ref # ID Name Req. Codes Notes

GE01 97 Number of Transaction

Sets Included

Y Total number of transaction sets

included in the functional group or interchange

GE02 28 Group Control Number Y Assigned number originated and maintained by the sender. Must match element GS06.

IEA Interchange Control Trailer

Required

Ref # ID Name Req. Codes Notes

IEA01 116 Number of Included Functional Groups

Y A count of the number of functional groups included in an interchange

IEA02 112 Interchange Control Number

Y A control number assigned by the Interchange sender. Must match

ISA13.