834 Benefit Enrollments and Maintenance 5010 Companion Guide · 2013. 6. 21. · 834 Benefit...

834 Benefit Enrollments and Maintenance 5010

Companion Guide

HIPAA/V5010220A1/834

Version 1.1

Company: Blue Cross of Idaho

Created 05/29/2013

An Independent Licensee of the Blue Cross and Blue Shield Association

2

Table of Contents

834 Benefit Enrollment and Maintenance ............................................................................................................................ ISA Interchange Control Header .................................................................................................................................... 5

GS Functional Group Header ........................................................................................................................................ 6

ST Transaction Set Header ............................................................................................................................................ 6

BGN Beginning Segment ................................................................................................................................................... 7

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

DTP File Effective Date ..................................................................................................................................................... 8

QTY Transaction Set Control Total ................................................................................................................................. 8

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

1000B Loop Payer N1 Payer .......................................................................................................................................................................... 9

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

1100C Loop TPA/Broker Account Information ACT TPA/Broker Account Information ........................................................................................................................ 10

2000 Loop Member Level Detail INS Member Level Detail .............................................................................................................................................. 11

REF Subscriber Identifier ............................................................................................................................................... 12

REF Member Policy Number ......................................................................................................................................... 12

REF Member Supplemental Identifier .......................................................................................................................... 13

DTP Member Level Dates ............................................................................................................................................... 14

2100A Loop Member Name NM1 Member Name ......................................................................................................................................................... 15

PER Member Communications Numbers ..................................................................................................................... 15

N3 Member Residence Street Address ........................................................................................................................ 16

N4 Member City, State, ZIP Code .............................................................................................................................. 16

DMG Member Demographics .......................................................................................................................................... 17

2300 Loop Health Coverage HD Health Coverage ...................................................................................................................................................... 18

DTP Health Coverage Dates ........................................................................................................................................... 19

REF Health Coverage Policy Number ........................................................................................................................... 19

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

2500 Loop Flexible Spending Account FSA Flexible Spending Account ..................................................................................................................................... 20

AMT Monetary Amount Information ............................................................................................................................. 21

DTP Date or Time or Period ........................................................................................................................................... 21

SE Transaction Set Trailer .......................................................................................................................................... 22

GE Functional Group Trailer ....................................................................................................................................... 22

IEA Interchange Control Trailer .................................................................................................................................. 22

3

1 Introduction 1.1 Disclaimer

Blue Cross of Idaho (BCI) created this Companion Guide for the 835 Health Care Claim

Payment Advice 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 an additional source of information created to assist providers and business partners

of Blue Cross of Idaho. You can download a free copy of the latest ANSI X12 Implementation

Guide at wpc-edi.com/content/view/533/377/.

Blue Cross of Idaho ONLY provides remittances for Blue Cross of Idaho claims

1.2 Document Purpose The purpose of this companion guide is to describe those aspects of processing an electronic 835

Health Care Claims Payment Advice 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 also

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/edi_clearinghouse/index.asp

2 Enrollment 2.1 Enrollment Information Any entity desiring to send or receive electronic transactions through the Blue Cross of Idaho

Clearinghouse must first be registered. Blue Cross of Idaho accepts one enrollment form for

multiple transactions. If you are interested in registering with Blue Cross of Idaho, simply

complete a copy of the Electronic Data Interchange (EDI) Enrollment Form available at

bcidaho.com/edi_clearinghouse/index.asp and fax it to 208-331-7203.

If you are a vendor, please select Vendor EDI Enrollment Form in the vendor column.

Providers need to select EDI Enrollment Form from the provider column.

835 Remittances Advise Blue Cross of Idaho ONLY provides remittances for Blue Cross of

Idaho claims.

After Blue Cross of Idaho receives and processes your Electronic Claims Submission Enrollment

Form, there are a number of tasks that must be completed:

Receive your login and password information.

Submit test files, assisted by a member of the Blue Cross of Idaho EDI Support Desk.

Obtain permission to submit production data files.

2.2 EDI Support

4

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

2.3 General Business Information Blue Cross of Idaho will only accept transactions from trading partners that completed the

enrollment process and have a submitter ID on file. We will reject all other transactions.

Blue Cross of Idaho complies with HIPAA regulations. Below are specific coding requirements

used by Blue Cross of Idaho, but remember 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.

3.1 Blue Cross of Idaho Business Rules

Blue Cross of Idaho complies with HIPAA regulations. Blue Cross of Idaho’s specific business

rules regarding HIPAA Claims Adjustment Reason Codes (Loop 2110 / Segment CAS) and

HIPAA Remittance Advice Remark Codes (Loop 2110 / Segment LQ02) are described below.

ISA Interchange Control Header

5

Required

Ref # ID Name Req Codes Notes

ISA01 101 Authorization Number Y 00 Code identifying type of

information in the

Authorization element

ISA02 102 Code set Summary Y 0000000000 Information used for additional

identification

ISA03 103 Security information

Qualifier

Y 00 Information needed Security

Information

ISA04 104 Security information Y Blank Information that acts as

Security

ISA05 105 Interchange ID Qualifier Y 30 The number used to identify the

sender or receiver

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

ISA07 105 Interchange ID Qualifier Y 30 Code indicating the sgtructure

requirement to identify the

sender or receiver ID element.

ISA08 107 Interchange Receiver ID Y 820344294 Information sent by the user to

identify the sender as their

sender ID

ISA09 108 Interchange Date Y YYMMDD Date the interchange was sent

ISA10 I09 Interchange Time Y HHMM The time the file was created

ISA11 I65 Repitition Seperator Y ^ The separators identify data

within elements.

ISA12 111 Interchange Control

Version Number

Y 00501 Code used to indentify 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 acknowledgememt

ISA15 I14 Interchange Usage

Indicator

Y P, T Code indicating Test or

Production

ISA16 I15 Component Element

Seperator

Y > Delimiter seperator

Element Separator *

Terminator Delimiter ~

GS Functional Group Header

6

Required


GS01 479 Functional Identifier

Code

Y BE Code identifying the

application related transaction

sets

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


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

7

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 Date=YYMMDD

BGN04 337 Time X 24 hour clock HHMM

BGN05 623 Time Code O MT Code for Time in accordance

with International Standards

BGN06 127 Reference Identification O Blank Reference information for a

particular Transaction Set

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

If BN05 is present then BN is required

REF Transaction Set Policy Number

Situational


REF01 128 Code qualifying the

Reference Qualifier

Y 38 Reference Identification

REF02 127 Reference Identification X Master Policy Number

Either REF02 or REF03 is required

DTP File Effective Date

Situational

8


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 CCYYMDD Actual date, time or range of

dates, times or dates and times.

QTY Transaction Set Control Totals

Situational


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 X Numeric value of quantity

Loop 1000A

N1 Sponsor Name

Required


N101 98 Entity Identifier Code Y P5 Code identifying a physical

location, property of individual

N102 93 Name Y Sender Client Name

N103 66 Code Qualifier Y FI Code Identifying the method of

code structure

N104 67 Identification Code Y Federal Tax id of the Plan

At least one of N102 or N103 is required

Loop 1000B

N1 Payer

Required

9


N101 98 Entity Identifier Code Y IN Organizational entity, physical

location, property or individual

N102 93 Name Y Should contain Blue Cross of

Idaho

N103 66 Identification Code

Qualifier

FI Code for system method of code

structure

N104 67 Identification Code X 820344294 Code identifying party or other

code

At least one of NM102 or NM103 is required.

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

Loop 1000C

N1 TPA/Broker Name


N101 98 Entity Identifier Code Y BO,

TV

Code identifying an organizational

entity, property or physical

location

N102 93 Name Y Name

N103 66 Code Qualifier X 94, FI,

XV

Code for structure

N104 67 Identification code X Actual code

At least N102 or N103 is required.

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

Loop 1100C

ACT TPA/Broker Account Information

Situational


10

ACT01 508 Account Number Y Account number Assigned

ACT06 508 Account Number X Account number Assigned

If ACT03 or ACT04 are present then the other is required.

If ACT05 is present then ACT06 is required.

If ACT07 is present then ACT05 is required.

ACT02 is the name of the account in ACT01. ACT07 is the same name as ACT06

Loop 2000

INS Member Level Detail

Required


INS01 1073 Yes/No Condition Y Y, N Yes or No Indicator

11

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 Guide for

complete list)

INS03 875 Maintenance Type

Code

O 001, 021, 030 001=Change, 030=Audit or

Compare (030 should always

be used for full files)

INS04 1203 Maintenance Reason

Code

O XN Codes to identify

maintenance change entities

(see Guide for complete list)

INS05 1216 Benefit Status Code O A, C, S, T Actual code identifying

Status change

INS06 C052 Medicare Status Code O Blank, D, E Identifies Medicare coverage

and associated reason for

Medicare Eligibility.

D=Medicare, E=No Medicare

INS06-

01

1218 Medicare Plan Code O Code identifying Medicare

Plan Required when INS06 is

used

INS06-

02

1701 Eligibity Reason Code O Reason for Eligibility

INS07 1219 Consolidated Omnibus

Budget

O Blank This field should be blank

INS08 584 Employment Status

Code

O FT, PT, RT Code displaying employment

status of claiment

INS09 1220 Student Status Code O F, N, P Code displaying student

status of a patient if 19 or

older, not handicapped and

not insured

INS10 1073 Condition Response

code

Y/N Code indicating a Yes or No

response. Y=Handicapped,

N=not handicapped

INS11 1250 Date Time period

Qualifier

X D8 Indicates date to follow in

CCYYMMDD format

INS12 1151 Date Time Period X CCYYMMDD Actual Date in above format,

Date of Death

INS13 1165 Confidentiality Code O Not Used

INS17 1470 Number O Generic Number if family

members have the same

birthdate (For dependents)

If either INS11 or INS12 is present, the other is required.

12

REF Subscriber Identifier

Required


REF01 128 Reference Identification

Qualifier

Y OF Reference Identification for

Subscriber number

REF02 127 Reference Identification X Social Security Number


REF Member Policy Number

Situational


REF01 128 Reference Identifcation

Qualifier

Y IL Reference Code

REF02 127 Reference Identification X BCI supplied Group Number.

This number references a specific

transaction set.


REF Member Supplemental Identifier

Situational


REF 128 Reference Identification

Qualifier

Y 23 23=Client Number

REF02 127 Reference Identification X Employee Id

13

REF04 NOT USED


Situational



Qualifier

Y DX DX=Department/Agency Number

REF02 127 Reference Identification X BCI supplied Sub Group Number

REF04 NOT USED


Situational



Qualifier

Y 17 17=Client Reporting Category

REF02 127 Reference Identification X BCI supplied Class Code or

Benefit Level Code

REF04 NOT USED


DTP Member Level Dates

Situational


DTP01 374 Date Time Qualifier Y 336,

337

336=Employment

Begin337=Employment Ends

DTP02 1250 Date Time Period

Qualifier

Y D8 D8=Date in format CCYYMMDD

14

DTP03 1251 Date Time Period Y Begin / End Date of Employment

DTP02 is the date or time period that will populate in DTP03

Situational



337

356=EligibilityBegin

357=Eligibility End


Qualifier

Y D8 D8=Date in format CCYYMMDD

DTP03 1251 Date Time Period Y Actual Begin / End Date of

Eligibility


15

Loop 2100A

NM1 Member Name

Required


NM101 98 Element Name Y IL IL=Subscriber

NM102 1065 Entity Type Qualifier Y 1 Person

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

Name

NM104 1036 Name, First O First Name

NM105 1037 Name, Middle O Middle Name or Initial

NM106 1038 Name Prefix O Prefix to Name

NM107 1039 Name Suffix O Suffix to Name

NM108 66 Identification Code

Qualifier

X 34 Number Indicating the type of

number following

NM109 67 Identification Code X Social Security Number

If either NM108 or NM109 is present then the other is required.

PER Member Communications Numbers

Situational


PER01 366 Contact Function Code Y IP IP=Insured Party

PER03 365 Communication Number

Qualifier

X HP,

TE

TE=Telephone, HP= Home Phone

PER04 364 Communication Number X Actual number from qualifier

above. Phone number


Qualifier

X EM EM=Email

PER06 364 Communication Number X Email address


Qualifier

X Blank

PR08 364 Communication Number X Blank

If either PER03 or PER04 is present then the other is required.



16

N3 Member Residence Street Address

Situational


N301 166 Address Information Y Address Line 1

N302 166 Address Information O Address Line 2

N4 Member City, State, and Zip Code

Required


N401 19 City Name O City name (free form)

N402 156 State or Providence Code X State

N403 1126 Postal Code X Postal Code

N404 26 Country Code X Country Code

N405 309 Location Qualifier X Leave Blank

N406 310 Location Identifier O Leave Blank

N407 1715 Country Subdivision Code X Leave Blank

Only N402 or N407 may be present

If either N406 or N405 is present the other is required

If N407 is present then N404 is required.

17

DMG Member Demographics

Situational


DMG01 1250 Date and Time period

Format Qualifier

X D8 Date Qualifier

DMG02 1251 Date Time Period X Actual Date of Birth

DMG03 1068 Gender Code O F,M Female, Male

DMG04 1067 Marital Status O I, M,

B

I=Single, M=Married,

B=Registered Domestic Partner

See Guide for additional codes.

DMG05 C056 Composite Race or

Ethnicity Information

X Blank

DMG05-

01

1109 Race or Ethnicity Code O 7, 8,

A, B,

C, D,

E, F,

G, H,

I, J, N,

O, P,

Z

7=Not Provided, 8=Not

applicable, A=Asiom or Pacific

Islander, B= Black,

C=Caucasion, D=Subcontinent

Asian American, E=Other Race,

F=Asain 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 X RET Classification of Race or

Ethinicity

DMG05-

03

1271 Industry Code X Please leave Blank

DMG06 1066 Citizen Status code X 1, 2, 3,

4, 5, 6,

7

Please leave blank

DMG10 1270 Code List Qualifier code X REC Please leave Blank

DMG11 1271 Industry Code X Code from a specific industry

code list

If either DMG01 or DMG02 is present then the other is required

If either DMG10 or DMG11 is present then the other is required.

If DMG11 is present then DMG05 is required.

18

Loop 2300

HD Health Coverage

Situational


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 O MM,

DEN,

EPO,

HMO,

VIS

MM=Major Medical, UR=

Utilization Review,

DEN=Dental, EPO=Exclusie

Provider Org. HMO=Health

Maintenance Org,

VIS=Vision

HD04 1204 Plan Coverage

Description

O Plan Code

HD05 1207 Coverage Level Code O 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

19

DTP Health Coverage Dates

Required



348,

349

303=Maintenance Effective,

348=Benefit Begin 349=Benefit


Qualifier

Y D8 Date Qualifier

DTP03 1251 Date Time Period Y Actual Date


REF Health Coverage Policy Number

Situational


REF01 128 Reference Id Qualifier Y IL IL=Group or Policy Number,

REF02 127 Reference Identification X Reference Information for a

specific Transaction Set. May

contain 12345678 if Group or

Policy number is not available

At least one or the other REF02 or REF03 is required.

Loop 2310

LX Provider Information

Situational


LX01 554 Assigned Number Y 1 Number assigned to separate

within transaction sets. Should

contain “1”

20

FSA Flexible Spending Account

Situational


FSA01 875 Maintenance Type Code Y 001,021,

024, 030

Code identifying type of item

maintenance

FSA02 1202 Flexible Spending

Account Selection Code

O D, H D=Dependent Care,

H=Healthcare

FSA03 1203 Reason Code O 36 36=Contribution or Plan

Allocation

FSA04 508 Account Number O Account number assigned

FSA05 594 Frequency Code O 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

O Plan or coverage description

FSA07 1161 Product Option Code O 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, 15=registered

Spousal case, 28=Exclusive,

29=Shopped

FSA08 1161 Product Option Code O Not Required

FSA09 1161 Product Option Code O Not Required

21

FSA04 is the flexible spending account policy number.

FSA05 specifies the frequency of contribution.

AMT Monetary Amount Information

Situational


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 O C, D Code indicating if it is a credit or

debit

DTP Date or Time or Period

Situational


DTP01 374 Date/Time Qualifier Y 390,

391

290=Payroll Begin, 391=Payroll

End

DTP02 1250 Date Time Period Format

Qualifier

Y D8 Date Qualifier

DTP03 1251 Date Time Period Y Actual Date

SE Transaction Set Trailer

22

Required


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 and must be

assigned by the Originator for a

transaction set

GE Functional Group Trailer

Required


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

The data interchange control number in GE02 must be identical to the same data element in the

associated functional group header GS06.

IEA Interchange Control Trailer

Required


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

834 Benefit Enrollments and Maintenance 5010 Companion Guide · 2013. 6. 21. · 834 Benefit...

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